1 DATA DRIVEN HEALTH CARE TRANSFORMATION Population Health Analytics as the Foundation for Primary Care Redesign Sylvia Meltzer, MD, LSSGBC Laura Spurr, MPS, PMP
2 Learning Objectives Organization description Change in industry landscape Population Health and Analytics Heart Failure and COPD New Care Models Transitions in Care Process change Primary Care Redesign
3 Organization Description Aurora Health Care is one of the largest not-for-profit, integrated health care systems in the United States. Wisconsin and northern Illinois. ~1.2 million patients 15 hospitals ~175 clinics 80 pharmacies 60 laboratories Home care services 1600 physicians 700 advanced practice providers
4 Accounting for a Change in Landscape CURRENT STATE Volume-based/Episodic care Results in: Healthcare costs expected to reach $4.4T in 2018 Unnecessary services Inefficient delivery of care Missed prevention opportunities FUTURE STATE Value-based/Continuous Care Results in: Proactive care management of patient populations Leveraged caregiver teams working at top of license Easy access to care Efficient delivery of quality care 4
5 Market Interrupters & Increased Competition In Ambitious Bid, Walmart Seeks Foothold in Primary Care Services By RACHEL ABRAMS AUG. 7, 2014 Welcome to Walmart. The nurse will be right with you.
6 Increased Consumerism *From The Advisory Board Primary Care Consumer Choice Survey
7 Changing Workforce and Demand
8 Current Model Does Not Support Need
9 Provider Burnout
10 Shifting the Model To meet patient needs. To relieve provider burnout. To expand panel size (take on more patients). To provide better care at lower cost. To stay competitive in marketplace.
11 Current to Future State Volume Everything in between Value
12 Start the Journey With Population Health Identifying what Population Health is for Aurora Health Care Help patients live well. Increase provider access to allow for expanded population based care models. Providing a team approach to care. Optimize our technology and practice to understand the patients we serve. Improve care coordination. Use data as an asset to identify populations and make meaningful changes.
13 Identified Population Health Initiatives Disease Management & Transitions in Care
14 Heart Failure and COPD Disease Management Projects PHASE 1 Purpose: Use Predictive Analytics to identify the highest risk populations forecasted to admit within 6 months for Heart Failure. Institute a disease-specific action plan to improve outcomes for this population. Planning: 03/2013 Live date: 06/2013 Focus Area: 5 clinics 1 hospital Target Group: 129 Patients Caregivers: 32 Providers 6 Health Coach RNs Leadership: Cross functional Enterprise wide PHASE 2 Purpose: Using Predictive Analytics to identify the highest risk populations forecasted to admit within 6 months for COPD. Institute a disease-specific action plan to improve outcomes for this population. Planning: 10/2013 Live date: 01/2014 Focus Area: 5 clinics 1 hospital Target Group: 263 Patients Caregivers: 32 Providers 6 Health Coach RNs 2 Pharmacists 1 Home Care 1 Specialist Leadership: Cross functional Enterprise wide
15 Disease Management: Identify the Need *example screen shots are from Optum Analytics
16 Determine the Focus Predictive Analytic Risk Stratification *screen shots are from Humedica MinedShare
17 Old Delivery Model Patient sees primary care provider in office Patient is scheduled to see PCP Treatment Regimen Patient is discharged from hospital Patient has an episode Patient is admitted as Inpatient Patient goes to ER
18 Identify Opportunities in the Process Use Health Coach RN as the conduit between provider and care team. Institute a collaborative/team-based workflow. Engage the patient in their care in an enhanced way. Use Heart Failure and COPD protocols as well as quality-driven treatment plans to improve care. Integrated additional professional services Develop electronic tools to allow for ease in utilization as well as comprehensive documentation.
