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Strategy Management in the Military Health System: Achieving the Quadruple Aim Ms. Paula Evans Office of Strategy Management Office of the Assistant Secretary of Defense for Health Affairs [email protected] 27 July 2010 Goals for this briefing At the conclusion of the session, participants will be able to: • Understand the MHS Quadruple Aim • Understand the MHS Strategic Imperatives • Understand the Pt Centered Medical Home • Understand the critical importance of MEPRS in monitoring strategic performance The Quadruple Aim MHS Quadruple Aim • Readiness – – – – Pre- and post-deployment Family health Behavioral health Professional competency/currency • Population Health – Healthy service members, families, and retirees – Reduced tobacco, ETOH and unhealthy eating • A Positive Patient Experience – Quality healthcare outcomes – Patient and family centered care, access, satisfaction • Cost – Responsibly managed – Focused on value 4 Achieving Excellence in the Delivery of Care • Performance is a characteristic of a system • Every system is perfectly designed to achieve exactly the results it gets • Design leads to performance; reliability leads to excellence • So if you want different performance, you need a different design • Process-by-process, change-by-change we can get better and improve across all six areas that described experience of care (Crossing the Chasm, 2001): • • Safe • Effective • Patient-Centered • Timely • Efficient • Equitable But, we need data….. Source: “Achieving the Quadruple Aim – Military Health Leading the Nation”, Don Berwick, MD, MPP, MHS Conference, January 27, 2010. Aligning the Incentives: Rewarding Both Outputs and Outcomes Deliver patient centered primary care and optimize performance around: Direct Care Prevention Purchased Care PMPM Enrollment Continuity ER Utilization Patient Satisfaction PMPM (Focus on pharmacy) • Improve health (HEDIS) • Enhance access and continuity (reducing no shows, ER visits) • Care is rewarding to patient and provider (satisfaction, retention, staff turnover) • Synchronize direction and incentives for TRO/MTF/Regional Commander, including initiatives that are: – – – – Facility-specific Good for entire region or service Good for all military patients Beneficial to the MHS as a whole MHS Strategic Imperatives Strategic Imperatives • The MHS has developed a set of strategic imperatives that Strategic Imperatives are the we believe will positively impact the Quadruple Aim critical few things we must • Strategic Imperatives are the things that will yield the do to achieve the Quadruple greatest return from the finite resources available Aim Each Strategic Imperative has one or more performance measures As an organization, we will align resources and focus management efforts on our Strategic Initiatives over the next 1-5 years • Each measure has specific targets for FY10, FY12, FY14 • The difference between our current performance and target performance is our performance gap • Each imperative will have an Executive Sponsoring Coalition (i.e. one of the Integration Councils) • To close our performance gap – we will concentrate efforts on a few strategic initiatives (i.e. Patient Centered Medical Home) MHS Strategic Imperatives Scorecard Strategic Imperative Readiness Individual and Family Medical Readiness Exec Sponsor Performance Measure FHPC Individual Medical Readiness TBD Psychological Health & Resiliency Population Health Engaging Patients in Healthy Behaviors Development Status Measure of Family Readiness (i.e., PHA for families) Current Performance Current Target Target (2012) Target (2014) 71% 80% 82% 85% - - - - FHPC PTSD Screening, Referral and Engagement (R/T) 44%/69% 40%/65% 40%/65% 40%/65% FHPC Depression Screening, Referral and Engagement (R/T) 60%/73% 40%/65% 40%/65% 40%/65% CPSC MHS Cigarette Use Rate (Will transition to: Percent of Patients Advised to Quit Tobacco Use) 22% 20% 18% 16% CPSC Body Mass Index - - - - CPSC HEDIS Index – Preventative Screens 12 12 13 14 CPSC HEDIS Index – Clinical Practice Guidelines 8 8 9 10 CPSC Overall Hospital Quality Index (ORYX) 87% 88% 90% 92% CPSC MEBs Completed Within 30 Days 30% 80% - - CPSC MEB Experience Rating 46% 45% 55% 65% CPSC Effectiveness of Care for Complex Medical/Social Problems - - - - JHOC 3rd Available Appointment (Routine / Acute) Experience of Care 24/7 Access to Your Medical Home 77%/63% 90%/75% 92%/77% 94%/79% JHOC Getting Timely Care Rate 74% 78% 80% 82% - - - - Personal Relationship with Your Doctor 45% 60% 65% 70% 59% 60% 62% 64% Per Capita Cost Align Incentives to Promote Outcomes and Increase Value for Stakeholders - - - - 10% 6% - - 72/100 65/100 60/100 55/100 Learning & Growth Effective Knowledge Management Using Research to Improve Performance Fully Capable MHS Workforce Concept Only JHOC Potential Recapturable Primary Care Workload for MTF Enrollees Percentage of Visits Where MTF Enrollees See Their PCM JHOC Satisfaction with Health Care JHOC Impact of Deployments on MTFs CFOIC Annual Cost Per Equivalent Life (PMPM) CFOIC Enrollee Utilization of Emergency Services CPSC User Assessment of EHR - - - - CFOIC Effectiveness in Going from Product to Practice (Translational Research) - - - - CFOIC Human Capital Readiness - - - - CFOIC Staff Satisfaction / Team Function - - - - Measure Algorithm Developed Current Performance Known and FY10 Target Approved IMR programs (e.g., addressing dental class 4, overdue PHAs, etc.) Psychological Health Evidence-Based Care Wounded Warrior Care Strategic Initiatives Healthy Behaviors/Lifestyle Programs Evidence Based Care Wounded Warrior Programs Patient Centered Medical Home Disability Evaluation System Redesign Evolution of Performance Planning EHR Way Ahead Out-Year Targets Approved Centers of Excellence BRAC / Facility Transformation Design Phase Approved Funded How Do We Support Change in the Right Direction? • Understand desired end-state – Balanced approach to Quadruple Aim – Readiness maximized – Healthy Outcomes and Patient Experience improved – Sustainable Costs • Emergency Department Use • Retail Pharmacy • Agree on goals – One size does not fit all – Year over year improvement • Facilitate and incentivize the change Balance Key MHS Initiative for Achieving the Quadruple Aim is the “Patient Centered Medical Home (PCMH)” Team-Based Healthcare Delivery Access to Care •Creation of Clinical Micropractices •Appropriate utilization of medical personnel •Improve communication among team members •Improve phone and electronic appt scheduling •Open access for acute care •Emphasis on coordination of care •Proactive appointing for chronic and preventive care Advanced IT Systems •Secure mode of e-communication •Creation of education portal •Reminders for preventive care •Easy, efficient tracking of population data Decision Support Tools •Evidence-Based Training •Integrated Clinical Guidelines •Decision Support Tools at the point of care Population Health •Emphasis on preventive care •Form basis of productivity measures •Evidence-based medicine at the point of care Patient Center ed Medical Home Patient & Physician Feedback Patient-Centered Care •Empower active patient participation •Seamless communication •Encourage patient participation in process improvement Refocused Medical Training •Emphasize health team leadership •Incorporate patient-centered care •Focus on quality indicators •Evidence-based practice •Real-time data •Performance reporting •Patient feedback •Partnership between patients and care teams to improve care delivery Model adapted from the NNMC Medical Home MHS PCMH Journey NNMC Services Develop nd MHS PCMH HA 2 MHS PCMH PCMH Pilot PCMH Policy & Policy Summit Performance Begins Guidance Sep 2009 Oct 2010 Planning Pilots Jun 2008 Apr– Jul 2010 Edwards & Begin MHS Conference Ellsworth Oct 2010 (Enterprise-Wide FHI Pilots Communications) Aug 2008 Jan 2010 Services Present Early Results of PCMH Performance Aug 2009 (R&A) 1st MHS PCMH Summit Sep 2009 Resources Aligned in 2012-17 POM Jun 2010 “Framework for Analysis” Approved (i.e. Measures and Standards) Dec 2009 ASD/HA and SG Congressional Testimony (for Stakeholders Buy-in) Feb 2010 2,634,614 Enrollees in a Level II PCMH End of FY 2012 Enterprise-Wide Secure Messaging Capability Available Jan - Mar 2011 Business Case to Support PCMH What should PCMH accomplish within Primary Care? • • • • • • Reduce visits/person Maintain total “touches” (visits + non-visits) Increase enrollment Increase market share Recapture PSC (savings) Increase preventive services What do we need to do? • • • • • What should PCMH accomplish outside