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

2. 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).

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

4. NCQA Certification Standards

6. What Evidence do we have that this approach works? J Rural Health. 2003 Fall;19(4):506-10.  Promoting pneumococcal immunizations among rural Medicare beneficiaries using multiple strategies. Montana Department of Public Health and Human Services Am J Manag Care. 2012 Dec;18(12):821-9.  Population-based breast cancer screening in a primary care network.

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

11. 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

12. Demographics (n=9,933 patients) Age, y (mean ± SD) 58.6 ± 16.89 18-49, 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

14. UIM: Overall MUSC ED, Hospital, rehospitalization over three years ED N of PTs Total # in 3+ yearsMeanMedianMinMax 1128420,7631.84 0 0222 HOSP_ALL N of PTs Total # in 3+ yearsMeanMedianMinMax 11284 9, 591 0.85 0 041 REHOSP w/in 30 days N of PTs Total # in 3+ yearsMeanMedianMinMax 112842,1440.190028

15. Obesity & CV risk HealthyHypertension Hyperlipidemia & Hypertension

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

17. UIM patients: Multiple chronic conditions

18. 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

19. Quality

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

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

22. 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

23. 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 % - 9.06% (p< 0.0001) 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)

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