Optimizing Population Health through Risk-Stratification ... Hong Presentation - FINAL.pdfOptimizing...
Transcript of Optimizing Population Health through Risk-Stratification ... Hong Presentation - FINAL.pdfOptimizing...
Optimizing Population Health through Risk-Stratification &
Team-based Primary Care
Clemens Hong MD, MPH Medical Director, Community Health Improvement Los Angeles County Department of Health Services
Oregon Primary Care Association
March 7, 2016
Outline
• Overview of Population Health & Care Management in Primary Care
• Using population risk-stratification to drive improved outcomes
• Los Angeles County
– Care Connections Programs
– Upcoming Opportunities
The Opportunity
• Move from units of care to episodes, people, & populations
• Focus on things shown to improve outcomes
• Continuously Improve
• Support Innovation – improve by leaps
• Use team-based approaches
• Engage the community
• Rapidly share learning
High-Risk
Patients
Rising-Risk
Patients
Low-Risk
Patients
Population health management approaches are at the core of this
delivery transformation effort
Inpatient Spend (Acute, Rehab, SNF) Outpatient
Spend
Traditional
Fee for
Service
Outpatient Spend Inpatient
Spend
Population Health
ManagementSpend
With
Enhanced
Coordination
Conceptual Strategy for Population Health Management
High-Risk
Patients (5%)
Rising-Risk Patients
(15-35%)
Low-Risk Patients
(60-80%)
Three Population Foci
Low Touch/High Volume • “Surveillance” • Wellness & Health
Coaching • Tools – Patient
Portals/Virtual Visits, Social Media
High-Risk
Patients (5%)
Rising-Risk Patients
(15-35%)
Low-Risk Patients
(60-80%)
Three Population Foci Med Touch/Med Volume • Face-to-Face
engagement • Chronic disease &
Health Coaching • Tools – Enhanced
Primary Care
High-Risk
Patients (5%)
Rising-Risk Patients
(15-35%)
Low-Risk Patients
(60-80%)
Three Population Foci High Touch/Low Volume • Frequent interaction • Chronic
Disease/Intensive Care Coordination
• Tools – Complex Care Management Teams
Challenges for Population Health & Care
Management Interventions: Drops in Potential
Adapted from J Eisenberg JAMA. 2000
Engagement
Finding opportunities
for improvement
Intervention
Identification
Potential opportunity
Realized improvement
Family/Caregivers PCMH/CCM Team
CM Patient
Trusting relationship between a patient & a proactive care team the foundation to care management
Health Delivery System Acute & Post-acute Facilities
Specialty Care
Providers
Behavioral Health
Home Health &
VNA
Social Service
Agencies
Government Service
Agencies
Public Health
Agencies
Payers & Purchasers
Family/Caregivers PCMH/CCM Team
CM Patient
Patient- Centered Medical Home
PCMH Team CCM Team
PCP CM
A strong relationship between care management & primary care teams critical for care management
Patient- Centered Medical Home
PCMH Team CCM Team
PCP CM
As is a strong relationship between the care team & other health system and community partners
Patient- Centered Medical Home
PCMH Team CCM Team
PCP CM
Acute & Post-acute Facilities
Specialty Care
Providers
Behavioral Health
Home Health &
VNA
Social Service
Agencies
Government Service
Agencies
Public Health
Agencies
Payers & Purchasers
Health Delivery System
Patient- Centered Medical Home
PCMH Team CCM Team
PCP CM
Care Management Structure
Patient- Centered Medical Home
CM Hub
PCMH Team CCM Team
PCP CM
Care Management Structure
Challenges for Population Health & Care
Management Interventions: Drops in Potential
Adapted from J Eisenberg JAMA. 2000
Engagement
Finding opportunities
for improvement
Intervention
Identification
Potential opportunity
Realized improvement
Challenges for Population Health & Care
Management Interventions: Drops in Potential
Adapted from J Eisenberg JAMA. 2000
Engagement
Finding opportunities
for improvement
Intervention
Identification
Potential opportunity
Realized improvement
• To align population, intervention, & outcomes
• Select a population at risk for future poor outcomes for which planned interventions can improve outcomes
• Tools: Quantitative, Qualitative, Hybrid
• Key Challenges
– Dynamic nature of risk
– Lack of full picture
– Care sensitivity is patient & program dependent
Goals of Population Risk Stratification & Segmentation
Effective Targeting of Care Management
Population Volume
Healthy
Chronic Illnesses
Medically Complex/ High Utilizers
Area of Greatest Opportunity?
