Presentation on theme: "Population Health Management Defined April 12, 2015"— Presentation transcript:
1 Population Health Management Defined April 12, 2015 Special thanks and kudos to Jerry Sobolik who could not be here today due to his child’s first communionIntro of PHM – Claudia (slides 1-10)About Mayo and Need for Action – Tim (slides x-y)Specific analytics use cases (and underlying metrics studied) – ClaudiaChallenges and next steps – Tim finishesTim Miksch, Section Head, Applied Clinical InformaticsThe Mayo ClinicClaudia Blackburn, Senior ManagerAspen Advisors, Part of The Chartis GroupDISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
3 Challenges and Next Steps Learning ObjectivesIdentify how to align an organizational healthcare model with a value- based reimbursement model to support the allocation of resources for high risk patientsExplain definitions and concepts associated with Population Health and Population Health ManagementSummarize the role of analytics in developing and evaluating programs and processesIdentify where your organization is on a Population Health Management (PHM) maturity roadmapPHMCore CompetenciesCase StudyChallenges and Next Steps
4 An Introduction to the Benefits Realized for the Value of Health PHM IT Treatment – the PHM tool allows identification of patients for better treatment.Electronic information allows for the holistic picture of the patient for best identification of risk and subsequent treatment
5 We will define PHM and the associated core competencies. Then we will study how Mayo Clinic has developed those competencies through a case study of their journeyAnd end with challenges and successful approaches
6 Population Health Management (PHM) The Future of Healthcare Paradigm Shift Today:Reactive andVolume-basedThe Future:Proactive andValue-basedDriversEncourage me!Treat me holistically!!Educate me!Health ReformPopulation health managementprovides comprehensiveauthoritative strategies forimproving the systems andpolicies that affecthealth care quality, access,and outcomes, ultimatelyimproving the healthof an entire populationI will payyou!Affordability GapTriple AimThis slide tells many stories, encompassing the different angles of population health management.At the top, the scale reflects the balancing act that providers face as they continue to stay in business through volume income but start to focus on value by investing in prevention and proactive population health care where they learn to economically manage a population, leading eventually to risk based contracts.The drivers on the left are pushing providers to value based care (and we have a single slide on some of these).Health care reform is moving towards paying a provider a set fee to handle a “case” so the provider has to focus on quality to keep the patient healthy thus keeping the expense of the case down.An affordability gap continues where salaries are not increasing as fast as health insurance thus consumers cannot afford insurance. Therefore, cost of care needs to come down so that premiums come down and are affordable.IHI has defined quality in terms of the triple aim: decrease cost, improve care experience and improve population health. Once again, moving to value based care meets these pressures.Weight of the Nation is supported by many of the quality agencies such as (I need to look these up online when I land) but refers to the fact that over the last years, each of our states has increased the average BMI from overweight to obese 1 and even obese 2 in some cases. This has caused less civilians to pass physical entrance tests into our military, it has caused us to be less competitive as a nation because our workers are less healthy (absenteeism and lack of presenteeism at work)Reimbursement – similar to health care reform, providers need to be prepared to accept less to take care of patients so they need to learn to keep the patient healthy and contract with other providers for total cost of care – similar to capitation.===The middle section is the definition of population health. It is not one strategy but an ongoing process to improve health quality outcomes.The right side depicts the fact that consumers (not patients) need and want care advocates, coaches, coordinators to help them through education and guidance become and stay healthy. Especially older folks who don’t understand healthcare but even younger consumers who need someone watching over them to encourage healthy behaviors (and get on them for unhealthy behaviors!).Weight of the NationReimbursementIndividuals are accountable for their healthwith the health system as their health advocate.
