Population Health Management

Transcription

1 Health Home Population Health Management Maryland Chronic Health Homes July 15, 2014 Sheppard Pratt Conference Center Towson, MD

2 Brent McGinty President/CEO Rachelle Glavin Director of Clinical Operations

3 Agenda 9:30 11:30 Missouri Introduction Missouri Coalition for Behavioral Healthcare How did we get here? Show Me Savings and Outcomes Population Health Management Things to Consider

4 Agenda 9:30 11:30 Population Health Management What is it? Roadmap for Success Planning for PHM Data collection, storage and management Population monitoring and stratification Patient engagement Team-based interventions Measuring outcomes What difference does it make? Small changes make a big difference Nurse Care Managers: The driving force

5 Missouri Introduction

6 Missouri Coalition for Community Behavioral Healthcare Represent 32 member organizations Community Mental Health Centers (CMHCs) Alcohol and drug abuse treatment programs Affiliated Community Psychiatric Rehab (CPR) providers Clinical call center Over 10,000 staff providing treatment and support services to approx. 250,000 people each year

7 The Coalition s Role Provide advocacy on behalf of our members and the people they serve. Work with the State legislature and departments on policies affecting behavioral health providers and consumers. Collaborative partner with the Dept. of Mental Health (DMH) and Dept. of Social Services (MO HealthNet) to develop program policies, deliver provider training, design and implement programs and initiatives. Provide training and technical assistance to our members. Monitor and administer statewide data analytics for CMHC HCHs, and aim to improve quality and clinical outcomes.

8 MO Evolution of Integration and Data in Behavioral Health Disease Registry ProAct BPM Mailings Notifications 2005 MO + CMT Healthcare Home + DM3700 Outreach Nurse Liaisons

9 Show Me Outcomes Cost Savings (after 1 year) Missouri s Health Homes have saved an estimated $23.1 million. Community Mental Health Centers have saved Missouri an additional $22.3 million for the 3,560 lives served in Disease Management TOTAL SAVINGS = $51.75 PMPM

10 Outcomes % of Clients w/ 1+ Hospitalization 40% 35% CMHC HCH Implementation January 1, % 25% 20% 15% First Year 9.1% 10%

11 Outcomes Diabetes (n = 2,464 cont. enrolled) 70% 60% 50% 40% 30% 20% 50% 47% 46% 38% 59% 67% 28% 40% 39% 2 years 57% 53% 42% Feb'12 Feb'13 27% June'13 22% 18% Jan'14 10% 0% Good Cholesterol (<100 mg/dl) Normal Blood Pressure (<140/90 mmhg) Normal Blood Sugar (A1c <8.0%)

12 Outcomes Hypertension and Cardio 70% 60% 50% 40% 30% 20% 34% 38% 2 years 62% 55% 55% 49% 37% 41% Feb'12 Feb'13 21% 24% June'13 Jan'14 10% 0% Good Cholesterol for Clients w/ CVD (<100 mg/dl) (302 clients) Normal Blood Pressure for Clients w/ HTN (<140/90 mmhg) (3,176 clients)

13 Outcomes Metabolic Syndrome Screening 80% 70% 60% 62% 61% 74% 2 years 50% 40% 46% Feb'12 Feb'13 30% June'13 20% 10% 12% Jan'14 0% Metabolic Syndrome Screening (All HCH Enrollees)

14 Prevalence BMI and Obesity 40% 35% 35% 38% 33% 30% 27% 25% 20% 18% 23% 20% 15% 10% 5% 0% 1% 2% Underweight Normal Overweight Obese Extremely Obese HCH Adults Gen. Adult Pop. 3%

15 Prevalence Chronic Disease 50% 44% 40% 30% 20% 24% 15% 26% 18% 35% 30% 38% 33% 20% 13% 10% 3% 2% 7% 0% HCH Adults Gen. Adult Pop.

