POPULATION HEALTH MANAGEMENT The Lynchpin of Emerging Healthcare Delivery Improve Patient Outcomes, Engage Physicians, and Manage Risk

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1 POPULATION HEALTH MANAGEMENT The Lynchpin of Emerging Healthcare Delivery Improve Patient Outcomes, Engage Physicians, and Manage Risk Julia Andrieni, MD, FACP Vice President, Population Health and Primary Care Healthcare Financial Management Association Gulf Coast 2015 Fall Institute October 16, 2015

2 WHAT IS POPULATION HEALTH MANAGEMENT? Definition: A data driven integrated health care delivery model that provides individualized care plans to populations based on health risks and chronic conditions. Population Health Management uses data aggregation and data analytics to design and monitor the effectiveness of individual healthcare needs. 2

3 THE EVOLUTION OF POPULATION HEALTH MANAGEMENT Population Health Management Clinical Integration Functional Integration Population Health Management Data Driven Quality of Care Stratify Population by Health Risk Individualize and Coordinate Care Plans Promote Patient Engagement Clinical Integration Accountable for Quality Standardize Utilization of Resources Cost Containment Managing Risk and Outcomes Functional Integration Care Coordination Patient Access Referral Management Team-Based Care (PCMH) 3

4 A RAPIDLY CHANGING HEALTHCARE LANDSCAPE FOCUSED ON VALUE OF CARE Payment Models are Driven by Different Incentives Payment Models Fee For Service FFS Linked to Quality Population Health Based Payment Incentive Driven By Volume Maximize number of appointments per patient Driven by Volume Linked to Quality Outcomes Pay For Performance Driven By Care Coordination Linked to Quality ACOs and CINs Bundled Payments 4

5 POPULATION HEALTH MANAGEMENT PROGRAM KEY ELEMENTS TITLE Care Management Infrastructure Primary Care Focused Clinical Network Care Management Infrastructure Functional Integration to Deliver Individualized Care Coordination of Care Identify Barriers to Achieving Better Health Outcomes Primary Care Focused Clinical Network Clinical Integration of Care Team Consumer Access and Convenience Data Driven Clinical Decision Making Patient Engagement Strategy Data Driven Clinical Decision Making Advanced Informatics to Stratify Health Risks Predictive Analytics to Guide Resource Utilization Patient Engagement Strategy Improve and Sustain Health Outcomes at a Lower Cost EHR Patient Portal, Apps, Wireless Health Monitoring Devices 5

6 THE MECHANICS OF POPULATION HEALTH MANAGEMENT 6

7 POPULATION HEALTH STRATEGY: USE DATA TO TARGET SPECIFIC PATIENT HEALTHCARE NEEDS Method: Use of IT intelligence to drive improvement in Clinical Outcomes and Patient Satisfaction I. Predictive Analytics Which Patients will be readmitted in the future? (Decrease readmission rates) Which Patients, who appear well today, are at risk for developing a serious illness? (Target individual risk factors) II. III. Patient Outreach Based on Patient Data Which uncontrolled Diabetic patients have not had an appointment in the past 3 months? (Identify gaps in care for healthcare under utilizers) Which Diabetic patients have not filled their prescriptions? (Prescription Gap Analysis to identify socioeconomic barriers) Physician Decision Support at Point of Care Physician reminders in real-time at the point of care when patient needs a test, service, or treatment. (EHR capabilities) Which Diabetic patients are most likely to be non-adherent to the care plan? (Evaluate readiness for change and literacy levels) 7

8 COORDINATION OF INDIVIDUAL CARE PLANS IS A CRITICAL ELEMENT POPULATION HEALTH RISKS PYRAMID Chronic Disease Management Patient Centered Medical Home Team Based Approach to Care Patient Outreach Rising Risk Patients 15%-35% Healthy Population Management Prevention and Wellness Urgent Care Access Patient Convenience Telemedicine Low Risk Patients 60% - 80% High Rising Risk At Risk Low Risk High Cost & Utilization of Resources Intensive Care Management 1 Nursing Care Manager to 200 High Risk Patients Home Health Monitoring Devices Pharmacist Medication Review High Risk Patients 5-10% Data Stratification of Health Risks Matched to Care Plans 8

