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Transcript Document

Population Health Management: Strategies and Tools You Can Use

March 19, 2013, 2:00 – 3:00 pm ET

Steven Christianson, DO

Medical Director VNS NY Homecare President ESPRIT Medical Care, Affiliated with VNS NY

Neil Smithline, MD, FACP

Director of Clinical Quality National Medical Audit Division Mercer Health and Benefits Laurel Sweeney (moderator) Senior Director Health Economics & Reimbursement Philips Healthcare

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Primary theme in health reform Evident in ACOs, bundling, medical homes… But what is it?

“Providing for all of the health needs of a specific group of individuals as they move through the health care system—and across the continuum of care.”

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No longer tied to individual service or visit Instead, based on the ability to improve the health of a specific patient population Changes represent major shift…

Health system Care provided Quality Payment base From Fragmented Disjointed Assuming it Individual Services To… Integrated Coordinated Proving it Overall Value 3

Medicare Model ACOs Bundled Payments Medical home Population Payment Population minimum 5,000, but 100,000s+ All patients; or those with specific conditions Patients of involved clinics Reimbursement based on meeting quality, cost metrics Reimbursement based on costs, quality metrics Extra $ per patient Number of entities 250 500 500 4

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What is real-world impact of population health management?

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What strategies/tools should you be using now?

Population Health Management: Strategies and Tools You Can Use

The Philips Healthcare “Reimbursement Simplified” Webinar Series Presents…

STEVEN CHRISTIANSON, DO, MM MEDICAL DIRECTOR VNSNY HOMECARE PRESIDENT ESPRIT MEDICAL CARE

Agenda

• • • • • • • • • • • Brief Introduction Definition of PHM Drivers of PHM Expansion for Providers What PHM Requires of Providers What Providers Need to Meet PHM Requirements PHM Strategies for Disease Management Providers PHM and ACO Non-Cost Quality Measures PHM Provider Incentives (2 Slides) Example VNSNY Nurse/Hospital Transition Program (2 Slides) Example ESPRIT Hospital/Health Plan/PCP Transition Program Example ESPRIT Health Plan/PCP Community Intensive Care Program SPARK ©

Population Health Management Definition (PHM)

At the provider level, the Care Continuum Alliance*, an industry group, has proposed the following definition of population health improvement. The population health improvement model highlights three components: 1.

The central care delivery and leadership roles of the primary care physician; the critical importance of Patient activation, involvement and personal responsibility; and the patient focus and Capacity expansion of care coordination provided through wellness, disease and chronic care management programs.

”

*

Care Continuum Alliance, “Advancing the Population Health Improvement Model, http://www.fiercehealthit.com/story/hennepin-health-project-looks-build-countywide-ehr-program-national-implica/2012-01-10

Drivers for Provider PHM Expansion

• • •

Rising Health Costs

– – Employers develop wellness, disease management strategies Payors developing Value/Performance reimbursement models and shifting risk to providers – Medicare Hospital reimbursement penalties for readmission now and later for not meeting quality standards

Shortage of Primary Care Physicians, Key to PHM

– Increase in multidisciplinary team care delivery models led by advance practice practitioners (e.g. Nurse Practitioners)

Patient Affordable Care Act of 2010 (ACA)

– ACO development with accountability, collaboration and aligned incentives for quality and care across the care continuum – – PCMH with focus on collaboration of providers with Hospitals Focus on multidisciplinary team based health care delivery

What PHM Requires of Providers

For Providers to flourish with PMH

• • • • • • Must think in terms of caring for an entire population and not just for the individual patients who actively seek care.

Must supply proactive preventive and chronic care to all patients, both during and between encounters with the healthcare system. Must maintain regular contact with patients and promote and support their efforts to manage their own health.

Care managers must actively manage high-risk patients to prevent them from becoming unhealthier with complications. Must use agreed to evidence-based protocols to diagnose and treat patients in a consistent, cost-effective manner Providers will continue to compete with one other, but they will also have to work together to coordinate care and exchange health information in a culture of shared responsibility.

