Linking Primary Care and Public Health: Achieving the triple aim through innovation in community based pediatric Primary Care

1. Linking Primary Care and
Public Health: Achieving the
triple aim through innovation
in community-based,
pediatric primary care
Alisa Haushalter, DNP, RN
Senior Director, Department of Population Health
Nemours Health and Prevention Services
A.I. duPont Nemours Pediatric Health System
November 18, 2014

2. Acknowledgement and Disclaimer
The project described was made possible by Grant
1C1CMS331017 from the Department of Health and Human
Services, Center for Medicare and Medicaid Services.
The contents of this presentation are solely the responsibility
of the authors and do not necessarily represent the views of
the Department of Health and Human Services or any of its
agencies.

3. Nemours Integrated Child Health System
Goal: To improve child health and wellbeing, leveraging clinical and
population health expertise.
Strategy: Nemours focuses on child health promotion and disease
prevention to address root causes of chronic disease and unhealthy
behaviors in addition to clinical care.

4. Connecting Clinical Care and Population Health
An Integrated Health System
Our Community Our Health System
Resources, Policies and System
Change
Health Care Organization
Health Policy Health Promotion
Practice Change
Self-Management
Support Delivery System Design Decision Support
Clinical
Information
Systems
Productive Interactions
& Spreading Change
Informed, Activated Patient, Family
and Community Partners
Organized, Prepared, Proactive
Health Team with patient/family
Improved Health Among Patients
Improved Health for Delaware’s Children
Source: Chang, Hassink, Werk, October, 2011

5. Working Across and Within Systems in a Community
Common Agenda
•Leadership and Partnership
Engagement
•Spread, Scale and
Sustainability
•Continuous Learning and
Improvement to Promote
Population-Level Solutions
Public
Health/
EBH
Business
Community
Schools
Child Housing
Care
Transportation
Courts
Families
Neighborhoods Non-profits/
foundations
State agencies
Hospitals/
primary care
Other
integrators
Integrator
Faith-based
Other
partners
Other
partners

6. Approaches to Population Health
Examples of 3.0 Transformation
 Two ways to approach population health:
– Start from the Community
– Start from Clinical Approach

7. Start from Community:
Obesity Prevention in Delaware
Strategy
• Defined the geographic population and a shared outcome
– Reduce prevalence of overweight and obesity by 2015 for children in DE, ages 2-17
• Established multi-sector partnerships where kids live, learn and play
• Pursued policy changes in multiple sectors
– Systems changes, licensing and regulation requirements
• Pursued practice changes to assist in implementation of policy changes
– Established learning collaboratives in various sectors (e.g. schools, child care and
primary care)
– Developed and/or adapted tools to promote practice change and adoption of new
policies in multiple sectors
– Provided tools and technical assistance to providers, and state professional
associations, including train-the-trainer model

8. Center for Medicare and Medicaid
Innovation Award
8
• Funding through the Affordable Care Act
(ACA)
• Center for Medicare and Medicaid
Innovation
• Funding to applicants for innovative ideas to
achieve the CMS Mission: “As an effective
steward of public funds, CMS is committed to
strengthening and modernizing the nation’s
health care system to provide access to high
quality care and improved health at lower cost.”

9. Start from Clinic:
Health Care Innovation Award:
The Nemours/AIDHC Model
• Nemours expanded its population-based strategy to explicitly link to primary
care
• Project Goals
– To reduce asthma-related emergency department use among pediatric
Medicaid patients in Delaware by 50% and asthma-related hospitalization by
50% by 2015, with incremental declines in 2013 and 2014
– Other goals include:
• Reduce asthma-related admissions and readmissions.
• Improve the rate of flu counseling and/or vaccinations
• Increase complete clinical adherence to evidence-based asthma guidelines
• Increase the number of children reached by implemented policy, systems
and environmental change strategies to support asthma-related child well-being
from baseline of 0 to 50,000

10. CMMI Population Health Model
Black text: Targeted population
Red text: Interventions

11. CMMI Population(s)
Delaware: The First State
11
Seaford, Sussex
Seaford Pediatrics
Zip Codes: 19973, 19956
Wilmington, NCC
Jessup Street Pediatrics
Zip Codes: 19801, 19802
Dover, Kent
Dover Pediatrics
Zip Codes: 19901,19904

12. The Nemours/AIDHC Model:
Primary Drivers of the Project
•Enhancement of family-centered medical home
•Development of “integrator” model surrounding each site
•Deployment of “navigator” workforce
•Use of technology

13. Changes to the EHR
• Same Day Appointment Access in Scheduling
• Well Child 12 Months Bright Futures
• Adolescent STI High Risk Notification
• Patient Lists for Chronic and Preventive Conditions
• QI Measures for Chronic and Preventive Conditions
• PEDS
• Adolescent Depression Screening
• Tracking Community and/or External Specialty Referrals
• Pre-Visit Contact Form (Telephone Encounter)
• Pre-Visit Contact Assessment (Office Visit)
• Self Care Plan
• Self Care Plan Snapshot Report: In progress
• Outpatient Care Plan available in Inpatient encounters: In progress
• Add "Discussed transition of care - Yes/No" to all Adolescent
• Add "Transportation" as a cancelation reason
• Overdue Result Routing Scheme for Internal Consults
• Urgent Care Referrals: In progress.

