1. Exclusively serving Indiana families since 1994. Population Health Management from the Managed Care Entity Perspective IPHCA Annual Conference 2015

2. -2- Population Health Management

3. -3- Improving the quality of care that is available to our members suffering from or at risk for chronic disease through research, education, advocacy, and the development and application of disease-specific, scientifically based standards and guidelines. Specific focus on reducing or eliminating inequity and disparities among various subpopulations, driven in part by social determinants of health. Preventive Health Service Promotion: A collaborative alliance between the member and their care team dedicated to assist the member in making self-directed behavioral changes. MDwise Definition of Population Health

4. -4- Member Identification and Stratification

5. -5- Verisk DxCG Risk Assessment Tool Health Needs Screener Comprehensive Health Assessment Tool/Condition-Specific Assessments Medical or pharmaceutical gaps in care Demographic and social factors Presence of behavioral health conditions Disease burden Input from members, caregivers, providers Evidence of potential quality indicators Evidence of under- or over-utilization Member Identification and Stratification

6. -6- State-mandated Levels of Service Disease Management (Low Risk) Care Management (Moderate Risk) Complex Case Management (High Risk) Targeted programs based on identified risk Integrating community and other resources Monitoring health and quality-of-life outcomes Primary and Secondary Prevention Management Interventions

7. -7- Educate members about their disease(s), coping strategies, and self-management skills Encourage member condition monitoring, medication adherence, and behavior modification to include healthy lifestyle choices Actively monitor members’ clinical symptoms, treatment plans, and adherence to evidence-based guidelines Coordinate care among all providers: PMP, specialists, behavioral health providers, ancillary providers, hospitals, laboratories, and pharmacies Management Interventions

8. -8- Connect members with support groups or community programs that provide continuing education and counseling Provide general coordination of care for recommended preventive services, including vaccinations and condition- specific screenings Provide feedback to PMPs on individual members between office visits Provide physicians with evidence-based guidelines to ensure consistency in treatment across targeted populations Management Interventions

9. -9- IEMS CORE Care Team Collaborative Program TracFone/Voxiva Text Messaging Program Imbedded Care Managers CMHC Projects Network Improvement Program (NIP) Team Member Profile for Provider Portal Peer Support Specialists Home and Provider Visits Transitions of Care Program MDwise Special Programs for Population Health Management

10. -10- Improvements in W34 and AWC for practices engaged with the NIP Team were 6 percentage points (16% v. 10%) higher than practices not working with NIP. Network Improvement Program (NIP) Team

11. -11- MDwise Cohesive Care HEDIS Rates Comparison HEDIS Rates for CMHC Project YearAWCW34LDL 2013 (CY2012)50.85%/50 th %ile69.34%/50 th %ile66.24%/50 th %ile 2014 (CY 2013)58.88%/50 th %ile76.89%/75 th %ile69.53%/50 th %ile

12. -12- Data Sharing Dedicated Case Manager for each CHC Embedded Case Managers Access to Case Management System—Jiva Everyone Needs Check-Ups Events Partnership Opportunities with Community Health Centers

13. -13- Questions?

14. -14- Contact Information Betsy Jerome, RN, MBA, CCM, PCMH CCE Director of Clinical Programs bjerome@mdwise.org Phone/Fax: 317-822-7167