0

Leveraging Nurses in Health

Transformation:

Population Health and Care

Management ModelsOCN Annual Conference

Judy Tatman, MSHA, BSN, RN October 20, 2016

1

Population Health & the

Triple Quadruple Aim

Caregiver

Engagement

2

3

The Cost Imperative• Value based healthcare is becoming the

expectation . . .

– CCOs

– Intel ACO

– Medicare Advantage, Medicaid,

– MACRA

Value = Outcomes + Experience

Costs

National Health Expenditures per Capita

1960-2010

Notes: According to CMS, population is the U.S. Bureau of the Census resident-based population, less armed forces overseas.

Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2010; file nhegdp10.zip).

5.2% 7.2% 9.2% 12.5% 13.8% 14.5% 15.4% 15.9% 16.0% 16.1% 16.2% 16.4% 16.8% 17.9% 17.9%

NHE as a Share of GDP

5http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective

66

77

88

Distribution of National Health Expenditures

(by Type of Service in Billions – 2010)

Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc.

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2010; file nhe2010.zip).

NHE Total Expenditures: $2,593.6 billion

Nursing Care Facilities & Continuing Care Retirement

Communities, $143.1 (5.5%)

10

Care Model – The Challenge

6 most costly components of care identified(align initiatives in each category to effect overall health expenditures)

11

Note: Dollar amounts in parentheses are the annual expenses per person in each percentile. Population is the civilian noninstitutionalized

population, including those without any health care spending. Health care spending is total payments from all sources (including direct

payments from individuals and families, private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians,

other providers (including dental care), and pharmacies; health insurance premiums are not included.

Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare

Research and Quality, Medical Expenditure Panel Survey (MEPS), Household Component, 2009.

Concentration of Health Care Spending in the

U.S. Population, 2009

(≥$51,951) (≥$17,402) (≥$9,570) (≥$6,343) (≥$4,586) (≥$851) (<$851)

Pe

rce

nt

of

To

tal

He

alt

h C

are

Sp

en

din

g

12

Caution: a unified approach is preferred

13

Patients as the organizing approach• High risk patients: Clinic-based care managers; Proactive Outreach

Team; Health Resilience Specialists; Elder at Home• Rising-risk patients: Medical Home & Chronic disease management.• Low-risk patients: Express Care, Wellness Promotion, Self-Care

Advisory Board content

14

Strategy: Patient segmentation• Evolve from numerous payer-specific pilots to organization wide commitment and

investment• Use a patient-centered model as we design our approach.

15

So where do we start?

1.Culture is Key

2.Define Organizational Infrastructure

3.Understand and address the gaps-

STAY FOCUSED

4.Celebrate current successes

16

Culture is Key to Transformation

1. Keep the person served at the center

2. Mindset of stewardship

3. Professional pride of each team member and top of license practice

4. Open and honest communication between providers, clinicians, and other team members

17

Oregon Population Health infrastructure

Population Health Council Focus on utilization

Prioritize and provide oversight to current Pop Health initiatives

Affordable Services Council Focus on unit cost

Prioritize and provide Oversight to current Unit cost initiatives.

Aligning the work of existing councils Care Management Integration Council

Pharmacy Integration Council

Population Health Backbone

Trend Bender and Medical Economics

18

Transitions and Navigating the System–Complex!

19

• What kind of help?

• Did we help?

• Who can we help?

• Who needs help?

Identify: individuals and groups

Stratify/

Prioritize

Intervene: operations and clinical

Measure/

Evaluate

Care Management:Build Capacity and Competency

20

Care Management Integration Council

Care management leadership from PMG, inpatient, home & community services, PHP, and other settings

• Leads development of a Providence integrated model of care management and connected care experience

• Drives greater affordability and quality

• Works within Providence across care venues and with community partners

• Works across region and with system teams

• Buoys trusted patient-centered medical home team

1. Effective information flow

2. Coordinated, safe transitions CMIC MembershipJudy Tatman, Executive Sponsor, Regional CNOJane Brandes, Director, HospiceJulie Heimark, Mgr HH Intake/Business DevelopmentAnn Kirby, Executive Director CMMeg Linza, Director Care Management, PMGNancy Trumbo, Reg. Director, Inpatient CMAmanda Purcell, Manager, Operations, ElderPlaceMelissa Topp, Manager, QMM CM, PHPBonnie Wilson, Reg. Director, Emergency Services

CMIC Executive TeamJudy Tatman, Executive Sponsor, Regional CNOSusan Abate, VP, PHP, QualityJames Arp, Chief Exec, Home and Community ServicesAnn Kirby, Executive Director, CMBen LeBlanc, MD, CMO, PMG

