Pediatricians Implement Office-based Care Management Guided by Meaningful and Actionable Population Health Management

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1 Pediatricians Implement Office-based Care Management Guided by Meaningful and Actionable Population Health Management Changing needs of technology and data for successful coordinated care transformation November 10, 2015

2 Albert Chaffin MD Pediatrician and Chair of Population Health Management at the Children s Health Foundation Julie Harris MBA Director of Quality Programs at the Children s Health Foundation

3 Introducing CHA and CHF Who we are: An alliance of 100+ private pediatricians in Oregon and Washington Our goal: Lead clinical improvement innovations and deliver the highest quality of care to children and their families The Alliance and the Foundation work together to: Develop and implement transformational quality improvement programs Drive quality care delivery, care experience and cost management Offer clinical and strategic expertise about meaningful pediatric measures and actionable workflow solutions 3

4 Rich Clinical QI Experience Demonstrated success with Developmental Screening, Immunization, Asthma Care Management, Behavioral Integration, Pediatric Care Management and Population Analytics programs Success at building pediatric asthma registry and driving results Explored evidence on Pediatric Care Management indicating that meaningful tools / measures are driven by the clinical team Clinical expertise with testing and operationalizing pediatric protocols care management tools and workflows Engagement of 100+ Physicians and Care Teams

5 Two-year old immunization rate 89%, compared to Oregon rate of 67% Demonstrated Results of Physician-led QI 90% of children followed for asthma had an encounter with their pediatric care team >90,000 children/family needs have been assessed for targeted care management

6 Today s Learning Objectives Learning objectives: 1. Evaluate the drivers for community-wide health information exchange and the supplemental value of clinically focused population health management tools in pediatrics and primary care 2. Demonstrate methodologies for assessing the multi-factored care management support needs of children/families and how this is actionable for population health management 3. Explore a physician-driven population health management solution implemented by over 100 pediatricians including demonstrated results and value to families, providers, CCO s and other community stakeholders. 4. Discuss implementation and the community-wide system impacts and evolution needed to sustain primary care population health management and achieve desired triple aim outcomes.

7 Drivers of HIE and PHM Areas of need and value: Clinical Care coordination, shared care plans, population health management, decision support Financial Influence in payment and contract negotiations, IT cost curve, valuebased contracting Administrative Practice optimization, measurement reporting, HIE preparation Strategic Informing pediatric measures, demonstration of quality and cost performance, competitive positioning

8 A Concerning Future of HIE Burden on Provider Groups Payer CCO State HIE Employer ACO $ $ $ $ Provider Practices Faced with numerous unique data sharing demands across their multiple systems with varying levels of data exchange and reporting capabilities

9 Achieving HIE is easier said than done

10 Providers Seek an HIE that is also Care Gap Alerts Care Management Supports Shared Care Plans Population Analytics Performance Reporting Meaningful Use Patient-Centered Medical Home HEDIS CCO Measures ACO Measures Clinically Relevant

11 Comprehensive, Meaningful & Actionable Data in the Hands of the Care Team The CHA/CHF Vision Pediatric PHM

12 PHM solutions can be a value added conduit for HIE Organized exchange and communication improves utility

13 Pediatric PHM CHA/CHF Pediatric Population Health Management Solution Creating a Pediatric HIE

14 Introducing our Pediatric PHM solution: CMART the CHA Care Management, Analytics & Reporting Tool built by Well Wel Aggregate patient info in one place Support care management workflows Offer analytics Help communicate and share care plans Registry Claims EMR

15 How CMART Works

16 Demonstrating Value and Engaging Providers by making HIE/PHM relevant to patient care Understanding BOTH the trends of patient populations and the individual needs of children and their families

17 Collecting Needs-based Risk Segmentation Data for Pediatric Populations CHA/CHF methodology based on provider assessment of patient-centered support needs at time of encounters Offers proactive needs-based segmentation rather than utilization-based risk modeling Support Level Assessments guide care management approaches and interventions for individual patients

18 Understanding Patient Needs Assessing medical conditions alone does not reflect overall support needs 3 key drivers of patient/family support needs: Medical complexity Patient Functionality Family factors A flexible and fluid assessment score - Care Management Tier - offers care teams actionable segmentation of their populations

19 Our Needs Assessment and Segmentation Tool At the point of encounter Guides physicians broader perspective Accepts varying forms of parent & youth input Result is meaningful and actionable Transforms care approach Informs care management

20 What this Needs-Assessment Data tells us about our Pediatric Population Support Level Needs of the Pediatric Population Patient's Current Support Level 1 (highest) 1% 2 (lots extra) 4% 3 (some extra) 22% 4 (standard) 73% n=81,796

