Population Health Management Defined April 12, 2015 TIM MIKSCH, SECTION HEAD, APPLIED CLINICAL...
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Transcript of Population Health Management Defined April 12, 2015 TIM MIKSCH, SECTION HEAD, APPLIED CLINICAL...
Population Health Management Defined
April 12, 2015
TIM MIKSCH, SECTION HEAD, APPLIED CLINICAL INFORMATICS
The Mayo Clinic
CLAUDIA BLACKBURN, SENIOR MANAGER
Aspen Advisors, Part of The Chartis Group
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Conflict of Interest Disclosure
Tim Miksch, MBA
Has no real or apparent conflicts of interest to report.
Claudia Blackburn, MBA
Is employed by Aspen Advisors, Part of The Chartis Group, which provides services that are discussed as a part of this presentation.
© 2014 HIMSS
Learning Objectives
• Identify how to align an organizational healthcare model with a value-based reimbursement model to support the allocation of resources for high risk patients
• Explain definitions and concepts associated with Population Health and Population Health Management
• Summarize the role of analytics in developing and evaluating programs and processes
• Identify where your organization is on a Population Health Management (PHM) maturity roadmap
PHM Core
Competencies
Case StudyChallenges and Next
Steps
An Introduction to the Benefits Realized for the Value of Health PHM IT
http://www.himss.org/ValueSuite
Population Health Management (PHM)The Future of Healthcare Paradigm Shift
Today:Reactive andVolume-based
The Future:Proactive andValue-based
Drivers
Health Reform
Affordability Gap
Triple Aim
Weight of the Nation
Reimbursement
Encourageme!
Educateme!
Treatme
holistically!!
I will payyou!
Individuals are accountable for their health with the health system as their health advocate.
Population health management provides comprehensive
authoritative strategies for improving the systems and
policies that affect health care quality, access, and outcomes, ultimately
improving the health of an entire population
Engaged Communities • Proactive care processes• Identified patients• Focused on wellness• Community resource navigator
Engaged Patients• Identified and incorporated
patient goals• Focused on continuity and
coordination• Facilitated communication
channels• Improved access to care
Identified Opportunities to Reduce Waste• 4 Rights• Duplication avoided• Improved coordination/transitions• Used automation to reduce resource needs• Improved screening and prevention• Aligned incentives to drive value
7
Achieving SuccessMaking the “Triple Aim” Possible
Better Health for the
Population
Population Health Management (PHM)Core Competencies
The goal of population health is to transform care delivery practices and administrative support to deliver improved outcomes and lower costs across the continuum of care for a specified population. Success will depend on changes in care practices, business processes and cross-organizational communications, all supported by information technology.
Member Engagement
Cross-Continuum Care Delivery and Medical / Care Management
Quality Outcomes Management / Reporting
Operational Performance Management and BI
Accounting
Integration and Infrastructure
Key Pillars of Population Health Management
Workflows, role changes, people, care coaches,
wellness program development, heath risk
assessment process, population engagement
Business vision, population definition,
policies, modeling, financials, contracts, procedures, market analysis, and value
proposition
Integration and interoperability
including HIE, patient portal, analytics,
coaching tools and health risk assessment
Risk, incentives, payment management,
shared savings
Mayo Community Practices
MAYO CLINIC in the MIDWEST Community and Regional Health System75 communities in MN, IA and WI
• 4 regions
• 18 hospitals
• 525,000 patients/year
• 1,000+ physicians
Primary care
At risk for PC
Arizona
• 90,000 patients/year
• Approx. 400 physicians
Primary care
At full risk for PC
MAYO CLINIC in the SOUTHWEST MAYO CLINIC in the SOUTHEAST
Florida
• 90,000 patients/year
• Approx. 400 physicians
Primary care
At full risk for PC
Academic Medical CenterRochester, MN
• 500,000 patients/year
• 2,000 physicians
• 125 primary care providers
Primary care
At full risk for PC
Office of Population Health Management• Formed in 2012
• Developed a Mayo framework for PHM
– Strategy
– Phasing
– Oversight
– Coordination
– Standardization
• Focused on the community practices
• Initially focused on primary care
• Value-based care
– Patient-Centered Medical Home
– Risk based reimbursement
The Changing Market
2010 2015 20200%
20%
40%
60%
80%
100%
Fee-for-service
Episode care
Condition-based care
Partial population care
Full population care
Source: “The View from Healthcare’s Front Lines: An Oliver Wyman CEO Survey”
WHAT? MMoCC is an enterprise-wide, multi-year roll-out to achieve the TRIPLE AIM:
• Improve Population Health• Improve Individual Experiences• Lower Costs
While aligning with financial models
Changing isn’t just for survival
The new model allows us to thrive
The Mayo Model of Community Care (MMoCC)
Implemented in strategic phases
WHO?Office of Population Health Management(OPHM)
Created by MCCPC to TRANSFORM Community Care
OPHM establishes the STANDARDIZED ELEMENTS for clinics to implement with APPROPRIATE LOCALIZATION
A new way of practicing is needed
OPHM defines strategy for the new model
Costs are rising
Reimbursement is decreasing
The measure of PRODUCTIVITY is no longer VOLUME
It is VALUE =
Small changes are not enough
Outcomes + Service Cost
Our survival is at risk
WHY?
