1. Session 11b: Linking Population
Health and Medical
Management
CDR James Ellzy, MD, CMQ
Teaching Faculty, DeWitt Army Family Medicine
Residency
& Immediate Past Director of MHS Clinical Quality
james.ellzy@amedd.army.mil
11-1
2. Outline
• MTF Utilization of Population Health
• MTF Utilization of Medical Management
• TMA Resources
11-2
4. Population Health - Outcomes
Where we were... Where we are moving…
FOCUS ON DISEASE FOCUS ON HEALTH
• Sub optimal satisfaction
• Enrollment • Increase appropriate access
• Appointment system • Improve population health
• Claims processing • Enroll and assess needs
• Sub optimal points of access • Primary disease/injury prevention
• Advice/Triage/E.R. • Clinical practice guidelines
• Highly episodic utilization • Demand management
• Many unplanned visits • Referral management
• Lack of continuity • Case management
• Decreased “health status” • Ensure continuity of care
• Increased satisfaction & loyalty
INTERVENTION PREVENTION
11-4
5. Why do we care?
• Because leadership is tracking it…
• Gaps exist in quality of care…
• Persons with disease/risk cost more…
• We work in a financially constrained
environment
• Improves outcomes, productivity,
satisfaction
11-5
7. Population Identification
and Assessment
Identification Assessment Data resources
• Who are… • What is the health • Medical record reviews
• The eligible status? • Health risk assessment
beneficiaries? • What are the lifestyle • Health related behavior
• Who is… risk factors (behaviors)? survey
• Enrolled to the MTF? • Who needs clinical • MHS Population Health
• Who is… preventive services? Portal
• Enrolled to your • What is the prevalence
clinic? of chronic disease?
• Who is… • Who are the high SCENARIO:
utilizers of services? Who is the
• Being seen in your
clinic? population at
each of your
three MTFs?
11-7
9. Demand Forecasting
• Requires:
• Accurate population identification (size, gender, age)
• Knowledge of:
• Health care needs of the population (imms & other CPS)
• Prevalence of disease/conditions within the population
• Clinical practice guidelines (including VA/DoD CPGs)
• Operationally defined & system-required demands (pre-
deployment requirements, physical exams, overseas
screening, etc.)
• Resources:
• Utilization Reviews (historical data such as chart reviews
and M2 queries)
• Demand Forecasting models
11-9
11. Demand Management
• A collection of proactive interventions focused on reducing unnecessary
health care utilization while encouraging the appropriate use of health care
resources.
• Strategies:
• Increasing SELF-CARE Strategies & Patient Education
• PCM Assignments (Right patient mix & distribution)
• Nurse Triage
• Message Center
SCENARIO:
• Making the most of every visit How could
• Immunizations at acute visits Colonel Smith’s
• Oral prophylaxis at dental exam appointment utilization have
• Medication refills at every visit
been better
• Optimizing ALL team members managed?
11-11
13. Capacity Management
Matching the quantity and
quality of healthcare services • Provider availability
provided at the MTF with the • Provider type needed
needs of the population.
• Support staff
• Ancillary support
Factors affecting capacity requirements
Management:
• Readiness requirements
• Patient demand
• Physical space
• Appointment types
• Equipment needs
• Open Access
• Group Appointments SCENARIO: Any pertinent issues
discussed yesterday afternoon?
11-13
15. Evidence-Based Care
and Prevention
• The provision of healthcare using a
systematically developed, research-based
approach
• Identifies people with or at risk for chronic disease
• Provides patients & families:
• Evidence-based information & tools (e.g. CPGs)
• Multidisciplinary team to follow plan of care
• Referral to resources, as needed (e.g., case
management, disease management)
• Health promotion and/or patient self-management
education
11-15
16. Evidence-Based
Healthcare Goals
• Improved Quality of Life SCENARIO:
What 3 chronic
• Higher Functional Status diseases of Col
• Self-Management Smith do we have
VA/DoD CPGs?