What Providers Need to Meet PHM Requirements

• • • •

Provider Performance Incentives

– Attractive enough to encourage extra time and investment required for provider organization/practice support capabilities for integrated care

Provider Accountability and Joint Decision Making

– Commitment to collaboration with support for multidisciplinary teams/intensivists that allow other clinicians to act on behalf of the PCP – Care provided based evidence based protocols and care packages

Information Sharing Capability

– Capability to provide access to all organization/practice clinical information across the continuum of care to all clinicians interacting with a given individual patient enrolled in an integrated care setting

Provider Patient Engagement in Primary Care

– – – Care plan jointly developed with patient who agrees and commits to it Mechanisms established to allow tracking of patient compliance An annual risk assessment that promotes and provides programs for increasing patient self-care not medical dependence

PHM Strategies for Disease Management Provider Programs

Survey of Disease Management Organizations*

43% have a PMH program, 80% PCMH participation, 60% ACO participation. Main program components HRA, Health Promotion, Wellness Care Coordination, Disease Management, Care Management • • • • PHM Team 50%-60% Health Coach, PCP/Specialist ’ Case Manager 30-40% Nurse Practitioner, Dietitian, Pharmacist How Program delivered Telephone, patient Portal Print, Internet Gap analysis feedback to providers Member Engagement Preventive healthcare reminders Web based education Self management tools Link to Community resources Program Effectiveness Measurement Patient Satisfaction, Patient compliance Clinical Outcomes *2012 Healthcare Benchmarks: Population Health Management,

Healthcare Intelligence Network HIN

PHM ACO Proposed Non-Cost Related Quality Measures

Proposed Baseline And Performance Measures For The “Triple Aim” In Accountable Care Organizations: Proposed Non-Cost Related Measures* • First aim: health of population – – HEDIS: adults age 50 and older who received recommended colorectal screening HEDIS: breast cancer screening for females ages 40 –69 – – – – – – HEDIS: flu shot for adults age 65 and older HEDIS: pneumonia vaccination status for adults age 65 and older HEDIS: comprehensive diabetes care hemoglobin A1c controlled (

8%) in adults ages 18 –75 QUEST: prevention of nearly 30 measures of harm (composite score) QUEST: observed to expected risk-adjusted mortality per 1,000 patients QUEST: composite score of evidence-based care for hospitalized cases • Second aim: experience of care – HEDIS: global rating of all health care – – HEDIS: global rating of personal doctor HEDIS: global rating of specialist seen most often *SOURCE Premier healthcare alliance. NOTES HEDIS is Healthcare Effectiveness Data and Information Set. QUEST is Quality, Efficiency, Safety with Transparency.

PHM Incentives for Providers

• • • Physician Quality Reporting System (PQRS) - report by submitting specially designated quality measure billing codes that align with evidence based clinical guidelines – – Used with Medicare provider PFP program in the ACA programs Payment

penalty

in the amount of -1.5 % of the “allowed charges,” in 2015 if not reporting in 2013 Medicare PCP Bonus – Office, Home, and Nursing Facility visits – 10% increase in fee schedule and allowances $200 for each Care Plan, and $100 for each maintenance – Allowed charges must equal 60% of Medicare payments for bonus Medicare Shared Savings (Accountable Care) Program – A voluntary shared savings program that promotes accountability for services to a Medicare population, goal quality and efficiency – Regular FFS Medicare payments are augmented by additional payment to the ACO for meeting quality and total expenditure goals, that are distributed to the ACO providers

PHM Incentives for Providers (Continued)

• • • Enhanced Medicaid Reimbursement for Primary Care Services • ACA increases Medicaid population ‘Medicaid Parity’ increased PCP reimbursement rates to at least Medicare in 2013-2014 • Family Medicine, General Internal Medicine or Pediatric Medicine are considered PCP. It also provides for higher payment for subspecialists related to those specialty categories Alternative Reimbursement Models Gainsharing, to share savings when participating in an integrated healthcare system that meets goals for reducing healthcare costs Bonus Payment usually for meeting quality and/or expenditure goal Bundled payment to promote efficiency and increase collaboration Member Incentives for PHM Participation Annual risk assessment patient preference for care determined No co-pays deductibles or other cost barriers to PCP preventive and health maintenance services Incentive payment for DM participation HRA completion

VNSNY Nurse/Hospital Transition Collaboration

An initiative to collaborate with hospital discharge planners and hospital programs

•On site embedded transition coordinator or program intake coordinator gets referrals initiates episode •Enhanced discharge planning with hospital programs and hospital discharge coordinator Heart Failure, COPD, Diabetes •Home visit episode – Patient and family/caregivers VNSNY evidence based disease protocols and teaching aids, coaching, focus on self-management with tools provided Medication reconciliation coaching on medication use Follow-up clinical appointment scheduling and coaching on patient preparation for preparation Risk assessment with high risk provided direct call # •Communication with PCP and other health care providers

ESPRIT Hospital/Health Plan/PCP Transition Program

ESPRIT ’s Transitional Care Program is a 30-day intervention based on the framework of Mary Naylor ’s TCM and Eric Coleman’s CTI that includes: In-hospital risk evaluation and stratification and multidisciplinary transitional care planning, NP-led team (NP, RN, LCSW) interventions via in-home and phone encounters: • Introduced piloted and accepted by the hospital medical staff that credentials the ESPRIT providers who deliver care in the program, paid for by the health plan.

