WellSpan Health Care Management Strategy. October, 2013

Transcription

1 WellSpan Health Care Management Strategy October, 2013

2 We will realize a fundamental, yet gradual, shift in how we deliver and receive payment for care From: A system that treats people mostly when they are sick or injured To: A system that PROACTIVELY manages the health of populations Revenue based on volume Revenue based on value From: Rewards based on volume = = + Quality + Efficiency + Satisfaction = Fee for Service Per Case (DRG) Bundled Payments Shared Savings Capitation

3 Striving for the Triple Aim Improve Population Health Access Communication Coordination Collaboration Integration Patient/Family PCM Home PCM Neighborhood Improve Patient Experience Reduce Costs

4 Driven by Mission, Guided by Strategies Our Mission Strategies Execution Working as one to improve health through exceptional care for all, lifelong wellness and healthy communities Achieve clinical excellence, Improve the health of populations in our community Provide a patient and family-centered experience Maintain our historical financial strength Build a clinically integrated physician organization This proposed care management strategy: Leverages efficient and effective clinical programs Advances population health management interventions and offers case management to identified individuals.

5 Early 2012 Organizational Structure

6 WellSpan s Population Health Strategy Focuses on the Different Needs of People at Different Stages of the Continuum of Care % Total Healthcare Spend Those with severe, acute illnesses or injuries Those with chronic illness Those who are well or think they are well % of patients 10% of the population consumes 66% of the total spend (member with > $10,000 expenses) Care Management 49% of the population consumes only 4% of the total spend (each spends < $1,000)

7 Different populations receive different care management interventions Chronic illness and preventive health registry patients (100,000) Population for whom we take financial risk (50,000)?? Target population for intensive case management (2,500)?? Total population of York and Adams counties (550,000) Total WellSpan Medical Group population (~250,000)

8 WellSpan s Functional Definition of Care Management Care Management is the term we use to describe the successful management of the health care needs of individuals and populations. Our success depends upon the design of our clinical programs and the use of population health management and case management interventions. We apply these activities across the span of an individual s life from wellness through illness and injury, to death with dignity.

9 Care Management Functional Design Clinical Program Care Design The Medical Home and its Neighborhood Population Management Actions that improve the health of groups of people Case Management Actions that improve an individual s care

10 Simple Rules of Care Management 1. MEDICAL HOME Medical Homes are the locus for coordination for all Care Management. 2. SHARED CARE PLAN We help patients develop their own Shared Care Plan that they and their family control and change over time. The patient's Shared Care Plan guides our efforts to promote their mental and physical wellness to restore their health, to palliate their symptoms, and to support death with dignity. 3. SELF-MANAGEMENT We promote health literacy and activation to engage a patient in their health care decisions. 4. ALWAYS AVAILABLE SUPPORT Our support services, in conjunction with community resources, are always available to help selected patients coordinate their health care needs, provide transportation, translation service, medication assistance, and food and shelter, if necessary. 5. PROACTIVE CARE We anticipate the social and clinical needs of individuals who are at risk of deterioration in health status that might be avoided by timely interventions by care management teams. 6. APPROPRIATE CARE Evidence-based care is the foundation of our care management program. When evidence-based recommendations are not available, we use WellSpan s consensus-based approach to define appropriate care.

11 ( Care Management Elements People Programs Payment We build too many walls and not enough bridges ~ Isaac Newton Processes Platform

12 Care Management Functional Design Clinical Program Care Design The Medical Home and its Neighborhood Each of WellSpan s clinical programs should be: Patient and Family Centered Reliable Accessible Coordinated Population Management Actions that improve the health of groups of people Case Management Actions that improve an individual s care

13 Programs our clinical programs must support individuals across the continuum of care Our Clinical Programs employ consistent care (re)design principles Patient Centered Medical Homes the locus for patient planning and coordination Clinical care consistent with our interpretation of evidence-based practices, whenever possible We identify specific providers outside of our System who provide care we are unable to offer Community programs Select regional and national referral centers based on System, not individual, choice

14 A deeper dive on the Patient-Centered Medical Home WellSpan is redesigning care around patient-centered medical homes (PCMH) within the Medical Neighborhood. Access Personal physician Physician directed medical practice Technology and process support Whole person orientation Performance reporting Patient selfmanagement support Care is coordinated and/or integrated

