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Population Health Management Defined April 12, 2015

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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 communion Intro of PHM – Claudia (slides 1-10) About Mayo and Need for Action – Tim (slides x-y) Specific analytics use cases (and underlying metrics studied) – Claudia Challenges and next steps – Tim finishes Tim Miksch, Section Head, Applied Clinical Informatics The Mayo Clinic Claudia Blackburn, Senior Manager Aspen Advisors, Part of The Chartis Group DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Conflict of Interest Disclosure
Tim Miksch, MBA Has no real or apparent conflicts of interest to report. Claudia Blackburn, MBA Is employed by Aspen Advisors, Part of The Chartis Group, which provides services that are discussed as a part of this presentation. This session will define the concept of Population Health Management (PHM) and provides a discussion of its core concepts, including organizational perspectives and strategies for aligning the right resources for realizing the value from PHM. It will further highlight the necessary elements required for PHM to deliver the appropriate value to patients and organizations, ranging from providers, to payers, to Integrated Delivery Networks (IDNs), Pharmacy Benefit Managers (PBMs), and the like. The session will provide participants with a basic overview of considerations in planning clinical and business intelligence inputs for population health management. Session content will include a discussion of PHM Core Concepts including: organizational readiness, stakeholder assessment, funding, program lifecycle identifying and engaging partners for successful PHM program (ACOs, payers, vendors, etc.) population segmentation unique data challenges (data sources, data governance) analytics for PHM (data management, data organization, reporting for descriptive, diagnostic, predictive outcomes, data modeling for prescriptive and cognitive insights) data-driven integrated care planning, monitoring, metrics, measurements patient/consumer engagement Learning Objectives • Identify how to align an organizational healthcare model with a value-based reimbursement model to support the allocation of resources for high risk patients • Recall definitions and concepts associated with Population Health and Population Health Management •Summarize the role of analytics in developing and evaluating programs and processes that support patient engagement. Identify where your organization is on a PHM maturity roadmap © 2014 HIMSS

3 Challenges and Next Steps
Learning Objectives Identify how to align an organizational healthcare model with a value- based reimbursement model to support the allocation of resources for high risk patients Explain definitions and concepts associated with Population Health and Population Health Management Summarize the role of analytics in developing and evaluating programs and processes Identify where your organization is on a Population Health Management (PHM) maturity roadmap PHM Core Competencies Case Study Challenges 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 journey And end with challenges and successful approaches

6 Population Health Management (PHM) The Future of Healthcare Paradigm Shift
Today: Reactive and Volume-based The Future: Proactive and Value-based Drivers Encourage me! Treat me holistically!! Educate me! Health Reform Population health management provides comprehensive authoritative strategies for improving the systems and policies that affect health care quality, access, and outcomes, ultimately improving the health of an entire population I will pay you! Affordability Gap Triple Aim This 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 Nation Reimbursement Individuals are accountable for their health with the health system as their health advocate.

7 Achieving Success Making the “Triple Aim” Possible
Engaged Communities Proactive care processes Identified patients Focused on wellness Community resource navigator Engaged Patients Identified and incorporated patient goals Focused on continuity and coordination Facilitated communication channels Improved access to care Better Health for the Population Mayo has adapted the IHI Triple Aim Identified Opportunities to Reduce Waste 4 Rights Duplication avoided Improved coordination/transitions Used automation to reduce resource needs Improved screening and prevention Aligned incentives to drive value 7

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 BI Member Engagement Cross-Continuum Care Delivery and Medical / Care Management Accounting Member 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 / Reporting Integration and Infrastructure

10 PHM Competency Characteristics
Foundational Advanced Innovative Member engagement Website of offerings available Interactive site, smart phone, incentives Coach proactively encouraging healthy behavior Cross-continuum care delivery and medical / care management Sites of care operate in silos, handoff on paper, relying on patient Some care planning and handoff between sites of care Consistent care planning, monitoring, consolidated clinical data views, different communication and seamless hand-offs among care settings Quality outcomes management / reporting Registries in the EHR Registries within a data warehouse with multiple feeds Measuring and monitoring across the continuum of care, including all participating entities Operational performance management / BI EHR reports such as MU attestations Data warehouse with analytics for reporting Constant monitoring of how they are performing to key business and care metrics from analytics engine Accounting Financial and PHM systems for analysis and payment incentive in Excel or other non-integration tool Some integration and analytics to provide individual and provider incentives Real-time reporting of status for both individuals and providers towards shared savings and incentives such as through portals Integration and infrastructure One or few systems are not integrated causing redundant work Most systems are integrated, but one longitudinal record does not exist electronically Track 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 proposition Risk, incentives, payment management, shared savings Workflows, role changes, people, care coaches, wellness program development, heath risk assessment process, population engagement Integration and interoperability including HIE, patient portal, analytics, coaching tools and health risk assessment


13 Mayo Community Practices
MAYO CLINIC in the MIDWEST Academic Medical Center Rochester, MN 500,000 patients/year 2,000 physicians 125 primary care providers Primary care At full risk for PC Community and Regional Health System 75 communities in MN, IA and WI 4 regions 18 hospitals 525,000 patients/year 1,000+ physicians Primary care At risk for PC MAYO CLINIC in the SOUTHWEST MAYO CLINIC in the SOUTHEAST Some 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-risk Arizona 90,000 patients/year Approx. 400 physicians Primary care At full risk for PC Florida 90,000 patients/year Approx. 400 physicians Primary care At full risk for PC

14 Office of Population Health Management
Formed in 2012 Developed a Mayo framework for PHM Strategy Phasing Oversight Coordination Standardization Focused on the community practices Initially focused on primary care Value-based care Patient-Centered Medical Home Risk based reimbursement

