Integrating Healthcare Through Population Health Management · 3/23/2017 · Integrating...
Transcript of Integrating Healthcare Through Population Health Management · 3/23/2017 · Integrating...
3/23/2017
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Integrating Healthcare
Through Population
Health Management
Joseph Parks, M.D.
National Council Behavioral Health Medical Director
Today’s Moderators
Madhana Pandian
Associate
Deann Jepson, M.S.
Co-facilitator
Slides for today’s webinar will be
available on the CIHS website:
www.integration.samhsa.gov
In the About Us/Innovation Communities 2017 tab
To participate
Use the chat box to communicate with other attendees
Use the question box to send a question directly to Dr. Parks.
Disclaimer: The views, opinions, and content
expressed in this presentation do not
necessarily reflect the views, opinions, or
policies of the Center for Mental Health
Services (CMHS), the Substance Abuse and
Mental Health Services Administration
(SAMHSA), the Health Resources and
Services Administration (HRSA), or the U.S.
Department of Health and Human Services
(HHS).
Setting the Stage
Dr. Joe Parks
National Council Behavioral Health Medical Director
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IC Learning Objectives- Screening and treatment of depression and diabetes
- Impact of comorbid depression and diabetes on treatment
outcomes for both
- Development of screening protocols, treatment pathways, and
disease registry to improve co-management of diabetes and
depression
- Use of data to improve clinical workflows and outcomes -
Population Health Management
- Develop work plan to achieve 2-3 goals related to one or more areas
of sustainability:
Staff core competencies
Quality metrics/Key Performance Indicator Development/Analysis
Billing/Cost Analysis
Overview of Today’s Webinar
What is population health?
What is population health management?
– Why do we need it?
– Good outcomes are dependent on patient behaviors.
– People with a serious mental illness (SMI) are more ill.
There is a psychiatry shortage.
Let’s look at a health home example.
How will the information presented in today’s webinar help you
with your Innovation Community workplan goals?
Population Health Definitions
The health of the population as measured by health status
indicators and as influenced by social, economic and physical
environments, personal health practices, individual capacity
and coping skills, human biology, early childhood
development, and health services (Dunn and Hayes, 1999).
A conceptual framework for thinking about why some
populations are healthier than others as well as the policy
development, research agenda, and resource allocation that
flow from it (Young, 2005).
Health Rankings
75
76
77
78
79
80
81
82
Japan
France
Australia
Canada
Germany
New Z
ealand
United K
ingdom
United S
tate
s
The IHI Triple Aim How do you deliver PHM in any care setting?
Assess Stratify
Implement Solutions
Measure & Report
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Population Management Principles
Population-based care
Data-driven care
Evidence-based care
Patient-centered care
Social determinants of health
Team care
Integration of behavioral and primary care
Population-based Care
Don't rely solely on patients to know when they need
care and what care to ask for and from whom - use
data analytics for outreach to high need/utilizer
patients.
Don't focus on fixing all care gaps one patient at a
time - choose selected high prevalence and highly
actionable individual care gaps for intervention across
the whole population.
The population-based health care provider is the
public health agency for their clinic population.
Data-driven Care
Patient registries
Risk stratification
Predictive analytics
Performance benchmarking
Data sharing
Population Management
Selects those from whole population:
– Most immediate risk
– Most actionable improvement opportunities
Aids in planning:
– Care for whole populations
– New interventions and programs
– Early identification and prevention
– Choosing and targeting health education
Data Uses
Aggregate reporting ― performance benchmarking
Individual drill down ― care coordination
Disease registry ― care management
– Identify care gaps
– Generate to-do lists for action
Enrollment registry ― deploying data and payments
Understanding ― planning and operations
Telling your story ― presentation like this
Principles Use data you have before collecting more.
Show as much data as you can to as many partners as you
can as often as you can.
– Sunshine improves data quality.
– They may use it to make better decisions.
– It’s better to debate data than speculative anecdotes.
When showing data, ask partners what they think it means.
Treat all criticisms that results are inaccurate or misleading
as testable hypotheses.
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More Principles
Tell your data people that you want the quick, easy data runs
first. Getting 80 percent of your request in 1 week is better than
100 percent in 6 weeks.
Treat all data runs as initial rough results.
Important questions should use more than one analytic
approach.
Several medium data analytic vendors/sources are better than
one big one.
