Population Health Management Defined - PowerPoint Presentation

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Population Health Management DefinedApril 12, 2015

Tim Miksch, Section Head, Applied Clinical InformaticsThe Mayo ClinicClaudia Blackburn, Senior ManagerAspen Advisors, Part of The Chartis Group

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.Slide2

Conflict of Interest Disclosure

Tim Miksch, MBAHas no real or apparent conflicts of interest to report.Claudia Blackburn, MBAIs employed by Aspen Advisors, Part of The Chartis Group, which provides services that are discussed as a part of this presentation.

© 2014 HIMSSSlide3

Learning ObjectivesIdentify how to align an organizational healthcare model with a value-based reimbursement model to support the allocation of resources for high risk patients

Explain definitions and concepts associated with Population Health and Population Health Management Summarize the role of analytics in developing and evaluating programs and processesIdentify where your organization is on a Population Health Management (PHM) maturity roadmap

PHM Core Competencies

Case Study

Challenges and Next StepsSlide4

An Introduction to the Benefits Realized for the Value of Health PHM IT

http://www.himss.org/ValueSuiteSlide5
Slide6

Population Health Management (PHM)The Future of Healthcare Paradigm Shift

Today:Reactive andVolume-based

The Future:Proactive andValue-based

Drivers

Health Reform

Affordability Gap

Triple Aim

Weight of the Nation

Reimbursement

Encourage

me!

Educate

me!

Treat

me

holistically!!

I will pay

y

ou!

Individuals are accountable for their health

with the health system as their health advocate.

Population

health management

provides comprehensive

authoritative strategies for

improving the systems and

policies that affect

health care quality, access,

and outcomes, ultimately

improving the health

of an entire populationSlide7

Engaged Communities

Proactive care processes

Identified patientsFocused on wellnessCommunity resource navigatorEngaged PatientsIdentified and incorporated patient goalsFocused on continuity and coordinationFacilitated communication channels

Improved access to care

Identified Opportunities to Reduce

W

aste4 Rights

Duplication

a

voided

Improved coordination/transitions

Used automation to reduce resource needs

Improved screening and prevention

Aligned incentives to drive value

7

Achieving Success

Making the “Triple Aim” Possible

Better Health

for the PopulationSlide8

Population Health Management Core Competencies and Key PillarsSlide9

Population Health Management (PHM)

Core Competencies

The goal of population health is to transform care delivery practices and administrative support to deliver improved outcomes and lower costs across the continuum of care for a specified population. Success will depend on changes in care practices, business processes and cross-organizational communications, all supported by information technology.

Member Engagement

Cross-Continuum Care Delivery and Medical / Care Management

Quality Outcomes Management / Reporting

Operational Performance Management

and

BI

Accounting

Integration

and InfrastructureSlide10

PHM Competency Characteristics

CompetencyFoundationalAdvancedInnovative

Member engagementWebsite of offerings availableInteractive site, smart phone, incentives Coach proactively encouraging healthy behaviorCross-continuum care delivery and medical / care management

Sites of care operate

in silos, handoff on paper, relying on patientSome care planning and handoff between sites of care

Consistent care planning, monitoring, consolidated clinical data views, different communication and seamless hand-offs among care settings

Quality outcomes management / reporting

Registries

in the EHR

Registries within a data warehouse with multiple feeds

Measuring and monitoring across the continuum of care,

including

all participating entities

Operational performance management / BI

EHR reports such as MU attestations

Data

warehouse with analytics for reporting

Constant monitoring of how they are performing to key business and care metrics

from analytics engine

Accounting

Financial and PHM systems for analysis and payment incentive in Excel or other non-integration tool

Some integration and analytics to provide individual and provider incentives

Real-time reporting of status for both individuals and providers towards shared savings and incentives such as through portals

Integration and infrastructure

One or few systems

are not integrated causing redundant work

Most systems are integrated,

but one longitudinal record does not exist electronically

Track all population members, providers, encounters, and assure

information sent from one system goes to the right destination (system) for the right patient, with appropriate data translation, normalization and securitySlide11