7 Achieving Success Making the “Triple Aim” Possible Engaged CommunitiesProactive care processesIdentified patientsFocused on wellnessCommunity resource navigatorEngaged PatientsIdentified and incorporated patient goalsFocused on continuity and coordinationFacilitated communication channelsImproved access to careBetter Healthfor the PopulationMayo has adapted the IHI Triple AimIdentified Opportunities to Reduce Waste4 RightsDuplication avoidedImproved coordination/transitionsUsed automation to reduce resource needsImproved screening and preventionAligned incentives to drive value7
8 Population Health Management Core Competencies and Key Pillars
9 Population Health Management (PHM) Core Competencies The goal of population health is to transform care delivery practices and administrative support to deliver improved outcomes and lower costs across the continuum of care for a specified population. Success will depend on changes in care practices, business processes and cross-organizational communications, all supported by information technology.Operational Performance Management and BIMember EngagementCross-Continuum Care Delivery and Medical / Care ManagementAccountingMember Engagement – members must be actively involved in health and wellness.Cross-Continuum Care Delivery and Medical/Care Management – requires consistent care planning and monitoring, consolidated clinical data views, different modes of communication and, seamless hand-offs among care settings.Quality Outcomes Management /Reporting – the difference for population health is the need for measuring and monitoring across the continuum of care. It includes all participating entities and should support a number of health reform programs.Operational Performance Management and BI – Population Health managers need to deliver great care at lower costs, which means there must be constant monitoring of how they are performing to key business indicators.Accounting – supports the business of operating the program and is a fundamental shift from typical healthcare accounting.Integration and Infrastructure – keeps track of members, providers, and encounters; ensures the right information sent from one system goes to the right destination (system) for the right patient, with appropriate data translation and data security. This is critical – every time a new entity or technology is added, it must be integrated into the total IPN IT solution.Quality Outcomes Management / ReportingIntegration and Infrastructure
10 PHM Competency Characteristics FoundationalAdvancedInnovativeMember engagementWebsite of offerings availableInteractive site, smart phone, incentivesCoach proactively encouraging healthy behaviorCross-continuum care delivery and medical / care managementSites of care operate in silos, handoff on paper, relying on patientSome care planning and handoff between sites of careConsistent care planning, monitoring, consolidated clinical data views, different communication and seamless hand-offs among care settingsQuality outcomes management / reportingRegistries in the EHRRegistries within a data warehouse with multiple feedsMeasuring and monitoring across the continuum of care, including all participating entitiesOperational performance management / BIEHR reports such as MU attestationsData warehouse with analytics for reportingConstant monitoring of how they are performing to key business and care metrics from analytics engineAccountingFinancial and PHM systems for analysis and payment incentive in Excel or other non-integration toolSome integration and analytics to provide individual and provider incentivesReal-time reporting of status for both individuals and providers towards shared savings and incentives such as through portalsIntegration and infrastructureOne or few systems are not integrated causing redundant workMost systems are integrated, but one longitudinal record does not exist electronicallyTrack all population members, providers, encounters, and assure information sent from one system goes to the right destination (system) for the right patient, with appropriate data translation, normalization and security
11 Key Pillars of Population Health Management For an effective PHM program that increases QUALITY, there are 4 key pillars: business vision and strategy; proper funding; clinical integration and technology for analytics to measure success.Business vision, population definition, policies, modeling, financials, contracts, procedures, market analysis, and value propositionRisk, incentives, payment management, shared savingsWorkflows, role changes, people, care coaches, wellness program development, heath risk assessment process, population engagementIntegration and interoperability including HIE, patient portal, analytics, coaching tools and health risk assessment