16 Population Health Management

17 Population Health Management A Roadmap for Provider- Based Automation in a New Era of Healthcare Institute for Health Technology Transformation (iht 2 ) Alide Chase, MS; Connie White Delaney, PhD, RN, FAAN, FACMI; Don Fetterolf, MD, MBA; Robert Fortini; Paul Grundy, MD, MPH; Richard Hodach, MD, PhD, MPH; Michael B. Matthews; Margaret O Kane; Andy Steele, MD, MPH, MSC

18 Intro Population Health Management The unsustainable growth of health costs, the growing lack of access to healthcare, and increasing disparities in care have forced the U.S. to start changing how healthcare is delivered Patient Protection and Affordable Care Act HEALTH HOMES! 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

19 Goal Population Health Management GOAL The goal of population health management (PHM) is to keep a patient population as healthy as possible, minimizing the need for expensive interventions such as emergency department visits, hospitalizations, imaging tests, and procedures. 1 While PHM focuses partly on the high-risk patients who generate the majority of health costs, it systematically addresses the preventive and chronic care needs of every patient. Because the distribution of health risks changes over time, the objective is to modify the factors that make people sick or exacerbate their illnesses. 1 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

20 Definition Population Health Management Definition: the health outcomes of a group of individuals, including the distribution of such outcomes within the group. 1 Provider Definition: The population health improvement model highlights three components: the central care delivery and leadership roles of the primary care physician; the critical importance of patient activation, involvement and personal responsibility; and the patient focus and capacity expansion of care coordination provided through wellness, disease and chronic care management programs. 1 (Care Continuum Alliance) 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

21 How to Succeed Population Health Management Supply proactive preventive and chronic care to all of a provider s patients, both during and between encounters with the healthcare system Maintain regular contact with patients and support their efforts to manage their own health Care managers must manage high-risk patients to prevent them from becoming unhealthier and developing complications Use of evidence-based protocols to diagnose and treat patients in a consistent, cost-effective manner 1 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

22 Connections Population Health Management Care Coordination Multidisciplinary Team Population Health Management System

23 Roadmap for Success Planning for Population Health Management Data Collection, Storage and Management Population Monitoring and Stratification Patient Engagement Team-Based Interventions Measuring Outcomes

24 1 PLANNING FOR POPULATION HEALTH MANAGEMENT (PHM)

25 Planning for PHM Requires a significant change in the way of thinking and the practice patterns of providers Caring for an entire population and not just for the individual patients who actively seek care Adopt a new way of doing business 1 Health information technology is absolutely necessary but not sufficient for creating practice-based population health management; committed executive and clinical leadership, care team development, and care coordination processes are also critical success factors. 1 phm 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

26 Planning for PHM Setting Goals and Objectives Showing Leadership Technology Assessment Rollout Strategy 1 phm 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

27 2 DATA COLLECTION, STORAGE AND MANAGEMENT

28 Data Collection, Storage & Management Efficient, systematic data collection, storage and management drive automation, quality measurement, and performance analysis; and, comprehensive, timely, relevant information is essential to high-quality patient care. 1 EHRs are not designed for PHM or for interoperability with other systems Registries must be population-wide databases, not limited to patients with specific diseases EHRs often do not contain much information about the care that patients have received outside a provider organization 1 phm 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

29 Data Collection, Storage & Management The first challenge is to gather patient-centered data from multiple sources. 1 Medicaid Claims Internal EHR Population Health Management Managed Care Claims Hospital /ER Medicare Claims phm 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

30 3 POPULATION MONITORING AND STRATIFICATION

31 Population Monitoring and Stratification To manage population health effectively, an organization must be able to track and monitor the health of individual patients. It must also stratify its population into subgroups that require particular services at specified intervals. 1 Health IT tools should be able to: Target patients in greatest need of services by narrowing subpopulations Make data on patients actionable by generating alerts to patients to see appointments with their providers Make data actionable by generating alerts to providers about patient care needs 1 phm 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

