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Webinar Login Directions Recommend calling in on your telephone . - - PowerPoint PPT Presentation

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Webinar Login Directions Recommend calling in on your telephone . Enter your unique Audio PIN so we can mute/unmute your line when necessary. Audio PIN : Will be displayed after you log into GoToWebinar. This button should be clicked

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Webinar Login Directions

  • Recommend calling in on your telephone.
  • Enter your unique Audio PIN so we can mute/unmute your

line when necessary.

  • Audio PIN: Will be displayed after you log into GoToWebinar.

This button should be clicked if you’re calling in by telephone. Here’s where your unique audio PIN number will appear.

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Montana Integrated Care Learning Community

Jeff Capobianco, PhD, LLP jeffc@thenationalcouncil.org Joan Kenerson King, RN, MSN, CS joank@thenationalcouncil.org

October 4, 2016

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Webinar Overview

1) Define the Terms Value-based Purchasing, Population Health Management and Risk Adjustment 2) Explain the difference between data, information, and knowledge. 3) Define population health management and identify the four steps required to conduct effective population health management. 4) Identify the internal mechanisms and staff competencies necessary to implement these concepts.

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“If you are not measuring a process, you don’t know what you are doing.” “If you are not measuring processes, you can’t improve.” “If you are not measuring processes, you are operating blindly and therefore are at risk for delivering ineffective and wasteful care at best.” If you are not measuring your care provision and administrative processes, you cannot achieve the triple aim of population health management, cost containment and customer centered care … in other words, survive in the healthcare marketplace today.

Why does data measurement matter?

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Effective & Efficient Healthcare

Effective Healthcare:

– Right Patient Need(s) Identified – Right Treatment(s) Provided – By the Right Professional(s) – At the Right Time(s) – Producing the Right Health and Satisfaction Outcome(s)

Efficient Healthcare:

– Clinical and administrative work flow processes that operate within optimal time and cost specifications.

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Aligning our Terms!

Value-base Purchasing requires… Population Health Management which requires… Risk Stratification therefore…

these concepts are not loosely linked but are structurally contingent on one another.

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Value-based Purchasing An Old Term Getting New Life

"The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of

  • care. Value-based purchasing brings together information on the quality
  • f health care, including patient outcomes and health status, with data on

the dollar outlays going towards health. It focuses on managing the use

  • f the health care system to reduce inappropriate care and to identify and

reward the best-performing providers. This strategy can be contrasted with more limited efforts to negotiate price discounts, which reduce costs but do little to ensure that quality of care is improved."

Source: Theory & Reality of Value-Based Purchasing: Lessons from the Pioneer. November 1997. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality- patient-safety/quality-resources/tools/meyer/index.html

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Data, Information, and Knowledge

What is data?

  • Granular or unprocessed information

(e.g., one A1c lab value or PHQ 9 measurement)

What is information?

  • Information is “big data” that have been organized, measured and communicated

in a coherent and meaningful manner (i.e., take multiple A1c lab vales or PHQ 9 scores)

What is knowledge?

  • Information evaluated and organized so that it can be used purposefully

(e.g., electronic medical record dashboards)

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What is the ultimate purpose of collecting and sharing data?

To turn it into action! (a.k.a. Continuous Quality Improvement)

Information Data Knowledge Action

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Defining Population Health Management

  • A set of interventions designed to maintain and improve

people’s health across the full continuum of care—from low- risk, healthy individuals to high-risk individuals with one or more chronic conditions

(Source: Felt-Lisk & Higgins, 2011)

  • Population management requires providers to develop the

capacity to utilize data to choose which patients to select for specific evidence-based interventions and treatments

(Source: Parks, 2014)

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Population Health Management

  • Strategies for optimizing the health of an entire client

population by systematically assessing, tracking, and managing the group’s health conditions and treatment response.

  • It also entails approaches to engaging the entire target group,

rather than just responding to the clients who actively seek care.

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Principles of Population Health

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Components of Population Health Management:

  • 1. Knowing what to ask about your population(s)
  • 2. A data registry to describe/risk stratify your population(s)
  • 3. Proficiency with quality improvement tools to respond to the

findings

  • 4. Using continuous quality improvement policies/procedures

to sustain data specification targets

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Quick Break for Questions & Comments?

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Components of Population Health Management:

  • 1. Know what to ask about your population(s)
  • 2. A data registry to describe/risk stratify your population(s)
  • 3. Proficiency with quality improvement tools to respond to the

findings

  • 4. Using continuous quality improvement policies/procedures

to sustain data specification targets

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What are the questions you want answers to about your populations?

