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1 Note: This is an authorized excerpt from 57 Population Health Management Metrics. To download the entire report, go to or call

2 57 Population Health Management Metrics: Assessing Risk to Maximize Reimbursement The data and analysis contained in this special report is derived from HIN s annual market e-surveys on key healthcare trends and coverage of relevant presentations by the Healthcare Intelligence Network. Executive Editor Melanie Matthews HIN executive vice president and chief operating officer Editor Patricia Donovan Contributing Editor Jessica Fornarotto Cover Design Jane Salmon 2014, Healthcare Intelligence Network

3 Table of Contents Population Health Management... 6 Collaboration, Medication Reconciliation, Wellness Key to Successful Population Health Management... 6 Existing Programs for Population Health... 8 Population Health Program Focus... 9 Targeted Populations Health Risk Levels Served Health Professionals on PHM Team Risk Stratification Tools Program Components Health Risk Assessment Carrots, Sticks and Technology Spike HRA Completion Rates Improving the Health of Dual Eligibles with HRAs Using HRAs HRA Eligibility Target Populations Uses for HRA Data Areas Addressed by HRAs HRA Formats Annual HRA Completion Rates Mandatory HRA Completion Penalty for Non-Completion Medication Adherence Two Key Trends in Medication Adherence Initiatives Existing Program to Improve MA Targeted Populations Conditions Most Receptive to MA Common Barriers to MA Program Components Tools and Technologies Pharmacist Included on MA Team Programs with Retail/Community Pharmacists Health Coaching Will Technology Reshape the Behavior Change Business? Existing Health Coaching Programs Targeted Populations Health Risk Levels Eligible for Coaching Program Participants Coaches Background Coaches Caseloads , Healthcare Intelligence Network

4 Care Coordination Key Attributes of a Highly Functioning Medical Neighborhood Utilizing Case Managers Targeted Case Management Populations Targeted Case Management Conditions Diagnosis Most Responsive to Case Management Identification Methods for Case Management Embedded Case Managers Case Manager Responsibilities Case Manager Caseload Existing Medical Homes Targeted PCMH Populations Targeted PCMH Conditions Technology Used in Medical Homes Patient Education and Engagement Strategies PCMH Team Members Case Manager Embedded in PCMH PCMH Impacts Measuring PCMH Effectiveness Reducing Readmissions and ED Use Key Post-Acute Partnerships That Reduce Readmissions Programs to Reduce Hospital Readmissions Targeted Populations Targeted Conditions Identifying Individuals Strategies to Prevent Readmissions Programs to Reduce Avoidable ED Usage Strategies to Discourage Avoidable ED Visits Staffing Solutions to Discourage Avoidable ED Usage Engaging PCPs to Reduce ED Visits Tactics to Reduce ED Visits by Recently Discharged , Healthcare Intelligence Network

5 57 Population Health Management Metrics: Assessing Risk to Maximize Reimbursement The sweet spot in population health management includes activities that cover all Triple Aim bases enhancing health status and outcomes, increasing efficiency and quality and reducing spend. A carefully curated population health management program that begins with risk stratification and fosters collaborations with stakeholders can do all that and more, including minimizing the need for ED visits and hospital readmissions. These charts and tables in this special report are enhanced by coverage of related programs in which organizations at the cutting edge of healthcare delivery, including Adventist Health and BDC Advisors, presented their programs and best practices. The Healthcare Intelligence Network thanks all the organizations that have provided valuable information via webinar presentations or HIN e-survey responses. 2014, Healthcare Intelligence Network 6

