Diversity, Inclusion and Health Equity, Cornerstones to Your Population Health Management Strategy AHA Leadership Summit July 23, 2015 Brenda Battle, MBA, BSN, RN Vice President, Care Delivery Innovation Urban Health Initiative Chief Diversity and Inclusion Officer
Please note that the views expressed by the conference speakers do not necessarily reflect the views of the American Hospital Association and Health Forum. AHA Leadership Summit 2
Objective Define Population Health Management Discuss UCM s drivers for moving quickly to PHM Discuss UCM s approach to PHM Discuss how diversity, inclusion and health equity are critical components to UCM s PHM strategy The UCM s comprehensive approach to care delivery redesign that includes addressing health disparities AHA Leadership Summit 3
Overview of Population Health Management AHA Leadership Summit 4
Defining Population Health Management Population Health Management (PHM) is a system of care delivery and care management processes that are carried out for the purpose of improving the health of populations. Several processes and parties are involved in achieving population health management. Processes Health care Assessment Care planning Care delivery Care coordination Care process improvement Population care analytics Medical informatics Value or risk-based reimbursement Parties Involved Health care provider organizations, including health systems, physician organizations, and particularly accountable care organizations and clinically-integrated networks Health plans, including private and government entities Medicare, Medicaid, Commercial, or employer sponsored health plan) Governmental agencies, public health, and other human services agencies Community resources, including various types of service organizations AHA Leadership Summit 5
Population Health Management reimbursement arrangements involves risk Population Risk Risk that a population s baseline health status will be different than expected Performance Risk Risk that utilization of services or cost of care for a population will be different than that predicted based on baseline health status AHA Leadership Summit 6
The amount of risk shared with a Provider Network can vary based on the nature of the contract FFS w/ Performance Incentives Population Health Pay-for- Performance Bundled Payments Shared Savings Partial Capitation Full / Global Capitation Increasing Risk AHA Leadership Summit 7
Overview of UCM AHA Leadership Summit 8
UCM Brief Overview Facilities / Capacity 618 total beds/155 children s beds - 338 MedSurg - 46 OBGYN - 30 PICU, 96 Adult ICU - 61 General Peds - 47 NICU 34 Operating Rooms Duchossois Center for Advanced Medicine - Primary ambulatory care facility Volume Admissions 27,806 Patient Days 180,486 Surgical Cases 19,804 Emergency Room visits 88,234 Observation Cases 7,778 $22.6 million charity care (FY14) Community 870,000 residents Race/ Ethnicity South Side Chicago White 10% 30% Black 70% 35% Asian 4% 5% Hispanic 14% 29% AHA Leadership Summit 9
There has been a substantial reduction (55%) in licensed inpatient beds on the South Side of Chicago, almost doubling UCM s share of beds and outpatient services Englewood hospital closes (140 beds) Central Community hospital closes (107 beds) Lakeside Community hospital closes (112 beds) UCMC continues to serve the South Side community with 606 beds) and ambulatory services 1986 2000 Today Woodlawn Hospital closes (148 beds) Chicago Osteopathic hospital closes (303 beds) Doctors Hospital closes (206 beds) Michael Reese Hospital closes (955 beds) Provident Hospital closes all but 25 beds and closes ER to ambulances (88 beds closed, reduced from 300 in 1985) AHA Leadership Summit 10
Rapid market changes in Illinois creates an imperative for UCM to build capabilities in population health management Rapid Market Change The reimbursement/delivery system model for government payers is rapidly changed from fee-forservice to value-based and population health models. UCM is highly dependent on its South Side of Chicago service area for patients UCM serves as a critical health care resource for the South Side market The South Side market is highly dependent on government payers (Medicare and Medicaid), and this is reflected in UCM s payer mix. Commercial business is also undergoing market transformation, though at a rate of change that is expected to be slower than that for government payers Imperative for PHM Medicaid to transform to 100% managed care and Medicare likely to shift to 25-50% Medicare Advantage managed care penetration by 2017 The 73 thousand South Side patients served by UCM representing 43% of all UCM patients, and account for 28-29% of UCM s revenues UCM leads in provision of outpatient Medicaid services, providing 20% more services than #2 UIC. 24% of UCM s South Side revenue is Medicaid and 33% is Medicare Establishing narrow network products that may not include UCM and transitioning from fee for service to bundled payment, gain-sharing, and value-based reimbursement arrangements AHA Leadership Summit 11