  • 1. Who are you serving? Who are you not serving but could / should be?
  • 2. What are the costs for the average patient?
  • 3. What kind of services are they getting; where, and when?
  • 4. What is the patient’s response to treatment?
  • 5. What is the patient’s opinion of his / her care?
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Components of Population Health Management:

  • 1. Know what to ask about your population(s)
  • 2. A data registry to describe/risk stratify your population(s)
  • 3. Proficiency with quality improvement tools to respond to the

findings

  • 4. Using continuous quality improvement policies/procedures to

sustain data specification targets

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Patient Registry

“…an organized system to collect uniform data (clinical and

  • ther) to evaluate specified outcomes for a population defined by

a particular disease, condition, or exposure, and that serves one

  • r more predetermined scientific, clinical, or policy purposes.”

Source: Gliklich RE, Dreyer NA, eds. (2010). Registries for Evaluating Patient Outcomes: A User’s Guide. 2nd ed.

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Registry Examples

  • Provider Excel / ACCESS DB (simplest)
  • Managed Care Portals
  • Electronic Medical Records
  • Health Information Exchanges (typically do not have registries)
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Population Health Management Measures Must Have Measure Specifications

Measure specifications provide the following:

1. Brief measure description explaining targets and procedure for collection. 2. Definition of measure numerator 3. Definition of measure denominator 4. Formula for calculating the measure 5. Exclusions to measure, if applicable 6. Description of report periods 7. Measure specific diagnosis & billing codes

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PHM Measure Specifications

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Components of Population Health Management:

  • 1. Know what to ask about your population(s)
  • 2. A data registry to describe/risk stratify your population(s)
  • 3. Proficiency with quality improvement tools to respond

to the findings

  • 4. Using continuous quality improvement policies/procedures

to sustain data specification targets

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Rapid-Cycle Change for Process Improvement

Rapid-cycle change is a systematic problem-solving approach to understand client needs, restructure processes, and make the most efficient use of available resources in response to data findings.

Source: The Network for the Improvement of Addiction Treatment (NIATx)

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w w w . T h e N a t i o n a l C o u n c i l . o r g

Dashboards

  • A dashboard translates your work

into metrics

  • It provides timely information &

insights

  • It makes it easier for staff to

monitor, analyze, & manage their work

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Dashboard Data Elements

  • Cost: Service Utilization, Case Rates, etc.
  • Operations: No Shows, Insurance Mix, etc.
  • Staff Work Plan: Performance on Scope of Practice Tasks
  • Clinical: Labs, Assessment / Screening Results, Vitals, etc.
  • Care Coordination: Medication Reconciliation, etc.
  • Benchmark Comparisons: Between Organizations, Clinicians,

Teams, etc.

  • Risk Cutoffs: Reveal when data are out of specification (e.g., A1c

> 6)

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Components of Population Health Management:

  • 1. Know what to ask about your population(s)
  • 2. A data registry to describe/risk stratify your population(s)
  • 3. Proficiency with quality improvement tools to respond to the

findings

  • 4. Using continuous quality improvement

policies/procedures to sustain data specification targets

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Sustaining Improvements through CQI

  • Leverage Dashboards for staff,

teams, supervisors, & senior leaders to see/understand progress/or lack there of!

  • Use Rapid-Cycle Plan-Do-Study-

Act for problem-solving when benchmarks show need for improvement

  • Supervisors to coach and manage

staff to maintain improvements!

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An Example: The Population Health Management of Depression

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Let’s look at Depression as an Example

  • 1. Know what to ask about your population(s)

 How are we doing with the treatment of our consumers who are depressed?

  • 2. Using your registry to Risk Stratify the population of

Depressed Consumers

 Pull & Aggregate Consumer PHQ-9 Scores by Team and Clinician.

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AIMS Center Free Dashboard Template

Name Date of Initial Assessment Date of Most Recent Contact Date Next Follow-up Due Number of Follow-up Contacts Weeks in Treatment Initial PHQ-9 Score Last Available PHQ-9 Score % Change in PHQ-9 Score Date of Last PHQ-9 Score Initial GAD-7 Score Last Available GAD-7 Score % Change in GAD-7 Score Date of Last GAD-7 Score Flag Most Recent Psychiatric Case Review Note

Bob Dolittle

3/2/2016 4/28/2016 5/12/2016

3 26 22 19

  • 14%

4/28/2016

12 10

  • 17%

4/28/2016

Flag as safety risk

2/18/2016 Betty Test

12/15/2015 6/15/2016 7/15/2016

10 37 12 1

  • 92%

6/15/2016

9 3

  • 67%

6/15/2016

Susan Test

11/20/2015 7/30/2016 8/13/2016

10 41 22 15

  • 32%

7/30/2016

18 14

  • 22%

7/30/2016

Flag for discussion & safety risk

4/17/2016 John Doe

9/15/2015 7/16/2016 8/15/2016

12 50 20

  • 100%

7/16/2016

14 1

  • 93%

7/16/2016

6/15/2016 Albert Smith

5/5/2016 7/22/2016 8/19/2016

5 17 18 18 0%

7/22/2016

14 10

  • 29%

7/22/2016

Flag for discussion

Nancy Fake

8/5/2016 8/5/2016 8/19/2016

4 No Score No Score No Score No Score Joe Smith

6/1/2016 8/8/2016 8/22/2016

5 13 15 9

  • 40%

8/8/2016

11 7

  • 36%

8/8/2016

7/24/2016

Treatment Status PHQ-9 GAD-7 Psychiatric Case Review

Indicates that the most recent contact was over 1 month (30 days) ago Indicates that the next follow-up contact is past due Indicates that the last available PHQ-9 score is at target (less than 5

