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Population Health Management David A. Burton, MD
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Population Health Management
Emphasis on the Continuum of Care Outpatient Inpatient Skilled Nursing Facility Home Home Health Care Hospice Cemetery Clinic Care
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Population Health Management
Paradigm Shift Outpatient Home Clinic Care Hospice Cemetery Skilled Nursing Facility Inpatient Home Health Care Population-Centric Management Inpatient Acute Care-Centric Management
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Poll question 1 2 3 4 5 Other combination Outpatient Inpatient
Home Health Hospice 2 Outpatient Inpatient Home Health Hospice Clinic Care 3 Outpatient Inpatient Home Health Hospice Clinic Care SNF 4 5 Other combination
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Population Health Management
Anatomy of Healthcare Delivery Screening & Preventive Symptoms Treatment and Monitoring Algorithms Admission Order Sets Supplementary Order Sets Pre-Procedure Order Sets Clinical Supply Chain Management Post-procedure Order Sets Discharge Bedside care practice guidelines, risk assessment and patient injury prevention protocols, bedside care procedures, transfer and discharge protocols Health Maintenance and Preventive Guidelines Standardized Follow-up Post-acute care order sets IP (SNF, IRF) Home health Hospice Management of Preventive, Ambulatory, Acute Medical, Invasive & PAC Modules Module-Focused Knowledge Assets Diagnostic Work-up Diagnostic algorithms Indications for Referral Indications for Intervention Triage Criteria Diagnostic Algorithms, Triage Criteria, Referral & Intervention Indications Population-Focused Knowledge Assets Home (Patient Portal) Triage to Treatment Venue Ambulatory Non-recurrent Ambulatory Recurrent Invasive Medical Invasive Surgical Acute Medical IP Med-Surg Acute Medical IP ICU Substance Selection Substance Selection Substance Preparation Invasive* Subspecialist Chronic Disease Subspecialist Bedside care Procedure * To Invasive Care Processes Post-procedure Care
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Population Health Management
Clinical Integration hierarchy - Care Processes Home Outpatient Clinic Care Inpatient SNF Home Health Hospice Hyperlipidemia Acute Myocardial Infarction (AMI) Cardiac Rehab Coronary Atherosclerosis Percutaneous Intervention (PCI) Coronary Artery Bypass Graft (CABG) Care Processes
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Population Health Management
Clinical Integration hierarchy - Care Process Families Home Outpatient Clinic Care Inpatient SNF Home Health Hospice Hyperlipidemia Acute Myocardial Infarction (AMI) Cardiac Rehab Coronary Atherosclerosis Percutaneous Intervention (PCI) Coronary Artery Bypass Graft (CABG) Ischemic Heart Disease Care Process Family
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Cardiovascular Clinical Program
Population Health Management Clinical Integration hierarchy - Clinical Programs Home Outpatient Clinic Care Inpatient SNF Home Health Hospice Cardiovascular Clinical Program Ischemic Heart Disease Care Process Family Heart Failure Care Process Family Vascular Disorders Care Process Family Heart Rhythm Disorders Care Process Family
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Clinical Integration hierarchy
Clinical Programs – ordering of care Primary Care Care Process Families e.g., Diabetes CV Care Process Families e.g., Heart Failure W&C Care Process Families e.g., Pregnancy GI Care Process Families e.g., Lower GI Disorders Resp- iratory Care Process Families e.g., Obstructive Lung Disorders Neuro Sciences Care Process Families e.g., Spine Disorders Musculo-skeletal Care Process Families e.g., Joint Replace-ment Surgery Care Process Families e.g., Urologic Disorders General Med Care Process Families e.g., Infectious Disease Oncology Care Process Families e.g., Breast Cancer Peds Spec Care Process Families e.g., Peds CV Surg Mental Health Care Process Families e.g., Depression
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Clinical Integration hierarchy