15 PCMH Secret Sauce Data Meeting Structure Culture Accountabilities Central Support

16 Live Dashboard Overview The Data Layered: WMG Practice Provider Care Team Patient Transparent Comparative Trended over time Refreshed monthly Baseline, goals and benchmarks Developed with WMG Quality Council provider input

17 Star awards Baseline Target Pacer line Trends 18

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19 Care Coordination Teams Optimizing deployment of existing staff PCMH Nurse Case Managers Health Plan And Hospital Health Coaches Social Workers

20 Each PCMH has an embedded care management support structure known as a Care Coordination Team (CCT). CCT Health Coach: full time presence at the PCMH practice who helps patients Address patients chronic and preventive health care issues Promote behavioral changes to improve their health Work with the case manager and social worker to address care coordination needs. CCT Social Worker: Shift their focus from hospital unit to PCMH practice Based in the hospital, but has defined office hours. Addresses financial issues that impact a patient s care decisions Identifies and coordinates community resources Assists patients with hospital discharge planning as well as support through the office setting Works daily with the health coach and case manager to identify and address care coordination needs of the patients. CCT Case Manager: Shift their focus from hospital unit to PCMH practice Based in the hospital setting but has defined office hours. Registered nurse who is trained and certified in case management Assists patients with identifying clinical resources to support the patient s goals for health. Has an understanding of benefit plans, payer processes, and health care standards to help advocate for the patent s plan. Works daily with the health coach and social worker to identify and address care coordination needs of the patients for the practice/providers.

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22 Our information system enables us to do data mining for high utilization and/or high risk patients. This enables WellSpan to successfully manage the health of populations of patients.

23 Current state PCMH CCT Deployed Case Managers and Social Workers to manage hospital patients by community PCP (YH and GH). CMRN and SW assigned WMG Practice for hospital and community outreach Community PCPs for hospital Case Management work Indentified Case Management liaison for SIBR rounds for each area. Identify CM specialty content expert area and developing neighborhood environment. Incorporating other support roles in the PCMH model Pharmacy Behavioral Health services Rehabilitation Services

24 LVAD Program HC CM SW Hospital Care Stroke program

25 Continued Identify specialty program coordinators (Service Lines) and develop CCT relationship: CVS: MSL: NSL: Ortho: OSL: SSL: BHS: WSL: LVAD Open Heart Medical Weight Loss Stroke Spine Neurological Programs (Concussion, Movement disorders) Joint Replacement Nurse Navigators PHAS Nurse navigators Mood Disorders High Risk Peri-natal

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27 Who Moved My Cheese? A new mental model for our providers FROM My Patient TO Our Patient My clinical preferences Oriented only to my practice site My plan for the patient I documented my thoughts in my medical record I coordinate my patient s care WellSpan s clinical standards and preferences Oriented to my practice within WellSpan s neighborhood The patient s Shared Care Plan I share my thoughts with colleagues in both written and verbal format My team works with others in the Neighborhood to coordinate care WellSpan s Medical Neighborhood

28 Understanding and Meeting Patients Unique Needs: Our Journey Fall Participate in IHI Learning Network Managing Complex Populations (Care Oregon, Cambridge Health Alliance ) Feb Jeff Brenner, MD ( HotSpotters ) visits York to help kick off pilot (2 visits to Camden, 1 to AtlantiCare) March August 2011 Monthly Superutilizer pilot o 12 patients o Monthly Community Meetings o Extra calls, social work input/contact, appointments, some home visits o Behavioral health consult and access, Trac Phones, fax machines, transportation, teleconferences, Area Agency on Aging, County Human Service, hospitalists June 2012 WellSpan funds strategic initiative Working As One September 2012 WellSpan Bridges to Health opens

29 What is an Ambulatory ICU? Bridges to Health Practice Studies Yale, Massachusetts General Hospital, British Health Service Virtual Ward Boeing Intensive Outpatient Care Program Hotel and Restaurant Employees International Union Hotspotter New York Times - AtlantiCare Now Las Vegas, Dartmouth-Hitchcock, Stanford

30 Analysis of Health Care Costs Reflect a Disproportionate Spend Those with severe, acute illness or injuries % Total Healthcare Spend PCMHs Those with chronic illness Those who are well or think they are well SuperUtilizer Programs % of Members

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