– The patient and their PCP must agree to participate to initiate • An embedded trained Nurse Transition Coordinator performs intake risk screening with evidence based tools – Charleston Comorbidity Index (CCI), KATZ ADL functional status – – – – Number of medications, inpatient or homecare in prior 6 month Depression screen Patient Health Questionnaire (PHQ-2) Cognitive status Six Item Screener (SIS) Self perceived health status and change in health status 17

ESPRIT Hospital/Health Plan/PCP Transition Program(Continued)

Primary components of the 30 day episode

• Medical case management including

NP/PCP and Health Plan case manager collaboration

on the medical plan • Medication reconciliation • Self management coaching (Colman ’s 4 Pillars) • Preparation for physician visits,

joint visit if indicated

•

24/7 coverage by NPs for member and PCP

• Self-management education on managing changes in health associated with multiple chronic conditions •

Identification of drivers of hospitalizations & interventions to address gaps in care and reduce hospital admissions.

• coordination with and “hand-off” to a primary medical and/or mental health home 18

ESPRIT Transitional Care Program Experience as of January 2013

Partnership with Partner Hospital

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Plan A Plan A and Partner Hospital

Program 2011 “ Go-Live ” Nov. 7, Provided 519 evaluations and 95 (30-day) episodes of care through 1/6/13 ESPRIT/VNSNY coordinated multi-organizational activities to operationalize program at the Hospital Program embedded a Transitional Care Coordinator into the hospital to perform screening, risk assessment and stratification and transitional care planning

Reduced all cause 30-day readmission rate by 49%

(from 7.9% to 4.0%)

ESPRIT Partnership with Plan B

       Program initiated in Brooklyn and the Bronx on Sept. 26, 2011 Expanded to Manhattan & Queens on October 26, 2011 Provided over 500 evaluations and 30 day episodes of care through 1/6/13 Transitional Care Coordinator/NP has conducted evaluations in multiple hospitals Participation in Plan ’ s Medical Management Rounds

Achieved 91% PCP visit rate within 30-days of hospital discharge in a population with a high rate of having no active PCP Reduced all-cause 30-day readmission rate by 45%

(from 29% to 16%)

ESPRIT

ESPRIT Health Plan/PCP Intensive Community Care Program SPARK

Contracting with health plans for 30 day episodes of care this is a community-based intensive care management program for patients with serious chronic and/or life limiting illnesses who demonstrate a need for intensive care management by repeat hospital/ED visits and/or high total health care expenditures. • Provided by an ESPRIT nurse practitioner led interdisciplinary team of palliative care providers (Hospice collaborating MDs, NPs and LCSWs) • Health Plan payment is by episode, but claims are provided documenting care provided and capturing the ICD-9 and CPT codes.

• Care delivery is tailored to the individual, most with multiple comorbidities with a blend of telephonic and home visits. • Management of end-of-life members not eligible or refusing Hospice in collaboration with their primary care provider (PCP) and coordinating with the health plan clinical staff in case conferences • Establishes member goals of care, which facilitates timely enrollment in Hospice, if appropriate.

ESPRIT Program Components SPARK

© Nurse Practitioner

Case Manager, Team Leader and Co-Manager of Medical Services

Hospice Physician

Collaborator

Patient/Caregiver

Primary Care Provider

Coordination of medical care

Social Worker

Psychosocial & Behavioral Health Interventions

Community Resources

Continued and future support

Health Plan CMO & Case Managers

Service Coordination

ESPRIT SPARK

Program Results

• •

Financial

– 38% reduction in all cause hospitalization rates when compared to the 12 months prior to SPARK admission – 42% reduction in hospitalization in members (18%) with an underlying serious (Axis 1) mental illness – 20% lower total medical costs PMPM in patients enrolled in SPARK ≥ 6 months

