The Road Less Traveled: Applying Performance Measurement Concepts in Population Health

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1 The Road Less Traveled: Applying Performance Measurement Concepts in Population Health Michael A. Stoto Professor of Health Systems Administration and Population Health Georgetown University

2 Presentation outline Population health framework IRS CHNA requirements Community health assessment Performance measures for implementation strategy

3 What is population health? Kindig and Stoddart: goal health outcomes of a group of individuals, including the distribution of such outcomes within the group IHI: improving the health of populations as one of 3 Aims for improving the U.S. healthcare system Young: conceptual framework for thinking about why some populations are healthier than others research agenda, policies and resource allocation that flow from it public health Less tied to governmental public health departments Explicitly includes the healthcare delivery system

4 Population health approaches Characterized by where they fall on a spectrum based on the population denominator Population health management: Intensive, team-based management of high-risk patients Value-based payment: P4P, ACOs, CPC+, Community-level collaboration, especially facilitated by Community Health Needs Assessments (CHNAs) All require both individual-level and aggregate data on the population served but differ in the relative importance of these data

5 Commonalities: population health Population health more than the sum of individual parts or a cross-sectional perspective upstream factors included in measurement (explicit) goal of reducing disparities and inequities Consideration of broader array of health determinants than healthcare or public health Institute for Healthcare Improvement Composite Model Responsibility for population health outcomes is shared but accountability is diffuse Measurement of shared responsibility for population health outcomes accountability for activities to improve health

6 Disparities Interventions Source: Adapted from Stiefel M, Nolan KA. Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper; 2012.

7 Population Health in the ACA 1. Coverage expansions 2. Quality improvement 3. Prevention and health promotion measures within the healthcare delivery system 4. Community- and population-based activities National Prevention Strategy Prevention and Public Health Fund ($1 billion in FY 2012) Community Transformation Grants Workplace wellness programs & insurance discounts IRS 505(r) requirements for non-profit hospitals conduct a Community Health Needs Assessment implementation plan to address identified priorities

8 Presentation outline Population health framework IRS CHNA requirements Community health assessment Performance measures for implementation strategy

9 Community Benefit requirements As a condition of their tax exemption, non-profit hospitals required to provide, and report on, benefits they provide to the community Community Benefits $62.4 billion (9.7% of operating expenses) in %: loses from Medicaid & means-tested programs 24%: financial assistance for indigent patients 36%: health professions education 4%: community health improvement $2 billion, <1% 3%: contributions to community groups total expenditures Not included: community building activities With declining rates of uncompensated care CB can (should?) shift to community health improvement CHNA requirements are the vehicle for doing this

10 CHNA requirements ( 501(r) in IRS code) Non-profit hospitals must conduct a Community health needs assessment (CHNA) once every 3 years CHNA = written document developed for a hospital facility including a description of community served by the hospital process and methods used to conduct the assessment including how the hospital took into account input from community members and public health experts identification of any persons with whom the hospital has worked on the assessment existing health care resources within the community available to meet community health needs prioritized health needs identified through the process

11 IRS Community health needs assessment (CHNA) requirements Implementation strategy to meet the community health needs identified through the CHNA process Considered as addressing a health need if the written plan either describes how hospital plans to meet the health need or identifies the need as one the facility does not intend to meet and explains why Must be tailored to the particular hospital, taking into account its specific programs, resources, and priorities May be developed in collaboration with other organizations must show the particular activities for the particular hospital covered by the strategy Paid for in part by CB funds

12 Community Health Improvement Process (Improving Health in the Community, IOM, 1997) Managing shared responsibility population health requires Shared CHNA to identify common priorities for outcomes with standard measures for comparisons with similar communities changes over time benchmarking Implementation plans for hospitals (and other entities) with performance measures indicating accountability for actions

13 Winter, 2011 Critical elements Common agenda Shared measurement systems Mutually reinforcing activities Continuous communication Backbone support organizations

Example: Holy Cross Hospital Healthy Montgomery priority Obesity: 50%+ are overweight or obese Holy Cross Hospital Mission: Outreach that improves health status and access for underserved, vulnerable

