Analytics Tools for Population Health Management. Arumani Manisundaram Director - Center for Connected Health Adventist HealthCare

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1 Analytics Tools for Population Health Management Arumani Manisundaram Director - Center for Connected Health Adventist HealthCare

2 About Our Organization(s) Adventist HealthCare Five acute-care and specialty hospitals 1,045 acute-care beds 178,792 acute admissions 450,000+ encounters annually 6,500 employees Based in Gaithersburg, MD Center for Connected Health EHR Roll Out / Adoption Health Information Exchange Tele-health / Telemedicine Health & Wellness / Pop. Health / ACO Mid-Atlantic ACO Physician-Led Partnership Providers / 100 Primary Care Physicians 14,000+ Covered Lives One of the Largest CMS - MSSP ACO s in Maryland 2

3 Defining Population Health Management Population health has been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group" Managing the complete health needs of not only the patients you see but also the ones that you don t see 3

4 Population Health Management 4 Basic Steps to Population Health Management 1. Define 2. Assign 3. Analyze 4. Focused Outreach 4

5 Population Health Management 4 Basic Steps to Population Health Management 1. Define: Define the population to manage Using Analytics (PM Software / Claims / Registry) PCP / Specialty Disease State Payer Cost Risk Stratification (HCC, Charleston, risk factors, etc.) 5

6 Population Health Management 4 Basic Steps to Population Health Management 2. Assign: Assign the defined the population to provider Attribution in-exact science CMS Defition 4 cut method 6

7 Population Health Management 4 Basic Steps to Population Health Management 3. Analyze: Focus on a specific population to improve Value Value = Quality / Cost 3 Levels of Analysis Basic Intermediate Advanced 7

8 Population Health Management 4 Basic Steps to Population Health Management 4. Focused Outreach: Customized Campaigns Specific Population Manageable Sizes Specific Clinical Targets Keeping Goals Simple Reasonable timeframes for completion Measure Patient / Provider response rates Measure / Track / Report impact of campaigns 8

9 Our early success with Population Health Management Round # 1 Medical Home Pilot 9

10 Medical Home Pilot: The Problem Adventist HealthCare is a self-insured employer 6.3% of covered lived accounted for 60% of the cost Analytics revealed deficiencies in our health plan s clinical outcomes and costs. 10

11 Medical Home Pilot: A Closer Look 121 individuals were high-risk poly users: Saw at least 15 different providers and had at least 9 prescribing physicians 46 poly members participated in the pilot (8 PCPs managed their care needs) 11

12 Medical Home Pilot: The Solution Having the Analytics as the back bone A personal health nurse was assigned to each PCP Responsibilities included: Dietary counseling Appointments for baseline screenings Follow-up appointments Exercise plans Pharmacy assessments Using Analytics - We formulated a way to engage patients to improve outcomes and reduce costs. 12

13 Medical Home Pilot: Results The number of high risk members was reduced by >48% Members moved into the moderate and low risk categories 13

14 Medical Home Pilot: Results The Care Coordinator had a direct impact on per-member-per-month (PMPM) performance Pilot participants PMPM costs dropped 35% $1,981 $1,043 Patient Engagement using Patient Portal MyHealthPlace Mobile Device Integration 14

15 Medical Home Pilot: Conclusion Using Claims-based Data Analytics and Patient Engagement Tools Effectively identified high-risk patients Improved patient outcomes Reduced costs Engaged patients on their terms 15

16 Evolved. Medical Home is available to more patients Available to all high-risk health plan members Expanded to offer MyHealthPlace to: Offer Comprehensive Workplace Population Health Solution Tight integration with: Self reported data Claims Data Health and Wellness Data HRA 16

17 Additional recent initiatives in Population Health Management Round # 2 CMS MSSP ACO 17

18 One of the largest CMS MSSP ACO in Region Total Number of Providers 1,042 Number of Primary Care 158 Number of Beneficiaries 14,022 Source: CMS 18

19 A suggested approach Analy.cs Pa.ent Engagement Care Planning Referral Network Care Coordina.on 19

20 Infrastructure Components Employed Prac?ces Affiliated Prac?ces Lab/ Rad Hospitals State HIE Payors Data Visualization Integra?on Engine empi Clinical Data Repository Data Cleansing / Harmoniza?on Analy?cs 20

21 Population Health Analytics 21

22 Overall Utilization 22

23 Patient Satisfaction Surveys 23

24 Additional recent initiatives in Population Health Management Round # 3 Clinical Integration Network 24

25 Selecting a Population Health Analytics Tool Choosing the right Analytics Tool is key Integrating the clinical and claims data across care continuum to give providers the whole view of their respective population and trends in health utilization and outcomes Predicting patients at-risk and reducing preventable costs by identifying unmet needs and clinical risk factors Making all clinical insights immediately actionable by combining a patient-centered view with multiple attribution models Driving performance improvement through deep comparative benchmarks. 25

