1. #HASummit14 Session #24: Allina: How this ACO Is Using Actionable Data and an Integrated Care Program to Improve Outcomes Ensor Transfeldt, MD, Spine Program Medical Director Allina Health Pre-Session Poll Question On a scale of 1-5, how effective is your organization’s ability to deliver coordinated care for complex conditions? 1)Not at all effective 2)Somewhat effective 3)Moderately effective 4)Very effective 5)Extremely effective 6)Unsure or not applicable

2. #HASummit14 About the Organization 2 Dedicated to the prevention and treatment of illness and helping people live healthier lives in communities in Minnesota and western Wisconsin Not-for-profit integrated delivery system, Pioneer ACO

3. #HASummit14 The Problem Low back pain (LBP) is a common and expensive medical problem The estimated annual associated costs for patients, employers, and insurers resulting from LBP exceed $100 billion per year in the United States, two-thirds of which are a result of lost wages and reduced productivity LBP is one of the most common reasons for missed work There are marked variations in spinal surgery internationally and between regions in the United States 3

4. #HASummit14 The Problem In 2010, Allina Health noted a poor grade for their spine surgery performance at some of their facilities on publicly reported data The accuracy of the rating was unclear, but Allina did not have good control of or access to their data to determine whether the report was accurate Analysis of available data indicated significant variation in outcomes Allina lacked a truly integrated, multidisciplinary approach to the treatment of patients with low back pain There was a significant lack of physician awareness and engagement in performance and outcomes 4

5. #HASummit14 5 Our Approach and Results

6. #HASummit14 Surgical Spine Quality Council Chair: Dr. Mehbod Medical Spine Quality Council Chair: Dr. Hillman Spine Program Development Group Chair: Dr. Transfeldt Allina Health Group Executive Committee 6 West Region Committee East Region Committee North Region Committee CKRI Spine Ops Committee IP Spine Nursing Group PATIENT DRIVEN Objective: recommend, prioritize, set goals, strategy, capital, performance oversight, communication TBD: OP Spine Nursing Group Allina Health Spine Program Governance

7. #HASummit14 CONTINUED SPINE CARE PATHWAY ACUTE SPINE CARE PATHWAY Coordinated Spine Care Model PREVENTION Allina Health Spine Care Model Consumer Education Payer organizations Employment groups Community Education AH “Back School” Community Health Fairs Wellness Organizations YMCA Life Time Primary Care Emergency/Urgent Care Specialty Care (MD) Specialty Care (non MD) Return to Primary Care Provider with After Care as needed Excellian Order: Ambu Consult to Spine Center No Improvement or lack of resources Spine Surgery Consult (if indicated) Medical Spine Specialist Consult (MD or Non MD) Clinical Triage / Care Navigation Evidence-Based Spine Treatment Further DX Workup Imaging Labs Conservative Treatment Sx management Physical therapy Chiropractic Integrative medicine Interventional Treatment Injections Surgery Chronic Pain Management Psychology Medication NO 80-90% OF Acute LBP responds to: Reassurance Education Exercise Physical Therapy Red Flags: Suspected Cauda Equina Syndrome Suspected Myelopathy Recent Trauma Suspected Cancer LMN Weakness Suspected Infection Community wellness programs Fitness/Activity Programs Episodic physical therapy or home program Self Referral (Telephone or Web Based) Improved? YES 7

8. #HASummit14 NO Clinical Care Guidelines for LBP Initial Evaluation Evaluation Elements: History and Exam Review Red/Yellow Flags Pain Rating (VAS) Quality of Life Instrument Evaluation Elements: History and Exam Review Red/Yellow Flags Pain Rating (VAS) Quality of Life Instrument Core Treatment Plan: Education & Reassurance Encourage activity PT or Chiropractic Care YES Red Flag Protocol Radiculopathy CPG YES NO Core Treatment Plan Reassess in 2-4 weeks Continue Core Treatment Plan Encourage ongoing exercise Reassess in 4-6 weeks Low Risk Determine risk of developing chronic back pain: Assess Yellow Flags Keele STarT Back Screening Tool Re-evaluation Improving? Re-evaluation YES Improving? Core Treatment Plan, PLUS: Physical Therapist with clinician trained in addressing psychosocial issues Mental Health Screening/Psychology Consider Spine Center referral Reassess in 1-3 weeks Moderate/High Risk Core Treatment Plan, PLUS: Reassure & Address Psychosocial Factors Consider Spine Center Referral Consider Integrative Medicine Referral Reassess in 1-3 weeks Core Treatment Plan, PLUS: Shared Decision Making: Further workup (Imaging, Labs) Medications Spine Center Referral Self Management Encourage fitness/activity program(s) Or PT Home Program Follow up as needed Re-evaluation Improving? SPINE CENTER REFERRAL YES NO Red Flags? 8