of Primary Care? Direct Care • • • Right number of providers for enrolled population Right number of support staff per provider Right space for efficient operations Right information systems Train our people to more effectively function as a team PMPM ER Patient PreventionEnrollment Continuity Reduce ER demand (savings) UtilizationSatisfaction Reduce inpatient demand (savings) Reduce specialty demand (savings) Purchased Care PMPM (Focus on pharmacy) Standards & Measures What They Are & Why They Are Different? • Standard: An established norm or requirement; usually manifested in a formal document that establishes uniform specifications, criteria, methods, or practices • Measure: A number or quantity that records an observable value or performance Example: Hybrid Car Standards •Uses two or more distinct power sources to move the vehicle •Low emissions (i.e. SULEV rated [Super-Ultra-Low-Emission Vehicle]) Measures •Fuel economy (mpg city/hwy) •Acceleration (time from 0-60 mph) In this example, standards distinguish hybrids from other cars while measures allow consumers to compare the performance hybrids against other cars. Why Do We Need Standards and Measures? • Standards and measures allow us to test a hypothesis: – Hypothesis: “The PCMH is a model of primary care that will have a significant positive impact on MHS’ pursuit of the Quadruple aim: enhanced patient experience, improved population health, better managed per capita cost, and increased medical readiness.” • Standards allow us to differentiate medical homes from traditional models for primary care – Standards describe the key characteristics required for a practice to qualify as a medical home – Standards do not force “one-size-fits-all”; they are simply a set of fundamental criteria that must be met – Without standards, the term medical home can be used loosely, potentially damaging the credibility of the medical home initiative • While standards can be used to determine what a medical home is, measures allow us to determine how they are performing – Performance versus control groups (Are medical homes doing better than traditional models for primary care?) – Longitudinal performance (How is a medical home doing over a span of time?) – Best performers (Where are the opportunities for best practice transfer? Tracking PCMH Implementation Number and percentage of enrollees getting their care from a Level 2 Patient Centered Medical Home 1. We have standards that define the patient centered medical home 2. We have measures and targets that describe the outcomes we want to achieve 3. We should articulate the number of patients that will migrate to a patient centered medical home, and by when 17 PCMH Enrollment Projections “THE TARGET” Total MHS Prime Enrollment With Plus (2009) Projected PCMH Prime Enrollees with Plus (end of FY 2010) Projected PCMH Prime Enrollees with Plus (end of FY 2011) Projected PCMH Prime Enrollees with Plus (end of FY 2012) Air Force 1,218,891 304,723 (25%) 731,335(60%) 1,103,864 (88%) Army 1,407,531 47,856 (3.4%) 281,506 (20%) 633,389 (45%) Navy 780,486 132,683 (17%) 390,243 (50%) 597,361 (75%) HCSC 1,500,000 45,000 (3%) 135,000 (9%) 300,000 (20%) Total 4,906,908 530,262 (11%) 1,538,084 (31%) 2,634,614 (54%) Notes: HCSC = Health Care Support Contractors (X) = % of enrolled population with Plus Estimated Overall Impact of PCMH on the Quadruple Aim Expected Performance from Level 2 PCMH Current Performance Measure X Expected Improvement R IMR ↑ TBD G HEDIS – Preventive ↑ 7% G HEDIS – Evidence Based Guidelines ↑ 4% Beneficiary Satisfaction ↑ 10% Y Y R Y R R Time to Next Available Appointment 3.75M - 75% 54% 31% ↑ 15% Getting Timely Care ↑ 14% PCM Continuity ↑ 16% PMPM ↓ TBD ER Utilization % of Enrollees Getting Care from Level 2 PCMH 11% ↓ 24 Projections 2010 2.5M - 50% 1.25M - 25% 500K - 10% 250K - 5% Projections 2011 = Overall Impact on Quadruple Aim Beneficiary Satisfaction: 59% 64% (62%) G Getting Timely Care: 74% 81% (78%) G PCM Continuity: 45% 53% (60%) Y ER Utilization: 72/100 60/100 (60) G Beneficiary Satisfaction: 59% 62% (62%) Y Getting Timely Care: 74% 78% (78%) G PCM Continuity: 45% 49% (60%) Y ER Utilization: 72/100 66/100 (60) Y Beneficiary Satisfaction: 59% 60% (62%) Y Getting Timely Care: 74% 76% (78%) Y PCM Continuity: 45% 47% (60%) Y ER Utilization: 72/100 69/100 (60) R Beneficiary Satisfaction: 59% 59% (62%) Y Getting Timely Care: 74% 75% (78%) R PCM Continuity: 45% 46% (60%) Y ER Utilization: 72/100 70/100 (60) R Projections 2012 (XX) Denotes FY12 target Importance of MEPRS in All This The MHS Value Equation for Measuring PCMH Success Experience Population Readiness + + of Care Health Value = Cost (Over a Span of Time) Creating a high value Military Health System is predicated on defining and measuring value. 