14 Example: Holy Cross Hospital Healthy Montgomery priority Obesity: 50%+ are overweight or obese Holy Cross Hospital Mission: Outreach that improves health status and access for underserved, vulnerable Strategic priority: women and infants Response to unmet need through Healthy Montgomery lenses Lack of access: Health centers in X, Y, Z locations; Ob/gyn clinic Unhealthy Behaviors: Community fitness program: Kids Fit Health Inequities: ob/gyn & perinatal obesity in pregnancy programs Measures: Semi-annual fitness assessments; # enrolled in obesity in pregnancy programs

15 Presentation outline Population health framework IRS CHNA requirements Community health assessment Performance measures for implementation strategy

16 Community Health Profile: RWJF County Health Rankings model Health outcomes represent how healthy a county is Health factors influences the health of the county Where we may be able to intervene: County Region State Nation

17 Criteria for a hospital s CHNA priorities Identify most significant health issues Magnitude of the problem percentage of population impacted Severity of the problem degree to which health status is worse than the state or national norm Presence of and high need among vulnerable populations Other indictors of concern Not just a patient survey! Evaluate which health issues to prioritize Organization s capacity to act resources, mission or other considerations The likelihood or feasibility of having a measurable impact Community resources already focused on an issue programs, funding, etc. Whether the issue is a root cause of other problems

18 Presentation outline Population health framework IRS CHNA requirements Community health assessment Performance measures for implementation strategy

19 Community Health Improvement Process (Improving Health in the Community, IOM, 1997) Specific entities in community must be accountable for the actions that they can take to improve population health Measure entity-specific performance towards community-wide improvement strategy CMS ACO Quality-Performance Measures Measures for health department, voluntary organizations, etc. Consistent measures needed to roll up to whole population

20 Performance (accountability) measures Assessing and measuring accountability, and holding organizations accountable for performance, requires identified body with clear charge to accomplish particular steps toward health goals ensuring that the body has the capacity to undertake the required activities measuring what is accomplished against the identified body s clear charge tools to assess and improve effectiveness and quality feedback loop as part of a learning system incentives technical assistance

21 Example: Simplified obesity driver diagram Outcome Obesity; related morbidity & mortality 1 drivers Physical activity Healthy eating patterns 2 drivers Structure Physical education in schools Safe sidewalks & recreation facilities Participation in exercise & weight-loss programs Healthy food availability in schools, markets, restaurants, etc. School board policies for PE and cafeterias Public works, parks and recreation, etc. Provider behavior, availability, and coverage for exercise & weight-loss programs Private sector restaurants, fitness centers, farmers markets, etc. Effect Drives Cause

22 Sample strategy-based performance measures for obesity Obesity, and related deaths Lack of exercise Shared responsibility Unhealthy eating patterns Counseling by health care providers Availability of weight loss and fitness/ physical activity programs (hospitals and local organizations) Health plan coverage for weight loss programs; employer-sponsored fitness programs (health plans, employers) Obesity prevention curricula, physical education, and healthy eating choices in schools (school board) Local promotion of healthy eating and increased physical activity through fairs, marathons, farmers markets, etc. (shopkeepers, storeowners, restaurants, fitness gyms, etc.) Safe sidewalks, recreation facilities, etc. (public works, recreation)

23 Choice of performance measures Broad view of health and its determinants Engage a variety of stakeholders Clear accountability for performance Evidence-based link to health outcomes Output & process measures ok if evidence supports link to intended outcomes Especially if long time lags expected to change outcomes Allow for some early wins Established validity and reliability, robustness and responsiveness to change Timely availability of data at a reasonable cost Inclusion in other indicator sets

24 Michael A. Stoto Georgetown University

Acknowledgements Thanks to the reviewers for their thoughtful comments and feedback.

Acknowledgements Thanks to the reviewers for their thoughtful comments and feedback. EDM Forum EDM Forum Community egems (Generating Evidence & Methods to improve patient outcomes) Publish 3-26-2015 Population