13 Mayo Community Practices MAYO CLINIC in the MIDWESTAcademic Medical Center Rochester, MN500,000 patients/year2,000 physicians125 primary care providersPrimary careAt full risk for PCCommunity and Regional Health System75 communities in MN, IA and WI4 regions18 hospitals525,000 patients/year1,000+ physiciansPrimary careAt risk for PCMAYO CLINIC in the SOUTHWESTMAYO CLINIC in the SOUTHEASTSome background about Mayo Clinic,Mayo Clinic in Midwest is comprised of 2 distant practices, the Academic medical center and the community and regional practices.Both see about 500 thousand patients annually, however in the Rochester practice, there is a fairly small primary care practice and it serves mainly our employees and dependents and the Rochester community. We are at nearly full risk for this population.The Mayo Clinic Health System is comprised of 75 practices located in communities in Southern MN, western WI and Northern Iowa. They are mainly primary care providers, with some specialty care providers. 18 hospitals and about 1000 providers. We have a mixed population and are about 50% at risk.Mayo Clinic in the SE and SW United States, each see about 90 thousand pts and are limited in their primary care and are not at risk for primary care paneled patients.AZ and FL do have employees and some government contracts which due to self insured, are at-riskArizona90,000 patients/yearApprox. 400 physiciansPrimary careAt full risk for PCFlorida90,000 patients/yearApprox. 400 physiciansPrimary careAt full risk for PC
14 Office of Population Health Management Formed in 2012Developed a Mayo framework for PHMStrategyPhasingOversightCoordinationStandardizationFocused on the community practicesInitially focused on primary careValue-based carePatient-Centered Medical HomeRisk based reimbursement
15 The Changing MarketThrough the course of work with many of you we are seeing thisWe must1) improve healthReduce costsImprove the patient experienceSource: “The View from Healthcare’s Front Lines: An Oliver Wyman CEO Survey”
16 WHY? WHO? WHAT? The measure of PRODUCTIVITY is no longer VOLUME Costs are risingReimbursement is decreasingThe measure of PRODUCTIVITY is no longer VOLUMEIt is VALUE =Small changes are not enoughOutcomes + ServiceCostOur survival is at riskWHY?WHO?Office of PopulationHealth Management(OPHM)Created by MCCPC to TRANSFORM Community CareOPHM establishes the STANDARDIZED ELEMENTS for clinics to implement with APPROPRIATE LOCALIZATIONA new way of practicing is neededOPHM defines strategy for the new modelWHAT?MMoCC is an enterprise-wide, multi-year roll-out to achieve the TRIPLE AIM:Improve Population HealthImprove Individual ExperiencesLower CostsWhile aligning with financial modelsChanging isn’t just for survivalThe new model allows us to thriveThe Mayo Model of Community Care (MMoCC)Implemented in strategic phases
17 Vision Patient centered, integrated care delivery model based on: Aligned incentivesCoordinated, collaborative processesEvidence-based prevention and disease management protocolsSeamless sharing of informationSupported by wellness and continuity care programs that focus on:Patient engagementCommunity integrationPrevention and health promotionDriven by analytics to support quality outcomes and value-based accountable reimbursement
18 Mayo Clinic Clinical Practice Committee Office of Population Health ManagementOPHM Advisory GroupExecutive TeamProgramsFunctional SubgroupsGeographic OperationsContinuity CareHealth & WellnessPreventionCare CoordinationChange Mgmt./ CommunicationsArizona OfficeChronic Condition ManagementData AnalyticsFlorida OfficeCommunity EngagementPalliative CareIT Tools and ApplicationMidwest OfficeWellnessCare TransitionsThis is the OPHM Org Chart.Ø Creation of org chart; AZ/FL/Midwest administrators; 10 programs created in 2012Ø Stakeholders at the biweekly OPHM Executive Steering committeeØ Charter to build OPHM are approved and deemed “vital few” thus funding allocated. 1 FTE = Jerry Sobolik in 2012Ø Then project charter for Humedica analytics at just MidWest in 2013Ø Payer enters : SCHA with riskWe report to the Mayo Clinic Clinical Practice Committee, we have an advisory group and an exec committee, 10 programs, 3 functional subgroups that cross all programs and 3 geographic offices to operationalize and implement the Mayo Model of Community Care.Team-based CarePatient EngagementAccess
19 MMoCC Focus Areas COST PHM FOCUS POPULATION Care Coordination Care teamsPatient engagementCommunity engagementAccessCare CoordinationCare TransitionsPalliative Care50%15%Disease Management35%35%WellnessPrevention15%50%POPULATION% of community2010 data from Mayo Clinic Health Sciences Research
20 MMoCC Impact 80% of costs Identify opportunities Act on opportunities HEALTH STATUSSituationalriskEarly riskHigh riskSymptomaticillnessComplexactiveillnessAbility to impactFamily HxEnvironmentDietExerciseCholesterolBPBlood sugarActive DzDiabetesWhat can you identify and what can you impact?HEALTH CARE SPENDLifetime
21 1 2 3 4 5 MMoCC Process DEFINE ASSESS STRATIFY ENGAGE MANAGE Population IdentificationHealth AssessmentRisk StratificationEnrollment / Engagement StrategiesManagement / InterventionsTailored Interventions—Care CoordinationDisease / Case ManagementHealth Risk ManagementHealth Promotion / WellnessMeeting patients where they are…physicallyhome | school | work | shopping | in the clinic…in the way that works best for them| text | internet | phone | video | face-to-face
22 Phased Implementation MMoCC 4Requires value-based contracts to succeedMMoCC 3More site resource investment – mixed volume/valueAdds specialty integration to care team conceptCommunity engagementFull alignment of incentivesMMoCC 2Laying the foundation while living in FFSShifts from individual practice to team-based panelsContinues focus on high utilization and expanded analytics and care managementIncreases focus on patient important outcomesStrong shift to total cost of care driversIntroduces value-based (TCOC) concepts and model (change management)Emphasis on team-based care foundation and care coordination introductionStandardized disease management and prevention recommendationsFocus on decreasing high utilization where it makes sense (30 d readmits…)