21 MHS Strategic Imperatives Scorecard & MEPRS Data Strategic Imperative Readiness Individual and Family Medical Readiness Psychological Health & Resiliency Population Health Engaging Patients in Healthy Behaviors Exec Sponsor Performance Measure FHPC Individual Medical Readiness Development Status Current Performance Current Target Target (2012) Target (2014) 71% 80% 82% 85% TBD Measure of Family Readiness (i.e., PHA for families) - - - - FHPC PTSD Screening, Referral and Engagement (R/T) 44%/69% 40%/65% 40%/65% 40%/65% FHPC Depression Screening, Referral and Engagement (R/T) 60%/73% 40%/65% 40%/65% 40%/65% CPSC MHS Cigarette Use Rate (Will transition to: Percent of Patients Advised to Quit Tobacco Use) 22% 20% 18% 16% CPSC Body Mass Index - - - - CPSC HEDIS Index – Preventative Screens 12 12 13 14 CPSC HEDIS Index – Clinical Practice Guidelines 8 8 9 10 CPSC Overall Hospital Quality Index (ORYX) 87% 88% 90% 92% CPSC MEBs Completed Within 30 Days 30% 80% - - CPSC MEB Experience Rating 46% 45% 55% 65% CPSC Effectiveness of Care for Complex Medical/Social Problems - - - - Experience of Care 24/7 Access to Your Medical Home JHOC 3rd Available Appointment (Routine / Acute) 77%/63% 90%/75% 92%/77% 94%/79% JHOC Getting Timely Care Rate 74% 78% 80% 82% - - - - 45% 60% 65% 70% 59% 60% 62% 64% - - - - 10% 6% - - 72/100 65/100 60/100 55/100 JHOC Personal Relationship with Your Doctor Per Capita Cost Align Incentives to Promote Outcomes and Increase Value for Stakeholders Learning & Growth Effective Knowledge Management Using Research to Improve Performance Fully Capable MHS Workforce Concept Only JHOC Potential Recapturable Primary Care Workload for MTF Enrollees Percentage of Visits Where MTF Enrollees See Their PCM JHOC Satisfaction with Health Care JHOC Impact of Deployments on MTFs CFOIC Annual Cost Per Equivalent Life (PMPM) CFOIC Enrollee Utilization of Emergency Services CPSC User Assessment of EHR - - - - CFOIC Effectiveness in Going from Product to Practice (Translational Research) - - - - CFOIC Human Capital Readiness - - - - CFOIC Staff Satisfaction / Team Function - - - - Measure Algorithm Developed Current Performance Known and FY10 Target Approved IMR programs (e.g., addressing dental class 4, overdue PHAs, etc.) Psychological Health Evidence-Based Care Wounded Warrior Care Strategic Initiatives Healthy Behaviors/Lifestyle Programs Evidence Based Care Wounded Warrior Programs Patient Centered Medical Home Disability Evaluation System Redesign Evolution of Performance Planning EHR Way Ahead Out-Year Targets Approved Centers of Excellence BRAC / Facility Transformation Design Phase Approved Funded Magic Linkage MEPRS Code Work Center Input • DMHRSi • DMLSS • Local Financial Systems Output • CHCS • SIDR • SADR Outcome • Surveys • M2 • Pop Health Portal What PCMH questions do we need answered that MEPRS would help on? • • • • • • • • • How many people are enrolled to a PCMH? What are the demographics of those enrolled to a team? What is the enrollment ratio, i.e. enrollee to providers? What is the demand rate for those enrolled in PCMH? How much primary care of those enrolled in PCMH is not seen by providers within the PCMH team? How much primary care seen by the team is for those not enrolled in the team? What is the productivity of the team? What is the overall cost of the team? What is the PMPM of individuals enrolled in PCMH? MEPRS Based Data is Essential for Knowledge Transfer • Having aggregate measures isn’t enough—we need information at the team level to evaluate performance and support best practice transfer of PCMH • At a fourth level MEPRS, data can be aggregated and analyzed by medical home team within a given MTF • A PCMH’s performance can then be compared with others. • We believe that as teams learn from each other, their performance will improve over time • Leadership