Key Pillars of Population Health Management

Workflows, role changes, people, care coaches, wellness program development, heath risk assessment process, population engagementBusiness vision, population definition, policies, modeling, financials, contracts, procedures, market analysis, and

value propositionIntegration and interoperability including HIE, patient portal, analytics, coaching tools and health risk assessmentRisk, incentives, payment management, shared savingsSlide12
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Mayo Community Practices

MAYO CLINIC in the MIDWEST

Community and Regional Health System

75 communities in

MN, IA

and

WI

4 regions

18

hospitals

525,000 patients/year

1,000+ physicians

Primary care

At risk for PC

Arizona

90,000 patients/year

Approx. 400

physicians

Primary care

At full risk for PC

MAYO CLINIC in the SOUTHWEST

MAYO CLINIC in the SOUTHEAST

Florida

90,000 patients/year

Approx. 400 physicians

Primary care

At full risk for PC

Academic Medical Center

Rochester,

MN

500,000 patients/year

2,000

physicians

125 primary care providers

Primary care

At full risk for PCSlide14

Office of Population Health Management

Formed in 2012

Developed a Mayo framework for PHM

Strategy

Phasing

OversightCoordinationStandardization

Focused on the community practicesInitially focused on primary careValue-based care

Patient-Centered Medical Home

Risk based reimbursementSlide15

The Changing Market

Source:

“The View from Healthcare’s Front Lines: An Oliver Wyman CEO Survey”Slide16

WHAT?

MMoCC

is an enterprise-wide, multi-year roll-out to achieve the

TRIPLE AIM:

Improve Population Health

Improve Individual Experiences

Lower Costs

While aligning with financial models

Changing isn’t just for survival

The new model allows us to thrive

The Mayo Model of Community Care (MMoCC)

Implemented in strategic phases

WHO?

Office of Population

Health Management

(OPHM)

Created by MCCPC to TRANSFORM Community Care

OPHM establishes the

STANDARDIZED ELEMENTS

for clinics to implement with

APPROPRIATE LOCALIZATION

A new way of practicing is needed

OPHM defines strategy for the new model

Costs are rising

Reimbursement is decreasing

The measure of PRODUCTIVITY is

no longer VOLUME

It is

VALUE =

Small changes are not enough

Outcomes

+

Service

Cost

Our survival is at risk

WHY?Slide17

Vision

Patient centered, integrated care delivery modelbased on:Aligned incentivesCoordinated, collaborative processes

Evidence-based prevention and disease management protocolsSeamless sharing of informationSupported by wellness and continuity care programs that focus on:Patient engagementCommunity integrationPrevention and health promotionDriven by analytics to support quality outcomes and value-based accountable reimbursementSlide18

Office of Population

H

ealth Management

Geographic Operations

Arizona Office

Florida Office

Midwest Office

Functional Subgroups

Change Mgmt./ Communications

Data Analytics

IT Tools and Application

OPHM

Advisory Group

Programs

Prevention

Community Engagement

Wellness

Care Coordination

Chronic Condition Management

P

alliative Care

Care Transitions

Team-based Care

Patient Engagement

Access

Health & Wellness

Continuity Care

Executive Team

Mayo Clinic Clinical Practice CommitteeSlide19

MMoCC Focus Areas

50%

15%

35%

35%

15%

50%

COST

% of community

POPULATION

Wellness

Prevention

Disease

Management

Care Coordination

Care Transitions

Palliative Care

PHM FOCUS

2010 data from Mayo Clinic Health Sciences Research

Care teams

Patient

engagement

Community engagement

AccessSlide20

MMoCC Impact

80% of costs

Lifetime

Ability to impact

Complex

active

illness

Symptomatic

illness

High

risk

Early

risk

Situational

risk

Family Hx

Environment

Diet

Exercise

Cholesterol

BP

Blood sugar

Active Dz

Diabetes

HEALTH STATUS

HEALTH CARE SPEND

Act on opportunities

Identify opportunitiesSlide21

ASSESS

STRATIFYPopulation Identification

Health AssessmentRisk StratificationEnrollment / Engagement Strategies Management / Interventions