26 Choosing an Analytics / Reporting Tool for Population Health Management Caradigm Explorys MedVentive / McKesson Optum (Humedica) Advisory Board Healthagen eclinicalworks - CCMR XG Health MedVentive / McKesson Phytel Healthagen HealthCatalyst 26

27 Its what you do with the data. 27

28 Contact Arumani Manisundaram Director Center for Connected Health Adventist HealthCare Tel

29 ANALYTIC, DATA, & TECHNOLOGY ENABLING POPULATION HEALTH THE ART OF THE POSSIBLE Company Confidential - For Internal Use Only Copyright 2013, SAS Institute Inc. All rights reserved.

30 AGENDA What if The Art of the Possible Challenges.....Not Insurmountable A Path Forward...Where Do We Start Company Confidential - For Internal Use Only Copyright 2012, SAS Institute Inc. All rights reserved.

31 ART OF THE POSSIBLE OPTIMIZED RESOURCE ALLOCATION Awareness Renewal Acquisition Engagement Conversion ACO Membership Lifecycle Patient Interventions & Support Programs Health & Wellness Programs Company Confidential - For Internal Use Only Copyright 2012, SAS Institute Inc. All rights reserved.

32 ART OF THE POSSIBLE LEVERAGING ALL THE DATA..BUT ONLY SO FAR Company Confidential - For Internal Use Only Copyright 2012, SAS Institute Inc. All rights reserved.

33 BUSINESS ISSUES POPULATION HEALTH Move from disease management to population health Develop 360 view of the individual Increase uptake of preventative care Identify and act on care gaps Anticipate needs of individuals served Prioritize communications with individuals Understand needed support services and staff roles to provide optimal mix of care options Reduce network leakage Leverage emerging Health 2.0 channels and trend towards mobility Company Confidential - For Internal Use Only Copyright 2012, SAS Institute Inc. All rights reserved.

34 CHALLENGES CHANGING FOCUS: IN-OFFICE VS. DAY TO LIFE 3600 seconds 4800 seconds 31,276,000 seconds Company Confidential - For Internal Use Only Copyright 2012, SAS Institute Inc. All rights reserved.

35 CHALLENGES CHANGE MANAGEMENT TO LEVERAGE DATA IN NEW WAYS Savings The Volume-to-Value Revolution - Rebuilding the DNA of Health from the Patient In, T. Main, A. Slywotzky 2012 Company Confidential - For Internal Use Only Copyright 2012, SAS Institute Inc. All rights reserved.

36 PATH FORWARD ENGAGE EVERY PATIENT AS A UNIQUE INDIVIDUAL Jim s health challenges: Struggles to maintain a health weight Has elevated A1C Family history of hypertension Jim s personal situation: 48 years old Full-time Accountant Enjoys movies One teen at home Janice s health challenges: Chronic astmas Has elevated A1C Family history of hypertension Janice s personal situation: 35 years old Full-time Dental Assistant Enjoys cooking Married Jeff s health challenges: Chronic back pain Continually misses physical therapy High stress with work/family obligations Jeff s personal situation: 33 years old Full-time General Contractor Two toddlers Single father Jane s health challenges: Struggles to maintain health weight Has elevated blood pressure Family history of heart trouble Jane s personal situation: 25 years old Part-time Consultant Travels regularly Jill s health challenges: Struggles to maintain a health weight Has elevated blood pressure Family history of heart trouble Jill s personal situation: 66 years old Retired Babysits her grandson twice a week Recently widowed Company Confidential - For Internal Use Only Copyright 2012, SAS Institute Inc. All rights reserved.

37 PATH FORWARD INSIGHTS BECOME AN ORGANIZATIONAL ASSET Internal: Define a patient data strategy Create an analytics platform Create patient segmentation frameworks Design/automate outreach program by segment Risk Scoring Model 1 5 Patient Behavior Sub-segments Company Confidential - For Internal Use Only Copyright 2012, SAS Institute Inc. All rights reserved.

38 PATH FORWARD GET STARTED..LEARNING COMES BY DOING Data Aggregation for Model Refinement Enhanced Aggregated Data Patient Risk Segmentation Modeling & Scoring External: Leverage technology for outreach Capture data from outreach Continually refine outreach Leading Indicator & Reports & Dashboards Patient Cohorts w/ Profiles & Patient Risk Scores atient / Intervention Tracking & Measurement Intervention Execution & Data Collection Patient Centered Patient Intervention Implementation Patient Interventions Identification & Setup Intervention Campaigns By Patient Cohort Company Confidential - For Internal Use Only Copyright 2012, SAS Institute Inc. All rights reserved.

39 Company Confidential - For Internal Use Only Copyright 2013, SAS Institute Inc. All rights reserved.

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