Clinical Integration, Population Health and Value-based Care

ClinicalIntegrationforValue-BasedCare

StevenMerahn,MDFAAPChiefMedicalOfficer,Centria Healthcare

Sept13,2017

Taking transcendent responsibility for the health status of a cohort or community requires a completely different operating model than caring for patients who “self-select” for care based on their own assessment of their condition.

TheChallengesofPopulationHealth

Thecompetenciesrequiredforsuccesscommunication,collaboration,engagement,andorchestration

arenotnativetohealthcareasaprofession.

TheProblem:NobodyReallyKnowsWhatToDoBut...wethinkcan,wethinkwecan.1

TheBIGQUESTIONS:

1.UnskilledandUnawareofIt:HowDifficultiesinRecognizingOne'sOwnIncompetenceLeadtoInflatedSelf-Assessments,JournalofPersonalityandSocialPsychology.1999,77:6

Istherearationalframeworkfor

operationalizingtheTripleAim?

Whatforcesofequilibriumare

workingagainstoursuccess?

Whatissuccess—arewedrivenby

intrinsicorextrinsicmotivation?

Whatcanwelearnfromotherdisciplinesto

supportoursuccess?

TheTurningPoint

DignityAuthenticityIntegrityEmpathySincerityUrgency

EmotivePerformance

TacticalPerformanceEfficiencyConsistencyAvailabilityReliability

ResponsivenessConvenience

ProductsandServices

• PrimaryCare• Specialists• SurgicalCare• Imaging• Lab

Channels

• MedicalHome• Ambulatory• inpatient• Homecare• Websites/App

Realizing the right brain ALWAYS

eclipses the left brain.

It’s not just people, process, and technology...IT’S PRESENCE.

Professionalintimacydevelopswhenprovidersandpatientsremainpresentineachothers’lives,evenwhentheyare

absentfromthedailyschedule.Assuch,theinfluenceoftherelationshipextendsbeyondtheimmediateencounter,

creatingaTherapeuticAllianceandimprovingmotivationandtreatmentadherence

SuccessfulSystemsOperateinThreeTiers

TIE

R

FUNCTIONALREQUIREMENTS

TIE

R

OPERATINGCAPABILITIES

TIE

R

INTERACTIONDESIGN

Text©2016StevenMerahn,MDallrightsreserved

Example:VehiclesT

IER

FUNCTIONALREQUIREMENTSPowertrainAcceleration(fuelcontrolandtransmission)Deceleration(brakingandtransmission)Steering(directionalmanagement)

TIE

R OPERATINGCAPABILITIES

Car:Useofthegasandbrakepedalsandsteeringwheel;gearshift/clutchMotorcycle:Useofthetwistgrip,handandfootbrakeandfootgearshiftBicycle:Footpedals,handbrakes,derailleurOperator:Vision,symbolrecognition,fine/grossmotorskills

TIE

R INTERACTIONDESIGN

Integratingtheoperationalcapabilitiesandfollowingtherulesoftheroadwhiledrivingwithothervehicles


ClinicalIntegrationforValue-basedCare

TIE

R

ACCOUNTFORTHEFUNCTIONALREQUIREMENTS

TIE

R

BENCHMARKTHEOPERATINGCAPABILITIES

TIE

R

ORCHESTRATETHEINTERACTIONDESIGN


Analytics/Reporting

PopulationSurveillance

Segmentation&Targeting

Outreach&Engagement

CarePlanning

ClinicalStrategy

ResourceManagedCare

Delivery

CareCoordination/Collaboration

Thresholds&Filters

System-LevelGoals&ProgramEligibility

RulesforSorting&CategorizingData

Communication&ActivationStrategy

ResourceAllocation&

StandingOrders

Programs&Services

Person-LevelGoals,SharedDecision

Making,&Coordination

Inputs

Data

Clinical,Claims,PDD,Financial,Operational,Consumer

GeneratedData

All functional requirements must be fulfilled. However, individual organizations may fulfill them differently with

various configurations of programs, platforms, partners, and personnel.

TheFunctionalRequirements

Textandmodel©2016StevenMerahn,MDallrightsreserved

OperatingCapabilitiesOrganizational

structure, governance, and culture to support

a population health management infrastructure.

Staffing, roles and responsibilities, training needs, and alignment.

OrganizationalCapacity

PatientExperienceManagement

ClinicalTechnologySystems

WorkforceReadiness

Data,Analytics,andReporting

Finance/BusinessModels

ClinicalProcesses&Operations

Clinical workflows, protocols, programs, and services. Quality and outcome measures.