Clinical Support Services – delivery of care ordered 12 Clinical Programs (“Ordering of Care”) Primary Care Care Process Families e.g., Diabetes CV Care Process Families e.g., Heart Failure W&C Care Process Families e.g., Pregnancy GI Care Process Families e.g., Lower GI Disorders Resp- iratory Care Process Families e.g., Obstructive Lung Disorders Neuro Sciences Care Process Families e.g., Spine Disorders Musculo-skeletal Care Process Families e.g., Joint Replace-ment Surgery Care Process Families e.g., Urologic Disorders General Med Care Process Families e.g., Infectious Disease Oncology Care Process Families e.g., Breast Cancer Peds Spec Care Process Families e.g., Peds CV Surg Mental Health Care Process Families e.g., Depression Diagnostic Clinical Support Service (work flow models) (e.g., Pathology and Laboratory Medicine, Diagnostic Radiology) Ambulatory Clinic Clinical Support Service (work flow models) (e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics)) Acute Medical Clinical Support Service (work flow models) (e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg) Invasive Clinical Support Service (work flow models) (Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP]) Therapeutic Clinical Support Service (work flow models) (e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy) Clinical Support Services (Delivery of Care)
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Heart Rhythm Disorders Ischemic Heart Disease
Clinical Program CARDIOVASCULAR Heart Rhythm Disorders Vascular Disorders Ischemic Heart Disease Heart Failure Care Process Families Care Processes ACS AMI PCI CABG ICD9 Diagnosis Code Groupings ICD9 Procedure Code Groupings CPT-4 Code Groupings ICD9 Volumes I-II 17,674 Diagnosis Codes ICD-9 Volume III 3,903 Procedure Codes 2013 CPT® Code Set 9706 Codes
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Population Health Management
Medicare 2011 fee-for-service payments by venue Clinic Care Outpatient Inpatient SNF Home Health Hospice $ 31.7 Billion 12.3% 77.6 Billion 30.1% 90.6 Billion 35.1% $ 29.7 Billion 11.5% $ 18.4 Billion 7.1% $ 10.1 Billion 3.9%
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Poll question How does your organization prioritize improvement projects Respond to desires of highest volume physicians with loudest voices Respond to regulatory and accreditation imperatives Based on pre-defined strategic criteria (including objective and subjective factors) Other
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Our Philosophy: Be Systematic
Services Installation Services, Critical Improvement Services Systematically Change Process and Behavior Analytic Applications Key Process Analysis, Dashboards, Advanced Analytics Systematically Apply Evidence and Standardize Late-Binding™ Data Warehouse Platform Data Warehouse, Architecture, Metadata Management, Security, and Auditing Systematically Integrate Data and Measure
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Catalyst’s Adaptive Data Model
Catalyst Adaptive Data Warehouse Catalyst’s Adaptive Data Model Metadata: EDW Atlas Security and Auditing Financial Sources (e.g., EPSi, Peoplesoft, Lawson) Departmental Sources (e.g., Apollo) Common, Linkable Vocabulary Financial Source Marts Departmental Source Marts Readmissions Administrative Sources (e.g., API Time Tracking) Administrative Source Marts Patient Source Marts Patient Satisfaction Sources (e.g., NRC Picker, Press Ganey) Diabetes Sepsis EMR Source Marts HR Source Mart EMR Source (e.g., Epic, Cerner) Human Resources (e.g., PeopleSoft) More Transformation Less Transformation 18 18
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Catalyst approach 3 2 1 Application families
Foundational Applications Discovery Applications Advanced Applications 3 Application families 2 Content-driven applications Data Acquisition Engine and Storage Metadata Engine Late-Binding™ Data Bus Late-Binding™ Data Warehouse Platform 1 Metadata-driven platform 19
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Clinical Integration Leadership Team (CILT)
Administration Vice-Chair CNO Vice-Chair Cluster CMO Cluster CNO Cluster Administrator CMO Chair Chief Information Officer Chief Knowledge Officer Cluster #1 Cluster #2 Cluster #3 Cluster # … Cluster #N Cluster = Hub Hospital/Region, Medical Group, Health Plan, Section/Division
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CV Clinical Program Guidance Team
