Population Health Management Dr. Noreen Nelson Clinical Assistant - - PowerPoint PPT Presentation
Role of Home Care in Population Health Management Dr. Noreen Nelson Clinical Assistant Professor New York University Rory Meyers College of Nursing Quality and Technology Solutions for Value Driven Home Care November 16-17, Saratoga
Clinical Assistant Professor New York University Rory Meyers College of Nursing Quality and Technology Solutions for Value Driven Home Care November 16-17, Saratoga Springs, NY
Popula latio ion Healt lth Man anagement (P (PHM) ) –Why Now?
Goal: keep a client population as healthy as possible by
department visits, hospitalizations, and more…
viability of home care organizations MACRA- 13 quality measures: Population Management & Care Coordination are two of the 8 subcategories meeting these quality measures. Home Care Agencies- collaboration opportunities
Multiple Chronic Conditions: A Day in the Life http://www.ahrq.gov/professionals/prevention-chronic-care/decision/mcc/video/index.html
The Patient Protection and Affordable Care Act(PPACA), commonly called the Affordable Care Act(ACA) or Obamacare, is a United States federal statute enacted by President Barack Obama on March 23, 2010.
The New York State Department of Health’s Population Health Improvement Program (PHIP) will promote the Triple Aim – better care, better population health and lower health care costs by selecting regional contractors to provide a neutral forum for identifying, sharing, disseminating and helping implement best practices and strategies to promote population health and reduce health care disparities in their respective regions.
Source: https://www.health.ny.gov/community/programs/population_health_improvement/
Development of Processes to demonstrate:
Drivers:
Payment Program (MACRA)
Triple Aim Video: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
PHM focus: high-risk patients who generate the majority of health costs Resulting in creation of
with a Twist
HealthCatalyst proposes this definition
health through the organized efforts and informed choices of society,
Winslow, Yale School of Public Health –early 1900s)
Source: Health Catalyst: https://www.healthcatalyst.com/population-health/
The twist … ….accomplished by mutual engagement and supportive accountability as co-collaborators to develop meaningful system processes by design, delivery, coordination, and payment of high-quality health care to achieve quality health outcomes for all (Nelson, 2016).
Programs
interventions
SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.
SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.
NYS
https://apps.health.ny.gov/doh2/applinks/ebi/SASStoredProcess/guest?_program=/EBI/PHIG/apps/dashboard/pa_dashboard
Albany
https://apps.health.ny.gov/doh2/applinks/ebi/SASStoredProcess/guest?_program=/EBI/PHIG/apps/dashboard/pa_dashboard&p =ch
Saratoga
https://apps.health.ny.gov/doh2/applinks/ebi/SASStoredProcess/guest?_program=%2FEBI%2FPHIG%2Fapps%2Fdashb
work
care received) Impact on population health: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
Role of Home Care: Population Health Management
Incorporates proactive strategies and interventions to coordinate, engage, and are clinically meaningful, cost effective & safe.
SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.
SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.
“Social and psychological circumstances can cause long-term stress. continuing anxiety, insecurity, low self-esteem, social isolation and lack of control over work and home life, have powerful effects on health” and let’s not forget depression!
(Source: Wilkinson, R & Marmot, M (Editors) (2003). Social determinants of health: The solid facts (2nd Ed.) p. 12 Retrieved January 17, 2016, from http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf)
“See” the Social Determinants
Equity
Source: http://www.healthypeople.gov/2020/topics-
Development
Source: Adherence and health care costs
Risk Management & Healthcare Policy. 2014; 7: 35–44. Published online 2014 Feb 20. doi: 10.2147/RMHP.S19801
What is Palliative Care?
Palliative Care: Patient Centered Care
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New York https://getpalliativecare.org/providers/new-york/
person’s quality of life, including treating pain, symptoms and stress associated with a serious illness.
concomitantly, regardless of a patient’s age or disease progression.
prognostic restriction, and is suitable for anyone who has suffered from dealing with a complex illness.
From Triple to Quadruple Aim: Care
Requires Care of the Provider
http://www.annfammed.org/content/12/6/573.full
gone.”
get out.”
feel…The feeling of being punished for delivering good care is nerve-racking.”
data manager, data entry clerk and steno girl… I became a doctor to take care of patients. I have become the typist.”
http://www.annfammed.org/content/12/6/573.full.pdf+html
practices found that electronic health record (EHR) technology has worsened professional satisfaction through time- consuming data entry and interference with patient care
nurses are associated with lower patient satisfaction
computer or working with inefficiencies
Quadruple Aim: Impact on Health Professional Caregivers
Achievement of quality outcomes, building trust and relationships with client consumers to improve engagement and compliance relies on a workforce that is satisfied, loyal and caring The secret to caring for clients is to care about our health care providers
https://www.youtube.com/watch?v=bs_7jWqSeIM
Why is this important?
burnout is growing on the frontlines –both with professional and lay person caregivers
and nurses predicted
Let’s keep in mind that millions of individuals’ lives are impacted as lay person caregivers
and/or billable time to achieve a better client centered engagement balanced with expected accountability.
support resolution of system barriers to achieve quality outcomes –stronger leadership by home care agencies.
collaborative quality improvement plan across the continuum for a specific population (one size does not fit all).