Transparent benchmarking improves attention and increases
involvement.
Most Important Principle
Perfect is the enemy of good.
Use an incremental strategy.
If you try to figure out a comprehensive plan first,
you will never get started.
Apologizing for a failed prompt attempt is better than
apologizing for a missed opportunity.
Six Population Health Management Services
1. Care management
2. Care coordination
3. Transitions of care management
4. Health promotion
5. Individual and family support
6. Referral to community services
Comprehensive Care Management
Identifying and targeting of high-risk individuals
Monitoring of health status and adherence
Identifying and targeting care gaps
Individualized planning with patient
Step 1 – Create Disease Registry
Get historic diagnosis from administrative claims
Get clinical values from metabolic screening, clinical
evaluation and management, and care plans
Combine into EHR Disease Registry (Central Data
Registry, PROACT)
Have online access available to all providers
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Step 2 – Identify Care Gaps and ACT!
Compare combined disease registry data to
accepted clinical quality indicators
Identify care gaps
Sort patient groups with care gaps into agency
specific to-do- lists
Nurse care manager helps team decide who will act
Set up indicated visits and pass on information with
request to treat
Care Coordination
Coordinating with the patients, caregivers, and providers
Implementing plan of care with treatment team
Planning hospital discharge
Scheduling
Communicating with collaterals
Why Behavioral Health Needs
Population Management
Legislation requires it
People with SMI more ill
Population management needs behavioral health
Psychiatry shortage
Population Health Management
Community health needs assessment requirements
Expansion of prevention and wellness services
Hospital readmissions reduction program
Community-based care transitions program
Accountable Care Organizations
Patient-centered medical homes
Health homes for chronic conditions
Increased funding for health centers
Care Coordination
Clinical Integration
Care Management
Important Provider Competencies
Characteristics:
• Outcomes-oriented
• Enabled by
technology
• Patient-centered
• Use of data and
analytics
• Performance
transparency
• Ability to partner
across
organizations
Life Expectancy
40
45
50
55
60
65
70
75
80
No Mental Disorder Any Mental DisorderGeneral Population
Any Mental DisorderPublic Sector
Bar 1 & 2: Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental
illness: 17-year follow up of a nationally representative US survey. Med Care. 2011 June;49(6):599-604
Bar 3; Daumit GL, Anthony CB, Ford DE, Fahey M, Skinner EA, Lehman AF, Hwang W, Steinwachs DM. Pattern of mortality in a
sample of Maryland residents with severe mental illness. Psychiatry Res. 2010 Apr 30;176(2-3):242-5
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Causes of Excess Mortality
Smoking
Obesity
Inactivity
Polypharmacy
Under diagnosis of medical conditions
Inadequate treatment of medical conditions
Per Member Per Month Costs
$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
PrivateSector
Medicare Medicaid
No Mental Disorder
Any MentalDisorder
MH/SUD costs in NY State’s Medicaid Program
$10,000
$12,000
$14,000
$16,000
$18,000
$20,000
$22,000
$24,000
$26,000
$28,000
$30,000
MH Disorder SU Disorder No MH/SUDisorder
Behavioral Health costs
Physical Helath costs
So, what to do...
NO one magic bullet
Integration of behavioral health
and primary care
Team care with everyone
working at the top of their training
Population health management
Healthcare delivery based on
deep partnerships
What is a Health Home?
Not just a Medicaid benefit
Not just a program or a team
A system and an organizational
transformation
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Health Care Home Strategy
Case management coordination and facilitation of healthcare
Primary care nurse care managers
Disease management for persons with complex chronic medical
conditions, SMI, or both
Behavioral health management and behavior modification as
related to chronic disease management for persons with medical
illness
Preventive healthcare screening and monitoring by mental health
providers
Integrated primary care and behavioral healthcare
Health Home Strategy
Health technology used to support service system
“Care coordination” best provided by a local community-based
provider
Mental health community support workers who are most familiar
with the consumer provide care coordination at the local level.
Primary care nurse care managers working within each health
home provide system support
Behavioral health consultants in each primary care health home
Statewide coordination and training support the network of health
homes
What is Different about Health Homes?