32 Population Monitoring and Stratification Multiple complex conditions High hospital/er utilizer Managing test scores out of range (A1c, LDL, BP) Changing lifestyle behaviors (tobacco, obesity) Assuring appropriate treatment is complete (i.e. retinal exam, metabolic screening) Medication adherence Engaging with a PCP Maintaining healthy lifestyle behaviors Self-management of chronic conditions Sweet Fruit Complex Conditions Bulk of Fruit Outcomes Low-Hanging Fruit Compliance Ground Fruit Prevention

33 4 PATIENT ENGAGEMENT

34 Patient Engagement In an organization dedicated to PHM, providers must care for patients between as well as during encounters. 1 Care teams must strive to deliver appropriate, evidence-based care during patient visits Ensure that care gaps are addressed when patients do not come into the office Requires motivating and collaborating with patients to help them take care of themselves Help patient understand their care plans and the importance of complying with recommended guidelines 1 phm 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

35 Patient Engagement The key to patient engagement is the clientprovider relationship. phm The overall agenda of population health management is to create a seamless communication, a seamless delivery of service, and a seamless engagement of the patient/consumer, whether that is in the home, the community, or in long term care. 1 (Connie white Delaney, PhD, RN, Dean, School of Nursing, University of Minnesota) 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

36 5 TEAM-BASED INTERVENTIONS

37 Team-Based Interventions Care teams led by physicians, nurse practitioners, or other professionals can manage more patients and address more of their needs than the current primary care model does. 1 High performance care teams utilize automated reports, alerts and patient communications to minimize manual tasks, reach more patients successfully and devote more clinical and coaching talent to patients who need them most. 1 phm 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

38 Building Clinical Protocols Intensive Care Coordination: TEAMcare* Meetings, Hospitals Client Education Care Coordination: Case Managers, Primary Care Physician, Specialists Client education Care Coordination: Case Managers, Primary Care Physician, Pharmacies Client Education Peer Specialists Celebrating Success and Treatment Goals Complex Conditions Outcomes Compliance Prevention

39 6 MEASURING OUTCOMES

40 Measuring Outcomes To describe population health at any given time, organizations can use a variety of measures, including those that describe processes (how many patients with diabetes received an appropriate HbA1c test?), intermediate outcomes (HbA1c or blood pressure levels), and long-term outcomes. 1 Standardized reports help analyze the data over time to identify trends and spot gaps in PHM Important to standardize reporting across provider organizations in order to create regional and national benchmarks Identifying the prevalence of health conditions by provider or site Evaluating provider and practice performance 1 phm 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

41 Management Reports at a Glance HCH Management Reports DM HCH Management Report Adherence HCH Management Report BPM HCH Management Report ProAct and CyberAccess User Report Progress Trend Reports Monthly MBS Completion Report Qtrly MBS Attribute Completion and Opt Out Report Qtrly DM HCH Management Report Qtrly ProAct/Cyber User Report Annual Outcomes Report

42 Metabolic Screening Completion Rates mbs 2014 May April March February January Healthcare Home # Complete # Flagged % Complete # Complete # Flagged % Complete # Complete # Flagged % Complete # Complete # Flagged % Complete # Complete # Flagged % Complete East Central Missouri Behavioral Health Services % % % % % Clark Community Mental Health Center % % % % % New Horizons Community Support Services % % % % % Preferred Family Healthcare, Inc % % % % % Tri-County Mental Health Services % % % % % Family Guidance Center % % % % % Ozark Center % % % % % Family Counseling Center % % % % % Pathways Community Behavioral Healthcare, Inc. 1, % 1, % 1, % 1, % 1, % Independence Center % % % % % North Central Missouri Mental Health Center % % % % % Community Counseling Center % % % % % Burrell Behavioral Health - Springfield 1, % 1, % 1, % 1, % 1, % Crider Health Center, Inc % % % % % Hopewell Center % % % % % Places for People % % % % % Community Treatment, Inc % % % % % Comprehensive Health Systems, Inc % % % % % Statewide HCH Total Population 12,836 4,835 73% 12,664 4,816 72% 12,755 4,609 73% 12,964 4,464 74% 12,941 4,582 74% Mark Twain Behavioral Health % % % % % Bootheel Counseling Services % % % % % BJC Behavioral Health- SE % % % % % Truman Medical Center Behavioral Health % % % % % Adapt of Missouri, Inc % % % % % Burrell Behavioral Health- Central % % % % % Ozark Medical Center % % % % % BJC Behavioral Health- SL % % % % % Comprehensive Mental Health Services % % % % % ReDiscover % % % % % Swope Health Services % % % % %

