Care Delivery &Integration Center Workshop

Managing Populations, Maximizing Technology:Population Health Management in the Medical Neighborhood

Bon SecoursVirginia Medical Group

October 15, 2013PCPCC Annual Fall Conference

PCPCC’s TenRecommended Health IT Tools to

Achieve PHM:

1. Electronic Health Records 2. Patient Registries 3. Health Information Exchange 4. Risk Stratification 5. Automated Outreach 6. Referral Tracking 7. Patient Portals 8. Telehealth/Telemedicine 9. Remote Patient Monitoring 10. Advanced Population Analytics

Source: Managing Populations, Maximizing Technology: Population Health in the Medical Neighborhood. Shaljian& Neilson; PCPCC 2013

BSVMG TransformationalVision Timeline

1/2009 12/2010 1/2011 4/2011 9/2011 12/2011 1/2012 3/2012 1/2013

First EMR Go-liveat IMAC

First NurseNavigator Placed

First PCMHGo-Live at MMC

First MyChartUser

First integrated EKGat Brook Run

First RegistryUtilized

First Managed CareContracting

ACOImplementation

First EP MUAttestation

Current Status:

EMR – 108 physician practices liveNCQA PCMH Level 3 – 71 providersMyChart Users – 73,884 BSHSI/68,223 VirginiaNurse Navigators – 51Registries – Diabetes, CHF, High Risk, Obesity,Asthma, COPD, Hepatitis CIntegrated Equipment – EKG, Spirometry, Vital SignsAdvanced Payment Models – ACO, Cigna, Anthem,Humana

PCMHNurse Navigator Team

Population Outreach:Phytel & Epic Registries

Epic Sample Logic…

Engaging Patients viaEMR Portal & Nurse Navigators

*The Average BSVHospital DischargeReadmission Rate forPrevious 6 months –14.2%

INCLUSION CRITERIA:1) Patient was seen as part of a Post Hospitalization Episode2) Must have a documented Initial Hospital Discharge Date to be counted inReadmit RateDEFINITION:A readmission is counted as having a documented Other HospitalAdmission Date within 30 days of the Initial Hospital Discharge Date

Number of“ActivatedPatients”

Virginia

BSHSI Total

68,22373,884

Number ofmessages/week

2,383

eRx TurnaroundTime

10hr 40min

AppointmentRequestTurnaround Time

8hr 1min

Messaging TAT 10h 34min

Epic Patient Portal:Navigator Readmissions:

Our Progress Toward Reform:2009-2016

Questions??

9©2013 Healthagen. All rights reserved.

Maximizing Technologies, Managing Populations:eHealth Innovations

Aetna’s Perspective

October 15, 2013

Brian Parker, President, Practice iQ

10©2013 Healthagen. All rights reserved.

Aetna is committed to the shift from volume tovalue

AetnaACO

AttributionCommercial

AetnaACO

AttributionCommercial

AetnaPCMH

ContractCommercial

AetnaPCMH

ContractCommercial

AetnaProvider

Collaboration

MedicareAdvantage

AetnaProvider

Collaboration

MedicareAdvantage

Incr

easi

ng te

chno

logy

, ser

vice

s, a

nd c

olla

bora

tion

Increasing value creation for all stakeholders

Less involvement required

More involvement required/“Enablement Models”

11©2013 Healthagen. All rights reserved.

How is value generated by PCPs?

Understand Cost & Quality

Accessible data to manageperformance and trackpatients

Population based decisionmaking with predictivemodeling

Health CareTechnologyHealth CareTechnology

11

Facilitate Appropriate CareDelivery

Identify and manage at-risk/high risk patients andthose with chronic conditions

Care coordination to driveappropriate utilization ofresources

Care ManagementCare Management22

Support and monitor PCMHsuccess

People to leadtransformation process andtrack ongoing performanceand progress

Managing inappropriate andredundant utilization basedon data analysis

Operational/PeopleServicesOperational/PeopleServices

33

Fields, D. (2010, May). Driving Quality Gains and Cost Savings Through Adoption of Medical Homes. Health Affairs, p. 29:5.

Motivate behavior change among providers withrewards for demonstrating consistent and successfulapplication of the medical home features

Mitigate costs related to implementing newtechnology, care management processes, and peopleto transform and successfully operate as a medicalhome

Incentive PaymentsIncentive Payments44

PCMH 2.0

Test andprescribe

vs.prevention and

healing.

Integrated Health Services

Behavioral health Dietician Health education Mind-body medicine Pharmacy

Validated physician-connected Health Risk Assessment Personalized Prevention Plan Chronic care management interventions

Preparing for Change

“The primary care practice of the future willhave a workflow very different from that oftoday.”

—Institute for Health TechnologyTransformation. April 2012.

EHR system System-wide secure messaging Clinic-facing patient dashboards Web-based interactive health risk

assessment/personal preventionplan

InteractiveHealth RiskAssessment

HealthCoaching

Track

Virtual Coaching(Web , Mobile)

Live Coaching(Phone, Electronic)

Onsite Coaching(PCMH/IHS Team)

CareManagement

Track

Care Management &Interactive Monitoring

(Biometric Devices, Apps,Clinical Dashboards)

PrimaryCare Office

Visits

PrimaryCare Office

Visits

Outreach(e-mail,

mail,phone)

Outreach(e-mail,

mail,phone) online

in clinic

WellnessPrescription

Nutrition Coaching Exercise PlanWeight Game Tobacco Cessation Care Management Home Monitoring

Risk-basedtriage

Risk-basedtriage