• Fewer Hospitalizations/Acute Visits
• Improved Quality of Care
• Reduced variation
• Decreased Costs More Resources Available
for Prevention Strategies
11-16
18. Program Evaluation & Feedback
• Implementing Clinical Practice Guideline (CPG) is
NOT enough
• Measure outcomes to evaluate your program’s
processes and performance
• Service required clinical metrics
• Use the Population Health Portal on CarePoint
• National benchmarks (examples)
• Healthcare Effectiveness Data and Information Set
(HEDIS®)
• Healthy People 2020
• Joint Commission-ORYX
11-18
20. Case Management (CM)
• Definition:
• A collaborative process under the Population Health
continuum that assesses, plans, implements,
coordinates, monitors, and evaluates options and
services to meet an individual’s health needs
through communication and available resources to
promote quality, cost-effective outcomes.
• DoD Medical Management Guide 2009
11-20
21. Case Management (CM)
• Goals:
• Promote quality, safe, and cost-effective care.
• Promote utilization of available resources to achieve clinical and financial
outcomes.
• Facilitate appropriate access to care.
• Collaborate with the patient/family, physician, healthcare providers, and
others to develop and implement a plan that meets the needs and goals
of the patient.
• Develop individualized patient plans of care.
• Offer objectivity, healthcare choices, and self-management solutions.
SCENARIO: • DoD Medical Management Guide 2009
How could Col Smith have benefitted
from Case Management?
11-21
22. Case Management (CM)
The MHS has three primary goals for CM:
• Improve the care, management, and transition of recovering Service
members.
• Broaden the application of CM to include beneficiaries with complex needs
and at-risk beneficiaries before they require complex care.
• Evaluate the impact of CM on the quality and efficiency of military health
care.
Additional goals applicable to caring for wounded warriors are to:
• Assist the recovering Service member in receiving quality medical and
behavioral health (BH), which may include lengthy inpatient stays and
transistions between facilities or between outpatient medical and BH
services.
• Assist the recovering Service member and his/ her family in understanding
the recommended treatment (including BH services) and in receiving timely
access to that treatment.
11-22
23. Utilization Management (UM)
• Definition:
• An organization-wide, interdisciplinary approach to
balancing cost, quality, and risk concerns in the
provision of patient care. UM is an expansion of
traditional Utilization Review (UR) activities to
encompass the management of all available
healthcare resources, including Referral
Management (RM).
-DoD Medical Management Guide 2009
11-23
24. Utilization Management (UM)
• Goals:
• Maintain the quality and efficiency of healthcare
delivery by:
• Providing patients with the appropriate level of care.
• Coordinating healthcare benefits.
• Promoting the least costly, most effective treatment
benefit.
• Determining the presence of medical necessity
-DoD Medical Management Guide 2009
SCENARIO: How could Col Smith have benefitted from a working
Utilization Management Program in this Multi-Service Market?
11-24
25. Disease Management (DM)
• Definition:
• An organized effort to achieve desired health outcomes in
populations with prevalent, often chronic diseases for
which care practices may be subject to considerable
variation. DM programs use evidence-based interventions
to direct patient care. DM programs also equip the patient
with information and a self-care plan to manage his/her own
health and prevent complications that may result from poor
control of the disease process. The term “condition
management” includes non-disease states (e.g.,
pregnancy).
-DoD Medical Management Guide 2009
11-25
26. Disease Management (DM)
• Goals:
• Improve clinical outcomes
• Increase patient and provider satisfaction,
• Promote appropriate utilization of resources
throughout the MHS
• Purpose:
• Improve the quality of life for individuals by
preventing or minimizing the impact of a disease or
chronic condition.
-DoD Medical Management Guide 2009
SCENARIO: What diseases of Col Smith’s should be
part of a Disease Management program?
11-26
27. Medical Management
Guidance
• Department of Defense Instruction (DoDI) 6025.20
(dated Jan 2006)
• Population Health/Medical Management Guides
• Available: www.tricare.mil/OCMO/publications.aspx
• Medical Management Webinars available. Schedule
at www.tricare.mil/tma/ocmo/webinars.aspx
11-27
28. Milliman Inpatient
& Outpatient Guidelines
• Enterprise-wide license for evidence based guidelines that
supports outpatient and inpatient care (replaced McKesson’s
Interqual on the inpatient side).
