1. Madeleine Schlefer & Dov Marocco

2. Agenda Overview of Santa Clara Valley Health and Hospital System
Center for Population Health Improvement (CPHI) Overview
The need for an understanding of high utilizers
Lessons learned
Next Steps

3. Santa Clara Valley Health & Hospital System
Santa Clara County
Santa Clara Valley Health & Hospital System
Valley Medical Center
Behavioral Health
Valley Health Plan
Custody Health
Public Health Department
Emergency Medical System
CPHI
Collaborative Leadership requires everyone to come to the table around a shared purpose. CPHI has taken on the HUMS project as a way to foster collaborative leadership.

4. Historical Overview of High User/Super User Programs
10-15 high utilizer programs at various stages
High utilizer programs worked off of “lists” that may be outdated
Sometimes look at one system or one population
Data matching is often done with the help of outside consultants and/or laborious processes
Population Health seen as hospital-centric for specific disease states and often only include paneled patients

5. Center for Population Health Improvement: Overview
VISION
The CPHI will integrate HHS priorities using data to address social inequities & assist vulnerable populations
Major categories of projects
Data access &
analytics
Program planning
&
evaluation
Population health research & assessment
Improvement &
innovation

6. High Utilizers of Multiple Systems as Use Case for Enterprise Data Warehouse
Target Populations requires knowing and understanding your patients across systems and is a key component of population health.
Our plan was sparked by the work of Maria Martinez & and others at the County and City of San Francisco HUMS/CCMS Program
We started slowly with just combining behavioral health data with physical health because we had that data accessible.
Several brainstorming meetings were required to develop a common definition of high utilizers.

7. Enterprise Data Warehouse as a Platform for Shared Data
Done!
Identification of HUMS Patients
Epic Data
Hospital Data
(ED, Inpatient & Urgent Care)
Behavioral Health Data (Emergency Psych Services, Acute Psych)
Non-Epic Data
VHP Claims Data
Custody Health Data
EMS Data
Patient records from all of the systems are matched using a matching system built into the EDW
Done!
In Progress
New Possibility: Import Acute Psychiatric Admission data for Pay 4 Success Part 2 Program
Next Priorities

8. Event Type/Number of Points
High User Point System
The point system evaluates the number of clinical events for each patient and assigns a number of points for each event. The total number of points for all clinical events in the past 12 months can be used to rank patients from highest to lowest use. By assigning more points to emergency visits, patients who use these services move to the top of the list.
Event Type/Number of Points
Example
Points
Inpatient Stay - 1 point per day
5 day stay in defined timeframe
= 5
ED Admission - 3 points per event
1 ED event in defined timeframe
= 3
Emergency Psych Admission (EPS) - 3 points per event
1 EPS event in defined timeframe
Acute Psych care facility (BAP) - 1 point per day
2 day stay at BAP in a defined timeframe
= 2
Urgent/Express care - 1 point per event
5 urgent care events in a defined timeframe
= 16

9. High User Point System
Length of Stay points were capped for each inpatient at the 75th percentile. This was done so that the total score of a patient who was in and out of the hospital for multiple inpatient stays would accrue more points than a patient who experienced one, long inpatient stay.
Department
LOS Cap
VMC BAP 400 19
VMC BAP 500 14
VMC Burn Center 12
VMC MICC 7
VMC 4 Med 6
VMC Medical ICU
VMC 4 Surg 5
VMC TCNU
VMC Trauma ICU
VMC 3 Surgical
VMC Coronary Care 4
VMC MSSU
VMC Surgical 3

10. High User Point System Validation
We are truly capturing high users of multiple systems
80% of the top 100 high users used both mental health and physical health services within our system
50% of the top 1,000 high users used both mental health and physical health services within our system
1% of the general SCVMC patient population uses both health and physical health services
This point system captures different patients than if we based high use off of charges
10% of the top 1,000 high users based on the point system are also in the top 1,000 patients based on highest charges
9% of the highest cost patients used both mental health and physical health services
The point system will get more robust as we add additional data sources
An informal study of a sample of our high users found that roughly 75% of the highest users were accessing emergency services at other hospitals

