Population Health Management

The Triple Aim in Coordinated Care

Impacting Population Health

Presenter: Helen Dao, B.A., MHA Dao Consulting Services, Inc.

www.daoconsultingservices.com (201) 448-2046

[email protected]

September 29, 2016

Copyrigh(c)DaoManagementConsultingServices,Inc. 2016

�  Explain definitions and concepts associated with Population Health and Population Health Management

�  The role of health analytics in population health management

�  Identify where your organization is on a Population Health Management (PHM)

�  Implement care coordination interventions to foster better clinical outcomes across a population

�  Implement PDSAs Cycles to track population health management quality improvement

Learning Objectives


What Is Population Health?

AHRQ Definition: An approach to care that uses information on a group ("population") of patients within a primary care practice or group of practices to improve the care and clinical outcomes of patients within that practice.


What Is Population Health? AHRQ Definition: An approach to care that uses information on a group ("population") of patients within a primary care practice or group of practices to improve the care and clinical outcomes of patients within that practice.

Special needs

Asthmatics

Geriatric

Community

Diabetics

Gender

Ethnicity

Housing

Behavioral Health

HTN


Have you Heard about the Triple Aim?

The Triple Aim- is defined as 3 inter-dependent components:*

1.  Improving the health of a population

2.  Improving the patients experience of care

3.  Reducing the per capita costs of care for populations

*Donald M. Berwick, Thomas W. Nolan and John Whittington, doi: 10.1377/hlthaff.27.3.759 Health Affairs 27, no.3 (2008):759-769 The Triple Aim: Care, Health, And Cost


Population Health Includes: Improving health outcomes of the group as a whole by identifying, monitoring and addressing the health need of individuals within the group. 1.  Health outcomes for a defined group that is at risk

(based on agreement of metrics and measures of health)

2.  Patterns of specific health determinants for the group at risk

3.  A continuous integration of resources, procedural, clinical, and IT infrastructure is essential to creating a clinical integrated network to improve population health*

*Adapted from “Using Technology to Optimize Population Health Care Coordination Outcomes. December 10, 2014 by Wendy Vincent, R.N., National Practice Director, Beacon Partners”


�  Are outcomes clinically defined? �  Do they include things like functional status, well-

being or specific health behaviors like diet and exercise or smoking cessation?

�  Do they include nonmedical health determinants like economic or housing status?

�  Are patients with a specific medical condition? �  Are patients with par ticular demographic

characteristics, such as age or gender?

How to Define a Population or Group?

Adapted from “Population Health: The Risks & Rewards. February 10, 2014. Howard Larkin. Hospitals and Health Networks.” Copyrigh(c)DaoManagementConsultingServices,Inc. 2016

Leveraging Technology Analytics

�  Dashboard

�  Data on patient utilization (RHIO)

�  Routing eligible patients to programs

�  Report from Health Information Exchange (Clinical data)

�  Define the clinical data that you need to know and track


Creating a Framework �  Identify specific capabilities to manage and coordinate

population health management.

�  Develop specific capabilities to manage and integrate IT with analytics.

�  Develop a framework to integrate clinical networks and care coordination.

�  Strategize the creation of registries based on clinical outcomes and nonclinical.

Keep in mind that these changes may require significant system reorganization.


Getting Ready for Population Health Management

�  At an operational level organizations must change their structure as well as workflows to implement PHM and adopt new types of automation tools and reporting.

�  Setting clear and realistic goals and objectives. It is helpful to keep in mind the Triple Aim of the Institute for Healthcare Improvement: improve the experience of care, improve the health of populations, and lower the per-capita cost of care.

While population health is only one of these aims, achieving that objective would help organizations attain the other two.


Example of Health Registries by MCPs

Integrating gaps in care (i.e., HEDIS measures) into the PCP and care coordinators workflow.


Example of Health Registry by Condition


Example Use from Care Coordinators

“I like managing the daily hospital admission PHM registry. I visit patients at the hospital and identify needs for care coordination and complete bottom up referrals for the different CC programs.”

___________________

“I enjoy working with my PHM registry for colonoscopy because I am able to identify patients that may have misconception about the colorectal screening, and I refer them to the RN for patients education.”