Clinical

– Patient Satisfaction: 100% of members surveyed in 2012 were either satisfied or very satisfied with SPARK Program (N-66) – – – 93% rate of completion of Advance Directives 93% rate of sustained or improved Quality of Life 54% enrollment into Hospice for Hospice eligible members (20% of SPARK patients) and had an ALOS on Hospice of 66 days

Useful Resources

An Internist ’s Practical Guide to Understanding Health System Reform http://www.acponline.org/advocacy/where_we_stand/access/internists_guide/

• This Guide is intended to serve as a practical resource for internists on health system reform legislation, the Patient Protection and Affordable Care Act (ACA), enacted in March 2010. The Guide is organized by the year in which a policy issue is to be implemented, making it easily apparent which new policies may be impacting physicians/patients immediately.

Gaining Ground: Care Management Programs to Reduce Hospital Admissions and Readmissions Among Chronically Ill and Vulnerable Patients http://www.commonwealthfund.org/Publications/Case-Studies/2013/Jan/Care-Transitions-Synthesis.aspx

• Three case studies illustrate the potential of care management programs to address this problem by improving care coordination and transitions among high-risk patients. Study sites included two academic medical centers and a managed care organization owned by a home health agency. The sites employed bundles of interventions involving multidisciplinary teams to improve provider communication, patient and family education, care transitions from the hospital, and follow-up ambulatory care.

ITH Population Health Management “A Roadmap for Provider-Based Automation in a New Era of Healthcare.

”

http://ihealthtran.com/blast372.html

• This guide represents the first comprehensive effort to define a roadmap for providers that are exploring population health management (PHM). The literature on patient-centered medical homes and accountable care organizations traverses some of the same fundamentals, but no other study or report has yet provided practical guidance on how to set up the infrastructure that uses the latest health IT applications to facilitate and automate PHM.

POPULATION MANAGEMENT It’s NOT “One size fits all”

March 19, 2013

Neil Smithline MD

San Francisco

What’s Your Goal What’s Your Time Horizon MERCER 1 o Prevention Low ROI 1 o Prevention Mod ROI April 25, 2020 1 o & 2 o Prevention High ROI 25

Three Key Steps We Fail at Step 2 and 3 1.

Identify those at risk 2.

Make sure they know what to do SPECIFIC knowledge Selective outreach 3.

Selectively activate the population – Two key tools From Knowledge to Action  Want to do it!

 Know what to do 

Who’s at Risk

MERCER April 25, 2020 26

How Do We Help Members Change Two Unique Tools for Targeted Outreach IndiGO • Using your existing data, targets members and treatments with greatest health and cost ROI • Propels physicians and patients into action PAM —Patient Activation Measure • Tells health coach how ready each member is to manage their own health • Set goals and tasks that allow member to succeed 27 MERCER April 25, 2020

IndiGO —Propels Patients and Physicians into Action

Ms. Jones. By taking an ACE Inhibitor, you will reduce your risk of heart attack and stroke by 31%. And if you take a statin, you can get a further 18% reduction.

• Providing this highly personalized message has been shown to “activate” both physician and patient – Physicians prescribe the right medications

4 times more often

– And patients fill their prescriptions

1.6 times more often

– Meds taken—

6.4 times more often

MERCER IndiGO • Targets treatments with greatest ROI for both member health and cost • Then propels physicians and patients into action 28 April 25, 2020

PAM —Patient Activation Measure No Way Maybe Starting Resilient  I’m not sure I can do anything to improve my health.

 I have the confidence to make changes, but need to start with small steps.

 I can make needed changes, but get stuck when the going gets tough.  Tell me what to do and I can do it—even in times of stress.

• Highly activated members succeed with printed/web materials and minimal support • Less activated need frequent support/supervision—regardless of how sick they are • PAM lets you tailor scarce resources to the individual’s need, thereby maximizing ROI • Allows you to monitor program’s effectiveness at increasing member activation —the key to improved self management MERCER April 25, 2020 29

How to Execute Where’s Your Population High Regional Concentration Dispersed Populations • Provider-driven population management strategies • Vendors on steroids • Good enough vs. best in class vendors • ACOs • Medical homes for the chronically ill — and about to be chronically ill • Require providers to highly train their staff in skills like – IndiGO – PAM – Motivational Interviewing – Socially tailored messages • Require vendors to highly train their staff in skills like – IndiGO – PAM – Motivational Interviewing – Socially tailored messages

