Population Health: Optimizing Healthcare across a System Case Study: Chronic Obstructive Pulmonary Disease Elvin Perkins, MBA, Six Sigma Black Belt Manager of ACO Operations It is an honor to be here today – and to have an opportunity to share our story – as one of our pulmonologists stated: “How we changed the way we care for our patients with COPD” First, I’d like to introduce Cone Health….

Cone Health System: Who We Are Regional Health System serving 6 counties in the NC Piedmont Six hospitals - Total Beds: 1,273 CHMG - 106 physician practice sites Triad HealthCare Network - Accountable Care Organization (ACO) Next Gen ACO, Full risk contracts – Humana PPO, Employee plan, Insurance product (Health Team Advantage) Shared savings contract, United Healthcare ± 90,000 lives Clinical integration occurs through our Accountable Care Organization, Triad HealthCare Network (THN). THN was “born” in 2011 with plans to be a clinically integrated network. As the Medicare rules changed, it became clear that there was no downside risk to applying for the Medicare Shared Savings Program, so we scurried to apply by the March, 2012 deadline. We were accepted into the MSSP program starting in July 2012…… and we were off and running!! THN is comprised of approximately 800 providers and has responsibility for approximately 80,000 lives. Transitioned to a full risk arrangement in January 2016 when accepted into the Next Gen program. Have full risk arrangements with 3 other payers, including our self-funded employee plan and our own insurance product Shared savings with 2 other payers

CMS – FIVE STAR RATING. Top 3 percent in Quality CH as a system has a powerful vision and incredible passion and commitment to provide exceptional healthcare. This year we’ve been recognized for a number of accomplishments. A few are noted on this slide Here is some of what we have achieved together just in the last few months… Folks, these are not just awards … these represent lives saved right here in our community! CMS – FIVE STAR RATING. Top 3 percent in Quality #1 in nation for Lowest Heart Attack Readmission Rate US News – top 2 percent in nation in Common Care Community Value Five-Star from Cleverly & Associates (healthcare Finance Firm) – –for Outcomes, Community Partnerships and Cost Effectiveness THN – 5th in nation of 320 ACOs in Quality; Among 100 ACOs to Know by Becker’s Hospital Review

Discuss why we began Population Health efforts Program Objectives Discuss why we began Population Health efforts with COPD Describe the initial process, findings, interventions, results, key learnings Discuss how we engaged the system and related challenges Share current state, sustainability, Phase II efforts Today, I’m excited to share our COPD story: why we began our population health efforts with COPD………

2012: Why COPD? Engaged Pulmonary – Critical Care Physicians! A Leading Cause of Death and Disability Impairs Quality of Life Leading Cause of Hospitalization for Older Adults Cost Burden: Est. > $200B over next 5 years THN – 23% of total claims 2015: CMS penalties for 30-d readmissions 80% of US deaths are due to: Heart Disease Cancer Chronic lower respiratory dx In 2011, CH Medical Group was a loosely federated group of practices that didn’t really work collaboratively or as one entity. As a system, however, we were in pursuit of the Triple Aim – Quality, Patient Experience, Cost. Our largest practice which had four divisions was charged to identify and work on a defined quality initiative. CMS penalties for readmissions beginning 2015

The Business Case: Significant Financial Opportunities Medicare Shared Savings COPD Population (ACO) Annual Costs: Total claims paid: $ 84,000,000 Missed Appointments: $ 530,000 Readmissions (potential): $ 696,800

Why COPD?? Because we Care!! So “Why COPD?” It’s easy….. Because we care! Because we Care!!

One hospital, all patients with principal or secondary diagnosis Data-Driven Initial Data One hospital, all patients with principal or secondary diagnosis 3007 visits – 2/3 via ED 1223 total inpatient stays 848 patients 247 patients had multiple admissions (2-10) 25% of readmissions were within 4 days 50% within 10 days 65 had 3 or more admissions to the hospital 258 hospitalizations, 1812 days 7.7% of patients accounted for 21% of IP stays and 21% of days **Related Co-morbidities, Certain Zip Codes, Times of Day….. 3007 total 2027 were via ED Key point: Principal or secondary dx

Heart Failure Similarities Pneumonia: Common Link January – June, 2010 2011 1939 admissions 1571 patients 274 patients had multiple admissions (2-7) 67 pts. had 3 or more admissions (228 total) 4% of admitted pts. accounted for 12% of total admissions 210 admissions 78 patients 2-7 admissions per patient 1232 Patient Days Median LOS: 13 days 76% had COPD, 71% had Heart Failure, 58% had both Only 44% had received both influenza and pneumococcal vaccine

Principal Diagnoses Population: 1478 patients admitted via ED 29% of ED visits were due to respiratory illness 50% due to cardiopulmonary illness Combining diagnoses into broader groups reveals that cardiopulmonary problems are predominant reason for encounter These conditions represent 50% of ED visits Data Source: Care Discovery Advanced January – June, 2010 Thomson Reuters

Demographics: 2 or more admissions Gender & Age Zip Codes Gender: 54% Female, 46% Male 4 Zip Codes (of 35) 60% Pulled demographic information from data repository Matched MR numbers 46% of those with multiple admissions Follow us on Twitter @ConeHealth #COPDGold

