Population Management What is that and why do I need to know? Elisha Brownfield, MD

What is Population Management? Population management is assessing and managing the health needs of a patient population such as defined groups of patients (e.g., patients with specific clinical conditions such as hypertension or diabetes, patients needing tests such as mammograms or immunizations).

NCQA Certification Standards NCQA Patient-Centered Medical Home 2011 February 1, 2011

NCQA Certification Standards

What Evidence do we have that this approach works? J Rural Health Fall;19(4):  Promoting pneumococcal immunizations among rural Medicare beneficiaries using multiple strategies. Montana Department of Public Health and Human Services Am J Manag Care Dec;18(12):  Population-based breast cancer screening in a primary care network.

Population Management  EHR enabled  Change in mindset – who is not here and needs to be?  Change in payment

University Internal Medicine (UIM) at MUSC  Faculty practice = 6000 patients  14 faculty – most part time  Resident practice = 6000 patients  96 residents on 1 month block rotations every 4 months  Total visits = 38,000 per year

Demographics (n=9,933 patients) Age, y (mean ± SD) 58.6 ± , No. (%)2654 (26.72) 50-64, No. (%)3285 (33.07) 65-75, No. (%)2357 (23.73) 75+, No. (%)1637 (16.48) Male, No. (%)3669 (36.94) White, No. (%)4833 (50.88) Married, No. (%)4596 (46.20) UIM Patient Demographic

UIM: Overall MUSC ED, Hospital, rehospitalization over three years ED N of PTs Total # in 3+ yearsMeanMedianMinMax , HOSP_ALL N of PTs Total # in 3+ yearsMeanMedianMinMax , REHOSP w/in 30 days N of PTs Total # in 3+ yearsMeanMedianMinMax ,

Obesity & CV risk HealthyHypertension Hyperlipidemia & Hypertension

Complex, CV disease & Depressed Chronic lung disease, Depression & CV risk Diabetes & CV risk Renal Disease, Depression, & CV risk

UIM patients: Multiple chronic conditions

12 Clusters and independent risk  Largest number of patients was in the multiple chronic condition cluster (1512)  Largest proportion of high-utilization patients was in the renal disease cluster (68%) RR=5.47  Visit adherence  < 80% adherence dramatically increases ED and hospitalization risk RR= 1.33  Social determinants  Zip codes with >25% of residents below poverty level RR=1.25  Dx: Sickle cell disease: 1% of population, 12% of utilization

Quality

Quality measures: A little team competition doesn’t hurt Resident practice Faculty practice

Hospitalizations 16% ED visits 25% Total ACSC Non-ACSC Inception cohort, interrupted time-series analysis Limited to MUSC utilization

UIM Tools for Population Management  Database: Epic, DDI  Personnel: Nursing, PharmD, Physicians, MSW, Registration, Data experts, Statisticians, Researchers  Electronic Medical Record  Standing orders  Case Management

UIM Team Meeting  Problem solving  Short-term QI  Hypertension Team Meeting – QI with large/color teams. Analyzing data  Diabetes Team Meeting – one color team discussed each week x 4 months in large group. 320 patients: overall drop in A1C 9.84 % % (p< ) Analyzing data  Hospital Discharge Team Meetings – Teams broken up into Case Management small groups. Analysis on-going. New problems identified and resources being pursued (i.e. Psych involvement in UIM)

What do we need?  Agenda  Goals  Demonstrated programs which are effective  Time/money/people