Treatment as Usual Health Homes
Individual practitioner
Episodic care
Focus on presenting problem
Referral to meet other needs
Managed care- Manages access to care
- Does not change clinical practice
Integrated primary/behavioral health
care team
Continuous care
Comprehensive care management- Coordinates care across healthcare system
- Uses data driven population management
- Transforms clinical practice
- Emphasizes health lifestyles and
self-management of chronic health problems
Health Home Target Populations
Patients with diabetes- At risk for cardiovascular disease and a
BMI > 25
Patients who have two of the
following:
- COPD/Asthma
- Diabetes (also as single condition)
- Cardiovascular disease
- BMI > 25
- Developmental disabilities
- Use tobacco
Primary Care Health Homes CMHC Healthcare Homes
Individuals with SMI or with
other behavioral health
problems who also have:
- Diabetes
- COPD/Asthma
- Cardiovascular disease
- BMI > 25
- Developmental disabilities
- Use tobacco
Missouri’s Health Homes
Providers
- 23 FQHCs
- 61 clinics
9 Hospitals- 36 clinics
3 Independent practices
- 3 clinics
Enrollment- 17,823 adults
- 1,168 children
- 18,991 total
Providers
- 26 CMHCs
- 120 clinics/outreach offices
Enrollment- 20,877 adults
- 3,359 children
- 24,236 total
Primary Care Health Homes CMHC Healthcare Homes
Health Home Team
Nurse care managers (1FTE/250pts)
Care coordinators (1FTE/500pts)
Home health director
Behavioral health consultants
(primary care)
Primary care physician consultant
(behavioral health)
Learning collaborative training
Next day notification of hospital
admissions
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Six CMS Required Health Home Functions
1. Care management
2. Care coordination
3. Managing transitions of care
4. Health promotion
5. Individual and family support
6. Referral to community services
HCH Responsibilities
Hospital Admissions
The importance of following up on hospital discharges
A joint letter prepared by the Missouri Hospital
Association and Missouri HealthNet was distributed to
all hospitals describing the health home initiative and
encouraged hospital cooperation.
A draft Memorandum of Understanding (MOU) has
been distributed to your CMHC administration to use as
a guide in developing a MOU with hospitals serving
your area.
HCH Responsibilities
Hospital Admissions
Hospitals are required by most payers, including Missouri
Medicaid, to contact the payer at the time of admission to
receive an Initial Authorization of Stay.
All-new authorizations for inpatient care are sent in an
overnight flat file data transfer from the inpatient
authorization unit to the health home analytics unit.
An access database is used to automatically sort the
patients by health home and generate an automated email
listing those patients with new authorizations to each health
home director.
HCHs receive daily emails regarding hospital admissions.
HCH Responsibilities
Hospital Admissions
HCH members discharged from the hospital must have a contact
within 72 hours of discharge
- This contact may be made by the individual's CSS, case manager, or NCM
Nurse care managers must complete a medication reconciliation
on HCH members discharged from the hospital
- Information regarding the enrollees’ medications may be collected by the
individual’s CSS or case manager for review by the NCM
Emergency Room Visits
In response to the anthrax scare following 9/11 all emergency
rooms were required to send a notification of every emergency
room visit to the state health department.
All new emergency room (ER) visit notifications are sent in an
overnight flat file data transfer from the state health department to
the health home analytics unit.
An access database is used to automatically sort the patients by
health home and generate an automated email listing those
patients with new ER visits to each health home director.
HCHs receive daily e-mails regarding ER visits.
CMHC Health Home Performance Progress
LDL, A1C, and Blood Pressure
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Metabolic Syndrome Screening
All CMHC
Health
Homes have
attained a
completion
rate above
80%!
