This presentation explains how population health is fundamental to value-based delivery models, including key principles and definitions of PHM, as well as how to assess your organization’s “population health readiness.”

1. Population Health Management Webinar:
Where are You?…And How to Get Where You are Going
Karen Handmaker, MPP,
VP Population Health Strategies
December 17, 2013

2. About the Presenter
Karen Handmaker, MPP
VP, Population Health Strategies
Phytel
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3. Learning Objectives
1. Assess your “population health readiness”
2. Understand your organization’s role in
“value-based” models
3. Recognize that population health
management is a technology-enabled team
sport
3

5. Are You Looking Below the Waterline?
Do you only focus on the top 3%?
>2/3
of catastrophic
patients this year
were not
catastrophic
the previous year
You must focus on everyone below the waterline
this year to prevent next year’s catastrophic cases.
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Source: Healthcare Risk Adjustment and Predictive Modeling, Ian Duncan

6. The “Triple Aim” is Driving Change
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7. Move from Volume to Value is Underway
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8. Patient-Centered Medical Home Model Has Traction
• Primary care is the “front line” for
population health
• PCMH initiatives are achieving
better health, better care, and
lower costs
• PCMH initiatives are reaching the
tipping point with broad public
and private sector support
• PCMH initiatives offer both shortterm and long-term cost savings
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9. Organizations on Pathways to Population Health
Physician integration
Initial planning
Clinical integration,
PCMH, infrastructure,
exploring population
health
Exploring
Physician integration/
alignment, learning
population health/ACO
Design and
piloting
Build ACO, expand
risk contracts,
continuous
improvement in
integration/alignment
Active
Rollout
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10. Are You Ready?
Care delivery and management
- Chronic care
- Continuity of are
- Non-traditional care
Align and engage physicians
- Continuum of care
- Physician leadership
- Risk and financial
arrangements
IT and informatics
- Electronic health records
- Analytics and decision support
- Patient-centric technology
Organization and environment
- Structure / Governance
- Strategic plan
- Workforce
Patient engagement and
activation
- Engagement / Activation
- Behavior change
- Self-care / Management
Health promotion
- Prevention
- Screening
- Educational Programs
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11. Shifting Expectations for “Provider Performance”
Fee for Service
PCMH
Accountable Care
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12. We Are Still in Transition…
Current View
30 Patients Per Day
14 have Chronic Conditions
Unknown Health Risks
Visits Too Short for Coaching
Volume‐Based/Episodic
New Population View
2500 Patient Population
900 have Chronic Conditions
1100-1250 have Mod-High Health Risk
Care Teams Leveraged by HIT
Value‐Based/Continuous
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13. Population Readiness Framework
Achieving Top Level Goals…
Strategic
Drivers
Financial
Incentives
• CIN Formation
• ACO/MSSP
• PCMH
Recognition
• Employer
Contracting
• Myriad Value‐
Based Contracts
• Quality
Targets/P4P
• Shared Savings
• MU Stage 2
…Requires Bottom Up Approach
Enterprise
Level PHM
Infrastructure
Practice Level
PHM Best
Practices
• EMR
• Data Analytics
and Reporting
• Patient Portal
• Care
Coordination
• Quality Culture
• Top of License
Care Teams
• Total Population
Workflows
• Actionable
Information
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14. PHM is a “Work in Progress”
Major Goals…
Strategic
Drivers
…But Emerging PHM
Financial
Incentives
PHM
Infrastructure
Best
Practices
PCMH Recognition
Payer P4P
Common EMR but
Use Varies
Workflows Largely
Manual
MSSP Award
MSSP Shared
Savings
CMs Employed
and Payer‐
Subsidized
Actionable Data
Minimal
Integration of PCP
Acquisitions
MU Stage 2
Patient Portal and
HIE Coming Soon
Care Teams Not at
“Top of License”
Medical
Neighborhood
Loosely
Coordinated
Focused on “Tip of
the Iceberg”
Direct Employer
Contracting
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15. This is HARD: No Quality, No Shared Savings
• Pioneer ACOs met quality
reporting in 2012, but
expressed concern about
meeting performance
benchmarks for 2013
• 9 Pioneers switched to
MSSP or dropped out
after Year 1
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16. “It Takes A Medical Neighborhood”
Achieving Care Coordination Measures
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17. REQUIRED: Structured Data, Sophisticated Algorithms,
Real Time Reports and Behavior Change
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18. Are You Leaving $$$ on the Table??
To meet your quality
goals, can you identify,
reach and assist all
patients who need:
•
•
•
•
•
A visit?
A test?
Care coordination?
Self-management
support?
Behavior change?
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19. New PCPCC Report:
Health IT is “Must Have” for Population Management
TEN RECOMMENDED HEALTH IT
TOOLS TO ACHIEVE PHM:
1. Electronic Health Records
2. Patient Registries
3. Health Information Exchange
4. Risk Stratification
5. Automated Outreach
6. Referral Tracking
7. Patient Portals
8. Telehealth / Telemedicine
9. Remote Patient Monitoring
10. Advanced Population Analytics
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20. “Bottom Up” Quality Model
QI
Patient
Engagement
Enabled Care Teams
Data Integrity
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21. Job 1: Data Integrity
•
•
•
•
Provider attribution
Consistent and complete data capture
Creating structured fields for quality measures
Design-in continuous data quality management
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22. Is This a Process?
“At registration, the front
desk should confirm the PCP
for every patient.”
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23. Provider Attribution Drives Valid Reporting
Apply algorithms based on visit data to improve