has asked OSM to propose a single approach for measuring all aspects of a PCMH team and present to the JHOC on 11 Aug 10 Our Challenges • Labor intensive to create individual identification of teams • Lack of standard implementation rules • Not so simple; very complicated • Inefficient processes for data entry • Inadequate training of staff to appropriately account for time • IM/IT disconnects Pay Off by Measuring Individual PCMH Teams • Identify top performers • Report to our investors using hard evidence (facts) on the results of the PCMH initiative • Prove something that no one has proven in the country • Share best practices and eliminate unwarranted variation What Will It Take? • Agreement to work together to find an optimal solution • Skill in designing efficient processes and procedures to capture data and allocate resources • Pilot testing to avoid unintended consequences • Willingness to act quickly and get to yes “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” - Charles Darwin 29 Back-up Slides Definitions – Strategic Imperatives Quadruple Aim Readiness Population Health Experience of Care Strategic Imperative Individual Medical Readiness Increasing the proportion of the Total Force (Active and Reserve Components) across six elements that define IMR: Periodic Health Assessment (PHA), no deployment-limiting conditions, dental readiness, immunization, readiness laboratory tests, and individual medical equipment. Psychological Health Improving health outcomes for the 20-30% of OIF/OEF Service member that report some form of psychological stress. Continued focus on research into and adoption of evidencebased care treatments for PTSD and TBI. Engaging Patients in Encouraging and incentivizing patients and families to take a more active role in their health. Healthy Behaviors Promoting a shift from “healthcare to health” by fostering the adoption of healthier lifestyles, particularly the reduction/elimination of tobacco and alcohol usage, increase in physical activity, and improvement in nutrition. Evidence-Based Care Transitioning from intuitive medicine to precision medicine through the development, proliferation, and adherence to evidence-based guidelines. Achieving lowest decile performance in the Dartmouth Atlas measures by reducing unwarranted variation. Coordinated Care for For medically and socially complex patients, establishing partnerships among individuals, Complex Cases families and caregivers, including identifying a family member or friend who will be supported and developed to coordinate services among multiple providers of care. 24/7 Access to Your Team Per Capita Cost Learning & Growth Definition Personal Relationship with Your Doctor Patients are provided information about how to access medical care at any time, 24 hours per day, every day of the year. The Medical Home ensures on-call coverage (pre-arranged access to a clinician) when the Medical Home is not open. All patient medical home visits are with the same team which is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals (i.e. whole-person orientation). The physician listens carefully to the patient and, when appropriate the patients caregivers. Compassionate and easy-tounderstand instructions are provided about taking care of health concerns. Value-Based Incentives and Reimbursement Deliver Information to Enable Better Decisions MHS Contribution to Medical Science Capable Medical Workforce Shifting from volume-driven to value-driven health care. Disincentivizing fragmented approaches of care delivery to performance-based payments and enhanced value that can improve health outcomes and decrease costs. Improve the Electronic Health Record family of applications and support to create a comprehensive, fast, easy to use, and reliable system that meets the MHS goals of improving quality, safety, readiness, outcomes and customer satisfaction. Reducing the research-to-practice divide by focusing the R&D portfolio on the areas that will have the greatest impact on our strategic imperatives. Ensuring a thorough understanding of the job families most critical to our strategic initiatives and then developing/recruiting the right people. Performance Measures •Individual Medical Readiness •Measure of Family Readiness (i.e., PHA for families) •PTSD Screening, Referral