POPULATION HEALTH. Annual Wellness Visit (AWV) Matthew Brown, MD Chief Medical Officer Presence Health Partners

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1 POPULATION HEALTH Annual Wellness Visit (AWV) Chief Medical Officer Presence Health Partners November 10, 2015

2 Purpose Presence Health partnered with physicians to form as a means of helping providers make the transition from reimbursement based on a volume of billable events to payments based on the value of care delivered. The purpose of this presentation is to describe strategies, tactics and tools to optimize the value of care delivered to our members. 2

3 Agenda + Why Population Health Why do I Need to Care? + Closing Care Gaps Annual Wellness Visits (AWV) + Best Practices Success Stories + What s in it for Providers? + Practice Tools + Q&A 3

4 WHY POPULATION HEALTH WHY DO I NEED TO CARE? OVERVIEW 4

5 This Matters Shift in Payor Mix Chief Medical Officer, PHP 5

6 How We Will Succeed Three Strategies to Improve Population Health Organize Physicians to Play a Central Leadership Role in Managing the Total Care of the Individual Patients Chief Medical Officer, PHP Equip Providers to Engage, Educate and Activate Patients in Better Self-Management of Their Health and Risk Factors Expand Care Coordination Capacity Through Enhanced Use of Non-physician Team Members 6

7 Managing Target Cohorts Risk Stratification of Attributed Lives into Healthy, At-Risk, Chronic and Complex Cohorts Chief Medical Officer, PHP Risk Mitigation and Management Tools Deployed Beyond the Physician Office Visit 7

8 Filling Gaps in Care Chief Medical Officer, PHP 8

9 THE ANNUAL WELLNESS VISIT (AVW) OVERVIEW 9

10 The Business Case for Annual Wellness Visits Opportunities to Close Gaps in Care + Improve patient health + Reverse underutilization + Existing patients, more revenue + Patient Matthew volume Brown, MD + Exceed Chief plan-incented Medical Officer, quality metrics PHP + Move you Provider Scorecard AWV dial + Decrease leakage/outmigration to better manage patients within Presence Health + Attain/keep attribution for physician + Opportunity to organize risk pools within a practice + Position for population health success 10

11 The AWV is a Preventative Visit Not a Routine Physical Examination + The AWV is a yearly dedicated preventive visit where a patient and their health care provider may discuss a beneficiary s health status and maximize the preventive services that are available to close gaps in care. Chief Medical Officer, PHP + The AWV is not a head to toe physical examination. + It allows for an opportunity to conduct health risk assessment and stratify the patient based on medical needs to improve their risk. 11

12 Essential Components of an AWV + Health Risk Assessment (HRA) + Review of health related risk factors + Standardized screens such as alcohol and depression + Targeted objective measures Chief Medical Officer, PHP + USPSTF recommended screenings + Personalized health plan/goals of care 12

13 Health Risk Assessment (HRA) + Collects self-reported information known to the patient + Can be administered by patient or health professional before, or as part of, the Annual Wellness Visit (AWV) Chief Medical Officer, PHP + Takes no more than 5 minutes to complete + Addresses the following topics: + Demographic data + Self assessment of health status + Psychosocial risks + Behavioral risks 13

14 Review of Health Related Risks + Documentation of significant family history + Review of personal risk factors such as smoking, alcohol usage, drug usage + Discussion of environmental risk factors such as finances, living situation, family and social support Chief Medical Officer, PHP + Reporting on activity level and dietary habits 14

15 Objective Measures + Vitals: BP, Height, Weight, BMI + Targeted physical exam based on identified risks, and health condition + Evidence based tools. Use of Decision calculators to document Chief Medical Officer, PHP specific risks such as Framingham for CV risk. 15

16 USPSTF Recommendations Chief Medical Officer, PHP 16

17 Annual Wellness CPT Visit Codes Chief Medical Officer, PHP 17

18 Annual Wellness ICD10 Visit Codes Chief Medical Officer, PHP 18

19 PRACTICE TOOLS OVERVIEW 19

20 Gaps in Care Opportunity: Annual Wellness Visit 20

21 Practice Tools + Personalized report card that reviews the recommended screenings and interventions. + Tools for patient education interventions such as smoking cessation, alcohol and drug abstinence, STD prevention, etc. + Engagement of resources such as case management, chaplain services, Chief Medical Officer, PHP community resources to address psychosocial, economic, and environmental risk factors. + Review Utilization based interventions: ED usage, inpatient services, and out of network utilization. 21

22 Provider Tools + Forms Existing In Development + Health Risk Assessment (HRA) + Stratification/Case Management + My Personal Health Report Card + Documenting and Coding Preventative Visits Chief Medical Officer, PHP + Letter to patient + FAQs / Need-to-knows + Sample visit template + Well male/woman exam form + After visit summary + ED use education brochure + Network utilization education flier + What you can do to maintain your health + Pathway to health checklist 22

23 BEST PRACTICES SUCCESS STORIES 23

24 Best Practices From Our PODS + Practice A + Two physicians and one NP + Primary care practice + Sees multitude of Medicare, Medicaid, and commercial + No EMR, still on paper + Total incentives earned: $42, Practice Matthew as Brown, a group MD reviews the quality Chief Medical metrics for Officer, commercial PHP payers + Seasoned office staff placed in charge of registry + Regular feedback on physician performance and need for metrics + Creation of a diabetes template that captures the quality metrics + Practice B + Solo practitioner + Diverse practice with commercial, Medicare, and Medicaid patients + Uses EPIC for EMR + Total bonus amount earned: $28,495 + Created diabetes check list that she follows for every patient + Reminder calls are repeated until completion of the recommended task (follow-up) + Her philosophy of care involves being a coach for her patients 24

25 Best Practices From Our PODS + Practice C + Solo practitioner + Diverse patient population: Medicare, and Medicaid and commercial + Uses Practice Fusion for EMR + Total incentive earned: $19,039 + Follows patients every three months regardless of controlled or uncontrolled + Has Matthew a checklist Brown, reminder MD for every patient Chief that Medical helps her Officer, capture PHP the quality metrics + Uses motivation style of interview to promote healthy activities and lifestyle changes + She continues to remind them for incomplete tasks until they are done + Practice B + Three providers, two sites + Pediatrics Practice + Medicaid, Medicare, and commercial program participation + Uses eclinical Works EMR + Total incentive earned: $21,158 + Working towards certification for PCMH + Has assigned clinical leads for each chronic disease projects such as asthma, immunizations, etc. + Registries and populations analytics managed by RN/Office staff + Follow-through on missed appointments and gaps in care + RN morning huddle to review appointments and needed actions + reminders for office visits + Process in place for immunization refusal 25

26 Total Provider Compensation 26

27 Q&A Mary Hervey, Manager Provider Relations/Network Development

28 Thank You! To receive CME credit, please complete the CME evaluation form and follow the submission instructions on the form. 28

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