UCM s approach to Population Health Management AHA Leadership Summit 12
When we consider managing the health of populations there are distinct population cohorts Patient populations that are attributed to us through primary care, MD referrals, specialty care or patient self-referrals including ED visits Community Populations that are comprised within the 12 zip code Community Benefit region, but who may or may not get their care at UCM AHA Leadership Summit 13
We have taken a macro approach to Population Health Management Aim to improve health outcomes which requires taking an active role in promoting and improving the health of populations, rather than simply engaging with individuals when they are injured or sick. Population Health Management A system of care management processes that are carried out for the purpose of improving the health of populations. Goal is to keep patient populations as healthy as possible, minimizing the need for expensive emergency department visits, hospitalizations, imaging tests, and procedures. AHA Leadership Summit 14
Our journey to integrate PHM and Equity Multi-year strategic plan and budget imperatives 2016+ 2014/15 2004 Urban Health Initiative instituted UCM s community health division 2012/13 Diversity, Inclusion and Equity effort began. Department instituted 2013 Planning for PHM Implemented and integrated multiple PHM strategies into care delivery processes Care Delivery Transformation. Care management integration AHA Leadership Summit 15
We are redesigning our Care Model to deliver more effective care across the care continuum Population Health/Family Assessment Risk Stratification No or Low Risk Patient s Health Risk Moderate Risk High Risk Health Promotion/Wellness Health Risk Management Care Coordination/Advocacy Disease/Case Management Patient Eligibility Applicability Priority Engagement Outreach Post-acute care Care Management Programs Risk Patient Health Risk CMP Care Management Program Tailored Interventions: Organizational and Community-based AHA Leadership Summit 16
Care Model Design Template AHA Leadership Summit 17
Care Practice Care Model Design AHA Leadership Summit 18
Our care delivery model incorporates diversity, inclusion and equity in the design. Identifying the patient population by specific demographic indicators (i.e. race/ethnicity, gender, age, BMI, SES, zip code, population need, etc. Health Risk Assessment(s) to provide insight into patient-specific needs. Examples include: Anxiety and Depression, Malnutrition Screening, Fatigue and Pain, Functioning, Physical performance, Cognitive, Social support, Spiritual assessment, Financial assessment, Health Literacy assessment, etc. Information from the health risk assessment will help to determine patient s support needs such as health promotion and wellness, health risk management, care coordination, disease case management, care management, etc. Engaging patients in the right care management program(s) requires skills in crosscultural communication, cultural competency/humility, and health literacy. Also requires understanding the patients social support system, available resources, etc. Care management programs should meet certain criteria including 1. Helping patients to self-manage via education, training, motivation or providing tools. 2. Care coordination across care teams, multiple settings and/or time. 3. Team care planning based on input from 2 or more team members. Data stratification allows us to understand gaps in care for our patient populations. The care delivery team should represent the patient population. AHA Leadership Summit 19
Patient referral management Assessment/Screen Frequency Thresholds/Notes Auto Referral Referral Financial Initial Auto referral to Social Work. Yes Social Work visit/ongoing /Multiple Health Literacy 1x Response: Quit a bit, often Yes Social Work Social Support 2, 0, 4, 22, 2, 0, 5, Based on MOSSS. Thresholds defined. Yes Social Work 17 1x Physical Performance Initial MD will direct care. Possible referral to PT/OT. Case by case. No PT/OT visit/ongoing /Multiple Spiritual Care 1x Referral to Chaplain/Spiritual care Yes Chaplain Memory /Cognition 2, 0, 7, 8, 2, 0, 8, 0 >=65 only, >11 cut-off Poor performance on Blessed Memory 1x Cognition PHQ-4 Initial MD/Provider will direct care. Possible referral to Psych/Onc. (Anxiety/Depression) visit/ongoing Case by case scenario /Multiple Nutrition (Abbott) 2, 0, 9, 5, 2, 0, 9, 126 Initial visit/ongoing /Multiple Drug Toxicity/Pharmacy High Risk for Toxicity Initial visit/ongoing /Multiple EASA- question 9 Nutrition/Appetite ( if high score- referral) Track Albumin level. >7- referral). Also need to include info on body weight. MD/Provider will direct care. Refer patients with low health literacy to Rx Clinic. Utilize home health services. VES 13 1x Only for patients >=65. >=85 automatic referral as are those with Yes VES>7 High Symptom Burden Initial (MDAnderson) visit/ongoing /Multiple Multiple ED Visits or non-chemo admission Yes No No Yes SOCARE Psychooncology Nutrition MD/Rx Clinic SOCARE 7 or greater on any item is an auto referral No Palliative Care Other Social Work- will farm out as appropriate unless other flags in other areas. Analytics help needed to define AHA Leadership Summit 20
