The Intersection of Population Health & the Health Care Workforce – Considerations for the Future

Anthony Keck EVP System Innovation and Chief Population Health OfficerBallad Health tony.keck@balladhealth.org

June 28, 2018

About Ballad Health

• Created by the merger of Mountain States Health Alliance and WellmontHealth System eff. 02.01.2018

• 21 hospitals, including:

o Three tertiary centers

• Two Level I and one Level II trauma

o Thirteen community hospitals

o Dedicated children’s hospital

o Freestanding inpatient behavioral health

o Three critical access hospitals

• 500+ free-standing SNF beds

• Outpatient MAT clinic

• Wound care, sleep labs, home care, DME, hospice, retail pharmacies

• 800+ provider group practice

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About Ballad Health

• 15,000+ team members

• 106,940 annual inpatient discharges

• 477,647 annual ER visits

• 2.8 million+ annual outpatient visits

• $2.17 billion annual revenue

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About Our Region

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• Mountainous terrain ofSouthern Appalachia

• Serving 29 counties in Tennessee, Virginia, Kentucky and North Carolina

• Approximately 1 million residents in the service area

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About Our Region

State Health Rankings:

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➢ Core “urban” counties of Washington and Sullivan rank 2 and 4 for clinical care

County Health Rankings – Health Outcomes by County

TENNESSEE VIRGINIA

Washington 19 of 95 Washington 63 of 133

Sullivan 25 of 95 Grayson 72 of 133

Greene 41 of 95 Wythe 78 of 133

Carter 47 of 95 Scott 92 of 133

Hamblen 55 of 95 Smyth 102 of 133

Unicoi 64 of 95 Russell 113 of 133

Hawkins 70 of 95 Tazewell 118 of 133

Johnson 77 of 95 Lee 119 of 133

Hancock 86 of 95 Buchanan 122 of 133

Cocke 92 of 95 Wise 124 of 133

Dickenson 125 of 133

TENNESSEE: 45th of 50 VIRGINIA: 19th of 50

Social Determinants of Health

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Accountable Health Communities Grant

• $2.52M in funding over 5 years to test if navigation services to Medicare and Medicaid beneficiaries would lower the overall cost of care

• 75,000 eligible Medicare and Medicaid beneficiaries will be screened for emergency department utilization and unmet social determinants of health

o Screenings occur in emergency departments, labor & delivery, inpatient psychiatric, and primary care providers

o All beneficiaries with identified unmet needs will receive community referral summary listing local resources

o At least 2,048 beneficiaries will receive navigation services (must have reported two or more ED visits in past 12 months and at least one unmet social need)

• Partnering with Virginia Department of Medical Assistance Services (DMAS)

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AHC Grant - Screening Tool (Self-Reported)

• ED utilization of past 12 months

• Describe current living situation (i.e., steady place to live or not, mold, pests, lack of heat, water leaks, smoke detectors, lead pipes/paint, working oven)

• Within past 12 months, ever worried about having enough food or food running out

• Any issues with reliable transportation for daily living

• Within past 12 months, have any utility companies threatened to shut off services

• How often is your safety threatened (i.e., physically, insults, threats with harm, screaming/cursing)

• Series of demographic questions (i.e., gender, ethnicity, race, education level, size of household, annual household income)

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AHC Grant - Pilot Experience - Screening

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2,547

1,602

1,165

598

256

0

500

1,000

1,500

2,000

2,500

3,000

BeneficiariesScreened

High RiskBeneficiaries

Beneficiaries withNeeds

BeneficiariesRandomized

Nu

mb

er o

f C

om

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Screen

ing

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Pilot-Screening Results(As of 4/17/18)

Control

Navigation

854

AHC Grant - Pilot Experience - Screening

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32%(815)

21%(525)

4%(110)

19%(478)

14%

(358)

0

100

200

300

400

500

600

700

800

900

Food Housing Safety Transportation Utility

Percen

t o

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om

ple

ted

Screen

ing

s

Pilot-Screening Results(As of 4/17/18)

A new model is needed

• Unlock some portion of the 30%+ of waste in the health system by reducing the wasteful duplication of resources created by two competitors simply shifting market share back and forth a few percentage points each year.

• Redirect these savings into better access and quality and invest in community based resources to improve the social determinant profile of our region.

• Build responsive services and systems by listening better to our patients and community rather that “medsplaining”.

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Certificate of Public Advantage & Cooperative Agreement

COPA Terms of Certification / Virginia Order Authorizing Cooperative Agreement

• Tennessee TOC: 116 Pages• Virginia Order: 151 Pages

• TOC 7 Sections

o Definitions

o Statutory Requirements and Factual Findings

o Monetary Obligations and Commitments

o Non-Monetary Obligations and Commitments

o Managed Care Contracts and Pricing Limitations

o Active Supervision

o Miscellaneous Provisions

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Ballad Health’s investments in our region

$85 million toward behavioral health to create capacity for residential addiction recovery services and develop community-based mental health resources, like mobile health crisis management teams and intensive outpatient treatment options.

$85 million in academics and research to educate and train healthcare providers that are in short supply, and build the research capacity of local universities and colleges to spur outside research investment.

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Ballad Health’s investments in our region

$75 million to address key population health needs, focusing on some of our most serious health challenges like diabetes, heart disease and infant mortality.

$28 million toward rural health services, including better access to same-day primary care, support for maternal and prenatal health, and more.

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Ballad Health’s investments in our region

$27 million toward children’s services to create pediatric emergency rooms in Kingsport and Bristol and expand pediatric telemedicine, mobile health and specialty clinics in rural areas.

$8 million to enable health information exchange to allow healthcare providers both inside and outside of Ballad Health to easily share health information that improves patient care.