Change Culture

Health Eats in Cafeteria Selective incentives Walk 100 miles with CEO Registrie s Selective reach out

I took the Pro Health pledge

30 30 MERCER April 25, 2020

New Engagement

FutureGRAM

Act on indicators of SK risk to effect a different future • Use IndiGO and PAM to reduce likelihood of acute episodes – Exact value of potential action (statins, exercise, etc.) in terms of risk reduction – Where and how each member should focus his/her efforts • Supplement with “Active Education” – Know your numbers – Know (or choose) your PCP – Support adherence to plan with games, regret lotteries, and incentives

FutureGRAM

: What are the details of the problem? How big is it?

Which Actions Have Greatest Value

MERCER April 25, 2020 31

MERCER POPULATION MANAGEMENT It’s NOT “One size fits all” From Knowledge to Action

Activated Members = Healthy Population

 Want to do it!

 Know what to do 

Who’s at Risk

April 25, 2020 32

Services provided by Mercer Health & Benefits LLC.

California Insurance License 0E75483

Questions?

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The moderator will pose questions to the panelists

We would like to hear your views on today’s webinar. Go to

http://www.surveymonkey.com/s/JPHNYVB

For more information on reimbursement, please visit the Philips Healthcare Reimbursement Website at

www.philips.com/reimbursement 34

Speaker Bios Neil Smithline, MD, FACP

Director of Clinical Quality National Medical Audit Division Mercer Health and Benefits Dr. Neil Smithline is responsible for overseeing the clinical standards associated with clinical performance management engagements. Dr. Smithline has more than 35 years’ experience in the medical community, including academic positions at the University of Arizona, College of Medicine and San Francisco General Hospital, UCSF. Over his career, Dr. Smithline has served as chairman of the internal medicine department, the intensive care unit, and the department of nephrology at the Tucson Medical Center and at El Dorado Hospital (Tucson).

Most recently, Dr. Smithline has been Mercer’s clinical lead for provider-based strategies—with medical group as well as large health systems. In this capacity he has negotiated ground-breaking contracts with world-renowned health systems, as well as innovative gainsharing agreements with medical groups that serve as templates for both medical homes and accountable care organizations. Dr. Smithline has been clinical lead for Mercer’s Chronic-Patient Centered Medical Home model. He has successfully implemented this model on behalf of individual employers, coalitions of employers, and Taft-Hartley Trusts.

Dr. Smithline has served several medical facilities as the medical consultant for clinical resource management, overseeing the quality and appropriateness of care provided. Dr. Smithline’s focus has been clinical resource management, evidence-based approaches to health care and medication management, patient risk management and medical cost reduction for hospitals, physicians, employers and insurance carriers. He also has extensive experience in working with medical group design, practices and reimbursement methods. Dr. Smithline is board certified in both internal medicine and nephrology, and he is licensed in California. He received his BA from Tufts College of Liberal Arts and his MD from Tufts University School of Medicine.

Speaker Bios Steven Christianson, DO, MM

Medical Director, VNS NY Homecare Owner/President Esprit Medical Care, Affiliated with VNS NY Visiting Nurse Services of New York (VNS NY) is one of the oldest home care companies in the US, with a skilled staff of over 2,400 registered and advanced practice nurses, 400 rehabilitation therapists, 360 social workers, and 4,000 home health aids providing expert home care services to 26,000+ patients daily and over 5.2 million visits annually in the NY City area. Dr. Christianson is the medical Director of VNS HomeCare, which is the certified home care agency that supplies the nursing, rehabilitative, and social services to patients.

Dr. Christianson is also the owner of Esprit Medical Care, which provides physician, nurse practitioner, and related professional health services to patients mostly in the community and in their homes. The firm has a current staff of more than 90 fully credentialed providers, and is affiliated with VNSNY. From 1998 – 2009, he served as medical Director of VNS CHOICE Managed Long Term Care, a partially capitated Medicaid long-term care health company. He also participated in all the planning and operational aspects and served as medical Director of the VNX CHOICE Medicare Advantage Special Needs Plan HMO.

He holds a BA in Zoology University of California, Berkeley 1968; Doctor of Osteopathy medical degree, Chicago College of Osteopathic Medicine 1973; with AMA Board Certification in Internal Medicine 1976, and a Masters in Management degree, Kellogg Graduate School of Management, Chicago 1989.