POPULATION_HLTH_MGMT

Transforming Population Health

through Care Teams and Enabling Technology

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TRANSFORMING POPULATION HEALTH Through Care Teams & Enabling Technology

FIERCEHEALTH IT WEBINAR JULY 17, 2014

Confidential 7/17/2014 Slide 3

» Trends and forces driving the

transformation of healthcare delivery

» Clinical care redesign, including

key barriers, new IT solutions, and

best practice models

» Texas Tech University Health Sciences

Center—population health objectives,

approach, and progress

» The story of Kryptiq CareManagerTM,

a market-leading PHM solution

» Interactive Q&A

TODAY’S DISCUSSION


» Dr. Ogechika Alozie Chief Medical Information Officer

Texas Tech University Health Sciences Center at El Paso

» Greg Caressi SVP Healthcare and Life Sciences

Frost & Sullivan

» Dr. Jaquelyn Hunt Chief Population Health Officer

Kryptiq and IHI Fellow

» Nathan Loveless Regional Vice President

Kryptiq

OUR SPEAKER PANEL

TRENDS & FORCES IMPACTING PHYSICIAN PRACTICES AND

INTEGRATED DELIVERY NETWORKS


» Healthcare initiatives—Triple Aim,

population health management, mobile

health, patient engagement—are to identify

and intervene to improve outcomes

Heart Disease

Stroke Cancer

Diabetes

Hypertension

Obesity

•Source: CDC and Frost & Sullivan analysis

More than 75% of healthcare costs are due

to chronic conditions (CDC, 2009)

Source: Frost & Sullivan

TARGETING CHRONIC CONDITIONS



PROCESS

CHANGE ANALYTICS INTEGRATION DATA

We are creating

millions of useful

data points,

from a wide

variety of

sources…

…But the data is

provided in

separate solutions

which prevent

getting a holistic

view of the patient

Predictive analytics

has arrived…Natural

language processing

will become a

commodity…

…But working with

only part of the data

Analytics alone cannot

transform healthcare.

Analytics need to

create actions, with

prompts and

information embedded

in workflows

(not in stand-alone

platforms)

HURDLES TO REACHING PROMISE OF DIGITAL HEALTH


GREAT LEAP FORWARD TO ACCOUNTABLE CARE

ANALYTICS

» Actionable information?

» How is it delivered?

» At what cost?

CARE DELIVERY SHIFTS

» Where to start?

» How to impact patients?

» Fix it earlier?



INPATIENT

CARE

WELLNESS

SERVICES

AMBULATORY

CARE

HOME

CARE

PATIENT

ENGAGEMENT

DATA

ANALYTICS

IMAGING

DIAGNOSTICS mHEALTH

CHRONIC

MANAGEMENT CDS @ POC

INVESTMENTS TO MEET ACCOUNTABLE CARE GOALS

CONDITIONS OF FOCUS

» Diabetes

» Cardiovascular conditions

» Chronic Obstructive Pulmonary Disease (COPD)


Source: The Institute for Health Technology Transformation, and Frost & Sullivan

» Success in PHM depends to a large

degree on changing the culture of

healthcare providers › Acceptance of data

› Utilization of data in changed processes

› Tracking and adjusting at individual and

organizational levels

» Solutions that can support change

management have a greater impact

» Impactful solutions have been tested

and incubated in healthcare provider

organizations

Define Population

Identify Care Gaps & Stratify Risks

Engage Patients

Manage Care

Measure Outcomes

AUTOMATED &

ONGOING

Data Integration

Analysis

Reporting

Communications

& Alerts

PHM IS A FOCUS OF INVESTMENT


Improving chronic care means addressing the following issues (ICIC):

Sources: Improving Chronic Illness Care, and Frost & Sullivan

Rushed practitioners not following

established practice guidelines

Lack of care coordination

Lack of active follow-up to ensure

the best outcomes

Patients inadequately trained to

manage their illnesses

Provide guidelines and individual

patient measures vs guidelines

Unified platform to share information

+ actions with care team

Dashboard of individual status and

follow ups needed for providers

Patient interaction, information and

motivational tools

OVERCOMING BARRIERS TO CHRONIC DISEASE CARE

CLINICAL CARE REDESIGN KEY CHALLENGES, EMERGING SOLUTIONS, AND

BEST PRACTICE MODELS


POPULATION HEALTH MANAGEMENT CAPABILITIES

High Functioning Primary Care

Care Management

Cohort Management

Patient Engagement

Quality & Change Management

Care team design, aligning work to licensure

Every patient, every time, every where

Support for frail and high need cohorts

Patient outreach and activation

Guiding organizational transformation


APPLYING TEAMS TO CARE


TEAMS AS A HEALTHCARE INTERVENTION

Shojania KG, et al. Effect of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control:

A Meta-Regression Analysis. JAMA 2006;296:427


THE FACTS

» This existence of primary care services improves Triple Aim outcomes

HOWEVER

» 52,000 = additional PCPs to care for population by 2015 (25% increase from 2010)

» 54.9% = average amount of recommended care received by American adults

» 22.6 hr/day = time required for a PCP to address all acute, preventive and chronic

care for a 2500 patient-panel

» 48.1% = PCPs reporting chaotic work pace

» 78.4% = PCPs reporting low control over their work

» 26.5% = PCPs reporting burnout

McGlynn E, et al. The Quality of Health Care Delivered to Adults in the United States NEJM. 2003;348:2635-45.