24 2015 Status All sites are actively engaged Standardizing across sites and regions is a challengeFor many, fee-for-service remains a driverData management processes are maturingKeys to our success:Engaged leadership at local levelsInstitutional supportStrong physician leaders in each programExcellent business analysis, project management and informatics support in place
25 VALUE = Outcomes + Service StructureDemand for healthcareSupply of resources to meet demandVALUE = Outcomes + ServiceCostOur pay will be based onWe need to utilize our staff wisely throughIdentify opportunities to impact health earlier and act on those opportunitiesWe need to think differently about how to activate our patients and communitiesAnd how we interact with themTEAM-BASED CAREANALYTICSPREVENTIONDISEASE MGMTCARE MGMT SYSTEMPATIENT ENGAGEMENTCOMMUNITY ENGAGEMENTWELLNESSACCESSCARE COORDINATIONPALLIATIVE CARECARE TRANSITIONS
26 Analytics and Reports Examples Report DescriptionRegistrationUnassigned and wrongly assigned patientsUnassigned Emergency Department high utilizersCare CoordinationDiabetic Mellitus (DM) patients who are most likely to be readmittedCongestive Heart Failure (CHF) patients who are most likely to be readmitted30 day readmission reports are located within the Care Coordination dashboard with DM and CHF 20%. Follow instructions from section 2.1 and 2.2Patients by Disease Evidence TypePatients with no Diabetes diagnosis but have other evidence of DiabetesPatients with no CHF diagnosis but have other evidence of CHFSo the reports that we have written in Optum Population analytics are in 3 critical foundational sections. Registration, Care Coordination and identifying patients with Chronic Disease by evidence type.
27 Example Use from Care Coordinators Care Coordinator identified a patient based on ER visits and reached out to her. She was very interested in COMPASS and did the PHQ9, and it was 17.“She was very interested in changing her life so that she could be around for her granddaughter. I have sent her a letter and will keep her on my watch. It was a good connection to at least let her be aware that services are available if and when she is ready.”“I have a patient who, because of care coordination, has improved her health to move from the PHM tool CHF “most” to the “more” list. The PHM tool still identifies her as higher risk, but she has done well with care coordination.”“It mostly has been helpful to me to identify patient populations that might be eligible for care coordination to reach out to the providers to get them on board with care coordination, pointing out that the PHM tool has already identified them as being higher risk.”Data from Optum Population Analytics Test environment and test providersThe purpose of this section is to identify a process and supportive tools that allow for proactive management of unassigned patients . Patient panel assignment to a Primary Care Provider (PCP) (the process of Panel Attribution) is foundational for population-based health care management. Accountability for managing these patients is embedded in at-risk contracts. Accuracy of attribution is essential for accurate quality reporting and in administering physician compensation models. PCPs are responsible for assisting a patient with all aspects of acute and chronic illness while helping each patient with continuing preventative services to help achieve a healthy life. Measuring how well the PCP is meeting these goals will be done by quality measures as determined by the Mayo Clinic and recognized regulatory or accrediting agencies. If a patient has a condition that is being managed by a specialty provider, the PCP is still ultimately responsible for the overall care and measured outcomes of that patient.This report focuses on both the unassigned patients and the ED frequent flyers. The registration staff use these reports to identify the patients who had a service in the past 2 years and if they do not have a PCP assigned they review who they saw the most or most recently and recommend to the provider the patient be attributed to them.For the ED Frequent fliers, we are focused on the patients seen 5 or more times in the past 12 months in a Mayo Clinic ED. if they do not have a PCP assigned they review who they saw the most or most recently and recommend to the provider the patient be attributed to them. our goal is to have 100% of these frequent visitors assigned to a PCP.
29 Challenges and Next Steps Practice standardizationResourcesCan’t stop processes and can’t add resources to changeNeeded to understand practice variation and standardizeInformatics knowledgeable in in EMR support teamsChallenge to implement tools to free up resources when processes and data aren’t standardized (IT, informatics)Rapid cycle iteration is challenging for practice tools without significant resource involvementDecision rights – “who says this is the new process….”Enterprise metricsPoint-of-care registry and care managementPatient consumer engagement utilizing EMR patient portal
30 An Introduction to the Benefits Realized for the Value of Health IT Treatment – the PHM tool allows identification of patients for better treatment.Electronic information allows for the holistic picture of the patient for best identification of risk and subsequent treatment
31 Questions? Thank You! Tim Miksch The Mayo Clinic email@example.com Claudia BlackburnAspen Advisors, Part of the Chartis Group@cblack67