We have begun to automate some of our care delivery features in order to make population health management feasible, scalable and sustainable. We still have a long way to go. Alerts PHM analytics and Clinical effectiveness Alerts Team-based care Care coordination Some Assessments Manual AHA Leadership Summit 21
We have instituted practices to help us to be more efficient in our work flow Value Stream Map and LEAN Improvement plan Build Team Based Primary Care Integrate Behavioral Health into Primary Care Documentation and Coding Improvements Analysis of Managed Populations Launched a PHM curriculum for PGY-3 IM Residents AHA Leadership Summit 22
Our Value-Stream and LEAN Improvements focused on improving work flow, patient engagement, care coordination and care transition processes AHA Leadership Summit 23
We have adopted team-based care in our primary care and some of our specialty care practices AHA Leadership Summit 24
Because many of our patients have co-morbidities that include behavioral health or depression, we have adopted an integrated behavioral health model in our primary care practices AHA Leadership Summit 25
Our work flow is designed to transition patients into care management programs based on their risk and individual needs Sample of Care Management DOM Programs Geriatrics Program Transitions of Care in the Elderly Geriatric Oncology- SOCARE Comprehensive Care Physician Program Diabetes- Southside Diabetes Collaborative Kovler Diabetes Center PCG Case Management CHF transitions Refractory Obstructive Lungs Disease Program Inflammatory Bowel Disease Program Anticoagulation Management Service Sickle Cell Anemia Program AHA Leadership Summit 26
Our Medical Home and Specialty Care Connect Program helps to get patients into follow up care after hospitalizations or Emergency Department visits. AHA Leadership Summit 27
We are the early stage of stratifying patient outcomes data to identify gaps in care so that we can address them through interventions AHA Leadership Summit 28
We are leveraging community assets and community benefit programs to improve the health of populations AHA Leadership Summit 29
Our community benefit programs support the PHM imperatives AHA Leadership Summit 30
Through a collection of innovative programs and technology UCM works closely with our partners to expand capacity with patient s primary care medical home UCM Programs Executed through SSHC 31
Mapping Community Assets for Self-Care AHA Leadership Summit 32
Connecting Health Care to Self Care HealtheRx AHA Leadership Summit 33
We also work with Health Leads Chicago to connect our patients with basis resources Health Leads staff work with us to connect patients to basic resources in their communities (i.e., food, heat, housing, etc.) Match patient needs to the communities they serve. Access resources through Internet searches and social media channels. AHA Leadership Summit 34
ECHO Chicago helps to building capacity and expanding access to subspecialty care on the South Side Project ECHO an innovative effort to expand access to specialized care for vulnerable, underserved communities. By using advanced communications technology to bring academic medical center expertise together with primary care providers on the ground, ECHO enables primary care providers to expand their skill set and expand their capacity to delivery complex care. AHA Leadership Summit 35
Bringing care to the neighborhoods, meeting unmet needs for children Services provided to children at 40+ schools on the South Side of Chicago Immunizations Physicals for school and sports Screenings for vision, hearing, lead poisoning, and anemia Urine tests Blood draws Behavioral Health STDs Etc. AHA Leadership Summit 36
Future plans for continued development of our PHM efforts Grow our clinically integrated network using the new care model design and integrated EMR Continue to develop the portfolio of care management programs to address gaps in care as determined by population health analysis Implement community health worker program Implement nurse navigator program Develop a centralized hub for care management, integrating inpatient and ambulatory AHA Leadership Summit 37
Population Health Management will require thinking outside of the box. AHA Leadership Summit 38
Thank you Brenda Battle, MBA, BSN, RN AHA Leadership Summit 39