Petterson SM, et al. Projecting US Primary Care Physician Workforce Needs: 2010-2025 Ann Fam Med. 2012;6:503-9. Linzer M, et al. Working Conditions in Primary Care: Physician Reactions and Care Quality. Ann Intern Med. 2009;151:28-36.


ALIGN KNOWLEDGE & ECONOMICS


CONFIGURATION OF THE TEAM

Core Team

2

Paneled Providers

2-4

Team Medical Assistants

1

Patient Relationship Rep

1

Care Coordinator

(MA or LPN)

1 Advanced Practice

Practitioner (non-paneled)

Case

Manager

Behaviorist

Clinical

Pharmacist

Diabetes

Educator

Home Health

Nurse

Extended Team


PROVEN RESULTS

TEXAS TECH UNIVERSITY

HEALTH SCIENCES CENTER POPULATION HEALTH OBJECTIVES, TECHNOLOGY

REQUIREMENTS, AND OUTCOMES


TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER

» Texas Tech University Health Sciences

Center El Paso, the Texas Tech University

System’s fourth university, has a mission to

provide education, research, and patient care

to far West Texas and beyond.

» Trained close to 4K healthcare professionals

and treated close to 1.5 million patients

» Leader in education and patient care with

research studies underway in the areas of

infectious disease, neuroscience, cancer,

diabetes and obesity


» Collaborate with area hospitals

and health centers

» Improve the health of the

community

» Decrease disparities in

minority and rural populations

PURSUING THE “TRIPLE AIM”


DEVELOPING A SUSTAINABLE MODEL


PRIORITIZING THE CHALLENGES

» Care delivery

transformation—

team-based, aligned,

managed

» Clinical, financial,

patient-supplied data

» Identify data sources

needed to promote clinical

change


» Identify chronic disease groups to

measure

» Patients risk-stratified based upon gaps

in care or uncontrolled conditions

» Interventions scheduled according to

practices guidelines and care team roles

» Care coordinated by providing consistent

view across the teams

» End result should be improved outcomes

› Cost containment may follow

ENABLING OUR PHYSICIANS & STAFF


Pro

cesses

MEASURING & OPTIMIZING PERFORMANCE

*Sample Data – For Illustration Only

Outc

om

es


» Embrace cultural and organizational change

» Expand practice of PHM to additional patient populations

and targeted subgroups

» Continue to improve key quality performance

indicators to recognize upside

» Enhance patient satisfaction by focusing on core measures

» Leverage technology to automate tasks,

streamline communication, and improve outcomes

TAKING THE NEXT FEW STEPS


» Multi-modal outreach based upon

patient characteristics, risks, and

preferences

» Patient scorecard to support

informed conversations and

self-management

» “Surround sound” approach to

complement existing engagement

tools, including patient portal

FUTURE PLANS - ENGAGING OUR PATIENTS

KRYPTIQ CAREMANAGER ENABLING CARE TEAMS WITH CLINICAL AND

FINANCIAL DATA AT THE POINT OF CARE


» Clinics and group practices pursuing

PCMH initiatives

» Integrated delivery systems focused on

resource optimization or value-based

payments

» Require provider-led health risk

management delivered at

the point of care

COLLABORATING TO SOLVE PROBLEMS DIFFERENTLY


» Data ingested from

multiple sources

» Populations stratified

according to clinical

and financial risk

» Hidden opportunities

in patient cohorts

identified using

predictive modeling

PRIORITIZING PATIENT COHORTS

Stratify at-risk segments of the population


» Unwarranted

variation in care

reduced

» Care team practices

at the height of

licensure

» Patient is an active

member of the

care team

SUPPORTING CARE TEAMS AT THE POINT OF CARE

Optimize workflows in the clinic


» At-risk populations

stratified to receive

appropriate care

» Resources are

aligned for cost-

effective care

» Patients receive

personalized

messaging,

coordinated across

organization

ALIGNING TEAM TASKS, RESOURCES, & CARE PLANS

Coordinate resources across the enterprise


» Omissions,

commissions, and

gaps reduced

» Greater visibility to

enable appropriate

interventions

» Care history across

the continuum

TAPPING INTO THE SURESCRIPTS NETWORK

Synchronize care throughout the community


“Deepest EHR

workflow integration”

MARKET LEADER IN POPULATION HEALTH

INTEGRATED

51 customers,

7 years peer-reviewed results

Begin with single clinic,

Scale to entire system


QUESTIONS?

“CareManager really is a very

powerful tool. It allows staff to

function at the top of their licenses,

can be time-saving, and most

importantly, improves the care

we deliver.”

SUE SCANLIN

CHIEF TRANSFORMATION OFFICER

VP POPULATION HEALTH

CONTINUUM HEALTH ALLIANCE

THANK YOU

FOR MORE INFORMATION OR A DEMO:

[email protected]

www.kryptiq.com

Questions

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