9 POPULATION HEALTH PILOT POTENTIAL PARTICIPANTS RISK LEVELS Diabetes (n=19) Hypertension (n=61) Cotinine+ (n=61) HIGH RISK n=141 High Risk 11% Rising Risk 21% Low Risk 68% AT RISK n=275 Diabetes (n=81) Hypertension (n=194) Controlled Diabetes (n=47) LOW RISK (n=863) Controlled Hypertension (n=165) No Diabetes or Hypertension (n=651) Houston Methodist Participants* (n= 1279) Note: Employees included=1097, Beneficiaries included=182 9

10 HM POPULATION HEALTH PILOT HOUSTON METHODIST POPULATION HEALTH PROGRAM TARGETS DIABETES, HYPERTENSION, AND NICOTINE-POSITIVE EMPLOYEES AND BENEFICIARIES Risk Stratify Employee/Beneficiaries Connect Employees/Beneficiaries with Primary Care Physicians Coordinate Care Use Biometric Screening Data HM Primary Care Network Nursing Care Navigators Refer to Specialists as Needed Individualize Care Engage Employees/ Beneficiaries Use of Home Healthcare Monitoring Devices TIMELINE: July 2014 August

11 HOUSTON METHODIST POPULATION HEALTH PILOT CONSISTED OF THREE CORE ELEMENTS Primary Care Physician Visits Wellness Courses and Coaching Care Navigator Interaction Visit PCP at least once every 3-6 months If the participant does not have a PCP, the Care Navigator connects them with a PCP Wellness Onsite at Hospital Nutrition Boot Camp Clinical Dietician Individual Consults Quit & Get Fit Telephonic Counseling Nutrition Wellness Coaching QuitPower Create individualized care plans with participants Health assessment Medication review No co-pay for generic blood pressure and diabetes medications Home health monitoring device data reviewed Create SMART goals 87% had a PCP Visit 59% completed a Healthy Directions course ** 88% connected with a Care Navigator Phase I Population Health Pilot (July December 2014) 11

12 EMPLOYEE INCENTIVES NEED TO SUPPORT PARTICIPATION IN POPULATION HEALTH MANAGEMENT 65% Of Enrolled Participants Completed All Three Core Program Requirements* Risk Level Health Condition % Completed High-Risk Rising-Risk Diabetes 40% Hypertension 59% Nicotine + 22% Diabetes 53% Hypertension 71% Total Target Pop 59% Low-Risk 1 Diabetes/ Hypertension 100% Low-Risk 2 N/A 100% Total Pop 65% HR Participant Incentive (Flat Rate) Future Incentives to be Linked to Insurance Premiums * Based on self-reported data; to be confirmed by claims data and HR Benefits 12

13 LESSONS LEARNED: POPULATION HEALTH PILOT DEMONSTRATED PARTICIPANTS LACKED PCPs Strategy Engage employees with incentives to improve health & wellness Engage physicians with partnership and incentives to increase quality & patient access 11% HIGH RISK (n=125) 22% RISING RISK (n=257) 67% LOW RISK (n=777) 47% without a PCP 49% without a PCP 56% without a PCP HM Partnerships Executive HM Sponsorship Human Resources Wellness Department Employee Health San Jacinto Hospital Leadership Primary Care Physician Network (Employed & Aligned) Houston Methodist Population (n=1159) Data Source: 2013 Houston Methodist Biometric Screening,

14 POPULATION HEALTH INITIATIVE: MATCHING HM EMPLOYEES/BENEFICIARIES TO OUR PRIMARY CARE NETWORK HM Employees/Beneficiaries Requested Assistance in Finding a Primary Care Physician ,785 HM Participants Requested Assistance in Finding a Primary Care Physician JAN-JUN 2014 JUL AUG SEP OCT NOV DEC JAN - JUN * 2015 * PCP Question added to WebMD Survey 1/1/14 Annual Employee/Beneficiary Biometric Screening Months JUL AUG 14

