The Primary Health model: A collection of population health solutions & services

Transcription

1 The Primary Health model: A collection of population health solutions & services Creating health care alignment with an employer-driven network The United States spends more money on health care than any other nation in the world about $2.8 trillion annually, yet our health rankings continue to land among the poorest. To date, 50 percent of adults in America have been diagnosed with at least one chronic condition, which not only increases cost for the individual, but contributes to employer spending on claims, absenteeism, short-term disability and worker s compensation. While employers are working aggressively to curb these rising trends with innovative health and wellness programming, they continue to struggle to achieve lasting clinical and financial results. Aligning incentives, improving outcomes Cerner s Primary Health model combines foundational wellness offerings with innovative population health services and technology to create an employer-driven network where providers and individuals are rewarded for health improvement and productivity. By tailoring the health care experience to the individual and fostering a meaningful relationship between the person and their health team, employers are poised to achieve sustainable clinical, financial and experiential outcomes. Our approach to population health management is simple: know and predict what will happen within a population, engage members, their family and care providers to take action, and manage outcomes to improve health and care. What we re spending* What makes us healthy 1 Derived from information from the Boston Foundation (June 2007) CDC Social Determinants of Health FAQ

2 Get to KNOW your population Data aggregation and segmentation: Understanding engagement and health risk Throughout a person s life, they will move from healthy to sick, engaged to unengaged, and anywhere in between. In a world of smart gadgets and gear, expectations are rising and evidence shows the more involved we are in our health, the more likely we re a high-performing and happy individual. Cerner aggregates financial claims, personal health assessment (PHA) results from the Cerner Wellness portal, and baseline clinical information. Using this data, we segment your population based on health risk. To understand engagement, Cerner collects and analyzes data related to health beliefs, motivations and hopes of a population to determine projected health outcomes based on an understanding of the following: Locus of control: Do individuals believe they are in control of their destiny or that luck plays a factor? Motivations: Is an individual more preventive or curative in their orientation? Hopefulness: Do individuals see multiple pathways to solve problems, have high or low energy to do so?

3 ENGAGEMENT Data use: How information gets used in technology and programming All of the accumulated data is then used by our health team, which includes a Cerner Health Navigator and Coach in partnership with a network of community physicians, to offer programs that manage health and engagement risk. Members, including employees and families, use the Cerner Wellness solution to engage in all components of wellness and lifestyle management programming. The portal includes a PHA, health tracking tools, education resources, incentive integration, device integration and team challenges. Health coaches and members alike use the wellness portal as part of their personalized, evidence-based wellness journey. The health team benefits from Cerner s population health management platform called HealtheIntent SM. HealtheIntent aggregates, transforms and reconciles data and empowers surveillance, monitoring and performance measurement for our team across 12 health risk categories that represent the biggest health cost avoidance opportunities: Rank Condition/Status 1 Heart Disease 2 Mental Health (Depression, anxiety) 3 Cancer 4 Asthma, COPD 5 Hypertension (High blood pressure) 6 Diabetes 7 Hyperlipidemia (High blood cholesterol) 8 Back and neck problems 9 Obesity 10 Pregnancy 11 Healthy but unfit 12 Healthy and fit More Engaged Focused Sick Plan participant Active Well Motivated 34,349 total members Disengaged Sick Potentially unaware 18% 82% Less Engaged Sick HEALTH Well Figure 1. Example of three segments. The disengaged sick segment often includes the most costly individuals, but moving the needle with this group can also have the greatest potential impact.