1

DEFINE

2

3

4

ENGAGE

5

MANAGE

Tailored Interventions

—

Care Coordination

—

Disease / Case Management

—

Health Risk Management

—

Health Promotion / Wellness

Meeting patients where they are

…physically

home | school | work | shopping | in the clinic

…in the way that works best for them

email | text | internet | phone | video | face-to-face

MMoCC ProcessSlide22

Phased Implementation

MMoCC 2Laying the foundation while living in FFS

Introduces value-based (TCOC) concepts and model (change management)Emphasis on team-based care foundation and care coordination introduction

Standardized disease management and prevention recommendations

Focus on decreasing high utilization where it makes sense (30 d readmits…)

MMoCC

4

Requires

value

-

based

contracts to succeed

MMoCC

3

More site resource investment –

mixed

volume/value

Shifts from individual practice to

team-based

panels

Continues focus on high utilization and expanded analytics and care

management

Increases focus on patient important outcomes

Strong shift to total cost of care drivers

Adds specialty integration to care team concept

Community engagement

Full alignment of incentivesSlide23

Diffusion Timeline

MMoCC Limited Implementation

2013201420152016

MMoCC

Previous

MMoCC 2 Foundation

MMoCC 3 Mixed

MMoCC 4 TCOC

PILOT 4-6 SitesSlide24

2015 StatusAll sites are actively engaged

Standardizing across sites and regions is a challengeFor many, fee-for-service remains a driverData management processes are maturingKeys to our success:Engaged leadership at local levelsInstitutional supportStrong physician leaders in each programExcellent business analysis, project management and informatics support in placeSlide25

Demand for healthcare

Supply of resources to meet demand

VALUE

=

Outcomes

+ Service

Cost

Our pay will be based on

We need to

utilize our staff wisely

through

Identify opportunities

to

impact

health earlier

and

act

on

those opportunities

We

need to think differently about how to

activate

our patients and communities

And

how we

interact

with them

TEAM-BASED

CARE

ANALYTICS

CARE MGMT SYSTEM

PREVENTION

DISEASE MGMT

PATIENT ENGAGEMENT

COMMUNITY ENGAGEMENT

WELLNESS

ACCESS

PALLIATIVE CARE

CARE TRANSITIONS

CARE COORDINATION

StructureSlide26

Analytics and Reports Examples

Report Description

Registration

Unassigned and wrongly assigned patients

Unassigned Emergency Department high utilizers

Care Coordination

Diabetic Mellitus (DM) patients who are most likely to be readmitted

Congestive Heart Failure (CHF) patients who are most likely to be readmitted

30 day readmission reports are located within the Care Coordination dashboard with DM and CHF 20%. Follow instructions from section 2.1 and 2.2

Patients by Disease Evidence Type

Patients with no Diabetes diagnosis but have other evidence of Diabetes

Patients with no CHF diagnosis but have other evidence of CHFSlide27

Example Use from Care Coordinators

Care Coordinator identified a patient based on ER visits and reached out to her. She was very interested in COMPASS and did the PHQ9, and it was 17. “She was very interested in changing her life so that she could be around for her granddaughter. I have sent her a letter and will keep her on my watch. It was a good connection to at least let her be aware that services are available if and when she is ready.”“I have a patient who, because of care coordination, has improved her health to move from the PHM tool CHF “most” to the “more” list. The PHM tool still identifies her as higher risk, but she has done well with care coordination.”“It mostly has been helpful to me to identify patient populations that might be eligible for care coordination to reach out to the providers to get them on board with care coordination, pointing out that the PHM tool has already identified them as being higher risk.”Slide28
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2015 NEXT STEPS

CHALLENGES

Challenges and Next StepsPractice standardizationResources Can’t stop processes and can’t add resources to change

Needed to understand practice variation and standardize

Informatics knowledgeable in in EMR support teams

Challenge to implement tools to free up resources when processes and data aren’t standardized(IT, informatics)

Rapid cycle iteration is challenging for practice tools without significant resource involvement

Decision rights – “who says this is the new process….”

Enterprise metrics

Point-of-care registry and care management

Patient consumer engagement utilizing EMR patient portalSlide30

An Introduction to the Benefits Realized for the Value of Health IT

http://www.himss.org/ValueSuiteSlide31

Claudia BlackburnAspen Advisors, Part of the Chartis Group

cblackburn@aspenadvisors.net@cblack67 Questions?Thank You!

Tim Miksch The Mayo Clinictmiksch@mayo.edu@tmiksch