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Thank You

Presented by:

Wendy Vincent, National Practice Director, Strategic Advisory Services

HFMA Dixie Institute

February 19, 2015

Population Health Management:

What it Means For You and Your

Organization

Heading – Ariel 40

Define Population Health Management

Identify targeted populations

Create effective governance structure

Use technology to accomplish goals

Establish realistic benchmarks

Integrate care approach through

community partnerships

2

Objectives

State of Healthcare

Storm Factors

Affordable Care Act: As of April 2014 – 8 Million Americans have signed up for healthcare, shocking the system as they present to PCP’s1

Rapid Baby Boomers, everyday 10,000 people turn 65

Reduction in Primary Care Physicians

Increase in prescription drugs, contributing to higher costs and more advanced treatments resulting in longer life expectancy

1) Familiar Physician, Dr. Peter Jackson

Heading – Ariel 40Top Concerns of Health Care Systems

5

1. What is the business model for population health?

2. Have I assembled the right network components?

3. Do we understand our patients as consumers?

4. What investments can we can make to help us with both fee-for-service and value-based incentives?

http://www.advisory.com/Research/Health-Care-Advisory-Board/Blogs/At-the-Helm/2014/05/Four-challenges-every-leadership-team-is-talking-about?WT.mc_id=Email|Daily+Briefing|Blog|HCAB|Jul-14-2014|||||

Why Is It So Important Now?

Healthcare Payment Reform

• End of fee for service

• Value-based purchasing

• ACOs and PCMHs

Reporting On Clinical Quality Is Retrospective

Care Coordination – what do we need to do right now to produce the best outcome for a single, particular patient

Population Health – focuses on the future, what can we and should we do in the future to produce better outcomes, higher quality and lower costs

Technology

• Broad EHR adoption

• mHealth

• Analytical tools

Population Health Management (PHM) Defined

Heading – Ariel 40Population Health

8

“The use of a variety of

individual, organizational and cultural interventions to help improve the illness and injury burden and the health care use

behavior of defined populations.”Dr. Michael Hillman,

Marshfield Clinic

“The health outcomes of a group

of individuals, including the distribution of such outcomes

within the group”

American Journal of Public Health

Heading – Ariel 40PHM Defined

9

Population Health describes the health outcomes of a group of

individuals, including the distribution of such outcomes within the

group. Population health outcomes are the product of multiple

determinants of health, including medical care, public health,

genetics, behaviors, social factors, and environmental factors.

Goal: Keep patient population as healthy as possible and reduce the

need for costly interventions such as ED visits, hospitalizations,

imagine tests, and procedures.

To support PCMH & ACOs, many organizations will need to start

implementing PHM to keep patient population healthier and reduce

costs.

Heading – Ariel 40PHM Framework

10

Heading – Ariel 40Patient Centered Medical Home

Engaged leadership

Quality improvement strategy

Empanelment

Patient-centered interactions

Organized, evidence-based

care

Care coordination

Enhanced access

Continuous, team-based

health relationships

ACOs

• Healthcare organizations are formulating

Clinically Integrated Networks (CINs)

• Network of Providers belong to ACO

• Physician metrics/scorecards are established

• Targets/Projections/Actuals – Shared Savings

• Population Health Management Systems are on

the rise for real time data

ACOs

Complete & timely information about their patients and the

services they are receiving

Technology and skills for population management and

coordination of care

Adequate resources for patient education and self

management

A culture of teamwork

Coordinated relationships with specialists and other providers

Ability to measure and report on the quality of care

Infrastructure skills for the management of financial risk

Commitment by leadership to improving value as a top priority

ACO Growth

14http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/

Heading – Ariel 40CMS State Innovation Programs

15

Challenges to Overcome

Technology Alignment with Business:

• Are we collecting the right data?

• Once we get it, what does it mean?

• How can we effectively use data?

Organizational Strategy:

• My organization doesn’t have a clear strategy

• Our areas are like silos with their own information

Process Changes:

• Each department has their own plan; roles and process

changes are needed towards a new optimal state but where do

we start?

Lower costs:

• How can overall costs for defined Populations be reduced?

Identifying Targeted Populations

Heading – Ariel 40Identifying Targeted Populations

18

What’s the best way to use our resources?

