CREATING A POPULATION HEALTH PLAN FOR VIRGINIA

Transcription

1 CREATING A POPULATION HEALTH PLAN FOR VIRGINIA

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3 Life Expectancy 1900, years old years old Age (Years)

4 Source: Year

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6 What is different? More Expensive Hospital stays Medications Surgery High Rates Hospital visits for chronic conditions MRI use

7 Source: Wikimedia Commons

8 United States Virginia 37% Virginians spend $49,427,000,000 per year on healthcare 27% 15% 6% 6% 2% 2% 6% Hospital Care Physician and Other Professional Services Prescription Drugs and Other Medical Nondurables Nursing Home Care Dental Services Home Health Care Medical Durables Other Health, Residential, and Personal Care

9 Leading Causes of Hospitalization in Virginia , ,000 80,000 60,000 40,000 20,000 0

10 global research analytics for population health

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12 1,159,396 tobacco users 3,838,092 overweight or obese VIRGINIANS

13 Population Health Approach

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15 WW I & II TB Antibiotics Source: PublicHealthHistory_print.htmlHistory of Public Health, Wayne LaMorte, Boston University School of Public Health

16 Emergence of HIV virus Drug resistance Medication compliance Physical Environment 10% Clinical Care 10% Percent Genes & Biology 10% TB Health Behaviors 30% Social & Economic Factors 40% Incarcerated; crowded conditions Source: Minnesota Department of Public Heath;

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18 Population Health Approach Data Integration Populations Quality measures Address determinants of health Care coordination Payment incentives that promote value

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20 Well Being Healthy Heart Emotional Wellness Aging Well Preventive Actions Quality Healthcare Strong Start

21 Plan for Well Being Determinants of Health/Drivers Recommended Policies Evidence-based Strategies Cost Return on Investment Key Indicators

22 CMS Recommended Metrics Buying Value Tool DMAS Quality American Health Rankings Public Health Reporting Systems VDH Metrics Commonwealth Fund County Health Rankings Analyzed 500+ of the most commonly utilized metrics to define population health

23 Sample Analysis: American Health Rankings Virginia Ranking By Metric

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25 Criteria National Numbers Cost Timely Health Team CMS Impact 1. Can it be compared easily to other national benchmarks? 2. Does it impact a significant number of Virginians? 3. ROI Analyses Possible? 4. Is it timely? 5. Can a majority of the community help impact the outcome? 6. Does it fit in the CMS SIM Parameters? 7. Can we improve performance in this area and have a positive impact?

26 Aligning Metrics With SIM and DMAS Quality Metrics Access To Healthcare Diabetes Heart Health Hospitalizations Immunizations Infant & Child Health Primary Categories HEDIS Measures of Priority In Virginia Medcaid Medallion 3.0 Contract CMS SIM Suggested Population Level Measures Cervical Cancer Screening, Breast Cancer Screening, Adult Access to Access to Healthcare, Percentage of respondents Preventive/ Ambulatory Health Services aged who reported colorectal test Percentage of Adults (aged 18 yeasr or older) Comprehensive Diabetes Care (all indicators) with Diabetes Having Two or More A1c Tests in the Last Year Controlling High Blood Pressure Taking medicine for high blood perssure among adults > 18 Childhood Immunization Status (Combo 3) Timeliness of Prenatal Care, Postpartum Visit, Well Child Visits in First 15 Months, 3rd, 4th, 5th & 6th Years, Adolescent Well Care Visits Adults aged 65+ who have had a flu shot within the past year; Youth: Estimated vaccinaton coverage with individual vaccines and slected vaccination series Mortality Metrics Percent of Live Births < 2500g Obesity Quality Health & Mental Days Adult Weight Classification by BMI, Youth: Students who were > 95th Percentile for BMI, Use of Appropriate Medications for People with Asthma, Follow Up care for Children Prescribed ADHD Medication, Antidepressant Medication Management, Follow- Up After Hospitalization for Mental Illness Sexually Transmitted Infections Tobacco Use Medical Assistance With Smoking and Tobacco Use Cessation Health Related Quality of Life-Physically and Mentally Unhealthy Days In the Past Months Stage 3 (AIDS) at the the time of diagnosis of HIV infection among persons aged 13 years and older, HIV Viral supression at most recent viral load test among persons 13 years and older Four Level Smoking Status, Percent of Smokers Who Have Made a Quit Attempt In The Past Year, Legislation - Smoke free Indoor Air, Youth: Smoked cigarettes on at least one day in the last 30 days

27 Creating A Set of Integrated Metrics Well Being Preventive Actions Healthy Heart Emotional Wellness Aging Well Strong Start Quality Healthcare

28 Healthy Connected Communities Air & Water Quality Food Security Community Walk-ability Well-being Survey Health Opportunity Index

29 Preventive Actions Children Immunized Living Smoke Free 65+ Receiving Flu Shot Breast Cancer Screening Cervical Cancer Screening Colorectal Cancer Screening

30 Quality Healthcare Access to Healthcare Smoking status and cessation advice or treatment Patients with diabetes who had: Hemoglobin A1c testing Eye exam LDL-C control (<100 mg/dl) Medical attention for nephropathy

31 Strong Start Infants Born at a Healthy Weight Tobacco Free Moms Babies Without Birth Defects Kindergarten Readiness Public School Children Who Don t Need Free/Reduced Lunch Students Who Graduate from High School

32 Healthy Heart Free of Cardiovascular Disease Controlled Blood Pressure Healthy Weight

33 Emotional Wellness Rate physical & mental health as good Follow up care for children with newly prescribed ADHD medication Sustained treatment for depression Follow up care after hospitalization for patients with mental health disorder

34 Aging Well Percentage of population with advanced directive No hospital re-admission within 30 days of discharge for patients 65+

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38 Creating System to Improve Population Health 1 - Integrate metrics that cross all spectrums of the health care system including HEDIS data. 2 - Living Community Health Assessment Real-time data Visualized data Statewide to local level data 3 - Incorporate cost drivers 4 - Create a process of accountability that is transparent & actionable at the district level. Quality Healthcare Metrics Healthy Connected Community Metrics Optimal Life Metrics Metrics Strong Start Metrics Protective Actions Metrics

39 Contact Information Josh Czarda, JD - VDH Performance Improvement, Lilian Peake, MD, MPH - VDH Office of Family Health Services,