• Clinical judgment still needs to be used
• As a commercial product, it doesn’t always match up with the TRICARE
benefit. TRICARE rules must be followed in their application and use!
• Other details
• Updated annually
• Requires an account/password,
• Free for MTF personnel use (paid by TMA)
• Username: mhs
• Password: referral
• Access link via: http://careweb.careguidelines.com
11-28
29. Milliman Inpatient
& Outpatient Guidelines
Ambulatory Care:
Imaging & Diagnostic Testing
DME & Injectables Inpatient and Surgical Care:
Referrals & Rehab Services Actionable Criteria
Detailed Care Pathways
General Recovery Guidelines: Observation care guidelines
Expanded decision support Integrated Quality Measures
Long-term acute care Easy evidence access
Evidence-based complex Patient Information Package
treatments
Problem oriented guidelines Behavioral Health Guidelines:
End-of-life guidance Clinical indications &
alternatives for admission
Recovery Facility Care: Detailed discharge criteria
Clinical indications Partial hospital care planning
Problem-oriented guidelines Flexible recovery courses
Detailed treatment plans Alternative care planning
Multiple length of stay measures
Care management tools
11-29
30. Military Health System Tools
and Resources
• MHS Population Health Portal (MHSPHP) on
CarePoint
• Highlights importance of accurate
documentation and coding = improving
data quality https://carepoint.afms.mil
• VA/DoD CPGs & toolkits:
• www.qmo.amedd.army.mil
11-30
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 This DOD model looks very linear – depicts in one graph: Population Health and Medical Management. This spans the entire spectrum/continuum. New model (as shown) replaces the Broad Spectrum Case Management Model in Medical Management Guide. Emphasize spectrum/continuum of health and care. As the focus moves toward illness/impairment, a more individualized approach is required (i.e. CM) Recently added: color shift, Prevention, and Palliative Care – many WII SM have chronic pain & issues requiring palliative care. It includes a health continuum which emphasizes the role of Case Management, Primary, Secondary, and Tertiary Prevention, and Outcome Measures in Broad-spectrum Case Management. It includes a health continuum which emphasizes the role of Case Management, Primary, Secondary, and Tertiary Prevention, and Outcome Measures in Broad-spectrum Case Management.
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 This is an illustration of the Population Health focus on Health and Prevention and a shift from focusing on episodic care and focus on disease. Note elements listed under the focus on Health (CPGs, demand mgmt, referral mgmt, and CM) Emphasis on prevention = decreased costs associated with disease prevented.
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 Because it’s the right thing to do……. Because our leadership is tracking it………
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 This is the DoD framework/model – the “Population Health Improvement Model” Population Health: is a systematic way of delivering proactive, effective, and efficient evidence-based healthcare in partnership with the community and out beneficiary population. Through PH strategies, you increase quality of care, lower costs, and improve health. This model is made up of 6 clinical and business process elements. The Department of Defense (DoD) PHI Plan provides guidance in support of a uniform health care system based on systematic business and clinical decision processes. This plan is a framework based on four main assumptions: 1. The delivery of “user-friendly,” quality patient care is critical for the MHS success. 2. Assimilation of best available evidence, judgment and experience are necessary to stay competitive. 3. The best allocation of scarce resources will be achieved through the systematic application of continuously improving standards of care, and is paramount for survival. 4. Ideal delivery of health care within the MHS depends on leveraging the capacity of contract partners with the direct care system. This Figure shows the overall process involved with PHI. It demonstrates the relationship of the various process elements associated with PHI to the completion of the MHS mission. There are two factors to the equation: the demand on the system and the capacity of the system to complete the mission. Basic laws of economics state that there is a gap that will exist between these two factors. Doctrine or management paradigms exist to minimize this gap. Detail regarding each component of this model will be presented to you in future sections of this Population Health Module
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 The first question to be answered in identifying the population is “ Who is the population?” - Look at age, gender, ben cat, risk factors, disease burden Assessment: do you have tobacco users? Heavy alcohol users? Depression diagnosis – could benefit from CM?, High utilizers - 10 or more outpatient visits, an ER visit or inpatient admissions? Sub-questions include …… who is an eligible beneficiary? NOT JUST WHO SHOWS UP FOR APPTS IN THE CLINIC! WHAT ABOUT THOSE YOU DO NOT SEE? They may have undiagnosed, or poorly managed chronic illnesses! Tools to help identify the population : DEERS M2: MHSPHP Dental Navy - DENCAS: Dental Common Access System Army - CDA: Corporate Dental Application Air Force - DDSW: Dental Data System-Web