21

Care Management Integration CouncilAreas of Focus

1. Build capacity and competency

2. Develop infrastructure

Gap analysis > filling the gaps

Role definition and collaboration

ROI calculation

IT communication pathways

Community resources

3. Develop interventions

Aligning across all risk contracts

Standardized risk assessment tools

Interventions for high needs populations

Transitions of care

22

Pushing on multiple levers simultaneously

Examples of what we are working on:

• Setting prioritized list of key initiatives and aligning stakeholders

• Addressing high acuity patients – care management

• Addressing low acuity patients – Prov RN, Express Care, and Express Care Virtual (continuum of access)

• Enhancing behavioral health resources and services across the continuum

• Using data to prioritize interventions

• Tracking the data (CMIC dashboard as example)

• Investing in IT and HIE platforms

– Consistent longitudinal care plan across IT platforms

– Care management user groups

• Working with community partners to address non clinical factors in the care plan

• Reinforcing key transition points to get patients back to primary care

• Developing TCOC culture within the clinics

23

PMG Overview

• See PMG Annual Report for more info• Note that we have a separate reporting

structure for Clinical Programs (cardiology, oncology, neurology, women’s health, children’s program, orthopedics, medicine, surgery, hospitalist)

PMG Express Care ClinicsDate opened Name Type

10.18.15 Kruse Way Stand alone1.25.16 Interstate Stand alone2.24.16 Fishers Landing Walgreens2.24.16 Milwaukie Walgreens2.24.16 Raleigh Hills Walgreens5.16.16 Happy Valley Walgreens5.16.16 Salmon Creek Walgreens5.16.16 Gresham Powell Walgreens6.27.16 Pearl District Stand alone7.18.16 North Lombard Stand alone7.25.16 Glisan & 181st Walgreens7.25.16 Hillsboro Walgreens7.25.16 Murrayhill Walgreens

10.31.16 Bethany Walgreens

14 Express Care Clinics

24

25

1. Continued development of care model: leveraging assets of integrated delivery system; actively implementing and directing patients to lower cost settings of care; developing more effective pathways between contracting, data, and utilization

2. Population Health Council prioritized cross-continuum interventions • Reduce Avoidable Low Acuity Admits• Discharge Transition Support-including the Coleman Model/Pathways• Optimizing care continuity for ED frequent visitors• Reduce ED Boarding for Behavioral Health (BH) Patients• Onboarding of new patients in risk-based products

3. Continued implementation and evaluation of new interventions• Elder at Home• Health Resilience Program• Proactive Outreach Team• New models for Home Health, Community workers, Pathways (Social

Determinants)

4. Increased emphasis on utilization and lower cost site of service within business units based on PHP and new system ACO data resources

Oregon Region: Comprehensive portfolio

26

2016 prioritized Population Health initiatives

1. Reduce Avoidable low acuity admissions

• TIAs, 1st Seizure, low risk CP, Cellulitis

2. Discharge Transition Support

• Coleman Model for high risk elderly patients

3. Optimize Care continuity for frequent ED utilizers

• Maximize Care Plan use in EDIE/Premanage

4. Reduce ED Boarding of BH patients

• Community MH care plan activation via employed and contracted

BH navigators

5. Onboarding new patients

• Chart building – risk stratification

• High risk patients to get PCP appt, care plans, case management

27

Celebrate successes : Case management programs for high risk population

Proactive Outreach Team • Team is ramping up. Currently 4 FTE (3 CM and 1 Pharmacist); adding 2 more

this year• Using Impact Pro and other predictive tools to target populations

Health Resilience Program• Contracted service with CareOregon, now bringing inhouse• Program launch 2014• 5 FTE in 6 clinics each with a case load of ~20• Clinics: North PDX, SE, Milwaukie, NE, Sunset, Cascade

Elder at Home• Program launch summer 2015• Core team of 24 FTE; 584 pts have opted in

Increased Use of Predictive Modeling, Identifying Risk, and Improving Outcomes

28

Summary

• Most operational elements are in place for success in population health; opportunity to further develop and enhance effectiveness and work better across the continuum and in partnership with PHP/ACO teams

• We’ll work across the continuum to further develop our model of care: this needs to include a new look at how Home Health is utilized differently, use of health coaches and community workers, and Pathways

• We’ll strive for a single model of care in primary care rather the developing unique care management teams and resources based on contract requirements

29

Summary

• Cost imperative to be successful in Population Health

• We’ll talk about interventions in terms of the patient segmentation pyramid

• Deliberate culture and infrastructure necessary

• Nursing plays a key role across the continuum and

transformation process and will need to develop new

competencies and skills

• We will get better at this over time

30