provider attribution accuracy
Patients with Activity
Last 24 Mos.
Patients with Activity
Last 24 Mos.
Patients assigned
to invalid PCPs
25%
Patients assigned
to valid PCPs
75%
Patients assigned
to valid PCPs
97%
Patients
assigned to
invalid PCPs
3%
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24. Sample Strategies to Improve Quality Measures
1. Existing Data Capture
Use consistent locations in EMR for structured and scanned data (e.g.,
lab results, test orders, patient-reported data)
2. New Data Capture
Create new structured fields rather than additional flow sheets for specific
measures (e.g., fall risk assessment, Rx in care plan)
3. Eliminate Free Text
Direct teams to use structured fields to collect data formerly entered as
free text (e.g., tobacco cessation counseling, follow-up for positive
depression screening)
4. Make Data Clean-Up Part of Standard Work
Assign staff to regularly review provider attribution, invalid data entries,
proper use of new workflows, etc. to enhance reliability
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25. Enabling High-Performance Care Teams
•
•
•
•
Start with population view
Stratify patient population by risk and needs
Assign care team members to defined cohorts
Create lean workflows with HIT to drive high performance
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26. Stratify Population for “Top of License” Workflows
40-50%
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27. Align Patient-Centered Care, PCMH and TQM
Source: Value-Based Health Care Delivery: Integrated Practice Units, Outcome and Cost Measurement, Professor
Michael E. Porter, Harvard Business School, DHCS Health Care Seminar, June 4, 2010
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28. Practice Innovations that Produce “Joy”
Source: In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices, Ann Fam
Med 2013;11:272-278. doi:10.1370/afm.1531.
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29. Optimize Care Team Roles with Automation
Patient Service
Representative or
Medical Assistant
•Schedule visits and tests
indicated in care gap and
Pre-Visit reports
•Send out pre-visit
communications and
conduct follow up using
automated Campaigns
Care Manager
Physician
•Stratify patients by risk
using Coordinate reports
and filters
•Review Patient-Centric
Registry reports for
attributed patients
•Use Campaign functions
to reach out to subgroups
of patients with care gaps
•Assign high risk patients
to Care Manager using
reports and filters
•Reinforce importance of
proper diabetes
management through
personal and automated
patient education
•Address all diabetes care
opportunities at every
encounter, even for nondiabetes visits, using realtime patient data
CMO/Quality
Committee
•Review performance on
each clinical goal overall
and by location and
provider
•Meet with MDs and Care
Teams at least monthly to
review progress
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30. Create Workflows with HIT Assists
1) All >9 A1c and no office visit are
sent a text message to call care
manager
2) All >9 and BMI >35 are sent an
automated invitation to a group visit
with a diabetes dietician
3) All between A1c 7 and 9 are sent an
automated message to encourage
visit website to take diabetes selfmanagement course
4) All diabetics <7.0 are sent an email
message emphasizing the
importance of nutrition and exercise
to maintain low A1c levels with a
link to a mobile app to track their
progress
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31. Patient Engagement
•
•
•
•
Know your patients as people, not care gaps
Incorporate behavior change principles into all encounters
Use HIT to engage all patients, not just those who present
Be proactive and persistent
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32. We WANT/NEED Him to Go Towards "Better Health"
Our agenda for Oscar:
•
Medication adherence
•
Come to follow-up
appointments
•
Improved self-monitoring
•
Participation in PT
•
Nutritious food choices and
increased calories
•
Living Will
•
Participate in Shared DecisionMaking
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33. Tying Strategies to Engagement
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34. Engage All Patients in Multiple Ways
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35. An Outreach Strategy is a Must
A strategy for identifying patients lost to planned follow-up
is critical to population health management
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36. Quality Improvement
•
•
•
•
Depend on real time data
Make data available at all levels of the practice
Always look below the waterline
Share results regularly
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37. How Are These Providers Doing?
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38. % of Patients with 9+ HbA1c
Result
Uncontrolled Percentage Increasing
14.0%
12.0%
10.0%
10.5%
8.8%
9.3%
8.0%
6.0%
4.0%
2.0%
0.0%
Year 1
(2009‐2010)
Year 2
(2010‐2011)
Year 3
(2011‐2012)
“How can this be if I am managing all of our
patients with A1c results >9?”
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39. Where Were 9+ HbA1C Patients Last Year?
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40. Track Performance to Target Improvement
• Monitor performance
measures
• Compare provider
and care team results
• Use drill-down
capabilities to find
outliers and take
action
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41. Automated Population Health Model
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42. Take Home Messages
The move from volume to value is underway
•
And most of you are on this path
Take a system approach and a population health view
•
Value-based payment changes everything
Population health management is a team sport
•
•
Across providers and sites of care
Between providers and patients
Build in HIT “assists” to enable and achieve PHM
•
•
•
•
Configure to the measures
Facilitate care coordination workflows
Automate patient engagement and monitoring
Put real-time data in the hands of the front line
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43. Questions?
Karen Handmaker
VP Population Health Strategies, Phytel
Karen.handmaker@phytel.com
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