  • r 50% decrease from initial score)

Indicates that the last available PHQ-9 score is more than 30 days old Indicates that the last available GAD-7 score is at target (less than 10

  • r 50% decrease from initial score)

Indicates that the last available GAD-7 score is more than 30 days old

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Let’s look at Depression as an Example continued…

  • 3. Proficiency with quality improvement tools to

respond to the findings.

 Develop/review work flows to see what process steps need to be changed/improved to bring the Depression Clinical Pathway into standard practice (e.g., screening using PHQ-9, providing treatment, monitoring scores as they progress to the benchmark target).

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Managing Depression: Clinical Work Flows in Primary & Behavioral Health Care

Source: Institute for Family Health

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Managing Depression: Clinical Pathways in Primary & Behavioral Health Care

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Let’s look at Depression as an Example continued…

  • 4. Continuous quality improvement

policies/procedures to sustain data specification targets.

 Put the changes/improvements into policy/procedure (e.g., supervision, huddles, administration meetings, etc.).

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Monitoring: Depression Care Population Outcomes

Year Quarter Improvement Rate 2015 Q2 33% 2015 Q3 44% 2015 Q4 76% 2016 Q1 71%

33% 44% 76% 71% 0% 10% 20% 30% 40% 50% 60% 70% 80% 2015 Q2 2015 Q3 2015 Q4 2016Q1

Improvement Rate

NY State Target = 50%

Metric Definition Improvement Rate: Number (#) and proportion (%) of patients in treatment for 70 days (10 weeks) or greater who demonstrated clinically significant improvement either by: a 50% reduction from baseline PHQ-9

  • r a drop from baseline PHQ-9 of at least 5 points and to less than 10.

Source: Institute for Family Health

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What it takes to use data effectively!

D for accessible, high-quality Data E for an Enterprise orientation L for analytical Leadership T for strategic Targets A for Analytical talent

Source: Davenport, Harris & Morison, Analytics at Work: Smarter Decisions Better Results

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  • October 12: Group Coaching Call, 1 PM MDT/3 PM EDT
  • November 10: Group Coaching Call, 1 PM MDT/3 PM EDT

Call: 1-888-727-2247 ID: 3478556

Upcoming Activities

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Thank you!

Jeff Capobianco, PhD, LLP jeffc@thenationalcouncil.org Joan Kenerson King, RN, MSN, CS joank@thenationalcouncil.org

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Further Reading and Resources

Felt-Lisk, S. & Higgins, T. (2011). Exploring the Promise of Population Health Management Programs to Improve Health. Mathematica Policy Research Issue Brief. http://www.mathematicampr.com/publications/pdfs/health/PHM_brief.pdf Parks, J., et al. (2014) Population Management in the Community Mental Health Center-based Health, Center for Integrated Health Solutions Homes http://www.integration.samhsa.gov/integrated-care models/14_Population_Management_v3.pdf http://www.integration.samhsa.gov/ (Great resource on everything integration) http://www.integratedcareresourcecenter.com/ (Website detailing what is happening with health reform in each state) http://www.chcs.org/ (Website focused on publicly funded healthcare and the transformations underway) http://www.h2rminutes.com/main.html (Updates on the ACA for professions—great site to sign up for email notices) http://integrationacademy.ahrq.gov/atlas (1.Framework for understanding measurement of integrated care; 2. A list of existing measures relevant to integrated behavioral health care; & 3.Organizes measures by the framework and by user goals to facilitate selection of measures).

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Further Reading and Resources

Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare; Institute for Health Technology Transformation http://www.exerciseismedicine.org/assets/page_documents/PHM%20Roadmap%20HL.pdf CREEPING AND LEAPING FROM PAYMENT FOR VOLUME TO PAYMENT FOR VALUE Webpage https://www.thenationalcouncil.org/capitol-connector/2014/09/creeping-leaping-payment-volume-payment-value/ Guide http://www.thenationalcouncil.org/wp-content/uploads/2014/09/14_Creeping-and-leaping.pdf Workbook http://www.thenationalcouncil.org/wp-content/uploads/2013/10/National-Council-Case-Rate-Tool-Kit.pdf Seven Steps to Performance-based Services Acquisition/Contracting http://159.142.160.6/comp/seven_steps/index.html CMS Innovation Center: Health Care Payment Learning and Action Network http://innovation.cms.gov/initiatives/Health-Care-Payment- Learning-and-Action-Network/

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