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 * Demand forecasting is an estimate the volume of care required by a given population. It requires accurate identification of the population in terms of size, age, gender, location and ID Health care needs of the population (including immunizations & other clinical preventive services) - How many women greater than 42yo? – will need mammos - How many children? Will be able to forecast the needs for immunizations and well child check ups Prevalence of condition/disease within the population & clinical practices used to treat a given condition/disease Operationally defined & system-required demands (includes pre-deployment requirements, physical exams, overseas screening, etc.) Demand forecasting lets the medical management team determine the staffing and budgets required to provide acute care, chronic care, clinical preventive services, and health promotion programs for the population Demand forecasts help the disease manager determine : Prioritize programs Collaborate with leadership, medical management staff, and stakeholders on staffing and resource needs. Proactively prepare to meet needs of beneficiary population Establish budgetary requirements
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 Refers to proactive interventions aimed at reducing unnecessary healthcare utilization while encouraging the use of appropriate healthcare resources Demand Management strategies include…… Consider tracking who is calling for what types of appts, and when do they want them (pm clinics?), and possibly with which provider Evaluate PCM assignments to assess the right patient mix for the provider role and patient distribution among providers Encourage the use o f effective decision support (CPGs) and self management tools , thus enabling beneficiaries to use healthcare resources appropriately. Use of demand management strategies will decrease the need for urgent episodic care. Focus is on prevention of illness and injury. Manage Demand through UM/UR
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 * *THINK CLINIC MANAGEMENT MTF capacity must be linked to best clinical and business practices Capacity management includes : Implementing proactive vs. reactive strategies Managing the clinical processes—\\clarify staff roles & responsibilities Controlling leakage to the network Optimizing supply and demand Reducing excess needs if possible Increasing throughput of the system by improving processes (i.e., do things right) Using evidence-based practices (i.e., do the right things) TOOLS : Template analysis tool (TAT) available in the TOC CPGs or decision support tools Coordination of referrals and utilization (UM and RM) Clinic Managers (trained – courses available) Clinic support staff to optimize clinicians time with patients Shared Appointments:
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 The Foundation of Quality Care = Evidence-based Care Evidence-based prevention is provided at three levels. Primary : *** *patient education , Health Promotion and Protection (e.g. PHA, immunizations) Example of diabetic: exercise and diet can help prevent secondary diabetes for those who have a family history or are otherwise predisposed Secondary : *** Screening, Early Detection and Case Finding (e.g. Hypertension, Caries, Cancer Screening) Example: predisposed, family history of diabetes – test blood sugars periodically Tertiary : Treatment, Keeping the disease/condition from worsening, and Rehabilitation (e.g. Diabetes, Asthma) CPGs are used here Diabetes: keep A1Cs under 9 CPGs – the foundation of a successful DM program.
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 These are the GOALS of evidence-based healthcare
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 it is imperative to measure the effects of your interventions . We live in a world that is data and outcomes driven. You must measure your data in order to evaluate your program. PHP is the tool that will be used by Services to measure the required clinical quality metrics . It is the same for all MTFs, and the plans are that these metrics will be pulled OUTSIDE of identify and manage high-risk the MTF (e.g., HSO or NEHC) · Are the interventions having a positive impact on utilization trends, health outcomes, and medical costs? (es: have ED visits decreased? Are CPS increasing?) · What is the MTF doing to proactively improve the health of beneficiaries? · What variance analyses are used to measure a program’s success (i.e., ascertain if interventions, such as if CPGs are improving care)? Healthy People 2010 Leading Health Indicators Physical Activity Overweight and Obesity Tobacco Use Substance Abuse Responsible Sexual Behavior Mental Health Injury and Violence Environmental Quality Immunization Access to Care
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 This model has been in place for a few years now – this model looks at the administrative or practical application approach rather than a spectrum of disease approach. Depicts both the direct care and purchased care service. It is a bi-directional responsibility. UM, CM, and DM are the 3 components of Medical Management - all intertwined. THE OUTCOMES of a MM program: quality is at the center , Appropriate, efficient cost And satisfactory access…… readiness makes us (military) unique.