43 Requirements for Complete Metabolic mbs ADULT HCH and CPRC Height Weight BMI Blood Pressure Blood Glucose OR A1c Lipid Panel Status of Antipsychotic Medication Status of Tobacco Use Pregnancy Status Waist Circumference* (optional) CHILD HCH and CPRC Height Weight Blood pressure Status of antipsychotic medication Status of tobacco use Pregnancy Status If a child has either a dx of diabetes or taking an antipsychotic medication, you must also collect: Blood Glucose OR A1c Lipid Panel

44 1 Define 2 Measure 4 Improve 3 Learn REVISING HEALTH HOME DISEASE MANAGEMENT PERFORMANCE MEASURES Revising DM Benchmark Goals Adding and Revising DM Indicators A Closer Look Weight Loss A Closer Look ProAct & CyberAccess Touches

45 DM Performance Measures Revised Benchmark Goals Indicator Goal Outcome (May14) NEW GOAL Asthma Med (A) 70% 90% 90% Asthma Med (C) 70% 91% 90% BP Control HTN (A) 60% 59% 70% LDL Control Cardio (A) 70% 52% 60% Diabetes BP Control (A) 65% 63% 70% Diabetes LDL Control (A) 36% 50% 60% Diabetes A1c Control (A) 60% 56% 60% No change Diabetes A1c Control (C) 60% 45% 60% No change Metabolic Screen (A&C) 80% 75% 80% No change No Tobacco Use (A) 56% 44% 56% No change No Tobacco Use (C) 56% 96% 95% Notes Reduced to align with Diabetes LDL Control (A) Increased to align with LDL Control Cardio (A)

46 DM Performance Measures Revised Indicators Indicator BP Control HTN (A) LDL Control Cardio (A) Diabetes BP Control (A) Diabetes LDL Control (A) Diabetes A1c Control (A) Diabetes A1c Control (C) BMI Control (A) BMI Control (C) Notes Reviewing specs of claims identifying the target population. (2014 NQF 0018) Reviewing specs of claims identifying the target population. (2014 NQF 0064) Reviewing specs of claims identifying the target population. (2011 NQF 0061) Reviewing specs of claims identifying the target population. (2014 NQF 0064) Reviewing specs of claims identifying the target population. (2011 NQF 0575) Remove measure from targeted indicators, and add NEW measures to monitor weight loss. DELETE, and add NEW measure to appropriately calculate BMI for children based on growth chart percentiles. NQF = National Quality Forum

47 DM Performance Measures NEW Indicators Indicator Diabetes A1c >9.0% (A) Diabetes A1c >9.0% (C) BP Prevention Control (A) LDL Prevention Control (A) Percentage of Weight Loss NEW BMI Control (C) Notes Creating new indicator to monitor A1c outside of normal range. Reviewing 2014 NQF Creating new indicator to monitor A1c outside of normal range. Reviewing 2014 NQF Creating new indictor to monitor BP control for all clients regardless of diagnosis. *Excluding clients in BP Control HTN and Diabetes BP Control measures. Creating new indictor to monitor LDL control for all clients regardless of diagnosis. *Excluding clients in LDL Control Cardio and Diabetes LDL Control measures. Creating new indicator(s) to monitor weight loss for BMI categories. Creating new indicator to appropriately calculate BMI for children based on growth chart percentiles.

48 A Closer Look Obesity and Weight Loss/Gain 60% 56% N = 2,046 50% 44% 40% 30% 20% Lost Weight Gained Weight 10% 0% HCH adults with at least two weight values and BMI>40 who were enrolled for at least one year as of 5/1/14.

