Automating Population Health Management to Deliver Sustainable, High-Quality Care. Michael Matthews, CEO MedVirginia / inhealth

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1 Automating Population Health Management to Deliver Sustainable, High-Quality Care Michael Matthews, CEO MedVirginia / inhealth

2 Objectives Describe how to use technology to meet the challenges of population health management Transition from fee-for-service reimbursement to accountable care Identify how to automate routine tasks, including identification of care gaps, risk stratification to patient engagement, and care management Develop a strategy for measuring outcomes and using analytics to improve performance and financial sustainability 2

3 Better Aligned Incentives Improved Patient Outcomes Agreement on Principles The Journey Towards Improved Patient Access, Enhanced Clinical Outcomes, And Better Aligned Incentives Begins Here. Health Information Exchange Patient Access and Engagement Population Health Analytics Patient- Centered Medical Home Coordination of Care 3

4 Corporate Resume In production for seven years First HIE in production on NwHIN (2009) ConnectVirginia Statewide HIE (2011) Author and first signatory to DURSA (2009) First HIE to connect to SSA (2009) First HIE to connect to VA and DoD health records systems (2010) One of 5 HIEs to watch by CMIO magazine (2011) One of 12 HIE Leaders by NeHC (2011) 4

5 Definition The population health improvement model highlights three components: the central care delivery and leadership roles of the primary care physician; the critical importance of patient activation, involvement and personal responsibility; and the patient focus and capacity expansion of care coordination provided through wellness, disease and chronic care management programs. Care Continuum Alliance 5

6 Population Health: A new idea?? With our present amount of sanitary knowledge, it is as criminal to have a mortality of 17, 19, and 20 per 1000 in the Line, Artillery, and Guards in England, when that of Civil life is only 11 per 1000, as it would be to take 1100 men per annum out upon Salisbury Plain and shoot them. Florence Nightingale writing to Sir John Hall in

7 Ahead of his time. 7

8 Tipping Point? Percent GDP Value Medicare / Medicaid Insurance Tax codes Employer engagement Aging Consumerism Lifestyle Right vs. Privilege Uninsured Economic Social Clinical Technological Safety Best practice Therapeutic Diagnostic Genomic Pharmaceutical Decision Support EHR HIE Analytics mhealth Telemedicine 8

9 It s not that complicated. Will the world be different in 10 years? If yes, should I do nothing or do something? If do something, should I start now or wait 10 years? If I start now, should I turn my world upside down over night or implement low-risk, highyield, scenario independent strategies? 9

10 New model of care: Population Health Management Traditional View Patients Who Arrive New View Entire Patient Population Fee for Service PCMH Accountable Care 10

11 ACO Model Components Patient-centered health homes that deliver primary care and coordinate with other providers. Aligned networks of specialists, ancillary providers and hospitals focused on outcomes. Explicit care integration and coordination mechanisms. Payor provider partnership relationships and reimbursement models identified under healthcare reform that facilitate and reward high value, not high volume, healthcare. Source: Premier ACO Collaborative Population health information infrastructure to enable community-wide care coordination. 11

12 Scope of Automation Health information exchange ADT clinical alerts Gaps in care Transitions in care Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare Institute for Health Technology Transformation 12

13 HIE: High Impact Use Cases Emergencies Chronically ill Uninsured Minority Wounded warriors Disabled Rural Incarcerated 13

14 Wounded Warriors Up to 60% of service member s healthcare is provided outside of the Military Health System. Private Sector Care 60% 40% 70 Veterans receive approximately 40% of their care outside of VA treatment facilities. DoD DoD-VA Continuum of Care VA 14

15 VLER Partners Fort Eustis McGuire VA Medical Center Hampton VA Medical Center Portsmouth Naval Hospital Fort Eustis Langley AFB 15

16 Serving the Disabled Avg. disability determination: 90 days With MedVirginia: 65 days 5% in 1-2 days CCD to SSA Algorithms by SSA Replication of model 16

17 Project Impact Case study commissioned by SSA Conducted by Kay Center for ehealth Research Perspectives: Claimant Provider SSA ROI 17

18 ADT Clinical Alerts _Learning_Guide_ADT_Feeds_Final.pdf 18

19 Patients Are Not Receiving Recommended Care McGlynn et al The Quality of Health Care Delivered to Adults in the United States NEJM June 26,

20 Risk stratification Target populations Outcomes reporting Quality metrics Patient outreach Telephonic PHR Analytics and Patient Engagement Text PHYTEL Population Management 20

21 Robust Protocol Engine Outreach Communications and Patient Self-Management Protocol Engine Evidence based standards Guidelines combined with expert opinion Specific practice requests Innovative proprietary protocols Patient Registry 21

22 Scheduler or Care Manager View of Outreach Events 22

23 Impact Ashok Rai, Paul Prichard, Richard Hodach, and Ted Courtemanche. Population Health Management. August 2011, 14(4): doi: /pop

24 Results Program data 3/1/12-2/28/13 Unique patients identified with gaps in care = 97,900 Contact success rate = 94% ROI = 10X 92,100 patients contacted 5,700 unsuccessful contacts 48,400 Patients Booked 24

25 Post Discharge Follow-up Improving Patient Post Discharge Care Improving Patient Satisfaction Scores Increasing Physician Services Interactions Readms 25

26 Transition : How it Works Patients contacted within hours of discharge Patient discharged Patient receives automated assessment Alerts are sent back to the nurse or case manager 26

27 Transition Follow-up List Follow-up list highlights patients with responses that generate escalations. 27

28 Riverside Medical Center 570 bed regional medical center Level II Trauma/ 42 beds 60,000 ED visits per year Improved Press Ganey scores from 58 to 63% Increased patient recommendation scores from 60 to 64% Reached 55% of discharged patients through automated contact Improved quality of care by providing additional support to patients who need it

29 Scope of Automation Health information exchange $2M revenue for 4 hospital system ADT clinical alerts Emerging data results Gaps in care 10X ROI for medical group Transitions in care Readmissions HCAPS scores Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare Institute for Health Technology Transformation 29

30 Constancy of purpose.. in a sea of change. 30

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