Population Health Management

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

Brent McGinty President/CEO bmcginty@mocmhc.org Rachelle Glavin Director of Clinical Operations rglavin@mocmhc.org

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

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

Missouri Introduction

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

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.

MO Evolution of Integration and Data in Behavioral Health Disease Registry ProAct BPM Mailings Email Notifications 2005 MO + CMT 2012 2010 + Healthcare Home + DM3700 Outreach 2008 + Nurse Liaisons

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 3700. TOTAL SAVINGS = $51.75 PMPM

Outcomes % of Clients w/ 1+ Hospitalization 40% 35% CMHC HCH Implementation January 1, 2012 30% 25% 20% 15% First Year 9.1% 10% 2008 2009 2010 2011 2012

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%)

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)

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)

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%

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.

Population Health Management

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

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. 1 2010 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.

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.

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.

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.

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

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

1 PLANNING FOR POPULATION HEALTH MANAGEMENT (PHM)

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.

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.

2 DATA COLLECTION, STORAGE AND MANAGEMENT

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.

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.

3 POPULATION MONITORING AND STRATIFICATION

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.

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

4 PATIENT ENGAGEMENT

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.

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.

5 TEAM-BASED INTERVENTIONS

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.

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

6 MEASURING OUTCOMES

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.

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

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 308 30 91% 311 25 93% 306 29 91% 328 21 94% 343 12 97% Clark Community Mental Health Center 239 37 87% 189 76 71% 162 100 62% 222 35 86% 230 27 89% New Horizons Community Support Services 282 48 85% 252 76 77% 242 84 74% 250 76 77% 255 75 77% Preferred Family Healthcare, Inc. 277 51 84% 278 47 86% 262 59 82% 248 72 78% 254 62 80% Tri-County Mental Health Services 300 62 83% 303 57 84% 320 53 86% 303 67 82% 285 81 78% Family Guidance Center 545 113 83% 542 87 86% 528 81 87% 531 75 88% 545 70 89% Ozark Center 449 98 82% 398 131 75% 397 106 79% 406 122 77% 426 108 80% Family Counseling Center 775 186 81% 772 168 82% 802 126 86% 817 92 90% 817 94 90% Pathways Community Behavioral Healthcare, Inc. 1,932 506 79% 1,897 517 79% 1,875 567 77% 1,856 592 76% 1,866 599 76% Independence Center 180 50 78% 186 39 83% 182 50 78% 179 57 76% 174 59 75% North Central Missouri Mental Health Center 257 75 77% 257 72 78% 248 87 74% 250 89 74% 257 75 77% Community Counseling Center 510 150 77% 518 134 79% 534 128 81% 541 103 84% 533 98 84% Burrell Behavioral Health - Springfield 1,024 310 77% 1,028 299 77% 1,041 267 80% 1,062 258 80% 1,068 260 80% Crider Health Center, Inc. 767 236 76% 762 243 76% 777 237 77% 724 290 71% 614 467 57% Hopewell Center 378 123 75% 303 191 61% 314 173 64% 319 171 65% 327 162 67% Places for People 279 92 75% 292 76 79% 294 75 80% 299 69 81% 293 72 80% Community Treatment, Inc. 259 90 74% 270 79 77% 276 76 78% 274 72 79% 263 67 80% Comprehensive Health Systems, Inc. 123 46 73% 138 26 84% 148 22 87% 153 16 91% 149 15 91% 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 268 102 72% 269 101 73% 271 107 72% 261 110 70% 267 103 72% Bootheel Counseling Services 420 169 71% 420 173 71% 415 185 69% 401 181 69% 407 174 70% BJC Behavioral Health- SE 400 173 70% 388 186 68% 342 197 63% 349 212 62% 331 246 57% Truman Medical Center Behavioral Health 406 191 68% 425 168 72% 417 178 70% 436 158 73% 459 133 78% Adapt of Missouri, Inc. 279 137 67% 269 142 65% 248 165 60% 236 172 58% 241 170 59% Burrell Behavioral Health- Central 451 280 62% 451 250 64% 537 137 80% 583 101 85% 613 93 87% Ozark Medical Center 143 95 60% 156 83 65% 147 86 63% 136 112 55% 124 86 59% BJC Behavioral Health- SL 759 595 56% 729 621 54% 743 594 56% 775 603 56% 723 675 52% Comprehensive Mental Health Services 203 175 54% 187 191 49% 189 186 50% 203 183 53% 210 181 54% ReDiscover 385 334 54% 415 303 58% 446 248 64% 492 190 72% 504 177 74% Swope Health Services 238 281 46% 259 255 50% 292 206 59% 330 165 67% 363 141 72%

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

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

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)

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 www.qualityforum.org

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 0059. Creating new indicator to monitor A1c outside of normal range. Reviewing 2014 NQF 0059. 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.