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Indices and Measures

• Population Health Index – 26 measures

• Access to Care Index – 28 measures

• Quality Index – 16 measures

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Indices and Measures – Population Health

Category COPA MeasureSmoking Smoking (% of adults self-reported as smokers)

Smoking Mothers who smoke during pregnancy

Smoking Youth tobacco use

Obesity Physically active adults

Obesity Physically active students

Obesity Obesity- Counseling & Education

Obesity Overweight and obesity prevalence among TN Public School Students

Breast Feeding Average mPINC score

Breast Feeding Breastfeeding initiation

Breast Feeding Infants breastfed at six (6) months

Substance Abuse NAS Births

Substance Abuse Drug deaths

Substance Abuse Adults - Prescription drugs

Vaccinations Children - On-time vaccinations

Vaccinations Vaccinations - HPV Females

Vaccinations Vaccinations - HPV Males

Vaccinations Vaccinations - Flu Vaccine, older adults

Child Health Teen pregnancy rate

Child Health 3rd grade reading level

Child Health Dental sealants (children 6-9)

Child Health Dental sealants (adolescents 13-15)

Child Health Infant mortality

Child Health Low birthweight

Mental Health Frequent mental distress

Diabetes # of people with pre-diabetes identified and referred to a prevention program

Mortality Ratio of premature deaths (higher density / lower density counties)

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Indices and Measures – Access to Care

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Category COPA MeasureED Pediatric Readiness of ED

ED Excessive ED Wait Times

Patient Access Specialist Recruitment and Retention

Patient Access Personal Care Provider

Utilization Preventable Hospitalizations - Medicare

Utilization Preventable Hospitalizations - Adults

Screenings Screening - Breast Cancer

Screenings Screening - Cervical Cancer

Screenings Screening - Colorectal Cancer

Screenings Screening - Diabetes

Screenings Screening - Hypertension

ED Asthma ED Visits - Age 0-4

ED Asthma ED Visits - Age 5-14

Perinatal Prenatal care in the first trimester

Mental Health Follow-Up after Hospitalization for Mental Illness (Children 6-17)

Mental Health Follow-Up after Hospitalization for Mental Illness (Adults 18+)

Mental Health Antidepressant Medication Management - Effective Acute Phase Treatment

Mental Health Antidepressant Medication Management - Effective Continuation Phase Treatment

Substance Abuse Engagement of Alcohol or Drug Treatment

Substance Abuse SBIRT administration - hospital admissions

Substance Abuse Rate of SBIRT administration - ED visits

Patient Experience Patient Satisfaction and Access Surveys

Patient Experience Patient Satisfaction and Access Surveys - Response Report

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Our Approach

Expanded Chronic Care Model

ECCM Model: Ballad Population Health Focus and Strategies

1. Develop population health infrastructure within the health system and the community• Ballad Department of Population Health• Accountable Care Community

2. Redesign Ballad as a community health improvement organization• Delivery system improvement and redesign• Information systems and decision support and information

exchange• Improved self-management and personal skill development

3. Enable community resources and sound health policy• Strengthen community action• Advocate for sound health policy• Create supportive environments

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Behavioral Health

Children’sServices

Rural Services

Population Health

Strategic Themes Across All Plans

• Early Intervention/Strong Starts

Theme #1

• Alternative Points of Access

Theme #2

• Team-Based Care & Navigation

Theme #3

• Integrated Behavioral Health

Theme #4

Workforce demands

Community based health workers

• Peers

• Parish nurses

• Promotoras/CHWs

• Navigators

• Community engagement specialists

Behavioral health specialists

• Psychiatrists

• Psychologists

• LCSW

Mid-level providers

• APNs

• PAs

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Technologists

• Data scientists

• Programmers

• Operational excellence

Primary care capacity and productivity

Competencies

• Team based care

• Patient engagement/active listening/motivational interviewing

• Community collaboration

• eHealth

• Implementation science

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Workforce Considerations for Population Health

What is population health?

1: Policies, systems and services designed to help each individual reach their fullest potential.

2: Whatever the payor says it is

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Workforce considerations

Relationship with a personal care provider is a strong predictor of better health. We are wasting considerable existing primary care capacity.

• Ineffective and burdensome data entry and charting

• Patients we don’t need to see physically or at all which clog up the system for those who need it most

• Activities better done by others

• Poor scheduling practices

• Lack of assistive technologies

• Too much low value care/too little high value care

• Too much “futile” care i.e care rendered useless because of unacknowleged social/environmental limitations

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Workforce Considerations

We need to get serious about behavioral health

• BH is a/the leading cause of disease burden in the world yet the private health care sector is generally content to let the government worry about it.

• Mental Health Parity has not been achieved

• Behavioral health training needs to be improved in primary care in residency and through continuing education

• We are not training a sufficient number of behavioral health providers

• We should expand capacity to provide telepsychiatry and to provide teleconsulting support to primary care – especially pediatrics

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Workforce Considerations

We need to change the way we train health care and public health professionals

• Interprofessional education and training (capstones, simulation, table top exercises)

• Poverty simulations and anti-racist training

• Public health and health systems cross-training

• Implementation science

• Culture of safety/failure analysis

• Communication – especially listening

We need to think about who we recruit. We need more providers who look like the community and have shared life experiences

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Workforce Considerations

FFS based payment systems inhibit population health

• FFS based payments systems tend to favor licensed professionals performing specifically defined health care services

• Global payments allow providers to determine what activities performed by what level of resource bring the most value to the patient

• Consolidation in hospitals and health systems combined with growing physician employment – especially primary care - may be inhibiting acceptance of more risk based contracts

We need to be comfortable with non-licensed professionals: peer counselors and mentors, community health workers, etc. We need to understand what they bring to the table and not try to “professionalize” them.

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