19 The New Model Health Coach RN performs outreach call Health Coach RN coordinates team members for the patient (Pharmacy, Home Care etc.) Divide pt. list among Health Coach RN Patient arrives for primary care visit Validate pt. inclusion with local providers Health Coach RN continues to follow schedule and work with pt. daily or weekly Analytic reporting for target group Patient sees Health Coach RN & Provider (co-visit) Team develops the tx plan and visit schedule
20 Patient Results This man has an EF 15%, DM, HF, CVA and multiple co-morbidities. He started the HFCC pilot by walking in with a cane with edema and severe SOB. He stated that he was SOB all the time. Weight was up and down multiple admissions last 7/22/13. Since then and with HFCC he has now received all his medications covered for him through the VA (big cost savings for the patient). He qualified for Cardio/Pulmonary Rehab. He is understanding his HF and his medications. He is now on the treadmill with Cardio/Pulm rehab min at 2.5% incline at 2.5 MPH 3 days/wk. He is back to working 9 hr days 2-3 days per week as a machine operator. He told me today that "I feel like he did when I was 50". Patient understands how to manage his weight and watch his symptoms and likes being kept in check with his disease process. -Aurora Health Coach, RN *note the term Health Coach and PCMH RN in this presentation are interchangeable.
21 Clinical Successes Drop in disease specific admissions: 60% reduction in HF admissions compared to previous year.* 20% reduction in COPD admissions after 5 months.** Significant decrease in disease specific readmissions. 20% decrease in all-cause admissions. Decrease in ER utilization. Increase in Patient Wellness (moving to lower risk). Increase in Patient Satisfaction Enhanced care coordination model with expanded delivery team. *Heart Failure measurement period is over 12 months. **COPD measurement period is 5 months.
22 Readmission Impact ~30% decrease in all-cause readmissions from 2012 to 2013! Month Readmission Rate 2012 Readmission Rate 2013 June 12.1% 11.6% July 10.7% 6.4% August 12.9% 8.8% September 11.9% 7.4% October 13.73% 6.41% November 11.25% 8.16% December 8.90% 7.26% average ~11.64% ~8.0%
23 Show Me the Money! Avoiding diversion opportunity costs. Avoiding readmission penalties. Increase in clinic efficiencies and ability to care for larger panel size. Improved access for new patients. Improved resource allocation. Significant financial savings in value based contracts
24 Population Health: Transitions in Care
25 Transitional Care Management Project PHASE 1 Purpose: Use Analytical Software to identify gaps in care. Institute an enhanced care coordination plan to improve outcomes for patients discharged from the hospital. Planning: 03/2013 Live date: 06/2013 Focus Area: 8 clinics 1 hospital Target Group: non-surgical discharges Caregivers: 47 Providers Leadership: Cross functional PHASE 2 Purpose: Use Analytical Software to identify gaps in care. Institute an enhanced care coordination plan to improve outcomes for patients discharged from the hospital. Expanded scope. Planning: 10/2013 Live date: 12/2013 Focus Area: 11 clinics 2 hospital Target Group: non-surgical discharges Caregivers: 53 Providers Leadership: Cross functional
26 Patients Discharged From Hospital Missing 7 Day Follow Up Appointment AVG 65% missing *screen shots are from Optum Analytics
27 How the Process Began Identified opportunity in our regions. Presented the hospital and surrounding clinics with the data. Gathered a cross functional work team comprised of caregivers from the hospital, clinic and quality areas. Reviewed the current model and identified the opportunities for improvement. External industry research for best practices Researched Transitional Care Management requirements and applications. Inpatient and clinic training. EMR build. Aligned with Quality initiatives. Developed the workflow as one uniform team hospital, clinic and system.
28 Old Model Patient Discharged from hospital with instructions for follow up. PCP may or may not be aware Patient ready for discharge Post Discharge Contact Hospital based No standard process for follow up appointment scheduling.? Clinic Visit within 7 days
29 New Model Hospital schedules directly with PCP within 7 days Automated message sent to clinic queue Patient ready for discharge 48 business hour phone call Scripted to meet CMS guidelines Key clinical indicators reviewed Message sent to PCP Scripted visit and tools to meet CMS guidelines TCM visit codes used. Clinic Visit within 7 days
30 Results Increasing follow up appointment with PCP within 7 days ~35% ~85% Reduction in readmission rates. ~1-4 percentile point decrease Improved patient satisfaction. Enhanced provider efficiency and satisfaction.
32 Show me the Money Increased office visits. Ability to use TCM codes with 2x the RVU value compared to traditional E&M codes. Ability to code E&M services at time of TCM visit if new issues exist. Reduced readmission rates.