11. 82 Encounters in 1 Year
High Utilizers
Sharing Data to support care coordination, program planning and evaluation
57 Encounters in ED
24 Encounter in EPS
1 Encounter in MPC Adult Express
Filters
Longitudinal Span of Patient Encounter History
Gap

12. Studying High Utilizers to Plan For Whole Person Care
Use Patterns of High Users and the Patient Population
Top 1,000 Users
SCVMC Population
Patients with the highest use of services based on a point system to identify patients utilizing urgent/emergent services
All patients with 1 or more in-person visits to hospital or clinic in the past year, excludes those in the column to the left
Number of Records
1,000
179,829
% of Patients with ED Visit
94%
32%
Avg. # of ED Visits
8.7
0.5
% of Patients with EPS Visit
49% 3%
Avg. # of EPS Visits
2.5
0.04
% of Patients with both EPS and ED Visits (emergency visit)
45%
1.3%
% of Patients with BAP stay
24%
<1%
% of Patients with inpatient stay
46% 8%
% of patients with behavioral health and physical health visit (ED and/or inpatient + EPS and/or BAP)
50% 1%
The highest users access emergency services at a much higher rate than other patients. This suggests a need for programming that addresses these patients’ needs before they determine they need emergency services.
The highest users access behavioral health services far more than the general population, suggesting these are high users of multiple service types.
The addition of VHP claims data, Behavioral Health data, Custody Health, and EMS data will allow us to know when, why, and how often high utilizers use different parts of our system and other County resources.

13. Studying High Utilizers to Plan For Whole Person Care

14. Studying High Utilizers to Plan For Whole Person Care

15. Studying High Utilizers and Payer Trends for Financial Planning
High Users are more likely to be in Medical Managed Care so there is no incentive to keep them as high users.

16. Data For Program Planning
Analysis has shown that while the level of use of the highest users remains relatively constant, the individuals who are the highest users at any given time is changing.
Reducing high use of the system means monitoring use of the system as a whole, not use by individuals.
To reduce high use of the system we need to identify patients who are about to become high users and intervene early.
Regression to the mean
How can we identify these patients sooner?
Regression to the mean

17. Coordination of Care Across Sectors
Care Coordination and Transitions Program
An interdisciplinary team that will identify and engage with SCVHHS high utilizers to ensure clients receive services that are effective in helping them reduce the need for care in an acute, emergency, and/or hospital setting
The team’s proposal identified seven new positions including a part-time medical director, a public health nurse, behavioral health specialists, a medical social worker, and others that are needed in order to create an effective team
Will assess, stabilize and connect complex clients to community-based care, with a goal of eliminating preventable readmissions and recidivism into acute settings
Engage with existing programs to prioritize capacity and resources effectively
Augment current efforts by providing staff time, system knowledge, and resources as those needs are identified in the context of care planning with individual clients

18. Lessons Learned
SCVHHS is moving towards being a more integrated system and this unique opportunity for WPC created a clear purpose to jointly develop a standard definition of high utilizers.
Matching data is not as hard as it used to be. Epic provides an advantage but other programs are available.
The key for us was just to start and run small tests of change. The point system you decide to use can be based on other similar models (Thank you SF) and then adapted for your needs.
The size of the high utilizer population and the information you know about them will grow over time. As the requirements grow so will the consideration regarding combining data, issues around data governance, and re-disclosure.
Combining behavioral health data can be a sensitive issue but is necessary and can be done; it may be helpful to do this under a Public Health lens. Typically the problem is not getting the data but rather disclosure to others. Our approach with County Counsel is to explain the problem we wanted to solve and ask them how to get there….there is always a way.