9. #HASummit14 The Need for Actionable Data 9 Implemented a late- binding enterprise data warehouse platform (EDW) to take advantage of available information and provide support for providers and managers. The EDW aggregates clinical, financial, operational, experience and other data to create consistent views of the data to inform decisions. The Spine dashboard is used to monitor and manage performance and to drive behavior change.

10. #HASummit14 The Spine Dashboard 10 The Spine dashboard is used to monitor and manage performance and to drive behavior change

11. #HASummit14 The Spine Dashboard 11

12. #HASummit14 The Spine Dashboard 12

13. #HASummit14 Poll Question #2 13 On a scale of 1-5, how effective is your organization at using data to drive behavior change and performance improvement? 1)Not at all effective 2)Somewhat effective 3)Moderately effective 4)Very effective 5)Extremely effective 6)Unsure or not applicable

14. #HASummit14 Results 14 Implemented a successful, highly collaborative coordinated care program for spine disorders including LBP Significantly improved access to good data and toward a data- driven culture Projected $2.7 million in implant savings achieved through standardization

15. #HASummit14 Results – LOS 15 Achieved a 16% reduction in LOS Length of Stay YearAverage LOSVolume 20124.251246 20133.971146 20143.751172 Jan-Apr 20153.61398

16. #HASummit14 Results – Post-Op Complications 16 Year-to-Date 2015 (Jan-Feb) 3.6% Reduction in post-op complications

17. #HASummit14 Future Plans Continue to develop a highly integrated, coordinated, multi-disciplinary, patient-centric approach to patients with spine issues Continue to improve quality and availability of data Continue drive toward value (high quality, low cost, appropriate care) Broadly introduce the fusion risk score (FRS) Measure the financial impact of the Spine program 17

18. #HASummit14 Lessons Learned 1. Data is not only critical for measurement; it can also influence behavior 2. Build an effective multi-disciplinary improvement team 3. Engage and effectively communicate with all stakeholders involved in the care process you are trying to improve 4. Create a compelling case for change 18

19. #HASummit14 Analytic Insights A Questions & Answers 19

20. #HASummit14 Choose one thing… 20 Write down one thing will you do differently after hearing this presentation

21. #HASummit14 Thank You 21

22. #HASummit14 22 Session Feedback Survey 1.On a scale of 1-5, how satisfied were you overall with this session? 1)Not at all satisfied 2)Somewhat satisfied 3)Moderately satisfied 4)Very satisfied 5)Extremely satisfied 2.What feedback or suggestions do you have?

23. #HASummit14 Upcoming Sessions Breakout Sessions – Wave 4 (1:15 PM – 2:00 PM) 26)Panel – How Community Hospitals Thrive with Analytics John Wadsworth, Vice President, Technical Operations, Health Catalyst 27)Quality Improvement in Healthcare: An ACO Palliative Care Case Dr. Robert Sawicki, MD, Senior Vice President, Supportive Care, OSF Healthcare Roopa Foulger, Executive Director, Data Delivery, OSF Healthcare Linda Fehr, RN, Division Director, Supportive Care, OSF Healthcare 28)Clinical Standards Work To Improve Evidence-Based Care Delivery: A How-To Workshop Charles Macias, MD, MPH, Chief Clinical Systems Integration Officer, Texas Children’s Hospital Terri Brown, MSN, RN, CPN, Assistant Director, Clinical Outcomes & Data Support; Research Specialist, Center for Research and EBP, Texas Children’s Hospital 29)Five Months to Improvement: How Stanford Built an Improvement Program the Gets Results Spencer H. Kubo, MD, Associate Professor of Radiology (Pediatric Radiology), Stanford University Medical Center 30)Breaking Down Silos: Resolving Academic, Medical, and Research Interests Once and for All Samuel L. Volchenboum, MS, MD, PhD, Assistant Professor of Pediatrics, Director, Informatics Program, The University of Chicago Medicine) 23 Location Imperial Ballroom B Imperial Ballroom A Grand Salon Murano Venezia