Nurse Director Vice-Chair CV Physician Chair* CV MD Lead CV Nurse Lead CV Administrator Cluster #1 Cluster #2 Cluster #3 Cluster #4 Ischemic* MD Chair Heart Failure MD Chair Rhythm Disorders MD Chair Vascular Disorders MD Chair * One of the Clinical Implementation Team chairs also serves as the Guidance Team chair (Ischemic MD Chair in this example)
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Clinical Implementation Team (CIT) Heart Failure Care Process Family
CV RN Director Vice-Chair Heart Failure MD Chair Cardiologist Heart Failure MD Lead CV Nurse Lead Facility #1 Facility #2 Heart Failure MD Chair Facility #3 Facility #4
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CIT Work Group Clinical Operations Director
Subject Matter Expert Data Capture Workflow Analysis Data Provisioning Data Analysis Clinical Operations Director CIT Chair (MD) Scientific SME Provider/Patient Education Team Front Line Clinical Ops Workflow SME Data Architect Knowledge Manager Administrative Application Steward Clinical Application Steward * CMIO, CQO, Chief Patient Safety Officer, or Chief Analytics Officer provided individual has requisite qualifications and skills
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Data Capture Workflow Analysis
Workgroup Roles Subject Matter Expert Data Capture Workflow Analysis Data Provisioning Data Analysis DATA CAPTURE Application Administrators (e.g., EMR Administrators, Financial System Administrators) Knowledge Managers Acquire key data elements Assure data quality Integrate data capture into operational workflow DATA ANALYSIS DATA PROVISIONING Interpret data Discover new information in the data (data mining) Evaluate data quality Move data from transactional systems into the EDW Build visualization for use by clinicians Data Architects (Analysis) Knowledge Managers Data Architects (infrastructure) Data Architects (Visualization)
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Poll question Which clinical organizational teams do you have
Executive team responsible for prioritization and governance of clinical improvement initiatives Domain governance teams (e.g., CV Clinical Service Line teams) Clinical implementation teams (e.g., Heart Failure improvement team) Infrastructure personnel/work groups to support clinical improvement teams
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Implementation flow diagram
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Standard “organizational” work
Implementation Design Launch Approval Results Review Kickoff AIM Statement Monthly Tasks and Checkpoints Mission Cohort Discover Data Analysis and Review BMJ Best Practices Building Multiple Potential AIM statements Supplement BMJ content Refine Cohort Refine Metrics Develop Draft Visualizations Develop Recommended AIM statement #1 Cluster Reps Obtain Front Line Input Finalize Cohort Develop Additional metrics based on feedback Develop Additional Visualizations to support PDSA cycle Cluster Reps Obtain Front Line Input Improvement Plan Implementation Plan Develop cluster rep assignments, and deliverables Collect cluster rep feedback Prepare Initial Results from AIM statement #1 Summarized report for historical review Refine, recommend AIM statement #2 7 Steps (Work Streams) 1 Gather Knowledge Assets 2 Define Cohort 3 Select AIM Statement Select, Build, Refine Metrics 4 Select Initial Metric Build and Refine Build and Refine Build and Refine Develop Implementation Plan for Process Improvement 5 6 Implementation 7 Measure Progress
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Pregnancy
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Surgical Services
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Discharge from hospital to post-hospital service
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Pressure injury prevention
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Standard organizational work
MD Contract Templates Slide Decks Meeting Agendas Team Charters Handbooks Job Descriptions Project Status Reports Job Family Grids Deployment Process Outlines Compensation Grids
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Poll question How prepared do you feel to implement population health management and shared accountability (e.g., ACO) strategies?
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Thank you
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