Area of Greatest Opportunity?
Area of Greatest Opportunity?
Complexity defined by Charlson & estimated Physician-defined Complexity (ePDC)
Complex
by
Charlson
24%
Complex
by
ePDC
37%
Complex
by
Both
39%
Total
Complex = 27,531 (19.2%)
Source: Hong CS JGIM 2015
0%
5%
10%
15%
20%
25%
30%
Not complex Charlson Only PDC Only PDC_Charlson
Primary Care Measures
Colon Cancer Screening DM A1c>9
Source: Hong CS JGIM 2015
*All p-values <0.05
0.00
0.10
0.20
0.30
0.40
Not Complex Charlson Only PDC Only PDC_Charlson
Acute Care Utilization (per person year) Over 4 Years
Admissions ED Visits
Source: Hong CS JGIM 2015
*All p-values <0.05
Clinical Outcomes by No Show Propensity Group
Source: Hwang AS JGIM 2015
Acute Care Utilization by No Show Propensity Group
Source: Hwang AS JGIM 2015
Challenges for CCM Programs: Drops in Potential
Adapted from J Eisenberg JAMA. 2000
Engagement
Finding opportunities
for improvement
Intervention
Identification
Potential opportunity
Realized improvement
Importance of Continuous Quality Improvement
• Design + Implementation = Effectiveness
• Track Quality Measures – Process & Outcome
• Example – IT Enabled, Team-based Care
– Embedded advanced analytics paired with role delineation
– For program management & quality improvement
• Rosters are all role-specific • Rosters are all actionable
• A user can send a task to another user
• A population-oriented care plan enables the user to see all that is happening with a patient
• A care team can be set up to include members that are typically not part of a care team
Important concepts for program planning
• Build strong relationships
• No perfect model
– Start with the best approach for the context/population
– Then use continuous quality improvement to improve
• Keys to efficient population management
– Work in multi-disciplinary teams
– Complement existing services
– Allocate resources to high-yield activities
– Focus on mutable issues (know your system’s assets)
– Use HIT infrastructure to enhance CM efficiency
Los Angeles County Care Connections Program & Beyond
Clemens Hong MD MPH
GIH Annual Conference
March 11, 2016
Using complex care management teams to improve care & reduce costs
Specially-trained, multi-disciplinary care teams
32
One proposed solution
to address healthcare cost problem
CCP
Admit/ ED
Care Connections Program (CCP) Aims
$
Serving ≈5% of LAC DHS’s Patients
≈20,000 out of 400,000 primary care patients
• Complex biopsychosocial needs
• Hard to engage • High utilization of
health care • High cost of care
Panel within a Panel
Patient- Centered Medical Home
PCMH Team CCM Team
Current Model Acute & Post-acute Facilities
Specialty Care
Providers
Behavioral Health
Home Health &
VNA
Social Service
Agencies
Government Service
Agencies
Public Health
Agencies
Payers & Purchasers
PCP CM
Patient- Centered Medical Home
Central CCM Hub
PCMH Team CCM Team
CCP “Enhanced” Model Acute & Post-acute Facilities
Specialty Care
Providers
Behavioral Health
Home Health &
VNA
Social Service
Agencies
Government Service
Agencies
Public Health
Agencies
Payers & Purchasers
PCP – CHW – RN
PCP
Care Connections Team
CHW PCMH
Embedded
Acute Event or Status Change
CCP Program Overview
Comprehensive Needs Survey
Care Transition Work if needed
Patient Engagement
Care Plan Development
Accompaniment/Routine FU
visits
Follow-up Assessment
Face-to-face: Hospital, Clinic Or home visit
“Step Down”
Revise Care Plan if needed
Patient Engagement
CHW Role
Social Support
Comprehensive Assessment
& Care Planning
Health System Navigation
Care Transition Support
HospitalReadmission
Earlydischargeplanning
Contactinpa entteam/CMin24H
ContactPCPin24H
ChecksinwithInpa entteam/CMdaily&par cipatesinD/Cplanning
GivePCPupdateswithchangesinpa entstatus
Ensurecoordina onwithfamily/caregivers