15 The Changing Market Through the course of work with many of you we are seeing this We must 1) improve health Reduce costs Improve the patient experience Source: “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 rising Reimbursement is decreasing The measure of PRODUCTIVITY is no longer VOLUME It is VALUE = Small changes are not enough Outcomes + Service Cost Our survival is at risk WHY? WHO? Office of Population Health Management (OPHM) Created by MCCPC to TRANSFORM Community Care OPHM establishes the STANDARDIZED ELEMENTS for clinics to implement with APPROPRIATE LOCALIZATION A new way of practicing is needed OPHM defines strategy for the new model WHAT? MMoCC is an enterprise-wide, multi-year roll-out to achieve the TRIPLE AIM: Improve Population Health Improve Individual Experiences Lower Costs While aligning with financial models Changing isn’t just for survival The new model allows us to thrive The Mayo Model of Community Care (MMoCC) Implemented in strategic phases

17 Vision Patient centered, integrated care delivery model based on:
Aligned incentives Coordinated, collaborative processes Evidence-based prevention and disease management protocols Seamless sharing of information Supported by wellness and continuity care programs that focus on: Patient engagement Community integration Prevention and health promotion Driven by analytics to support quality outcomes and value-based accountable reimbursement

18 Mayo Clinic Clinical Practice Committee
Office of Population Health Management OPHM Advisory Group Executive Team Programs Functional Subgroups Geographic Operations Continuity Care Health & Wellness Prevention Care Coordination Change Mgmt./ Communications Arizona Office Chronic Condition Management Data Analytics Florida Office Community Engagement Palliative Care IT Tools and Application Midwest Office Wellness Care Transitions This is the OPHM Org Chart. Ø  Creation of org chart; AZ/FL/Midwest administrators; 10 programs created in 2012 Ø  Stakeholders at the biweekly OPHM Executive Steering committee Ø  Charter to build OPHM are approved and deemed “vital few” thus funding allocated. 1 FTE = Jerry Sobolik in 2012 Ø  Then project charter for Humedica analytics at just MidWest in 2013 Ø  Payer enters : SCHA with risk We 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 Care Patient Engagement Access

19 MMoCC Focus Areas COST PHM FOCUS POPULATION Care Coordination
Care teams Patient engagement Community engagement Access Care Coordination Care Transitions Palliative Care 50% 15% Disease Management 35% 35% Wellness Prevention 15% 50% POPULATION % of community 2010 data from Mayo Clinic Health Sciences Research

20 MMoCC Impact 80% of costs Identify opportunities Act on opportunities
HEALTH STATUS Situational risk Early risk High risk Symptomatic illness Complex active illness Ability to impact Family Hx Environment Diet Exercise Cholesterol BP Blood sugar Active Dz Diabetes What can you identify and what can you impact? HEALTH CARE SPEND Lifetime

Population Identification Health Assessment Risk Stratification Enrollment / Engagement Strategies Management / Interventions Tailored Interventions Care Coordination Disease / Case Management Health Risk Management Health Promotion / Wellness Meeting patients where they are …physically home | 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 4 Requires value-based contracts to succeed MMoCC 3 More site resource investment – mixed volume/value Adds specialty integration to care team concept Community engagement Full alignment of incentives MMoCC 2 Laying the foundation while living in FFS Shifts from individual practice to team-based panels Continues focus on high utilization and expanded analytics and care management Increases focus on patient important outcomes Strong shift to total cost of care drivers Introduces value-based (TCOC) concepts and model (change management) Emphasis on team-based care foundation and care coordination introduction Standardized disease management and prevention recommendations Focus on decreasing high utilization where it makes sense (30 d readmits…)

23 MMoCC Limited Implementation
Diffusion Timeline MMoCC Limited Implementation 2013 2014 2015 2016 MMoCC Previous MMoCC 2 Foundation MMoCC 3 Mixed MMoCC 4 TCOC PILOT 4-6 Sites

24 2015 Status All sites are actively engaged
Standardizing across sites and regions is a challenge For many, fee-for-service remains a driver Data management processes are maturing Keys to our success: Engaged leadership at local levels Institutional support Strong physician leaders in each program Excellent business analysis, project management and informatics support in place

25 VALUE = Outcomes + Service
Structure Demand for healthcare Supply of resources to meet demand VALUE = Outcomes + Service Cost Our pay will be based on We need to utilize our staff wisely through Identify opportunities to impact health earlier and act on those opportunities We need to think differently about how to activate our patients and communities And how we interact with them TEAM-BASED CARE ANALYTICS PREVENTION DISEASE MGMT CARE MGMT SYSTEM PATIENT ENGAGEMENT COMMUNITY ENGAGEMENT WELLNESS ACCESS CARE COORDINATION PALLIATIVE CARE CARE TRANSITIONS

26 Analytics and Reports Examples
Report Description Registration Unassigned and wrongly assigned patients Unassigned Emergency Department high utilizers Care Coordination Diabetic Mellitus (DM) patients who are most likely to be readmitted Congestive Heart Failure (CHF) patients who are most likely to be readmitted 30 day readmission reports are located within the Care Coordination dashboard with DM and CHF 20%. Follow instructions from section 2.1 and 2.2 Patients by Disease Evidence Type Patients with no Diabetes diagnosis but have other evidence of Diabetes Patients with no CHF diagnosis but have other evidence of CHF So 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 providers The 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 standardization Resources Can’t stop processes and can’t add resources to change Needed to understand practice variation and standardize Informatics knowledgeable in in EMR support teams Challenge 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 involvement Decision rights – “who says this is the new process….” Enterprise metrics Point-of-care registry and care management Patient 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
Claudia Blackburn Aspen Advisors, Part of the Chartis Group @cblack67

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