Creating a Population Health Management Program
and other providers.
Health Care Providers as Caregivers in Alignment with Consumers & their Caregivers
Holistic Population Health Management includes system support to deliver care based
back methods and evidence based practice
analysis
management, behavioral health and public/community engagement
Agency for Healthcare Research and Quality (AHRQ) Practice-Based Population Health: Subpopulations
patients who require preventive care or tests.
to run queries to narrow down the subpopulation of patients or to access patient records or additional patient information.
Agency for Healthcare Research and Quality (AHRQ) Practice-Based Population Health: Subpopulations
patients can be made actionable through notifications for patients and members of the practice.
comparison groups.
useful to practices if it can be printed, saved, or exported and if it can be displayed graphically.
Goal: Improve the quality and effectiveness of care while controlling costs for a defined group of people. Challenges
procedures.
Population Health Management https://www.youtube.com/watch?v=ha3i7Pb15wM
Barbara Turner, PhD, RN, FAAN Elizabeth P Hanes Professor Director, Population Care Coordinator Program Online Program Available
http://pccp.nursing.duke.edu/contact/
Content
Ambulatory Nurses
chronic, prevention)
Content
take when they assume that all patients may have difficulty comprehending health information and accessing health services. Health literacy universal precautions are aimed at—
for all patients, so that the risk of miscommunication is minimized.
navigate.
Source: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html
Managing Caregiver Stress
https://www.youtube.com/watch?v=_hi7fUUao_Y
Agency for Healthcare Research & Quality SHARE APPROACH FACT SHEET; link to toolkit -6-8 hour training
http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum- tools/shareddecisionmaking/tools/sharefactsheet/share-approach_factsheet.pdf
American Nurses Association: 2016 Culture of Safety
http://www.nursingworld.org/cultureofsafety
Social Determinants of Health: Claire Pomeroy
https://www.youtube.com/watch?v=qykD-2AXKIU
Name of Lead Entity Region(s) in which QE will publicly report provider performance Date of QE Certification Health Care Cost Institute All 50 states and the District of Columbia June 17, 2014 Amino All 50 states and the District of Columbia December 4, 2014 OptumLabs All 50 states and the District of Columbia November 30, 2015 FAIR Health All 50 states and the District of Columbia May 18, 2016
database designed to make Medicare, Medicaid, Assessments, and Part D Prescription Drug Event data more readily available to support research designed to improve the quality of care and reduce costs and utilization.
For additional information
Centers for Medicare & Medicaid Services: Home Health Agency (HHA) Center
https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html
https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-12-16-Home- Health-Benefit.html?DLPage=1&DLSort=0&DLSortDir=descending
Quality Payment Program
Certified Health Information Technology
https://www.healthit.gov/policy-researchers-implementers/about-onc-health-it-certification-program
certified Health Information Technology which has been successfully tested and certified by the ONC Health IT Certification program.
Source: Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet. 2014;384(9937):45-52. PubMed abstract.
National Center for Chronic Disease Prevention and Health Promotion Office of the Director
Linked to Clinical Services
– National Diabetes Prevention Program. – Chronic Disease Self-Management Program.
diabetes, arthritis, falls in older people).
their chronic conditions.
– Weeks to months of structured lifestyle interventions. – Standard protocols customized to particular communities.
Projects That Link Health Care and Community Approaches
Project Description Million Heartsa Million Hearts is a large national effort that aims to prevent 1 million heart attacks and strokes from 2012 to 2017 by making heart-healthy lifestyle choices easier and by improving care for people needing treatment. The National Diabetes Prevention Programb The National Diabetes Prevention Program links people at high risk of developing diabetes to community-delivered, evidence-based lifestyle interventions that can greatly reduce their risk of developing diabetes and, because it is delivered by lay people in community settings, can be more convenient and cost-effective than similar interventions delivered in health care settings.
Projects That Link Health Care and Community Approaches (cont.)
Project Description Partnership for a Healthy Durhama The Partnership for a Healthy Durham has pulled together many stakeholders to improve health among the most vulnerable residents of Durham County, North Carolina. The project has expanded
high-quality health care to include environmental approaches to promoting physical activity and efforts to improve primary education. Truman Medical Centers Healthy Harvest Produce Marketb Truman Medical Centers, an acute care hospital system located in an urban food desert, has established a farmers market to enhance access to fresh and healthy fruits and vegetables for its patients and staff.
Healthier People Lower Health Care Costs
Vision for the CDC Chronic Disease Prevention System
Improving community conditions to support healthful behaviors and promote effective management of chronic conditions will deliver:
students to schools
to businesses and employers
population to the health care system