VisionPatient centered, integrated care delivery modelbased on:• Aligned incentives• Coordinated, collaborative processes • Evidence-based prevention and disease
management protocols• Seamless sharing of information
Supported by wellness and continuity care programs that focus on:
• Patient engagement
• Community integration
• Prevention and health promotion
Driven by analytics to support quality outcomes and value-based accountable reimbursement
Office of Population Health Management
Geographic Operations
Arizona Office
Florida Office
Midwest Office
Functional Subgroups
Change Mgmt./ Communications
Data Analytics
IT Tools and Application
OPHM Advisory
Group
Programs
Prevention
Community Engagement
Wellness
Care Coordination
Chronic Condition Management
Palliative Care
Care Transitions
Team-based Care
Patient Engagement
Access
Health & Wellness Continuity Care
Executive Team
Mayo Clinic Clinical Practice Committee
MMoCC Focus Areas
50% 15%
35% 35%
15% 50%
C O S T
% of communityP O P U L AT I O N
•Wellness•Prevention
• Disease Management
• Care Coordination
• Care Transitions• Palliative Care
P H M F O C U S
2010 data from Mayo Clinic Health Sciences Research
Care teams
Patient engagement
Community engagement
Access
MMoCC Impact
80% of costs
Lifetime
Abi
lity
to im
pact
Complexactive illness
Symptomaticillness
High riskEarly riskSituational risk
• Family Hx• Environment
• Diet• Exercise
• Cholesterol• BP• Blood sugar
• Active Dz• Diabetes
HEALTH STATUS
HEALTH CARE SPEND
Act on opportunities
Identify opportunities
ASSESS STRATIFYPopulation Identification Health Assessment Risk Stratification Enrollment / Engagement Strategies Management / Interventions
1DEFINE
2 3 4ENGAGE
5MANAGE
Tailored Interventions—
Care Coordination—
Disease / Case Management—
Health Risk Management—
Health Promotion / Wellness
Meeting patients where they are
…physicallyhome | school | work | shopping | in the clinic
…in the way that works best for thememail | text | internet | phone | video | face-to-face
MMoCC Process
Phased Implementation
MMoCC 2Laying the foundation while
living in FFS
• Introduces value-based (TCOC) concepts and model (change management)
• Emphasis on team-based care foundation and care coordination introduction
• Standardized disease management and prevention recommendations
• Focus on decreasing high utilization where it makes sense (30 d readmits…)
MMoCC 4Requires value-based contracts to succeedMMoCC 3
More site resource investment – mixed
volume/value
• Shifts from individual practice to team-based panels
• Continues focus on high utilization and expanded analytics and care management
• Increases focus on patient important outcomes
• Strong shift to total cost of care drivers
• Adds specialty integration to care team concept
• Community engagement
• Full alignment of incentives
Diffusion Timeline
MMoCC Limited Implementation 2013 2014 2015 2016
MMoCC Previous
MMoCC 2 Foundation
MMoCC 3 Mixed
MMoCC 4 TCOC
PILOT 4-6 Sites
2015 Status
• All sites are actively engaged
• Standardizing across sites and regions is a challenge
• For many, fee-for-service remains a driver
• Data management processes are maturing
• Keys to our success:
– Engaged leadership at local levels
– Institutional support
– Strong physician leaders in each program
– Excellent business analysis, project management and informatics support in place
Demand for healthcare
Supply of resources to meet demand
VALUE = Outcomes + ServiceCost
Our pay will be based on
We need to utilize our staff wisely through
Identify opportunities to impact health earlier and act on those opportunities
We need to think differently about how to activate our patients and communities
And how we interact with them
TEAM-BASED CARE
ANALYTICS CARE MGMT SYSTEMPREVENTION DISEASE MGMT
PATIENT ENGAGEMENT COMMUNITY ENGAGEMENT WELLNESS
ACCESS PALLIATIVE CARE CARE TRANSITIONSCARE COORDINATION
Structure
Analytics and Reports Examples
Report DescriptionRegistration• Unassigned and wrongly assigned patients• Unassigned Emergency Department high utilizersCare Coordination• Diabetic Mellitus (DM) patients who are most likely to be readmitted
• Congestive Heart Failure (CHF) patients who are most likely to be readmitted
• 30 day readmission reports are located within the Care Coordination dashboard with DM and CHF 20%. Follow instructions from section 2.1 and 2.2
Patients by Disease Evidence Type• Patients with no Diabetes diagnosis but have other evidence of Diabetes• Patients with no CHF diagnosis but have other evidence of CHF
Example Use from Care Coordinators
• Care Coordinator identified a patient based on ER visits and reached out to her. She was very interested in COMPASS and did the PHQ9, and it was 17.
“She was very interested in changing her life so that she could be around for her granddaughter. I have sent her a letter and will keep her on my watch. It was a good connection to at least let her be aware that services are available if and when she is ready.”
• “I have a patient who, because of care coordination, has improved her health to move from the PHM tool CHF “most” to the “more” list. The PHM tool still identifies her as higher risk, but she has done well with care coordination.”
• “It mostly has been helpful to me to identify patient populations that might be eligible for care coordination to reach out to the providers to get them on board with care coordination, pointing out that the PHM tool has already identified them as being higher risk.”
2015 NEXT STEPSCHALLENGES
Challenges and Next Steps
• Practice standardization
• Resources – Can’t stop processes and can’t add
resources to change
– Needed to understand practice variation and standardize
– Informatics knowledgeable in in EMR support teams
• Challenge to implement tools to free up resources when processes and data aren’t standardized(IT, informatics)
• Rapid cycle iteration is challenging for practice tools without significant resource involvement
• Decision rights – “who says this is the new process….”
• Enterprise metrics
• Point-of-care registry and care management
• Patient consumer engagement utilizing EMR patient portal
Claudia BlackburnAspen Advisors, Part of the Chartis [email protected]@cblack67
Questions?
Thank You!Tim Miksch The Mayo [email protected]@tmiksch