Artificial Intelligence for SDoH · 2020-01-29 · Connected Communities of Care Playbook is one of...
Transcript of Artificial Intelligence for SDoH · 2020-01-29 · Connected Communities of Care Playbook is one of...
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Artificial Intelligence for SDoH
Steve Miff, PhD
February 7, 2020
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• Key Innovations Driving Healthcare Digital Innovation • SDoH Applications and Case Studies
AGENDA
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HEALTHCARE INNOVATION IS GROWING FASTER THAN EVER
Source: Adapted from Sg2 and Friedman T. Thank You for Being Late, An Optimist’s Guide to Surviving in an Age of Acceleration. Farrar, Straus & Giroux: 2016.
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MASTER TITLE
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SOCIAL DETERMINANTS OF HEALTH
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…health begins
where we live,
learn, work, play
and pray.
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THE RAPIDLY EXPANDING WORLD OF “LIFE” DATA
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EXPANDING WORLD OF SOCIAL DETERMINANTS OF HEALTH DATA
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AI AND PRESCRIPTIVE ANALYTICS REQUIRE NEW ECOSYSTEMS
Next-Gen Data
Visualization
Data Emersion
[AR/VR]
Disruptive/
Enabling
Platforms
Communication Science
Next-Gen
Measures
End
User
Insights
Physical
Sciences
Data Science strengths
need to be complemented
with other capabilities
Data Science Excellence
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MASTER TITLE
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• The Long Arc of Innovation • Trauma Mortality Model • Preventing Adverse Drug Events (PARADE)
CASE STUDIES
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The Long Arc of Innovation: Isthmus & Trauma Case Examples
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Visuals do not contain PHI and are for illustrative purposes only
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Trauma score A predictive score
that predicts risk of
mortality in the next
48 hours for adult
(18+ years) patients
with Trauma
Activation Level of 1
or 2
Real Time Workflow Integrated Live Since August 5th
Trauma Model To Save Lives
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Visuals do not contain PHI and are for illustrative purposes only
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Does the algorithm take weekends off?
Sun, Sep 15, 11:10 AM
Poly trauma patients who came in yesterday – still no score
Support team is already looking into
it
There was an issue with error-checking
logic for missing respiratory rate
data
Let us meet tomorrow to
clinically validate the change in logic
Sun, Sep 15
6 weeks into go-
live of trauma
mortality model
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About 15 months earlier
(Feb. 2018)
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Effective Use of Data & Analytics Can Tackle Healthcare’s Most Challenging Problems
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Cloud-based machine learning platform API based integration
with workflow tools
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Innovation Process At Work: PARADE Case Example
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Innovation Process At Work: PARADE Case Example
Program Sustainability
PARADE
2-yr
Impact
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MASTER TITLE
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• Connecting Clinicians with Community Based Organizations to Address SDOH
CASE STUDIES
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THE SDoH MODEL
Pieces Iris™ technology to create bi-directional
exchange of information, smart referrals and
individual tracking.
ROI and SROI to support ecosystem to provide better healthcare to the individuals in their communities. Strive to improve healthcare trends across the national continuum.
Build clinical workflows and utilize predictive
analytics and AI to prevent readmissions, save lives and
reduce healthcare costs.
Develop CBO workflows and understand SDOH’s impact on quality of life and how connected communities build a support system for a path to self sufficiency.
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Technology
Clinical
Sustainability
Community
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VA
LU
E T
O P
AT
IEN
T &
SY
ST
EM
Clinical & Claims Data Only
SDOH Proxies from Clinical & Claims Data and/or coarse SDOH at county and zip levels
Precision SDOH based on blocks and neighborhoods characteristics (Dallas Community Data for Action )
Lack of complete picture of patient’s environment Can lead to suboptimal interventions. Costly & inefficient
Social Care workflow tools (IRIS, TAVHealth)
Understand root causes of poor outcomes and health disparities at population level. Rudimentary actionable information at individual level.
Gain detailed understanding of social needs, services provided, and health equity at individual level.
SDoH Analytics and Technology Models
Level 0 Level 1 Level 2 Level 3
SDOH Maturity Model
Develop more specific and actionable understanding of root causes of poor outcomes and health disparities.
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DALLAS COMMUNITY DATA FOR ACTION
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DALLAS COMMUNITY DATA FOR ACTION [DCDA] HELPS LEADERS
VISUALIZE SOCIAL DETERMINANTS OF HEALTH
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School Age Children With
Low SNAP
Measures of Resilience
Area Deprivation
Index
Explore Specific
Neighborhoods
DCDA - Dallas Community Data for Action. DCDA was developed by PCCI in collaboration with Community Council of Greater
Dallas, UTD Public Health and the DFWHC Foundation. It was in part funded by the CCGD through a block grant.
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SDoH INTEGRATION TO IDENTIFY AT RISK POPULATIONS: MEDICAID PRETERM BIRTH PREVENTION PROGRAM
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Increased prenatal care attendance
Increased patient engagement
Increased timely, evidence-based interventions
Preterm birth
By going upstream to provide outstanding
prenatal care and patient engagement,
PCCI can help providers decrease
preterm birth rates, leading to:
• Healthier mothers and babies
• Better health outcomes and shorter
LOS
• Cost savings for patients, providers,
and payers
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ML Based Risk Stratification, Care Re-Design and Personal Engagement
Metric Improvement
Prenatal Visit Attendance 24% (p=0.013)*
Preterm Birth Rate 27%
Baby Cost PMPM 54%
Normalized Total Baby
Cost
$1.03 million
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CONNECTED COMMUNITIES OF CARE
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CONNECTING PEOPLE WITH CLINICAL AND SDoH NEEDS
The Accountable Health
Communities Model tests
whether systematically
identifying and addressing the
health-related social needs of
Medicare and Medicaid
beneficiaries’ through
screening, referral, and
community navigation services
will impact health care costs
and reduce health care
utilization.