4 ENGAGE individuals specific to their preferences and risks Health navigation: Creating an experience for the individual Setup: At program kick-off, Cerner creates a Health Performance Management strategic plan with goals that cross multiple categories. From this plan, a Health Navigator will be assigned and held responsible for creating an annual engagement plan crossing all service areas which might include management of screening, education and prevention activities. A Cerner Health Navigator is the first line of support via or phone if there are questions about the portal, tools or any services that might be offered. They work complementary to an organization s internal resources. Match Me to My Team: One unique attribute of Cerner s Health Navigation offering is our physician matching service. Health Navigators take responsibility for identifying or matching an individual to a physician, and seek to remove obstacles an individual might have in accessing or receiving treatment consistent with their needs. Cerner physician matching uses more than twenty preference-related data points, and our proprietary algorithms match individuals to local physicians based on compatibility, proximity, medical philosophy, condition-based education programming, experiential amenities, etc. Cerner also commits to transmit wellness summary data to physician partners on the person s behalf. Due to a fragmented health care system, it makes it difficult to have a seamless experience. Health Navigation is a direct result of our emphasis on person-centered programming and is one of the first team members to meet with an individual after risk stratification. What s a Health Navigator vs. a Health Coach? Health Navigators help create experiences for an individual. They re responsible for: Creating a customized engagement plan Matching individuals to health coaches and physicians based on preferences and risks Using segmentation analysis to refine strategies and offer personalized communication and seamless service experience Health Coaches help create positive health outcomes for an individual. They re responsible for: Aligning with an individual s primary care physician (PCP) on a care plan Monitoring an organization s population to intervene when risks are identified Achieving results in risk categories

5 MANAGE your population Health coaching: Managing health risk programs in partnership with a physician While physicians diagnose and treat illness, they don t always have time to teach their patients to take proactive steps with nutrition, lifestyle and stress reduction. Cerner s health coaching is an allencompassing, evidence-based model that is focused on lifestyle/condition management. Coaches and physicians work together to provide a comprehensive plan for health. Health can be complicated, so Cerner Health Coaches help guide individuals to better health by introducing and leveraging each individual s influential health team and resources, whether that is a relationship or available technology. We strive to keep the healthy population healthy and support the participants with conditions to achieve optimal health. Our standalone coaching services are offered in three ways: Prescriptive coaching and lifestyle management: One-on-one coaching sessions over the phone can help members understand their health status and set goals for improvement. Using motivational interviewing, our programming is designed to meet people where they are through identifying their barriers and readiness to change. All Cerner Health Coaches are certified through the National Society of Health Coaches and hold a registered nurse, registered dietician or American College of Sports Medicine credential. On-site coaching: On-site health coaches make our expertise an essential facet of a workplace health strategy. They provide confidential, face-to-face guidance and empower participants to take charge of their risks and well-being. Our coaches use data collected to tailor their interactions and program components for more personalized engagement. Digital and Secure Messaging: Personalized suggestions from our Ask a Trainer or Ask a Dietician portal widgets help participants take small manageable steps towards their health in near real time. Health Coaches Promoting a continuity of care plan Health is complicated. Cerner Health Coaches help guide individuals to better health by introducting and leveraging each individual s influential health resources whether that be a relationship or available technology.

6 MANAGE your population Create my plan for health Cerner helps every individual create a dedicated health team consisting of a PCP, health coach and specialist, based on risk level. Whether an individual is low, moderate or high risk, the team works together to deliver the right amount of personal attention to each participant to reverse unhealthy habits and lead healthy, happy lives. Person-centered health plans and programming can improve outcomes and reduce costs, so much so that our coaches and physicians are incentivized based on an individual s opinion on how well a facility treated them. Figure 3. Personalized plan for health A health coach can help individuals maintain, prevent or control risk factors and create personalized wellness action plans to foster sustainable behavior change. Low risk: MAINTAIN Moderate risk: PREVENT High risk: CONTROL Physician (PCP) Health Coach Confirm maintaining healthy state Set care plan Encourage to continue healthy behavior Confirm compliance, establish action plan and follow up to review progress and reassess action plan goals Diagnose, write script (if necessary) and set care plan Confirm compliance, establish action plan and follow up to review progress & reassess action plan goals Diabetes example: Assess current exercise, stress, diet and tobacco use; build knowledge base and create self-awareness and confidence Diabetes example: (in addition to low risk): Review PCP care plan and increase skill development Diabetes example: (in addition to moderate risk): Teach behavior modification techniques to prevent remission; highlight the health risks of diabetes; confirm PCP appointment Dietitian and Exercise Specialist Wellness action plan: Log exercise, food and weight Educate Wellness action plan: Promote ADA diet and medication compliance, log BP and consult with an exercise specialist Educate and set conditionspecific diet and exercise regime Wellness action plan: Log glucose; consult with a registered dietitian; demonstrate knowledge of diet and promote medication compliance Educate and set conditionspecific diet and exercise regime