Health IT systems, capabilities, IT infrastructure.

Financial expectations, cost tracking, contracting for value-based goals.

Data sources and quality, storage, and management. Analytic and reporting models for clinical, operational, and financial purposes.

Communication, engagement and

activation, shared decision

making, tactile and emotive experience.


Orchestratingandoptimizinggoal-directedcollaboration,operatingrelationships,andknowledgemanagementbetweentheprograms,platforms,partners,andpersonnelthatcompriseapatient’shealth-

resourcecommunity.

InteractionDesignforPopulationManagement


ValueIsBasedinthe“EssentialTriad”CarePlanning CareDelivery Collaboration

Whatarethegoalsforthispatient?

Whattoolsandresourcesarerequiredtomeetthosegoals?

Areweachievingprogresstowardsgoals?


CarePlanning

System-levelgoals

Person-levelgoals


CarePlanningTaxonomy:SingleSourceOfTruth


Care PlanStrategy Wellness Universalprevention Selectedprevention Indicatedprevention Conditionmanagement Compassionatecare

StrategicTarget Individualfocus Community- based Characteristic- based Conditionorrisk- based Diagnosisorevent-based Prognosis-based

StrategicFramework

Targetswholepopulationto

achieveorsustainlevelsofphysical,mentalandsocial

well-being

Targetswholepopulation(nation,localcommunity)andaimstopreventor

delayuniversalhealthrisksorconditions

Targetsgroupsorindividualswhoseriskisaboveaverage;

subgroupsmaybedistinguishedbytraitssuch

asage,gender,familyhistory,geography

Targetsgroupsorindividualswithanexistingconditionor

otherdataoridentifiersindicatingcondition-

relatedrisks

Targetsgroupsorindividualswith

confirmeddiagnosisorotherconditionthatisunstable,whosequalityofcondition-relatedcaredoesnotmeetevidence-

basedstandardsorwhosehealthstatusis

poor

Patientswithanyseriousillnesswhohave

physical,functional,psychological,or

spiritualdistressasaresultoftheirconditions

and/orassociatedtreatments

Source:MerahnS.KnowledgeRepresentationand CarePlanning forPopulationHealthManagement.JMedPract Manage.2015Sep-Oct;31(2):126-30.

ResourceManagedCareDelivery:Allocation,Escalation,De-escalation

CAREPLANOPERATIONALCATEGORIES

Wellness/Lifestyle

Management

UniversalPrevention

SelectedPrevention

IndicatedPrevention

ConditionManagement

CompassionateCare

IndividualFocus

Community-based

Characteristic-based

Conditionorresult-based

Diagnosisoreventbased

Prognosis-based

CAREDELIVERYRESOURCES

Hospice Intensive/Post-OpCare

InpatientCare/SurgeryInpatientCare/Medicine

TransitionsinCareAmbulatoryCare(Specialty)CaseManagement

AmbulatoryCare(PCP) BehavioralHeath HomeCare SocialServicesCareCoordinationCoaching/Navigation

CommunityServicesOutreach/Engagement/ActivationTargetedEducationalPrograms/CampaignsSelf-Selection/Self-Service


CollaborationasaFormalDiscipline

• Collaborationisamutuallybeneficialrelationshipbetweenindividualsororganizationswhoworktowardcommongoalsbysharingresponsibility,authority,andaccountabilityforachievingresults.

Results

Reducedhospitalizationsby60%.

Reducedemergencydepartmentuseby40%.

Reducedrehospitalizationsby30%.

Sustainedhighlevelsofpatient/familyengagement.

Re-engineeredprovidermindsettowardsrelationship-drivencare.

Implementedcollaborationasaprofessionaldiscipline.

Added$2,000+perpatientinannualvalue-basedrevenue.

Reducedprovidercensustounder500.

Reduceddailyvisitstobetween10and12.

Revitalized physicianprofessionalidentity.

Destroyed assumptions aboutpopulationhealthmanagement.

Withahigh-need/high-costpopulation:

FuturePlans

Usethemodeltorevitalizethe

experienceofcareforpatientsandprofessionals.

Expandtheportfolioofresourcesavailableto

manageconditionsbycareplancategory—including

lookingoutsideofhealthcarefortoolsandtechnologies.

Formalizethemodelforcollaborationand

conductcomparativeeffectivenessresearch.

Continuetoevaluatethepowerof

professionalintimacy.

AQuestions &

Answers

21

Contact Dr. [email protected]

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Clinical Integration, Population Health and Value-based Care

Healthcare

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