• Identify high risk

Readmissions

Repeat ED visits

LOS

• Specific diagnoses

Diabetes

Congestive heart failure

High blood pressure

Asthma

• Geographic/population areas

• Community Health Needs Assessment

Heading – Ariel 40Identification Mechanisms

19

Predict resource usage

Heading – Ariel 40Conditions Analysis

20

Screenshot from Caradigm Risk Management tool

Heading – Ariel 40Risk Assessment

21 Screenshot from Caradigm Risk Assessment Tool

Heading – Ariel 40Organizational Considerations

22

What are your resources across the continuum of care?

• Case managers

• Transition of care program

• DSRIP efforts

• PCMH development

• Care coordination

• Community resources

Governance

Heading – Ariel 40Governance Key to Success

24

Leadership endorsement of new staffing models and roles

Define specific roles and responsibilities

How will you

communicate

efforts?

How will you

ensure care and

resources are

centered around

the patient?

How will you

involve the

community?

How will you

integrate efforts

into the continuum

of care?

Heading – Ariel 40Key Considerations

25

Who will review and analyze data?

Avoid redundancy and overlapping efforts

Avoid silos

What committees do you already

have in place?

• Quality committee

• Ambulatory care committees

• Policy and procedure committees

• Credentialing committees

What has or hasn’t worked well in the past?

Technology

Heading – Ariel 40Effectively Using Technology

27

Automate workflows for appropriate utilization of

resources

Connect care team in coordinating patient care

HIE

Communicate via a portal

• Patients

• Physicians

• Affiliates and community resources

Track and report data in timely manner

Use appropriate metrics to evaluate the program

Heading – Ariel 40Example: Patient Portal

28Screenshot from Allscripts FollowMyHealth™ patient portal

Heading – Ariel 40Primary Care

29

Registry member

Portal for EMR management

Push alerts for recalls and

immunizations or upcoming

needs for blood testing

Self-scheduling online

Diabetes management

Heading – Ariel 40Care Management/Coordination

30 Screenshot from Caradigm Care Management Tool

Heading – Ariel 40Care Gaps

31Screenshot from Caradigm Care Management Module

Evaluation Criteria

Heading – Ariel 40Establishing Benchmarks

33

Gather data

• EMR

• Claims data

Input critical

• Staff

• Patients

• Providers

Evaluation techniques

• Timely data

• LACE index

• PHM tool

Set realistic targets

Where are you NOW

compared to your

benchmarks?

Integrated Care Approach

Heading – Ariel 40Connect with Your Community

35

Heading – Ariel 40Outreach Strategy

36

Risk assessment

Define population

Define new roles and workflows

Define issues to address

Develop plan to target needs

• Education

• Counseling

• Preventative clinics/care

Communication strategies to target underserved

populations

Heading – Ariel 40Integrated Care Example

37

Heading – Ariel 40Key Takeaways

38

Develop PHM strategy and program

Use data to define your populations (internal and external)

Ensure your strategy aligns with organizational goals

Create a governance structure to drive change and

accountability (new roles)

Engage in Risk Model Programs (ACOs and MSSPs)

Develop care coordination programs through new optimal

workflows (Re-admission programs, PCMHs)

Use technology to automate processes

Create an outreach approach to integrate care throughout

the community

Change is Hard

39

Heading – Ariel 40Questions?

40

Wendy Vincent, RN, is an accomplished healthcare executive with 30 years of

professional experience across all areas of healthcare. She has served in both

executive and senior leadership positions with academic medical centers and large

Integrated Delivery Networks. Wendy understands the unique opportunities and

challenges associated with optimizing people, process, and technology. She has

been successful with helping organizations identify areas to improve care quality,

increase operational efficiencies, and optimize revenue. Wendy is a strategic thinker

and planner with strong problem-solving and organizational skills. She is accustomed

to building relationships at all levels of leadership and staff. She holds a Bachelor of

Science in Nursing with graduate work in Nursing Education. She is actively involved in nursing, clinical, and IT professional societies.

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Thank YouFor more information

please contact

Thank You

wendy.vincent@BeaconPartners.com

Wendy Vincent