15 HM POPULATION HEALTH MANAGEMENT STRATEGY PROVIDED OPPORTUNITIES TO ALIGN INDEPENDENT PRIMARY CARE PHYSICIANS 39% of Population Health Participants have PCPs in our Primary Care Network 69% of Population Health Participants have PCPs in our Primary Care Network 4% Participants without a PCP Opportunities for Aligning Physicians 16% Employed Physicians (n=6) 23% Aligned Private Physicians (n=9) 31% Independent Physicians (n=18) 16% Employed Physicians (n=9) 57% Independent Physicians (n=34) 53% Aligned Private Physicians HMPAQ (n=31) Baseline July 2014 End of Pilot August 2015 Population Health Pilot Participants Matched to Primary Care Physicians (PCPs) 15

16 PHYSICIAN POPULATION HEALTH PARTNER INCENTIVES QUALIFYING CRITERIA Same Day Patient Access Collaboration with Nursing Care Navigators for Patient Management PILOT Flat Rate Incentive for Initial Participation Strategy to Increase Independent Physician Alignment PROGRAM Incentive based on volume and quality outcomes. Example: $125 per participant per year multiplier x2 for decreasing High Risk to Low Risk 16

17 HOME HEALTH MONITORING DEVICES INCREASE PATIENT ENGAGEMENT AND AWARENESS LESSONS LEARNED Target High Risk Participants to Engage in their own Health. 48% of High Risk Participants Utilized Home Health Monitoring Devices. Care Navigators Monitored Patient Device Data. Blood Pressure and Blood Sugar Data Securely Transmitted to Primary Care Physicians. Participants have asked to Keep Devices to Continue Monitoring their own Health Conditions. 17

18 ENGAGING PATIENTS IN THEIR HEALTH IMPROVES AND SUSTAINS OUTCOMES Patient Portal Remote Monitoring Automated Reminders Self-Management, Care Plan Guidance Reach into Community, Home Convenient Accessibility For All Monitoring, Support of Ongoing Care Needs Level of Patient Support Staffing Resources Degree of Change Financial Investment Low Moderate High Source: Health Care Advisory Board interviews and analysis. 18

19 LESSONS LEARNED: POPULATION HEALTH MANAGEMENT PROGRAM GOALS (PHASE II) Increase Physician Population Health Partners Increase Participants Enrolled Increase Wellness Course Completions Develop Physician Advisory Board Increase Number of Enrollees Who Complete Phase II *70% of enrolled participants to complete Phase II Phase II Goals Develop a Scalable Plan for System Expansion *Scalable plan developed by August 2015 Increase PCP Visits Increase Use of Home Health Monitoring Devices Increase Nursing Phone Call Compliance 19

20 WITH THE SAME POPULATION, PARTICIPATION INCREASED 370% IN PHASE II OF THE PROGRAM HOUSTON METHODIST PARTICIPANTS Risk Level Eligible Participants Active Participants % Active Participants High Risk % Rising Risk % Cotinine+ Only % Phase II Total High and Rising Risk Phase II Maintenance % Phase II Total Phase I Total 64 As of 05/20/15 20

21 HIGH RISK PARTICIPANTS A COMPARISON OF THE POPULATIONS IN PHASE I & II Phase I: 29% High Risk (n=33) Phase II: 32% High Risk (n=51) Cotinine + 21% Diabetes 6% 2 Conditions 27% Hypertension 46% Diabetes 18% 3 Conditions 6% 2 Conditions 27% Cotinine + 24% Hypertension 25% 2014 Hypertension Diabetes Two Conditions Cotinine + Three Conditions

22 RISING RISK PARTICIPANTS A COMPARISON OF THE POPULATIONS IN PHASE I & II Phase I: 71% Rising Risk Phase II: 68% Rising Risk Hypertension 62% Diabetes 33% 2 Conditions 5% Hypertension 58% Diabetes 27% 2 Conditions 15% 2014 Hypertension Diabetes Two Conditions