N= 6,553
(at 3.5 years)
N= 20,648
(Dec 2015)
A1C Levels Over Time
About 7% had uncontrolled A1c levels
10.1
9.2
8.9
8.6
7.5
8
8.5
9
9.5
10
10.5
Baseline Year 1 Year 2 Year 3
CMHC-HH
10.0
9.29.1
9.1
7.5
8
8.5
9
9.5
10
10.5
Baseline Year 1 Year 2 Year 3
PCHH
1 POINT DROP
IN A1C
21% ↓ in diabetes
related deaths
14% ↓ in heart
attack
31% ↓ in
microvascular
complications
132
115
112
106
100
110
120
130
140
150
160
Baseline Year 1 Year 2 Year 3
CMHC-HHs
LDL Levels Over TimeAbout 45% had uncontrolled LDL levels
132
121119
116
100
110
120
130
140
150
160
Baseline Year 1 Year 2 Year 3
PCHHs
10% DROP
IN LDL
LEVEL
30% ↓ in
cardiovascular
disease
Blood Pressure Changes
Over Time
6 POINT DROP
IN BLOOD
PRESSURE
• 16% ↓ in CD
• 42% ↓ in stroke
152.9144.1 143.3 141.4
96.989.7 89.1 87.4
30
50
70
90
110
130
150
170
Baseline Year 1 Year 2 Year 3
PCHHs
SystolicDiastolic
152.9
134.9 134.4 133.1
97.9
86 84.9 83.3
30
50
70
90
110
130
150
170
Baseline Year 1 Year 2 Year 3
CMHC-HHs
Systolic
Diastolic
20-24% had uncontrolled BP levels
Hospital Follow-up Jan. 2012 – July 2014
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
20
12-1
20
12-2
20
12-3
20
12-4
20
12-5
20
12-6
20
12-7
20
12-8
20
12-9
20
12-1
0
20
12-1
1
20
12-1
2
20
13-1
20
13-2
20
13-3
20
13-4
20
13-5
20
13-6
20
13-7
20
13-8
20
13-9
20
13-1
0
20
13-1
1
20
13-1
2
20
14-1
20
14-2
20
14-3
20
14-4
20
14-5
20
14-6
20
14-7
%Follow-Up
Diabetes
Adults continuously enrolled
N= 1,889 (at 3.5 years)
N= 4,526 (Dec 2015)
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Hypertension & Cardiovascular Disease
Adults
continuously
enrolled
CVD N= 232
(at 3.5 years)
CVD N= 564
(Dec 2015)
HTN N= 2,401
(at 3.5 years)
HTN N= 6,111
(Dec 2015)
Percent of Clients with 1+ Hospitalization
10%
15%
20%
25%
30%
35%
40%
2008 2009 2010 2011 2012
First Year
9.1%
CMHC HCH Implementation January 1, 2012
ER and Hospital Days per 1,000 Hospital Encounters
N= 17,084 (2011)
N= 18,776 (2012)
N= 19,103 (2013)
N= 20,345 (2014)
ER Encounters
N= 17,084 (2011)
N= 18,776 (2012)
N= 19,103 (2013)
N= 20,345 (2014)
6534 5792 5498 5694
36320 36924 34540 36336
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
50000
Pre 12011
Year 12012
Year 22013
Year 32014
PsychiatricER Visit
General MedicalER Visit
15% 14% 14% 14%
85% 86% 86% 86%
Average # of ER & Hospital Encounters
N= 17,084 (2011)
N= 18,776 (2012)
N= 19,103 (2013)
N= 20,345 (2014)
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Initial Estimated Cost Savings After 18 Months
CMHC Health Homes
20,031 persons total served (includes dual eligibles)
Cost decreased by $98.22 PMPM
Total cost reduction $31.0 M
PC Health Homes
23,354 persons total served (includes dual eligibles)
Cost decreased by $18.22 PMPM
Total cost reduction $5.3 M
What Makes it Possible? A relationship of basic trust between:
Department of Mental Health
Missouri HealthNet (Medicaid)
State Budget Office
Missouri Coalition of CMHCs
Missouri Primary Care Association
Transparent use of data instead of anecdotes to explore and
discuss issues
Willingness of all partners to tolerate and share risk
Principled negotiation and Motivational Interviewing
Partnership Principles
DO
Ask about their needs first
Give something
Assist wherever you can
Make it about the next 10
Pursue common interest
Reveal anything helpful
Take one for the team
DON’T
Talk about your need first
Expect to get something
Limit assistance to a project
Make it about this deal
Push a specific position
Withhold information
Let them take their lumps
SMR. Covey, The Speed of Trust
Behaviors that Promote Trust
Character
― Talk straight
― Demonstrate respect
― Create transparency
― Right Wrongs
― Show Loyalty
Competence
― Deliver results
― Get better
― Confront reality
― Clarify expectations
― Practice Accountability
Character & Competence
― Listen first
― Keep commitments― Extend trust
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Questions?
Thank you for joining us today.
Please take a moment to provide
your feedback by completing the
survey at the end of today’s
webinar.
If you have additional questions/comments, please send them to:
Joe Parks – [email protected]
Deann Jepson – [email protected]
Madhana Pandian – [email protected]