14. Before and After: Chronic Asthma
Before Care After
Identification of
Needs
During scheduled well child visits, clinician tries to remember to
ask about flu vaccine, environmental allergens, psychosocial
needs, etc and also complete all the requirements of a health
maintenance visit.
Children with asthma who are at high risk
receive a call from a CHW to ask
specifically about their asthma related
needs, including assessment of asthma
control, flu vaccine, environmental
exposures, psychosocial needs. Follow-up
with home visits and office visit,
psychology and community service
referrals are made as appropriate
Asthma Action Plan Clinicians use a variety of different ways to produce Asthma
Action Plans. These are found in various places in the electronic
medical record, and often not easily visible between specialties.
Each time the patient comes, a new Asthma Action Plan needs to
be created from scratch.
Clinicians across the Nemours Enterprise
use one common asthma action plan
(SmartForm) that is visible to everyone on
the “Snapshot” screen of Epic. Rather than
start a new plan each time, the Asthma
Smart Form can be updated at each
relevant visit.
School Asthma
Management
School nurses call the office asking for clarification of child’s
asthma treatment
School nurses access child’s Asthma
Action Plan via Nemours Link.
Medication Use Patients have no way of knowing whether their rescue inhaler is
full or empty.
Patients with Medicaid have access to a
rescue inhaler with a counter so they
always know how many doses are left.
Asthma Education Clinicians try to educate patients quickly during office visits.
Parents feel uncomfortable taking up the clinician’s time and do
not get opportunity to reinforce what they have learned (ex-spacer
technique).
CHWs assess patient understanding of
how to use their medications/devices
during home visits, correct
misunderstandings, and connect patients
with nurse coordinator for further
teaching.

15. Before and After: Acute Asthma Care
Before After
Accessing Care Parent takes child straight to the ED. Parent calls KHOC first. KHOC checks
asthma action plan, provides home
management advice, calls the patient back
for follow-up. Calls MD on call if needed.
Refers to ED appropriately for
exacerbations that would not respond to
home management.
Communication
between ED and
Practice
Patients are treated in the ED and discharged or admitted to the
inpatient unit. Often, the PCP is not aware of the admission until
the next time the patient comes to clinic.
The ED clinician sees on the “ED
Dashboard” that the patient belongs to the
“Asthma Registry”. The clinician reminds
the patient of the asthma action plan and
contacts the PCP and CHW to ensure
follow-up.
Care Coordinators receive an automated
report of ED visits by patients on the
registry, so they can contact the patient for
follow-up.
Readmission Risk Patients are treated and released without a systematic assessment
of readmission risk and potential strategies to reduce them.
Registry patients receive an assessment to
understand what led to the admission, so
that appropriate interventions can be
made. (for example, smoking ban in public
parks; healthy homes assessment, etc.)

16. Community Level Policy and
Practice Changes
• Medicaid Formulary change
• Smoke Free Wilmington Ordinance
• Healthy Housing and Integrated Pest
Management
• Student Health Collaboration
• Community Partnerships
– New partnerships
– Evolving relationships

17. ED Visits for Asthma registry patients
from 2012 to 2013

18. Next Steps/Sustainability –
Year 3 and Beyond
• Maintaining momentum
• Add Population to the Model - 30 day readmissions
• Evaluation
• Dissemination
• Capacity Building
• Spread and Scale
• Sustain
– Cultural Shifts
– Systems and Structural Changes
– Policy Changes
– Practice Changes
– Community Level Changes

19. Spread, Scale and Sustainability
Accelerating Population Health Innovation
• Designed to accelerate the cultivation and national spread
of innovative system redesign strategies focused on
improving population health.
• Nemours/UCLA Center for Healthier Children, Families and
Communities effort, funded by Kresge Foundation
Exploring Financial Sustainability through Medicaid
• “Medicaid Funding of Community-Based Prevention- Myths,
State Successes Overcoming Barriers and the Promise of
Integrated Payment Models”
http://www.nemours.org/content/dam/nemours/wwwv2/filebox/about/Medicaid_Funding_of_Community-)

20. Population Health Lessons Learned
• Focus on child well-being outcomes for a geographic population and
intervene early to prevent problems;
• Develop a shared measurement system focused on improving child and
family outcomes;
• Reach children where they live, learn and play;
• Coordinate programs and connect services so that program silos are
eliminated and children are better served;
• Create policy and systems change/development to impact populations with
sustainable change - essential elements of a comprehensive children’s system
in addition to practice changes;
• Identify the integrators and support them.
• Consider sustainability at front end and throughout the life of the project
• Be intentional about harnessing lessons learned to inform spread, scale and
sustainability; and

21. Acknowledgement and Disclaimer
The project described was made possible by Grant
1C1CMS331017 from the Department of Health and Human
Services, Center for Medicare and Medicaid Services.
The contents of this presentation are solely the responsibility
of the authors and do not necessarily represent the views of
the Department of Health and Human Services or any of its
agencies.

22. Alisa Haushalter, DNP, RN
Senior Director, Department of Population Health
Nemours Health and Prevention Services
2200 Concord Pike
Applied Bank Building, 7th Floor
Wilmington, Delaware 19803
302-298-7615
alisa.haushalter@nemours.org
www.nemours.org