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 Springs, NY Dr. Noreen Nelson NYU Meyers College of Nursing

Popula latio ion Healt lth Man anagement (P (PHM) ) – Why Now? Goal: keep a client population as healthy as possible by Dr. Noreen Nelson NYU Meyers College of Nursing • Incorporating Healthy People 2020 • Minimizing the need for expensive interventions such as emergency department visits, hospitalizations , and more… • Improving collaborative efforts between all settings to maintain financial 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. Dr. Noreen Nelson NYU Meyers College of Nursing

Population Health Im Improvement Program 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/ Dr. Noreen Nelson NYU Meyers College of Nursing

New Era of Healthcare: Population Health Management (PHM) Development of Processes to demonstrate: • Improving the patient experience of care, including quality and satisfaction; • Improving the health of populations; and • Reducing the per capita cost of health care. • What’s missing?..... Dr. Noreen Nelson NYU Meyers College of Nursing

New Era of Healthcare: Population Health Management (PHM) Drivers: • Medicare Access and CHIP Reauthorization Act of 2015 Quality Payment Program (MACRA) • Reimbursement-higher for • Accountable Care Organizations • Bundled Payments for Care Improvement (BPCI) • Patient-Centered Medical Home Model • Health Homes Triple Aim Video: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx Dr. Noreen Nelson NYU Meyers College of Nursing

New Era of Healthcare: Population Health Management (PHM) PHM focus: high-risk patients who generate the majority of health costs Resulting in creation of • Health Action Priorities Networks (HAPN) or in New York State, HealthlinkNY • Delivery System Reform Incentive Payment Program (DSRIP) • Qualified Entities (nationwide) Dr. Noreen Nelson NYU Meyers College of Nursing

Population Health Management--- Public Health Definition with a Twist HealthCatalyst proposes this definition • “ the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals .” (C .-E.A. 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). Dr. Noreen Nelson NYU Meyers College of Nursing

Population Health Management (PHM) Programs • Targeted to a defined population • Utilize a variety of individual, organizational, and societal interventions • To improve health outcomes and • Client satisfaction Dr. Noreen Nelson NYU Meyers College of Nursing

SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.

SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.

New York State Prevention Agenda Dashboard - State Level 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 oard%2Fpa_dashboard&p=ch&cos=41 Dr. Noreen Nelson NYU Meyers College of Nursing

Promoting health is challenged by • the way health information is shared (cultural relevance), • the choices people make (behaviors), • the places where people live (social conditions, environment), and work • their access to care (health care insurance coverage and quality of care received) Impact on population health : https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health Dr. Noreen Nelson NYU Meyers College of Nursing

Role of Home Care: Population Health Management Incorporates proactive strategies and interventions to coordinate, engage, and are clinically meaningful, cost effective & safe. • Care processes that include • Consideration of factors impacting a person’s health • Design/strategies that provide coordination across the continuum • Engagement of consumers to be involved in their own health • Matching providers and technology with individual’s needs • Better connection with established community & social services Dr. Noreen Nelson NYU Meyers College of Nursing

SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.

SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.

Impact of Social Determinants of Health “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” a nd 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) Dr. Noreen Nelson NYU Meyers College of Nursing

“See” the Social Determinants • Neighborhood and Built Environment • Economic Stability • Access to Healthy Foods • Poverty • Quality of Housing • Employment • Crime and Violence • Food Security • Environmental Conditions • Housing Stability • Education • Social and Community Context • High School Graduation • Social Cohesion • Enrollment in Higher Education • Civic Participation • Language and Literacy • Perceptions of Discrimination and • Early Childhood Education and Equity Development • Incarceration/Institutionalization • Health and Health Care • Access to Health Care Source : http://www.healthypeople.gov/2020/topics- • Access to Primary Care objectives/topic/social-determinants-health/addressing-determinants • Health Literacy Dr. Noreen Nelson NYU Meyers College of Nursing

Medication non-adherence costing $300 billion annually Source: Adherence and health care costs Risk Management & Healthcare Policy. 2014; 7: 35 – 44. Published online 2014 Feb 20. doi: 10.2147/RMHP.S19801 • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934668/pdf/rmhp-7-035.pdf Dr. Noreen Nelson NYU Meyers College of Nursing

Reframing Our Thinking to Improve Client (Consumer) Satisfaction • Palliative care focuses on maximizing a person’s quality of life, including treating pain, symptoms and stress What is Palliative Care? associated with a serious illness. Palliative Care: Patient Centered Care • Whether the goal is life prolongation • https://www.youtube.com/watch?v=DKTzESwCUXQ&list=PLI or cure, palliative care is provided jsDla1RqFDV_Ma1AHC1p0gvv3rbtGAA • Get Palliative Care https://getpalliativecare.org/ concomitantly, regardless of a New York https://getpalliativecare.org/providers/new-york/ patient’s age or disease progression. • Unlike hospice, palliative care has no prognostic restriction, and is suitable for anyone who has suffered from dealing with a complex illness. Dr. Noreen Nelson NYU Meyers College of Nursing

Quadruple Aim From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider http://www.annfammed.org/content/12/6/573.full Dr. Noreen Nelson NYU Meyers College of Nursing