33 The Reason Why I had a patient discharged from the hospital after having a pulmonary embolism, but she thought she was just in the hospital for a panic attack. The patient was sent home on Coumadin. The clinic performed the 48 hour phone call and found out that the patient was not taking Coumadin because she did not understand the medication or why she should be taking this. They were able to get her back on her medications right away. Without the 7 day process, she would have just been seen in a week or two and easily could have had a recurrent episode and died before then. Dr. Julia Hester-Diaz
34 Next steps
35 Evaluate Primary Care Model
36 Value of Primary Care Primary care capacity and competency are critical elements in the successful transformation to accountable care and a value-based health care market 36
37 Primary Care Redesign Objectives Help patients live well, providing high quality care. Improving patient experience, providing ongoing guidance to the right care at the right time. Improve patient access and increase Aurora population base. Enhance engagement through top of license, team-based care. Prepare our organization to manage risk. Optimize outcomes relative to cost and spending. Instill a culture of sustainable, self-improving operational excellence.
38 Making the Triple Aim Happen
39 Redesign Program Components Population Health LEAN foundations Top of license practice Schedule Optimization Prevention and Wellness Quality improvement Patient Base 12 month process development process
40 Primary Care Redesign PILOT ALPHA Purpose: Implement various workstreams aimed to establish a foundation for enhanced care, focused on patient wellness, caregiver empowerment, and value based models. PILOT BETA Purpose: Implement various workstreams aimed to establish a foundation for enhanced care, focused on patient wellness, caregiver empowerment, and value based models. Planning: 09/2013 Live date: 01/2014 Focus Area: Caregivers: Deployment Team: 2 clinics 2 hospital 18 Providers Project Management Physician Champions Quality Operations Improvement Educational Development Change Management Informatics Nursing Growth Development Strategic Planning Administration Planning: 03/2013 Live date: 05/2014 Focus Area: Caregivers: Deployment Team: 5 clinics 5 hospital 27 Providers Project Management Physician Champions Quality Operations Improvement Educational Development Change Management Informatics Nursing Growth Development Strategic Planning Administration
41 Patient Experience Overall patient experience has increased, with some outlier decreases due to staffing. Care Management Impact Score increased or remained the same for all sites during this deployment s measurement period.
42 Volume Clinic visits increased for all sites wrvus increased for all providers.
43 Tracking Outcomes (example) *Content is for illustrative purposing only and not real data
44 Primary Care Redesign Two Converging Initiatives TRIPLE AIM ACCESS & INCREASED POPULATION DECREASED ER VISITS & HOSPITALIZATIONS HIGH QUALITY SERVICES & TEAM BASED CARE EFFICIENT OPERATIONS & INCREASED REVENUE INNOVATIVE REDESIGN System Wide Establishing the foundation for change 1-2 PILOT CLINICS
45 Innovative Redesign Design a transformative/new model primary care clinic. Leverage resources towards better health for the population, better care for individuals and lower costs of care through continuous improvements. Extend well beyond the physical walls of the clinic. Integrate with other key service lines such as behavioral health.
46 Care Model Structure Facility Process Care Team Patient
47 Major Processes Components Access Scheduling New Patient Onboarding Connecting with AHC system/pcp (marketing related) Patient Encounter (Before, During, After) Rooming AVS Communicating Outcomes Registration What s Going on in the Exam Room Population Management Managing Chronic Disease Medication Management Care Coordination Consults/Referrals, Hospital Transitions, Specialists, Handoffs Comprehensive Chronic Disease Care (across all conditions) Patient Engagement Care Team Models Proactive Care Team Person-oriented Communication Education/Motivatio n Enabling Selfmanagement Understanding your Patient (whole person) Whole Person Care Clinic Management LEAN-driven Performance Criteria (patient wait times, etc.) Clinic Design Patient/Provider Flow, Wayfinding, etc. Integrated Behavioral Health Answering Questions Integrating w/other Specialty Needs Connection for Ongoing Support Wellness Conducting Tests and Communicating Results Listening Coaching Self-care Patient Education Community Connection
48 How Does Facility Design Fit In? Helps support an efficient, patientcentric delivery model. Workflows influence design of model Patient input helps focus facility on ease of use, comfort, flow New clinic locations are an opportunity to put some of these processes in place
49 Milestone Timeline ACTIVITIES TIMELINE STATUS Primary Care Redesign System roll out Innovative Pilot Redesign Development Innovative Pilot Redesign Implementation SEPT OCT 2015 Q Q Q Q IN PROGRESS IN PROGRESS
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