23 IS THERE A DIFFERENCE BETWEEN THOSE WHO PARTICIPATED (INTERVENTION GROUP) IN THE POPULATION HEALTH MANAGEMENT PROGRAM AND THOSE WHO OPTED OUT (CONTROL GROUP)? The High Risk Participants Decreased from 27% to 13%. Uncontrolled DM, HTN 27% Suboptimally Controlled DM or HTN 73% Baseline Pre-Population Health Program (n=115) PHM Program High Risk Rising Risk Low Risk Uncontrolled DM, HTN 13% INTERVENTION GROUP Subop timally Contro lled DM or HTN 37% Contro lled DM, HTN or Nicoti ne- 50% 6 Month Outcomes Post-Population Health Program (n=115) 23

24 POPULATION HEALTH MANAGEMENT CONTROL GROUP OUTCOMES The High Risk Participants Health Risk remained unchanged for those who opted not to participate. Uncontrolled DM, HTN 27% Suboptimally Controlled DM or HTN 73% Pre-Population Health Program (n=215) No PHM Program High Risk Rising Risk Low Risk CONTROL GROUP Uncontrolled DM, HTN 26% Subop timally Contro lled DM or HTN Contro 37% lled DM, HTN or Nicoti ne- 37% No Participation in Population Health Program (n=215) 24

25 POPULATION HEALTH MANAGEMENT PROGRAM OUTCOMES 50% of Participants Achieved Targets for Diabetes, Hypertension and Nicotine+ in 6 months. Uncontrolled DM, HTN or Nicotine+ 30% Suboptimally Controlled DM or HTN 70% PHM Program Uncontrolled DM or HTN 13% Suboptimally Controlled DM or HTN 37% Controlled DM, HTN or Nicotine- 50% High Risk Rising Risk Low Risk Baseline Pre-Population Health Intervention 6 Month Outcomes Post-Population Health Intervention 25

26 74% OF PARTICIPANTS WITH UNCONTROLLED HYPERTENSION*, NORMALIZED THEIR BLOOD PRESSURE IN 6 MONTHS. High Risk Rising Risk Low Risk BLOOD PRESSURE CONTROLLED 74% IMPROVEMENT IN BLOOD PRESSURE 21% BLOOD PRESSURE REMAINED UNCONTROLLED 5%* High Risk and Rising Risk Hypertension Participants Data *Uncontrolled Hypertension is defined as: SBP equal to or greater than 160 and/or DBP equal to or greater than

27 POPULATION HEALTH PROGRAM PARTICIPANT SURVEY RESULTS What Motivated You To Enroll In This Program? Improve My Health 79% 84% Onsite Wellness Program 10% 18% Incentives 36% 42% Generics No Co-Pay 11% 25% Connect with PCP Care Navigator Interaction 4% 2% 7% 36% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Phase I (n=126) July December 2014 Phase II (n=83) January August 2015 Population Health Program Participant Survey Results: 12/2014 & 8/

28 Percentage of Total Participants POPULATION HEALTH MANAGEMENT OUTCOMES PHASE I COMPARED TO PHASE II Population Health Program Goals 100% 90% 93% 87% 88% 95% 80% 70% 60% 50% 51% 59% 69% 44% 69% 40% 30% 30% 20% 10% 0% Eligible Participant Enrollment Completion Wellness Program Completion Primary Care Appointment Completion Nursing Care Navigator Calls Physician Population Health Partners Engagement Phase I (July December 2014) Phase II (January August 2015) 28

29 POPULATION HEALTH PROGRAM PARTICIPANT SURVEY RESULTS Participants Perception Of Their Success In The Population Health Program Successful 52% 76% Somewhat Successful 19% 33% Somewhat Unsuccessful 4% 9% Unsuccessful 1% 7% 0% 10% 20% 30% 40% 50% 60% 70% 80% Phase I (n=126) July December 2014 Phase II (n=83) January August 2015 Population Health Program Participant Survey Results: 12/2014 & 8/

30 POPULATION HEALTH PROGRAM PARTICIPANT SURVEY RESULTS Participants Perception Of The Population Health Program s Convenience Easy to Add to My Schedule 25% 55% Somewhat Easy 33% 45% Somewhat Difficult 11% 17% Difficult 1% 13% 0% 10% 20% 30% 40% 50% 60% Phase I (n=126) July December 2014 Phase II (n=83) January August 2015 Population Health Program Participant Survey Results: 12/2014 & 8/

