1. 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….

3. Cone Health System: Who We Are
Regional Health System serving 6 counties in the
NC Piedmont
Six hospitals - Total Beds: 1,273
CHMG 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

4. 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

5. 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………

6. 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

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

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

9. 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

10. 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

11. 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

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

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

14. 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 #COPDGold

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

16. 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

17. “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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Results

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

25. 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!

26. 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:
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

27. 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% % Sustained for 3 Years!

28. Sustainability
Phase II

29. 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)

30. 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