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 Focus is on meeting the care needs of individuals with catastrophic, complex cases/conditions (vice the population/groups) – Should be accomplished in a collaborative fashion with all involved in the case (the entire team: social workers, behavioral health, personnel etc) 6 steps of CM Process (inbedded in the definition): Assess Plan Implement Coordinate Monitor evaluate
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 Focus is on meeting the care needs of individuals with catastrophic, complex cases/conditions (vice the population/groups) – Should be accomplished in a collaborative fashion with all involved in the case (the entire team: social workers, behavioral health, personnel etc) 6 steps of CM Process (inbedded in the definition): Assess Plan Implement Coordinate Monitor evaluate
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 THE 6 RIGHTS : The right patient The right care The right provider the right time the right place The right cost The ultimate goal of UM is: quality healthcare provided efficiently, and at the appropriate level of care. ******* Resource Mgmt meets Quality The 12 step UM process is the quality improvement process used to gather info through data analysis. UM looks at the cost of services and how people access them along with the utilization rates.
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 THE 6 RIGHTS : The right patient The right care The right provider the right time the right place The right cost The ultimate goal of UM is: quality healthcare provided efficiently, and at the appropriate level of care. ******* Resource Mgmt meets Quality The 12 step UM process is the quality improvement process used to gather info through data analysis. UM looks at the cost of services and how people access them along with the utilization rates.
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 DM programs use interventions that are evidence-based to direct the patient’s plan of care. DM programs also equip the patient with information and a self-care plan to manage one’s own wellness and prevent complications. Self management is the 4 th step in DM. MTFs see decrease service demand and increased medication adherence. Self talk principle: you believe what you hear yourself say. Disease Management Goals - Standardize care - Empower patients to live healthier lifestyles through patient education and self management strategies - Decrease costly emergency visits and inpatient stays - Improve appropriate medication and treatment usage DM in the MHS: CHF and Asthma started in 2006, Diabetes added 2007. Planning the implementation of COPD (Jun), Depression/anxiety (Oct), and cancer screening.
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 DM programs use interventions that are evidence-based to direct the patient’s plan of care. DM programs also equip the patient with information and a self-care plan to manage one’s own wellness and prevent complications. Self management is the 4 th step in DM. MTFs see decrease service demand and increased medication adherence. Self talk principle: you believe what you hear yourself say. Disease Management Goals - Standardize care - Empower patients to live healthier lifestyles through patient education and self management strategies - Decrease costly emergency visits and inpatient stays - Improve appropriate medication and treatment usage DM in the MHS: CHF and Asthma started in 2006, Diabetes added 2007. Planning the implementation of COPD (Jun), Depression/anxiety (Oct), and cancer screening.
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 Useful in primary care setting to ensure care is given there before referring up to specialty care can be used for imaging, diagnostic testing, rehab services, ambulatory surgery, immunizations, injectables, referrals Onsite training: instructor led onsite training sessions in the North, South, and West regions. Each Region will host 2 training sessions/year. And Virtual Classroom training available.
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010 MHSPHP – population identification, tracking outcomes, compliance with evidence-based practice New system update/revision expected in Oct 09 Changing the provider interface to make it faster and increase capabilities Working to have Excel in the website (vice opening Excel separately) Labs, Xrays, and Mammograms will be updated/refreshed every 72 hrs vice monthly PHP data is the source for reporting an MTFs clinical performance in the Business planning tool. CPGs help standardize DM (and other PH/MM processes) and may be used as a framework for evaluating interventions.
Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery January 2010