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.

% 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%

% 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 -6-10 lbs -11-15 lbs -16-20 lbs -21-25 lbs -26-30 lbs > -30 lbs 0-10 lbs >10 lbs

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

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 0.23 0.65 0.42 0.82 0.28 0.48 0.43 0.43 0.41 0.42 0.90 Arthur Ctr 0.33 0.29 0.67 0.52 0.83 0.53 0.75 0.66 0.65 0.69 1.21 BJC - SE 0.40 0.14 0.40 0.36 0.22 0.30 0.06 0.03 0.05 0.05 0.35 BJC SL 0.39 0.27 0.29 0.27 0.21 0.29 0.31 0.44 0.45 0.40 0.69 Bootheel 0.33 0.15 1.30 1.37 1.24 0.88 0.62 0.52 0.52 0.55 1.43 Burrell -C 0.68 0.71 0.71 1.56 1.03 0.94 1.41 1.51 1.64 1.52 2.46 Burrell -SW 1.27 1.26 0.68 0.53 0.43 0.83 1.39 1.56 1.37 1.44 2.27 Clark 1.01 1.53 0.86 0.35 0.12 0.77 0.08 0.06 0.10 0.08 0.85 Com. Couns. Ctr 0.87 0.91 1.22 1.23 1.24 1.09 0.53 0.37 0.47 0.46 1.55 Comp. Health Sys. 0.15 0.56 0.33 0.60 0.15 0.36 0.03 0.03 0.01 0.02 0.38 Comp. MH Srvs 0.20 0.23 0.44 0.15 0.81 0.37 0.63 0.27 0.26 0.39 0.75 Comtrea 0.16 0.19 0.08 0.17 0.03 0.13 0.45 0.33 0.44 0.41 0.53 Crider 1.15 1.09 1.24 1.05 1.14 1.13 1.21 0.85 0.79 0.95 2.08 Fam. Couns. Ctr 0.61 0.53 0.39 0.62 0.82 0.59 0.35 0.65 0.51 0.50 1.10 Fam. Guid. Ctr 0.54 0.64 0.58 0.89 0.72 0.67 1.11 1.22 1.39 1.24 1.91 Hopewell Ctr 0.19 0.16 0.05 0.2 0.17 0.15 0.70 0.81 0.71 0.74 0.89 Independence Ctr 1.59 0.92 0.62 0.76 0.32 0.84 0.25 0.27 0.25 0.26 1.10 Mark Twain 2.08 0.84 0.76 1.03 0.79 1.10 2.14 2.83 2.89 2.62 3.72 New Horizons 1.26 0.73 1.00 1.39 1.19 1.11 1.10 0.70 0.77 0.86 1.97 No. Central 6.27 0.04 0.50 0.36 2.91 2.02 0.33 0.37 0.30 0.33 2.35 Ozark Ctr 1.81 1.35 1.18 1.26 1.12 1.34 0.74 0.53 0.57 0.61 1.96 Ozark Med. Ctr 0.09 0.18 0.04 0.03 0.04 0.08 0.02 0.03 0.06 0.04 0.11 Pathways 1.45 1.30 1.53 1.3 1.32 1.38 1.37 1.49 1.32 1.39 2.77 Places for People 1.64 1.74 0.78 0.45 1.49 1.22 0.29 0.42 0.23 0.31 1.53 Preferred 0.69 0.43 1.18 0.39 0.81 0.70 0.23 0.32 0.22 0.26 0.96 ReDiscover 0.29 0.29 0.09 0.08 0.15 0.18 0.04 0.14 0.15 0.11 0.29 Swope 0.25 0.24 0.28 0.35 1.21 0.47 0.07 0.09 0.13 0.10 0.56 Tri-County 1.01 0.58 1.88 1.45 1.79 1.34 0.70 0.58 0.40 0.56 1.90 Truman 1.00 1.17 0.70 1.90 1.45 1.24 0.07 0.11 0.05 0.08 1.32 Statewide Avg 0.96 0.66 0.70 0.74 0.83 0.78 0.60 0.61 0.59 0.60 1.38

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

What difference does it make?

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

Small Changes Make a Big Difference! Cholesterol 10% in cholesterol = 30% in CVD (120-100) 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

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 8.5 1 POINT DROP IN A1C! 21% in diabetes related deaths 14% in heart attack 31% in microvascular complications

Improving Uncontrolled LDL Baseline to Year 1 Reduced the mean LDL 131 to 116 10% DROP IN LDL LEVEL! 30% in cardiovascular disease Baseline to Year 2 Reduced the mean LDL 131 to 113

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

Nurse Care Managers: The Driving Force

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.

Nurse Care Managers The Driving Force

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

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

THANK YOU! Brent McGinty, bmcginty@mocmhc.org Rachelle Glavin, rglavin@mocmhc.org