31 POPULATION HEALTH PROGRAM PARTICIPANT SURVEY RESULTS Participants Perception Of The Impact Of The The Population Health Program On Their Productivity Increased Productivity at Work 21% 43% Somewhat Increased Productivity 51% 66% Somewhat Decreased Productivity 6% 12% Decreased Productivity 1% 0% 0% 10% 20% 30% 40% 50% 60% 70% Phase I (n=126) July December 2014 Phase II (n=83) January August 2015 Population Health Program Participant Survey Results: 12/2014 & 8/

32 PARTICIPANT FEEDBACK FROM POPULATION HEALTH PILOT SURVEY HbA1C reduced from 7.4 to 6.2 through 20lb weight loss with low carbohydrate diet and PCP follow-up. Started a log of blood sugars twice a day. The Pilot program worked for me. I learned how to make better choices. I still need to learn more ways to eat healthier. The program raises self-awareness. This motivated me to make life style changes to improve my overall health. This program should be permanent and corporate wide. SCALE-UP (JAN. 2016): APPROXIMATELY 2,000 HIGH RISK AND RISING RISK PARTICIPANTS 32

33 POPULATION HEALTH MANAGEMENT PROGRAM GOALS AND BENEFITS Goal 1: Increase Clinical Quality and Patient Satisfaction Benefits: Increase Patient Loyalty and Market Share by Matching Patients to a Primary Care Physician Improve Clinical Outcomes with Individualized Care Plans Increase Patient Engagement in their own Health Goal 2: Increase Physician Alignment with a Physician Population Health Partner Strategy Benefits: Increase New Managed Care Patients matched to Primary Care Physicians Increase Physician Utilization of Houston Methodist Hospitals, EDs and Specialty Services Increase Physician Loyalty (Employed and Aligned Physicians) Goal 3: Promotion of Wellness and Prevention for Self-Insured Employers Decreases Healthcare Costs Benefits: Decrease Employee Per Member Per Month Spend Decrease Re-admission Rate of Employees Increase Cancer Screening and Prevention with Early Detection Decrease Employee Sick Days and Increase Employee Productivity 33

34 NEXT STEPS: EXAMINE LESSONS LEARNED EXPAND POPULATION HEALTH PROGRAM SYSTEMWIDE What are Population Health Colleagues Ranking as High Priority Responsibilities? 1,2 Patient Data Aggregation and Analytics 93% Risk Stratification Tool One EHR Systemwide Targeting Specific High- Risk Populations for Intervention 83% Coordination of Nursing Care Navigator Program Interventions Defining the Organization s Management for Population Health Management 80% Population Health Work Group with Executive Sponsorship Creating a Business Case for Population Health Management Initiatives and Outcomes 80% Human Resources Created Employee Health Tracks and Have Linked to Insurance Premiums Establishing Patient-Centered Medical Homes in Primary Care 77% NCQA Level 3 Accreditation awarded to 4 Primary Care Practices 1) Advisory Board Company Population Health Advisor Survey, n=30, fall ) Percentage of survey respondents strongly agreeing or agreeing that responsibility is high priority * Epic Healthy Planet (2016) Adapted From: The Advisory Board Company, The Future of Care Management 34

35 CORPORATE POPULATION HEALTH MANAGEMENT STRATEGY 35

36 POPULATION HEALTH MANAGEMENT PARADIGM CHALLENGES & SUSTAINABILITY ALIGNMENT OF PAYMENT STRUCTURE TO SUPPORT MODEL OF CARE Commercial and government payers support fee for service Decrease in per member per month may require an extended time period to realize OPERATIONAL COMPLEXITY Data aggregation and analysis requires investment in IT capital infrastructure Investment in the labor costs to develop a care management program Tracking and reporting of clinical outcomes matched to healthcare dollars saved CONSUMER DRIVEN CONVIENIENCE CONTINUES TO TRANSFORM HEALTHCARE DELIVERY Partnership with retail clinics? Telemedicine and apps? Consumer health monitoring devices? Consumer Apps? 36

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