49 % of Enrollees by % of Weight Lost/Gained 30.0% 27.1% 25.0% 20.0% 35.6% 18.4% 19% 15.0% 10.0% 10.0% 9.8% 10.4% 8.1% 5.0% 5.4% 4.7% 4.5% 1.1% 0.0% -0-2% -3% -5% -8% -10% -12% -15% >-15% 0-10% >10%

50 % of Enrollees by Pounds of Weight Lost/Gained 30% 25% 37.5% 23.9% 20% 20.2% 15% 18.4% 15.7% 10% 5% 9.5% 8.9% 7.2% 5.9% 5.1% 3.6% 0% -0-5 lbs lbs lbs lbs lbs lbs > -30 lbs 0-10 lbs >10 lbs

51 % Loosing/Gaining More than 10% of Body Weight 40% >10% Loss >10% Gain 35% 30% 25% 20% 15% 10% 5% 0%

52 A Closer Look ProAct & CyberAccess Touches PMPM 2014 ProAct Average Intensity CyberAccess Average Intensity Healthcare Home Jan Feb March April May Average Average Combined Feb March May (5 months) (3 months) Total Avg Adapt Arthur Ctr BJC - SE BJC SL Bootheel Burrell -C Burrell -SW Clark Com. Couns. Ctr Comp. Health Sys Comp. MH Srvs Comtrea Crider Fam. Couns. Ctr Fam. Guid. Ctr Hopewell Ctr Independence Ctr Mark Twain New Horizons No. Central Ozark Ctr Ozark Med. Ctr Pathways Places for People Preferred ReDiscover Swope Tri-County Truman Statewide Avg

53 Measuring Progress and Outcomes Measures drive improvement! Better client health outcomes More efficient clinical workflows Connecting systems of care

54

55 What difference does it make?

56 PERFORMANCE PROGRESS A1C, LDL, BP Small Changes Make a Big Difference!

57 Small Changes Make a Big Difference! Cholesterol 10% in cholesterol = 30% in CVD ( ) High Blood Pressure ~ 6 mm/hg BP (> 140 SBP or 90 DBP) = 16% in CVD 42% in stroke Diabetes 1% point HbA1c = 21% in diabetes related deaths 14% in heart attack 37% in microvascular complications

58 Improving Uncontrolled A1c Baseline to Year 1 Reduced the mean A1c 9.9 to 8.9 Baseline to Year 2 Reduced the mean A1c 9.9 to POINT DROP IN A1C! 21% in diabetes related deaths 14% in heart attack 31% in microvascular complications

59 Improving Uncontrolled LDL Baseline to Year 1 Reduced the mean LDL 131 to % DROP IN LDL LEVEL! 30% in cardiovascular disease Baseline to Year 2 Reduced the mean LDL 131 to 113

60 Improving Uncontrolled BP Baseline to Year 1 Reduced the mean BP Systolic: 144 to 134 Diastolic: 90 to 84 Baseline to Year 2 Reduced the mean BP Systolic: 144 to 131 Diastolic: 90 to 82 6 POINT DROP IN BLOOD PRESSURE! 16% in cardiovascular disease 42% in stroke

61 Nurse Care Managers: The Driving Force

62 Population health management requires healthcare providers to develop new skill sets and new infrastructures for delivering care. 1 1 Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

63 Nurse Care Managers The Driving Force

64 Things to Consider Health Home Initial Implementation Stage: Training and Support Enrollment, Attestation, Payment Process CARF Accreditation Integration of Healthcare Home into the current CPR program HIPAA and Care Coordination with hospitals and community providers Effectively using the Primary Care Physician Consultant role Improving completion rates for Metabolic Syndrome Screening Effectively using the Care Management Reports (ProAct) Nurse Care Manager Caseload Size

65 Things to Consider Health Home Training needs for Nurse Care Managers and Community Support Specialists Annual Physician Institute Children in Healthcare Home Practice Coaches Data Interventions to address weight issues, tobacco use and substance use Revisions to performance measures Levels of Care Continue to train and collaborate

66

67 THANK YOU! Brent McGinty, Rachelle Glavin,