Some Challenges �  Having accurate and timely information is essential for

population health management. This may include:

�  Access to complete medical records �  Accurate physician billing records �  Access to timely and accurate registries �  Ongoing collaboration with other organizations �  Defined collaboration with MCOs (Managed Care

Organizations) �  Having different systems such as EHRs, labs, and different

vendors �  Well trained staff �  Lack of effective workflows �  Lack of workforce �  Reconciling multiple lists from different sources


The How…Clinical Integration at Your Practice

�  Building an multidisciplinary integrated network requires physician leadership to design and implement team-based care models that make full use of available care resources.

�  Ongoing physicians and staff education on concepts including patient-centered medical homes and care coordination.


…And the How to Steps to Care Coordination

�  Making the best use of clinically integrated services requires ongoing care coordination.

�  Reducing unnecessary hospitalizations and urgent care in complex populations provides the greatest economic returns, and this is typically accomplished through intensive case management, disease management and coordination of home and outpatient care


Example of Population by Care Coordination Interventions


Example of Population by Care Coordination Interventions, Cont.


Example of Population by Utilization


Example of Population by Utilization, Cont.


Example of Super Users Pop


TEAM Coordination Actions are Defined and Routed by Program

Algorithms

Source: Himms – Transforming Health Through IT. 2015.


Population Health Management Workflow QA/IS&collaborate&in&identifying&target&population&&

Registries&are&generated&&&distribute&based&on&specific&identified&subpopulations&

According&to&priorities:&• Diabetes(• Hypertension(• Asthma(• Heart(disease(• Chronic(Renal(Failure(• COPD((• Substance(abuse(• ADHD(• Depression(• Other((

Pop&2:&By&Complexity&

Care&Coordination&Registries(assigned(and(managed(by(care(coordinators(to(activate(outreach(activities(

Pop&3:&by&Age&Group&

Pop&1:&By&Disease&

Manage&chronic&conditions&+&social&determinants&of&health:&

• Diabetes(• Hypertension(• Asthma(• Heart(disease(• Chronic(Renal(Failure(• Serious(mental(illness:(

Schizophrenia/Bipolar(Disorder(

• Other((

Care&Coordination&Registries(assigned(and(managed(by(care(coordinators(to(activate(outreach(activities(+(develop(care(plans(

According&to&priorities:&• Immunizations(• Well(care(visits(• Care(for(Older(Adults(

(COA)((

Pop&4:&by&Social&Determinants&of&Health&

According&to&priorities:&• Housing(• Employment(• Benefits(• Health(care(services(• Education(• Support(system(• Food(• Safety(• Other(

Care&Coordination&Registries(assigned(and(managed(by(care(coordinators(to(activate(outreach(activities.((Conduct(chart(review(to(collect(data.(

Care&Coordination&Patient(group(assigned(based(on(nonclinical(needs(

Registry& Registry& Registry& Registry&


Example of Health Registries by Disease & Priorities


How to Improve

�  Quality assurance of workflows and data are important components of registry success. The goals for quality assurance should be established for each registry, and the efforts made and the results achieved should be described.

�  IHI uses the Model for Improvement as the framework to guide improvement work.

�  Learn about the fundamentals of the Model for Improvement and testing changes on a small scale using Plan-Do-Study-Act (PDSA) cycles.

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx Copyrigh(c)DaoManagementConsultingServices,Inc. 2016

Now what? �  Implementing Changes

After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, now we implement the change on a broader scale — for example, for an entire pilot population or on an entire unit.

�  Spreading Changes After successful implementation of a change or package of

changes for a pilot population or an entire unit, now we can spread the changes to other parts of the organization.

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx Copyrigh(c)DaoManagementConsultingServices,Inc. 2016

In Summary �  Effective and continuous coordinated care is the key to

improving patient’s satisfaction, lowering health care cost, and getting good at coordinating care for different subpopulations needs in order to improve clinical and nonclinical outcomes.

Let’s review:

�  The Triple Aim- is defined as 3 inter-dependent components:* �  Improving the health of a population

�  By the use of PHM registries and integration of care coordination intervention as well analytics

�  Improving the patients experience of care �  Outreach, engagement, resources, and continuum of care

�  Reducing the per capita costs of care for populations �  Preventing hospital readmission, duplication of services such as

labs, care coordination, etc


Q&A

Helen Dao, B.A., MHA

Dao Consulting Services, Inc.

(201) 448-2046 / (201) 686-7152

[email protected]


Population Health Management

Healthcare

Transcript of Population Health Management