through Risk-Stratification & Team-based Primary Care Clemens - PowerPoint PPT Presentation

Optimizing Population Health through Risk-Stratification & Team-based Primary Care Clemens Hong MD, MPH Medical Director, Community Health Improvement Los Angeles County Department of Health Services Oregon Primary Care Association March 7, 2016

Outline • Overview of Population Health & Care Management in Primary Care • Using population risk-stratification to drive improved outcomes • Los Angeles County – Care Connections Programs – Upcoming Opportunities

The Opportunity • Move from units of care to episodes, people, & populations • Focus on things shown to improve outcomes • Continuously Improve • Support Innovation – improve by leaps • Use team-based approaches • Engage the community High-Risk Patients • Rapidly share learning Rising-Risk Patients Population health management approaches are at the core of this Low-Risk Patients delivery transformation effort

Conceptual Strategy for Population Health Management Traditional Outpatient Inpatient Spend (Acute, Rehab, SNF) Fee for Spend Service Population With Health Inpatient Enhanced Outpatient Spend Management Spend Coordination Spend

Three Population Foci Low Touch/High Volume • “Surveillance” • Wellness & Health Coaching High-Risk • Tools – Patient Patients (5%) Portals/Virtual Visits, Social Media Rising-Risk Patients (15-35%) Low-Risk Patients (60-80%)

Three Population Foci Med Touch/Med Volume • Face-to-Face engagement • Chronic disease & High-Risk Health Coaching Patients (5%) • Tools – Enhanced Primary Care Rising-Risk Patients (15-35%) Low-Risk Patients (60-80%)

Three Population Foci High Touch/Low Volume • Frequent interaction • Chronic Disease/Intensive Care High-Risk Coordination • Tools – Complex Care Patients (5%) Management Teams Rising-Risk Patients (15-35%) Low-Risk Patients (60-80%)

Challenges for Population Health & Care Management Interventions: Drops in Potential Potential opportunity Identification Engagement Finding opportunities for improvement Intervention Realized improvement Adapted from J Eisenberg JAMA. 2000

Trusting relationship between a patient & a proactive care team the foundation to care management Family/Caregivers PCMH/CCM Team Patient CM

Health Delivery System Social Acute & Service Post-acute Agencies Facilities Specialty Government Care Service Providers Agencies Family/Caregivers PCMH/CCM Team Patient CM Payers & Behavioral Purchasers Health Public Home Health Health & Agencies VNA

PCMH Team CCM Team Patient- Centered CM PCP Medical Home A strong relationship between care management & primary care teams critical for care management

As is a strong relationship between the care team & other health system and community partners PCMH Team CCM Team Patient- Centered CM PCP Medical Home

Health Delivery System Social Acute & Service Post-acute Agencies Facilities Specialty Government Care Service Providers Agencies PCMH Team CCM Team Patient- Centered CM PCP Medical Home Payers & Behavioral Purchasers Health Public Home Health Health & Agencies VNA

Care Management Structure PCMH Team CCM Team Patient- Centered CM PCP Medical Home

Care Management Structure PCMH Team CCM Team Patient- CM Centered Hub CM PCP Medical Home

Challenges for Population Health & Care Management Interventions: Drops in Potential Potential opportunity Identification Engagement Finding opportunities for improvement Intervention Realized improvement Adapted from J Eisenberg JAMA. 2000

Challenges for Population Health & Care Management Interventions: Drops in Potential Potential opportunity Identification Engagement Finding opportunities for improvement Intervention Realized improvement Adapted from J Eisenberg JAMA. 2000

Goals of Population Risk Stratification & Segmentation • To align population, intervention, & outcomes • Select a population at risk for future poor outcomes for which planned interventions can improve outcomes • Tools: Quantitative, Qualitative, Hybrid • Key Challenges – Dynamic nature of risk – Lack of full picture – Care sensitivity is patient & program dependent

Effective Targeting of Care Management Population Volume  Healthy Area of Greatest Opportunity?  Chronic Illnesses Area of Greatest Opportunity?  Medically Complex/ High Utilizers Area of Greatest Opportunity?

Complexity defined by Charlson & estimated Physician-defined Complexity (ePDC) Complex Complex Complex by by by Charlson ePDC Both 39% 24% 37% Total Complex = 27,531 (19.2%) Source: Hong CS JGIM 2015

Primary Care Measures Colon Cancer Screening DM A1c>9 30% 25% 20% 15% 10% 5% 0% Not complex Charlson Only PDC Only PDC_Charlson *All p-values <0.05 Source: Hong CS JGIM 2015

Acute Care Utilization (per person year) Over 4 Years Admissions ED Visits 0.40 0.30 0.20 0.10 0.00 Not Complex Charlson Only PDC Only PDC_Charlson *All p-values <0.05 Source: Hong CS JGIM 2015

Clinical Outcomes by No Show Propensity Group Source: Hwang AS JGIM 2015

Acute Care Utilization by No Show Propensity Group Source: Hwang AS JGIM 2015

Challenges for CCM Programs: Drops in Potential Potential opportunity Identification Engagement Finding opportunities for improvement Intervention Realized improvement Adapted from J Eisenberg JAMA. 2000

Importance of Continuous Quality Improvement • Design + Implementation = Effectiveness • Track Quality Measures – Process & Outcome • Example – IT Enabled, Team-based Care – Embedded advanced analytics paired with role delineation – For program management & quality improvement

• Rosters are all role-specific • Rosters are all actionable

• A user can send a task to another user

• A population-oriented care plan enables the user to see all that is happening with a patient • A care team can be set up to include members that are typically not part of a care team

Important concepts for program planning • Build strong relationships • No perfect model – Start with the best approach for the context/population – Then use continuous quality improvement to improve • Keys to efficient population management – Work in multi-disciplinary teams – Complement existing services – Allocate resources to high-yield activities – Focus on mutable issues (know your system’s assets) – Use HIT infrastructure to enhance CM efficiency

Los Angeles County Care Connections Program & Beyond Clemens Hong MD MPH GIH Annual Conference March 11, 2016

Using complex care management teams to improve care & reduce costs One proposed solution to address healthcare cost problem Specially-trained, multi-disciplinary care teams

Care Connections Program (CCP) Aims Admit/ $ ED CCP

Serving ≈5% of LAC DHS’s Patients Panel within a Panel • Complex biopsychosocial needs • Hard to engage • High utilization of health care • High cost of care ≈20,000 out of 400,000 primary care patients

Current Model Social Acute & Service Post-acute Agencies Facilities Specialty Government Care Service Providers Agencies PCMH Team CCM Team Patient- Centered CM PCP Medical Home Payers & Behavioral Purchasers Health Public Home Health Health & Agencies VNA

CCP “Enhanced” Model Social Acute & Service Post-acute Agencies Facilities Specialty Government Care Service Providers Agencies PCMH Team CCM Team Patient- Central Centered CCM PCP Medical Hub Home PCP – CHW – RN Payers & Behavioral Purchasers Health Public Home Health Health & Agencies VNA

Care Connections Team CHW PCMH Embedded

CCP Program Overview Patient Comprehensive Care Plan Engagement Needs Survey Development Face-to-face: Hospital, Clinic Or home visit Accompaniment Revise Care /Routine FU Plan if needed visits Care Transition Work if needed Acute Event or Status Change Follow-up “Step Down” Assessment

Patient Engagement Social Support Comprehensive Assessment & Care Planning CHW Role Health System Navigation Care Transition Support