Day and Time of Arrival SURPRISE! Peak times – Weekdays, 8-3

HF + COPD + Malnutrition: $75,354 PMPY Other Findings Heart Failure COPD Cost PMPY : $29,880 HF + Malnutrition: $68,828 N = 462 $31.8 M Admissions: Mean, 2.4 Max: 9 Cost PMPY: $22,422 COPD + Malnutrition: $63,491 N = 384 $24.4 M Admissions: Mean 2.3 Max: 14 COPD When regression performed specifically on this population, the key conditions correlated with high cost were: septicemia, DM with RF, Protein-calorie malnutrition, Aspiration or Bacterial pneumonia Heart Failure When regression performed on this population specifically, key related conditions were: Malnutrition and Septicemia followed by COPD and DM with acute complications HF + COPD + Malnutrition: $75,354 PMPY N = 215 Follow us on Twitter @ConeHealth #COPDGold

Improvement Strategies Key Variables and Improvement Strategies Six Sigma Y = f(x)

System-wide opportunities Patient opportunities Focus 5 Key Focus Areas Needed to focus and be very clear regarding expectations for each area System-wide opportunities Office opportunities Patient opportunities ED opportunities IP opportunities

“Cone Health COPD Gold” Engagement is Critical – Patients, Providers, Staff! Obstructive Lung Disease patients at high risk for exacerbations History of COPD 3 or more admissions in 6 months COPD patients who need to ENGAGE in their health Understand COPD and how to live with it Know how to prevent and respond to exacerbations

System-Wide Opportunities Priority Area: System -Wide Problem Interventions No Standard for follow up appointments 7 days to follow up appointment post ED or Hospitalization Inpatient referrals, multidisciplinary No Standard for consultation Automatic consultation with pulmonary specialists for COPD Gold patients No way to “identify” high utilizers (CH COPD Gold) Epic flag - # EDV and admits in 6 mos. No process to monitor the “GOLD” population Program manager Patient Perspective Patient Story: Video production

Emergency Department Opportunities Priority Area: Emergency Departments Problem Interventions Differential Dx Challenges Created reference tool: COPD, HF, PNA No way to ID COPD Gold Epic flag - # EDV and admits in 6 mos. No ED plan if COPD Gold presented BPA with hard stop: Influenza and PNA given if D/C from ED COPD order sets and COPD Action Plan Admission-Discharge algorithm Vaccinations of “at risk” group See above No accountability or ability to schedule f/u appointment Scheduling basket Knowledge Deficit 9-hour COPD workshop Clearly defined staff member’s role with COPD GOLD population

In-Patient Opportunities Priority Area: In-Patient Areas Problem Interventions No Clear Practice Standards Clinical pathway Internal consultations Screen for depression/anxiety Nutrition consult Resp. therapy Pulmonary Ability to identify GOLD patients Epic flag - # EDV and admits in 6 mos. No IP plan for COPD Gold Clinical pathway driven through order sets Inpatient referrals with critical team members – multidisciplinary (RT, nutrition, SW, etc.) Discuss and offer COPD GOLD card Emmi Transition Vaccines Knowledge Deficit 9-hour COPD workshop Clearly defined staff member’s role with COPD GOLD population

Physician Office Opportunities Priority Area: Physician Offices Problem Interventions No Standard for follow up appointments & Misplaced accountability Same day access for COPD GOLD (if needed) No process to manage cancellations, unscheduled appts. Scheduling Basket Office accountable to call, schedule if ED D/C Process to manage and reduce cancellations for COPD GOLD patients Ability to identify GOLD pts Epic flag - # EDV and admits in 6 mos. COPD staging by providers CAT tool and Action Plan use by patients No Office plan for COPD Gold See above Vaccine campaign, focus, and accountability Knowledge Deficit 9-hour COPD workshop Clearly defined staff member’s role with COPD GOLD population

Patient Opportunities Priority Area: Patient Engagement Problem Interventions COPD GOLD program GOLD Card with “benefits” Message: CH cares, we want to help you Action Plan, CAT tool, 24-hr hot line, transportation, free delivery of meds Emmi Transition Medication management and costs Created list of low-cost med alternatives for providers Free medication delivery The patient’s perspective Patient focus group sessions Patient video Acknowledged the potential for anxiety & depression Pulmonary rehab Incorporated meditation strategies into the program Worked to improve scheduling More to be done in this area

Results

COPD GOLD Admission Rate by CY Admission rate 73% of baseline (Lowest point: 56%) P-Value: 0.000

ED to Admission: COPD - All Cause Percent of COPD Patients Visiting ED Who Were Admitted MC & WL: Percent with ED Visit Leading to Admission for 6-Months: "All Cause" * ED to Admission: 70% ~ 55 % Sustained 3 years!

Financial Impact: 18 Months Health Care Cost avoidance $14.9M in eighteen months – July 2013 to Dec 2014 Decline in admissions Reduced LOS Reduced admission rate by 32% 1,910 admissions “avoided” 1st 18 mos. Statistically significant reduction, P-value: 0.000 Value per admission: $7,000 Savings: $13.4M (1st 18 mos.) Rate sustained x 3 yrs! July -Dec 15 4.3 3.9 Jan - Jun 16 4.4 5,500 hospital days avoided Valued at $275/day Savings in 18 mos: $1,512,500

ED to Admission: COPD Patients with PNA as Primary Dx MC & WL: Percent with ED Visit Leading to Admission for 6-Months: "Pneumonia" * ED to Admission: 7% 4 % Sustained for 3 Years!

Sustainability Phase II

Phase II 4 years later…….. Impressive, sustained results Admissions and readmissions bumping up COPD Gold Re-Design underway Creating permanent COPD Navigator position Re-educating, refreshing COPD GOLD efforts EOL recognition and interventions (Largely Avoided)

Key Take-Aways Focus is critical Patience is necessary It took years to get where we were; it is worth some time to get it right so improvements are tangible and sustainable! Need leadership champion(s) This was big! We needed someone in the weeds, making sure the GOLD patients were identified and appropriate actions implemented. Keep it simple Must be willing to abandon the things that don’t work