Hospitaltohometransi on
Visitpa entatdischarge
Reviewdischargeplan&transi onalcareplan
Performmedica onreconcilia on&addressesmedica onmanagement
Educatepa entonred-flags&createred-flagsac onplans
Ensurecoordina onwithfamily/caregivers
Schedulefollow-uphomevisitwithin72Hpost-D/C
Schedulefollow-upPCPvisitfor1weekpost-D/C
Homevisitswithin72Hpost-D/C–reviewtransi onalcareplan,medica on,&red-flags
Assessneedfordiseasemonitoringdevices/DME
Assessneed/desireforadvanceddirec ve/goals-of-careplanning
Updatecareplanasneeded
Accompanypa enttopost-D/CPCPvisit
Addressingriskfactorsforacutecareu liza on
Assessforunmetsocialandresourceneeds
Assessforbarrierstocare
Engagesclientinbehaviormodifica onusingMI
Assessforhome-health&community-basedcareneeds
Primary Drivers Activities Outcome
Readmission
Driver Diagram
Patient Engagement
CHW Role
Social Support
Comprehensive Assessment
& Care Planning
Health System Navigation
Care Transition Support
Chronic Disease Support &
Health Coaching
Patient Engagement
CHW Role
Social Support
Comprehensive Assessment
& Care Planning
Health System Navigation
Care Transition Support
Chronic Disease Support &
Health Coaching
Advanced Illness management
support
A Multi-faceted Program
Community Health Workers
Care Without Walls
Community Engagement
Social Needs Navigation
Care Transition & Acute Care Planning
Chronic Disease Management
Data-driven Improvement
Components
Advanced Illness Management
Pharmacy Intervention
Phase 1: Demonstration
March/April 2015 – March
2017
5 DHS primary care practices in South and
East LA
Hire 25 CHWs CHW training by WERC &
Anansi Health 1,250 patients
Phase 2: Expansion
Apply lessons from Phase 1 Replicate model across LAC DHS
Up to 15X expansion possible
Challenges
• Poor baseline health system infrastructure – Data Integration & real-time data access
• Implementation – Front-line provider engagement & patient selection
– Perception of program as “External”
– Poor understanding of intervention & CHW role
– Consistent delivery of intervention
• Culture “Clash” – Innovation vs “production engine”
CHW Training/Supervision
• Training Topics
– Motivational Interviewing/Harm Reduction/Trauma-Informed Care
– Chronic disease self-management support – health coaching
– Goal Setting/Care Planning
– Program protocols – emergency, medication review
– Disease specific topics
– Other core competencies – boundary setting, safety
• CHW Supervision
– Programmatic – CQI meetings, performance evaluation
– Clinical – Weekly one-on-one, Monthly group, case conferences
• Clinical Support – Primary care team
Patient Selection Approach
Hybrid Approach – quantitative gate 1. Primary care team refers patients based on criteria 2. Criteria verified through chart review 3. Randomly select subset of patients for the intervention 4. PCP Over-ride
High-risk criteria: – 2 Acute Care Utilization Equivalents (1 admit = 2 ED visits = 4 UC visits) – 1 Acute Care Utilization Equivalent PLUS 1 High-risk condition:
• CHF, IHD/Stroke/PVD, COPD, Asthma, DM w/ A1c>9, Uncontrolled HTN w/ cardiac/renal complications, ESLD, ESRD, progressive dementia/Anxiety/Depression/Bipolar disorder/psychotic disorder with functional impairment, Active Substance Use Disorder, or Age>90yo (HIV carved out)
– Poorly controlled chronic condition with co-occurring mental illness or substance use disorder independent of acute care utilization
• Rosters are typically disease-centric, not ideal for patient outreach
• 1-view – a roster of rosters centered around patients
• This roster is optimized for outreach • With 1 click on the arrow to the left…
• A row expands, and opens a pane displaying contact information, all the notes across all diseases pertaining to that patient, and a section for the user to enter a note