The Five Pillars of Population Health Management. Dr. Christopher Mathews Senior Vice President and Chief Medical Officer ZeOmega

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1 The Five Pillars of Population Health Management Dr. Christopher Mathews Senior Vice President and Chief Medical Officer ZeOmega

2 ZeOmega a forerunner in Population Health Management Transformation into performance management driving population healthcare Supporting Delivery System Excellence Company founded, Initiates development of Jiva care management platform Jiva reengineered to be first flexible platform to configure & automate workflows ZeOmega raises Series A funding Contracts with GHC, a national leader in both Patient-Centered Medical Homes and ACOs $21.5 million growth equity financing Health system begins managing 40,000 lives using Jiva First Jiva go-live Integrates data and analytics to drive intelligence, and embeds in the workflow ZeOmega contracts with several payers, covering millions of lives. IDC MarketScape identifies ZeOmega as a major player in Care Management 2013 ZeOmega, Inc. All Rights Reserved.

3 How We Got Here Healthcare s Perfect Storm World Health Organization: Healthcare = 18% of GDP and rising; Consumer out-of-pocket costs = 21% Regulatory changes: MU, HIPAA, MLR, ICD-10, ACA Affordable Care Act: Adding millions of previously uninsured into system Sociopolitical forces driving health insurance exchanges and healthcare retail markets 76 million Americans eligible for Medicare in next 15 years Increased use of cloud computing, mobile devices with personal & clinical data Almost half of us have chronic conditions requiring at least one form of medication Use of genomic medicine trending upward 2013 ZeOmega, Inc. All Rights Reserved.

4 How the Perfect Storm Is Impacting Healthcare Organizations Stakeholders must re-think roles while controlling costs and improving care requiring them to shift from traditional care management to PHM Rapid technological innovation is making solutions available that were not possible before

5 What Is Population Health Management? Triple Aim Per Capita Cost Population Health Experience of Care Improve the overall health of the population being served by increasing the quality of care Improving the overall experience for individuals Lowering the per capita cost of care through improvement Effective Population Health Management should be based in the Triple Aim Strategy

6 What Is Population Health Management? Improving the overall health and well-being of an individual Across the Care Continuum From birth to end-of-life Across Multiple Care Settings From home to hospital to hospice, and all settings in between Across Multiple Domains of Health Medical, behavioral, and psychosocial determinants of health and doing it consistently for every individual in the population we serve.

7 What Is Needed For a Successful PHM Program? Care Manager Utilization Manager Nurses & Clinicians Social Workers Care Teams Long Term Acute Care Inpatient Rehab Facilities Skilled Nursing Facilities Home Health Hospice Post Acute Providers Pharmacists Administrators Financial Analysts Clinical Analysts Supervisors Compliance Personnel CFO Analysts Patient / Caregivers Rules Engine Physicians Payers Ambulatory Care Acute Care Health plans Agencies Reinsurers Employers

8 The Five Pillars of Population Health Management Population Health Management Program Design and Governance Data Integration & Aggregation Actionable Intelligence Holistic, Patient Centered Care Management Consumer Engagement

9 P1: Program Design & Governance PHM Goals Current Capabilities The Plan Compliance, Cost, Quality, Clarity on measurement of the short and long term goals Assessment of current capabilities and strengths Current Weaknesses and gaps in capabilities required to achieve long term goals Ensures incentives of all stakeholders are aligned Achieves short term goals quickly, and builds on these to tackle long term goals Leadership commitment and change management strategies. Technological capabilities can determine how successful your PHM program will be. Performance Measurement & Monitoring Metrics to measure achievement of goals Periodic (preferably real time) monitoring

10 Structured Unstructured P2: Data Integration & Aggregation Interoperability is the new wine in the old bottle Key Considerations: Master Patient Index Point to Point Batch Real time, self authenticating data exchange Legacy Current Next Generation Master Provider Index Elimination of duplicates Tracking the authenticity & quality of data sources Natural Language Processing Data Normalization & Tagging Non-Clinical Demographic, Claims, Billing, RCM Clinical Imaging, Lab, Diagnostics, Pharmacy, EMR, Biometrics

11 Low Actionability & Effectiveness High P3: Actionable Intelligence Unstructured data Real-time Big Data Analytics drives personalized pop health + Behavioral, Provider quality, biometrics, EMR structured data, + Consumer data, Environmental data Predictive Analytics Platform driven real-time adjustment of risk, propensity to change, Optimization of resources based on out come and behavioral change prediction - NEXT BEST THING TO DO Claims, ICD9/CPT + HRA, Demographics, Personal Preferences + Lab, Drug, Diagnostic Data Mining & BI Ad-hoc reporting Basic Reporting Embedded analytics in workflow Risk Identification and stratification Dashboards (STAR, ACO Measures, Patient registries) BI Tools, Limited to power users, Static dashboards to support business users Example: Compliance Reports, Standard Outcomes reports Low Accuracy & Effectiveness of Analytics High

12 P4: Holistic, patient-centered care management Pharmacists Analysts Care Teams Rules Engine Post Acute Providers Administrators Payers Evidence-based medicine, that is completely personalized to the individual Meeting the patient, their advocate, and the care team where they are with the right technologies Actionable intelligence that accounts for not only medical needs but also behavioral, psychological, social, financial, emotional, environmental, spiritual, and cultural factors in driving actions the NEXT BEST THING TO DO Caregivers Physicians

13 P5: Consumer Engagement It is all about getting to Patient Commitment and Empowerment Analytics that clearly assess need for change, propensity to change, factors that drive change, factors that induce change fatigue Medication alerts, Engage Educate Empower Deliver the right information at the right time in the right communication channel to the right stakeholder Educational Mailers, Coaching Campaigns Decision Support Tools Cost Price Transparency Quantification of Quality Convenience

14 The Five Pillars of Population Health Management Dr. Christopher Mathews Senior Vice President and Chief Medical Officer ZeOmega

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