Resource
Summary Clinical
Encounter
SDOH
Survey
Iris Entry
Case
Manager
Electronic
Referral Monthly
Follow-up
Needs
Resolved
Housing • Utilities
Food • Transportation
Safety
Core Needs Addressed
Program Objective
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The project described was supported by Funding Opportunity Number CMS-1P1-17-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
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• Cloud-based: accessible anywhere you get the internet
• Updated geo-mapped, referral directory • Simple, configurable intake forms • Security:
HIPAA compliant 2-factor security
• Multiple levels of consent • Multiple user roles to handle sensitive
information • Custom quick reports • Training, legal documents, workflows
CONNECTING SDoH NEEDS TO COMMUNITY RESOURCES
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WHEN DATA SPEAKS- COMMUNITY
Across the AHC Zip Codes, we are seeing on average 2.4 needs per person
[CELLRANGE], [CATEG
ORY NAME]
[CELLRANG
E], [CATEGORY NAME
]
[CELLRANGE], [CATEG
ORY NAME]
[CELLRANGE], [CATEG
ORY NAME]
[CELLRANGE], [CATEG
ORY NAME]
[CELLRANGE], [CATEG
ORY NAME]
Food, Housing and Transportation Continue to be the Greatest Reported Needs
The project described was supported by Funding Opportunity Number CMS-1P1-17-001 from the U.S. Department of
Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility
of the authors and do not necessarily represent the official views of HHS or any of its agencies.
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CASE STUDY: CHRONIC CONDITIONS AND FOOD INSECURITY
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Objective The objective for the project is to decrease adverse health events among food insecure and under-resourced
populations with hypertension or diabetes in the Dallas metropolitan area by improving multisector care
coordination through data sharing and collaboration between the Parkland Health & Hospital System
(PHHS) and hunger relief agencies that regularly serve this population.
Results
• 8% drop in ED visits vs 46% increase in non-intervention group
• 90% agree or strongly agree the program – and the support from the CBOs – has made them more able
to manage their disease, fill their prescriptions and keep clinic appointments
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CONNECTED COMMUNITIES OF CARE PLAYBOOK
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“Kudos to Kosel and Miff to produce a playbook that is pragmatic and timely. It will no doubt serve as a bellwether as others attempt to clarify their relationship between health and healthcare. I would wager that there will be many copycats of their inaugural work in this area. I only wish that Kosel and Miff had completed the Connected Communities of Care earlier so we could have shared it with our community-based partners as we built the nation’s first College of Population Health on the campus of Thomas Jefferson University in Philadelphia.” – David Nash, MD Founding Dean Emeritus at Jefferson College of Population Health “Health care providers must shift their focus from health-care delivery alone to promotion of health and wellness in the communities they serve. This requires highly collaborative relationships across community-based and healthcare oriented organizations. The Building Connected Communities of Care Playbook is one of the first step-by-step guides that provides specific details and steps to start taking action. The mix of lessons, practice pointers and case studies make the insights useful for communities of all shapes and sizes.” – Elena Marks, President Episcopal Health Foundation “Creating connected communities of care is the next frontier in healthcare. PCCI and their Dallas partners started this innovative work well-before other municipalities. This playbook candidly articulates how to build a connected community and shares practical lessons learned. While important for executives from payors and providers alike, chief information and technology officers will particularly find this useful since it will help them accelerate and scale social determinant of health initiatives.” – Richard [Dick] Daniels, CIO Kaiser Permanente
https://www.crcpress.com/Building-Connected-Communities-of-Care-The-Playbook-For-Streamlining-Effective/Kosel-Miff/p/book/9780367800062
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• Developing a Multi-Channel SDoH Model
CASE STUDIES
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30,000
PATIENTS
21 PROVIDER
CLINICS
MULTI-CHANNEL PROGRAM FRAMEWORK
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RESULTS… $24M in Savings
Clinical
Improvement
● 32% - 50% improvement in asthma
controller medication prescription
● 15% improvement in the asthma
medication ratio (HEDIS metric)
● Patient engagement - 70% high
satisfaction and engagement score
Utilization
Improvement
● 31% drop in annual rates of
asthma ED visits
● 42% drop in annual rates of
asthma inpatient admissions
● 40% drop in total annual costs
● $24M savings
Financial
Improvement
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• SDoH will evolve into PDoH – Personal Determinants of Health
• PDoH will: • Be broadly integrated into Cognitive Health Records and built into AI-based risk
predictive models
• Evolve to integrate pharmacogenetic/genetic based data and measures of self-
care capacity
• Enhance access via digital connected communities
• Bridging isolation (mental and physical) will be a key focus
• Evolving towards Person Empowered Health
BUILDING CONNECTED COMMUNITIES - SDoH 2025
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CHOLUTECA BRIDGE, HONDURAS
• Rained 75 inches in less than four days
• Destroyed 150 bridges in Honduras
• Did not destroy the Choluteca Bridge
1998 Hurricane Mitch
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… AFTER HURRICANE MITCH
“The graceful arches of the
Choluteca Bridge stand
abandoned, a white concrete
sculpture far from shore, linking
nothing to nowhere.
The Choluteca Bridge itself is
perfect… except that it now
straddles dry land.”
“We Can Do It If….” Vs. “We Can’t Do It Because…”
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THANK YOU
PCCInnovation.org
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