7 MANAGE your population New financial incentives for care coordination and performance It s widely recognized that the current fee-for-service payment model provides few incentives for the improvement of care coordination and person-centered health outcomes envisioned in a high-performance network. Cerner s proposed payment reforms are intended to reward for positive and measurable health and experience outcomes. Cerner payment strategies for providers range from early incentives for participation and measurement, to opportunities for shared savings, to comprehensive financial risk-sharing approaches with strong incentives around cost containment. It is a phased approach, and Cerner will work with an organization to determine level of readiness. Let s look at an example hypertension. Today, are physicians seeing your hypertensive employees completing the following steps? Measured: Blood pressure measurement Recognized: Persistent blood pressure mm Hg Plan: High blood pressure plan of care established Additional recommended steps or information: Lipid panel, serum creatinine, tobacco use screening and cessation Without de-identified aggregation of claims, wellness and physician practice clinical system information, completion of these steps is unknown. New incentives help to create a high-functioning employer-driven network: Management: Better overall management of care and reductions in unnecessary steps Accountability: Shared accountability for performance (both coach and physician) Experience: Consultative discussions with partners to improve experience Condition Measure Data source: Wellness Data source: Claims Data source: Claims Hyperlipidemia Blood pressure measurement* Blood pressure mm Hg* High blood pressure plan of care Lipid panel* Serum Creatinine Tobacco use screening and cessation* *Intervention responsibility of BOTH the coach and physician

8 Getting results Our end goal is to create health communities that deliver high quality, evidencebased health services at a reasonable cost. We have designed every aspect of programming with results in mind. Our work in population health management has revealed one simple truth only 20 percent of any given population will have the chance to stay healthy if they do nothing. Most of us need a plan that focuses on impacting determinants of health behavior, environment and delivery of care. Based on studies of our own data, we know that an employer can expect to see average trends in multiple categories that impact financial expense and productivity. About Cerner You can be confident in our offering because we have more than 25 years of on-site health care experience and more than 30 years in health care technology. We are continually finding new and innovative ways to deliver value to our clients. As a five-time Platinum Winner of the Best Employers for Healthy Lifestyles award, we have achieved outstanding results for our own employees. Let us show you what we can do for yours. Contact us Figure 4. Total expense baseline Cerner client data and industry studies suggest that an employer can expect (on average) that they will see the numbers below contributing to total expense baseline. / workplacehealth@cerner.com / / cerner.com/workplacehealth Managing your trend At Cerner, we know that when health is managed at the individual level, the benefits are actualized system-wide. It s our goal to partner with like-minded organizations looking for a simple evaluation, implementation and resultsoriented approach to meet a population s health and wellness needs. We believe our Primary Health solutions and services will provide the necessary programs for ensuring accountability around health and include the steps necessary to achieve improved and sustainable outcomes. Cerner Corporation / 2800 Rockcreek Pkwy / Kansas City, MO / USA This document contains Cerner confidential and/or proprietary information belonging to Cerner Corporation and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of Cerner. All Cerner trademarks and logos are owned by Cerner, Corp. All other brand or product names are trademarks or registered marks of their respective owners. Cerner Corporation. All rights reserved _v1