6 Elizabeth Miller is the vice president of care management at White Memorial Medical Center, part of Adventist Health. Population Health Management Collaboration, Medication Reconciliation, Wellness Key to Successful Population Health Management Zumba, yoga, Thank God It s Free Fruit Friday (TGIFF)? Maybe not top-of-mind elements of accountable care, but all three are helping healthy employees to stay healthy, and luring others to engage in their own health self-management, the keys to successful population health management (PHM), said Elizabeth Miller, vice president of care management at White Memorial Medical Center, part of Adventist Health, during a recent webinar at the Healthcare Intelligence Network. In Managing Risk in Population Health Management, Ms. Miller shared the key features of the PHM program at White Memorial, the program s impact on Adventist s 27,000 employees and how the program was being rolled out to its patient population. By incorporating elements of the Triple Aim and collaborating with all stakeholders, including patients, providers, health plans, employers, hospitals and local community members, a PHM program can achieve optimal outcomes, including minimizing the need for ED visits, lowering costs, maintaining and improving individuals health across the continuum of care, and reducing readmissions, Miller says. Medication reconciliation plays a key part in preventing populations from being admitted or readmitted to the hospital, Miller continues, because it is one of the chief causes for readmission. She cites numerous instances where nurse practitioners go into people s homes to do medication reconciliation only to find that they are going to two cardiologists simultaneously and taking medications from both of them, not realizing how detrimental this can be to their health. Elements of the PHM program include using robust data sets, risk stratification, and predictive modeling to identify populations, and target highrisk individuals with one or more chronic diseases, including the top five: coronary heart failure (CHF), chronic obstructive pulmonary disease (COPD), asthma, diabetes, HIV. Once eligible populations are targeted and enrollment criteria met, analytics, intervention and program development are established for the top 5 percent, or very high risk, and 10 percent, or high risk, and then wellness programs for the 85 percent, or medium risk. Ongoing assessments and evaluations of interventions follow, usually by care managers, including periodic reassessments of goals, and measuring outcomes with set metrics. 2014, Healthcare Intelligence Network 7

7 Existing Programs for Population Health 102 healthcare companies responded to HIN s survey on Population Health Management in September To control costs, healthcare organizations and employers are turning to population health management, defined as the management of integration and outcome measurements of any program affecting the health and productivity of a specific population or group. We wanted to see who has a population health management (PHM) program. Existing Programs for Population Health Do you have a formal population health management program? 42.0% 58.0% Yes No 2014 Source: HIN Population Health Management Survey September, 2012 HIN s PHM survey, conducted in September 2012, documented the efforts of 102 healthcare organizations in PHM, including program areas, populations served, how the appropriate level of intervention is identified and much more. According to the organizations who responded to the survey, 58 percent have a PHM program, while 42 percent do not. One survey respondent stated that the greatest success achieved with their program was a 50 percent reduction in ED and inpatient admissions in pediatric chronically ill members. 2014, Healthcare Intelligence Network 9

8 Mandatory HRA Completion To get a better handle on population health, mandatory HRAs are on the rise, according to respondents to HIN s 2013 HRA survey. We wanted to see the incidence of healthcare companies mandating HRA completion. Mandatory HRA Completion Is HRA completion mandatory or voluntary? 21.0% Mandatory Voluntary 79.0% 2014 HIN Health Risk Assessments Survey October, 2013 HIN s e-survey on HRAs discovered that about 53 percent of the healthcare companies who responded to the survey provide incentives for HRA completion, which helps to sweeten HRA completion rates. The survey found that 79 percent of respondents make their HRA completion voluntary (a rise from 15 percent in 2010), while 21 percent make completion mandatory. 2014, Healthcare Intelligence Network 25

9 Embedded Case Managers As care coordination by healthcare case managers continues to drive clinical and financial outcomes in population health management, the healthcare industry is expecting to see lots more case managers not just in newly launched initiatives but co-located in nursing home, long-term care (LTC) and assisted living settings. We wanted to see which organizations are embedding or colocating case managers at care sites. Embedded Case Managers Are your case managers embedded or colocated at care sites? Yes No 46.2% 53.8% 2014 HIN Healthcare Case Management Survey May, 2013 When HIN launched the Healthcare Case Management in 2013 e-survey, it documented that 53.8 percent embed or colocate their case managers at care sites, while 46.2 percent do not. In seeking more details about embedded case management, the survey found that 56.8 percent of organizations embed case managers in the primary care practice, and 52.3 percent in hospitals. One survey respondent said that the most notable improvement or innovation resulting from embedded case management is the decrease in avoidable hospital admissions. 2014, Healthcare Intelligence Network 50

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