and Engagement (R/T) •Depression Screening, Referral and Engagement(R/T) •MHS Cigarette Use Rate (Will transition to: Percent of Patients Advised to Quit Tobacco Use) •Body Mass Index •HEDIS Index – Preventive Screens •HEDIS Index – Clinical Practice Guidelines •Overall Hospital Quality Index (ORYX) •MEBs Completed Within 30 Days •MEB Experience Rating •Effectiveness of Care for Complex Medical/Social Problems •3rd Available Appointment (Routine / Acute) •Getting Timely Care Rate •Potential Recapturable Primary Care Workload •Percentage of Visits Where MTF Enrollees See Their PCM •Satisfaction with Health Care •Impact of Deployments on MTFs •Annual Cost Per Equivalent Life (PMPM) •Enrollee Utilization of Emergency Services •User Assessment of EHR •Effectiveness in Going from Product to Practice (Translational Research) •Human Capital Readiness •Staff Satisfaction / Team Function 31 Strategic Imperative Definitions Mission Outcome Strategic Imperative Definition Improved Mission Readiness Individual Medical Readiness Although we continue our pursuit of all aspects of readiness we will focus on increasing the proportion of the Total Force (Active and Reserve Components) that has a known readiness status and on reducing the rate of deployment limiting conditions. Increased Resilience and Optimized Human Performance Psychological Health Improving health outcomes for the 20-30% of OIF/OEF Service member that report some form of psychological stress. Continued focus on research into and adoption of evidence-based care treatments for PTSD and TBI. Healthy Community Engaging Patients in / Healthy Behavior Healthy Behaviors Encouraging and incentivizing patients and families to take a more active role in their health. Promoting a shift from “healthcare to health” by fostering the adoption of healthier lifestyles, particularly the reduction/elimination of tobacco and alcohol usage, increase in physical activity, and improvement in nutrition. Health Care Quality Evidence-Based Care Transitioning from intuitive medicine to precision medicine through the development, proliferation, and adherence to evidence-based guidelines. Achieving lowest decile performance in the Dartmouth Atlas measures by reducing unwarranted variation. Effective Medical Transition For medically and socially complex patients, establishing partnerships among individuals, families and caregivers, including identifying a family member or friend who will be supported and developed to coordinate services among multiple providers of care. Coordinated Care for Complex Cases Strategic Imperative Definitions (Cont’d) Mission Outcome Strategic Imperative Definition Access to Care 24/7 Access to Your Team Patients are provided information about how to access medical care at any time, 24 hours per day, every day of the year. Access may be in-person, by phone or by secure messaging using enhanced technology. Beneficiary Satisfaction Personal Relationship We seek to ensure that all primary care visits are with the same provider or team which is responsible for providing health care needs or arranging care with Your Doctor with other qualified professionals. Care is personal, the PCM and the entire team listen carefully to the patient and, when appropriate the patient’s caregivers. Compassionate, individualized and easy-to-understand education is part of every encounter. Performance Based Management Value-Based Incentives and Reimbursement Shifting from volume-driven to value-driven health care by implementing performance-based payments focused on improving health outcomes over time. Deliver Information to Enable Better Decisions Functional EHR Improve the Electronic Health Record family of applications to create a comprehensive, fast, easy to use, and reliable system that supports the quadruple aim by enabling better decisions, especially at the point of care. MHS Contribution to Using Research to Medical Science Improve Performance Reducing the research-to-practice divide by focusing the R&D portfolio on the areas that will have the greatest impact on our strategic imperatives. Capable Medical Workforce Ensuring a thorough understanding of the job families most critical to our strategic initiatives and then developing/recruiting the right people to be a part of our team. Fully Capable MHS Workforce