Population HealthJanet Appel, RN, MSN

Director of Informatics and Population Health

Sharp Rees-Stealy brings the concept of Continuum of Care to life as our programs work together to provide Patient Centered Quality Care to our patients who are living with a chronic medical condition. Our integrated programs ensure that our patient’s individualized needs are met while receiving the best level of care for their personal situation. With a focus on empowering our patients to self manage their health, our RNs, MAs, Educators and Health Coaches help patients understand their disease, access resources and navigate the healthcare systems across the continuum.

Our underlying premise is based on the fact that when an individual reaches the optimum level of

wellness and functional capability, everyone benefits: the patients being served, their support

systems, the health care delivery systems and various reimbursement sources. CMSA

The department of Population Health offers NCQA certified programs, expertise and resources for multiple chronic conditions, senior services, behavioral health, quality initiatives and telemedicine. The staff consists of Certified Registered Nurse RN Case Managers, Medical Assistants, Licensed Social Workers, Certified Health Coaches, RN and Registered Dietitian Educators, Care Specialists, Data Analysts and Experienced Project Managers.

Our Population

• Managed Care Lives –

178,000

– Commercial – 164,000– Seniors – 16,000

• ACO/PPO Lives – 55,000

• Total Membership = 220,000

• Asthma – 500• COPD – 500• Chronic Kidney Disease –

1,000• Heart Failure – 2,074• Active Tobacco Users –

10,405• Diabetes – 18,000• Hypertension – 38,000

Care Management

• Triage/Navigation• Post Hospital Discharge Calls• Patient Outreach• Patient Engagement• Shared Action Planning/Goals

Setting• Self-Monitoring Tools• Ongoing Assessments and

Evaluations• Ongoing Communication with

Providers

• Face to Face Visits at Home and/or Provider Office

• Coordination of Care/Services• Health Coaching• Patient Education- individual,

group classes, web based, printed materials

• Behavioral Health• Advanced Care Planning• OON Service Coordination

Nurse Navigator

• Facilitates Timely Access to Appropriate Healthcare and Resources for Patients and their Families

• A Skilled Communicator who Empowers Patients with Education and Knowledge

• Has a Broad and Comprehensive Knowledge of Preventative Care, Chronic Disease and Care Coordination

• Self-Referrals Accepted

Disease Management

• Education and support customized to the patient’s level of health, allowing them to self-manage their chronic medical condition, promote wellness and prevent complications

• Diabetes• Hypertension• Heart Failure• COPD• Chronic Kidney Disease• Senior Enhanced

Programs

Complex Case Management

• Coordination and assessment for members who have experienced a critical event or diagnosis that requires extensive use of resources and system navigation in order to receive appropriate care & services

Chronic Care Nurses

• Patient Support and Care Management in the Primary Care Offices.

• Focus on High Risk Seniors with 5 or More Chronic Conditions and Post Hospital Follow-Up Visits

• Personalized Face to Face Assessments

• Collaborative Goal Setting

• Office and Telephone Follow-up

• Education and Support

Health and Wellness

• Promotion of knowledge, healthy attitudes, and practices to help our patients achieve their personal best health.

• Healthier Living• Dietician Consultation• Healthy Hearts• Stress Management• Strength Training• Smoking Cessation

Home Visits

• In-home provider visits• RN• MSW• Community Health Worker

• Licensed Social Workers• Community Health Workers• Chronic Condition Support

Group

Community Resources

Enhanced Pharmacy Services

• Medication Therapy Management

• Medication Reconciliation

• Innovative Pharmacy Service-Meds to Bed/Refill Clinic

Telemedicine

• Online Mobile Resources and Support

• Solutions Management• Biometric Devices• Cloud-based Dashboard

Oversight• Smart Phone Applications• Bluetooth Capable Devices• Web-based Interactive

Education, Support and Counseling using Lync

• Interactive Voice Response• Comprehensive Text Messaging

Sharp Rees-Stealy Telehealth Programs

• Asthma• Congestive Heart Failure• Hypertension• Diabetes• Chronic Kidney Disease• Tobacco Cessation• COPD • Post Discharge Texting Program

Outcomes

• Clinical • Engagement• Referrals/Growth• Quality Metrics• Quality of Life• Patient Activation• Patient/Physician/Employee Satisfaction• Financials

Telehealth BP Pilot Program Clinical Outcomes

CHF Readmissions30 Day CHF Readmission Rate SRS Senior HMO Population

Diabetes Texting Clinical Outcomes

Status

Members In

ProgramAPC

CompliantAvg Days in

ProgramAvg Pre-Enr A1c

Avg Post-Enr A1c

Avg A1c Decrease

% Members w Improvement

Complete 57 16% 187 9.56 8.38 -1.21 76.92%

Enrolled 28 25% 106 9.82 8.35 -1.21 94.74%

Quit 64 40% 55 9.46 8.16 -1.36 87.72%

Registered 37 17%   9.88 8.35 -1.5 85.71%

March 10, 2014 through November 4, 2014

Growth

Enrollment/Engagement

Asthma Quality MetricsAsthma Medication Ratio Compliance (IHA P4P Measure)

Financials

Admissions / ED Visits per 1000 SRS Senior HMO Members YTD

Admissions / ED Visits per 1000 SRS Senior HMO Members YTD