Pushing the Envelope of Population Health

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1 Pushing the Envelope of Population Health Timothy Ferris, MD, MPH Senior Vice President, Population Health Management, Partners HealthCare May 15, 2014 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.

2 Disclosure of Conflicts of Interest I have no conflicts of interest.

3 Population Health Management priority programs Primary Care Specialty Care Care Continuum Patient Engagement Infrastructure Patient Centered Medical Home (PCMH) High risk care management (palliative care) Mental health integration Virtual visits Active referral management (curbsides) Virtual visits Procedural decision support (appropriateness) Patient reported outcomes Episodes of care (bundles) SNF care improvement (network/waiver/snfist) Home care innovation (mobile observation/telemonitoring) Urgent care Shared decision making Customized decision aids and educational materials Single EHR platform with advanced decision support Data warehouse, analytics, performance metrics 3 V 2.1

4 3 phases of work for improving population health Phase 3 Phase 2 Phase 1 1 Primary care: The hub for managing populations: preventive services, chronic illness, high risk 2 3 Specialty care: Where a large fraction of costs are incurred, especially in commercial populations Care Continuum: Opportunities to track patients over time using new approaches and technology 5 Wellness promotion: Programs to prevent or delay the progression of illness 4 Patient engagement: Involving patients in better self-management of care Ongoing: IS, analytics and central infrastructure 4

5 Complex care management Care managers embedded in primary care practices Coordinate the care of patients at risk for poor outcomes, hospitalizations Supported by health IT (universal EHR, patient tracking, home monitoring) Adoption rapid and near universal among provider groups who are taking on financial risk populations MGH Experience Year Patients MDs CMS Demonstration Phase , Expansion Phase , Pioneer ACO , Ferris TG, et al; Cost Savings from Managing High-Risk Patients in The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington (DC): National Academies Press (US); , Care Culture and System Redesign. Available from: 5

6 6 Medicare Demonstration care team Healthcare & Community Services Non Acute Hospice VNAs Community Agencies Palliative Care and Hospice Community Resource Specialist Care Agencies Complex Care Team Substance Abuse Specialist PCP Care Manager Specialist Pharmacist Mental Health Team Financial Service Specialist Elder Service Network Transport Providers Civic Organizations

7 Medicare Demonstration results Patient Outcomes Hospitalization rate: 20% lower ED visit rate: 25% lower Mortality rate: 4% lower Savings 7.1% net savings (12.1% gross) Approximately 4% annual savings for the total population For every $1 spent, the program saved at least $2.65 Cohort Gross Savings % Net Savings % MGH (1) 10.4% 5.9% MGH (2) 19.8% 15.1% BWH 7.0% 2.9% NSMC 4.1% -0.7% Average 11.83% 7.28% Source: Lessons from Medicare s Demonstration Projects on Disease Management and Care Coordination, Lyle Nelson, Congressional Budget Office, January 2012, Working Paper Future Directions Specialty specific programs, palliative care RTI evaluation FullFTIreport.pdf 7

8 icmp identification process Goal: identify medically complex, chronically ill patients who would benefit from a primary care embedded, longitudinal, care management program Key features: Algorithm: 1. one year of claims data 2. threshold for prospective risk score 3. combination of clinical conditions and utilization triggers Automatic inclusion criteria for patients with a certain risk score or age regardless of the types of clinical conditions or utilization triggers Primary Care Physician makes the final decision about eligibility 25% of algorithm eligible patients removed by PCP decision (10% care needs are met and 15% patient doesn t need high touch program) Patients can refuse participation 8

9 icmp performance metrics Process measures Patients identified by algorithm Enrollment measures (reached and receptive, eligible, etc) Patient engagement (completed care plans) Patients declining enrollment and discharged Patient activities % of patients with post discharge assessment completed and documentation of communication between the inpatient care management and icmp care manager Patient survey measure % of patients who knew their care manager and could identify them by name New outcomes measures Medical admissions per 1,000 9

10 Virtual visits and technology tools Technology Pediatric Virtual Video Pilots 313 Video Conferencing Pedi ICU Burns Center Child and Adolescent Psychiatry Telephone Text Messaging 100% 80% 60% Active Referral Management Visits Avoided 16 Referrals Reviewed 100% 80% 60% Curbside* 54 Visits Avoided Visits Conducted Active Referral Management/ Electronic Curbside 40% 20% 0% Diabetes Endocrine Thyroid n=599 n=255 n=66 40% 20% 0% Cardiology n=602 *Expected results based on projected modeling for a 3 month period. Pilot in early stages. 10

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