21 Summary of Assessment/Segmentation Results

22 Summary of Assessment/Segmentation Results Medical Complexity of the Pediatric Population (CHA Assessed population compared to Research) Patient's Current Medical Complexity Complex multisystem condition(s) 2% 2 or more chronic health conditions 10% One chronic health condition 22% No chronic dx but risk factors 4% No chronic dx and no risk factors 62% n=64,648

23 Summary of Assessment/Segmentation Results Actionable information about patient and family factors driving support needs/level

24 Clinical Value through Patient-level Care Gap Alerting and Reporting to Guide Care Management

25 CMART Patient level care gap alerting and reporting Guides team-based patient and panel care management Gap lists facilitate shared care using staff to top of their licenses o o o Pre-visit planning by Medical Assistants Referral and lab follow up by Medical Receptionists Individual patient education and management by RN Care Managers, Behavioral Specialists, Nutritionists and/or other Health Coaches Point of care, patient level guidelines Evidence-based protocol driven care alerts

26 CMART Pediatric Clinical Protocols 1. Asthma 2. ADHD 3. Autism 4. Cerebral Palsy 5. Dermatology 6. Developmental Disorders 7. Diabetes - Type I & Type II 8. Downs Syndrome 9. Foster Care 10. Pediatric BMI (Obesity) 11. Pediatric Dental 12. Pediatric Mental /Behavioral Health 13. Well Care and Screenings for Adolescents 14. Well Care and Screenings for Infants and Children

27 Areas of CMART care goals CCO Relevant Measures: o o o o o o o o o Well Child Checks Developmental Screening Immunizations Adolescent Well Care Depression Screening Asthma Care Management Medication Management (ADHD Med Checks) SBIRT Utilization Management (ED & Hospital Follow-up)

28 CMART Care Goals Dashboard

29 Measurements in Action Example: 6 Well-Child Check-ups by 15 months of age timely alerts based on clinical data rather than retrospective claims measures Alert list:

30 Patient Gap List (Alert)

31 Aggregated Data Summary for Patient

32 Real-time Performance Reporting

33 Measurements in Action Example: Developmental Screenings Care gap alerts identified opportunity for improved process for onboarding CCO patients

34 Measurements in Action Example: Annual Adolescent Well Care Continuous alerting (rolling 12 month lookback) smooths out annual workload Real-time Performance Report

35 Measurements in Action Example: SBIRT CMART allows manual data collection or import from EMR Aggregated data from CMART and EMR offers opportunity to supplement claims-based measures

36 Measurements in Action Supplemental EMR Data for Measurement Reporting Sample analytics of potential supplemental data

37 Measurements in Action Practice workflow example: ED Utilization Comprehensive Data: CMART has direct interface with EDIE, practice EMRs and Claims (if provided) to give comprehensive view Goal related care alerts: primary providers receive realtime ED alerts and care gap reports Workflow implementation: o Provider teams have established workflows for ED follow-up outreach with goal in 3 days o CMART enables outreach documentation that can be tied to the care goal Performance Reporting: Real time reports show progress toward goals

38 Goal-related care alert

39 Patient s Care Summary

40 Care Management Action Plan

41 Care Management Outreach Assistance Enables linking outreach to care goals

42 Care Management Outreach Calendar

43 Real-time Performance Reporting

44 Impacts and Sustainability

45 Data partners Engaging collaborators Hospital, Pharmacy, ER, Claims, Immunizations, Disease data from registries (Asthma & SLA) Clinical partners Evolving community-wide systems of care and support

46 Utilization and cost data sharing CCO and provider collaboration is key CCDA standards now pave the road

47 Valuing Patient-Centered Primary Care in Payment Models Dietitian Medical Reception Medical Assistant BH Provider Care Coordinator Patient Medical Provider Nurse Advice & Triage Limitations of Solely Fee-For- Service Payment Model Referral Coordinator RN Care Manager

48 Keys to Operational Feasibility and Sustainability Integrate with EMR and clinical tools Support clinical workflows Enable the proactive office encounter Avoid redundancy and improve efficiency Ensure direct patient care benefit Improve payment for team based care Clinical Care coordination, shared care plans, population health management, decision support Administrative Practice optimization, measurement reporting, HIE preparation Financial Influence in payment and contract negotiations, IT cost curve, value-based contracting Strategic Informing pediatric measures, demonstration of quality and cost performance, competitive positioning

49 Speakers: Questions? Albert Chaffin MD Pediatrician and Chair of Population Health Management at the Children s Health Alliance achaffin@panwpc.com Julie Harris MBA Director of Quality Programs at the Children s Health Alliance jharris@ch-alliance.org