![Page 1: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/1.jpg)
APCM Learning Session - January 2018 1
![Page 2: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/2.jpg)
Welcome to the
APCM LEARNING SESSIONJanuary 25th, 2018
Are you on Twitter or Facebook? If you feel inspired to post on social media about this APCM Learning Session, use
#OregonAPCM or #OregonCHCs and tag OPCA @OregonPCA
![Page 3: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/3.jpg)
Introduction Slide
APCM Learning Session - January 2018 3
![Page 4: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/4.jpg)
Learn who’s in the room!
4APCM Learning Session - January 2018
![Page 5: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/5.jpg)
Health Centers
Phase 1 - March 2013
Mosaic Medical
OHSU-Richmond
Virginia Garcia
Phase 2 – July 2014
Benton County
Multnomah County
OHSU-Scappoose
Yakima Valley
Phase 3 – July 2015
Clackamas County
Rinehart
Rogue
Phase 4 – July 2016
Neighborhood
NWHS
Winding Waters
Phase 5 – July 2017
La Clinica
Wallace
Phase 6 – July 2018
Lane County
Valley Family
5APCM Learning Session - January 2018
![Page 6: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/6.jpg)
Funders, Partners, and Fellow PCAs
6APCM Learning Session - January 2018
![Page 7: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/7.jpg)
Learning Session Welcome
APCM Learning Session - January 2018 7
![Page 8: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/8.jpg)
8APCM Learning Session - January 2018
![Page 9: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/9.jpg)
Expanded teams and new roles
Community partnerships and
solutions
SDoHinterventions
Patient partnership and new visit types
Advanced Care Model: Foundational TA
…a new visit type. …a new care team role. …a social care response.…a new partner.
October 16th, 2015 March 7-8th, 2016 July 22nd, 2016 November 3-4th, 2016
Test out…
Date:
Identify a subpopulation of focus…
…Partner with them in meaningful ways.
…use actionable and real time data.
Quality Meaningful Engagement Cost of CareSegmentation4 quadrants :
Care teams…
…are built to reflect patient needs.
…increase access through new visit types.
…partner with patients to co-create and provide self-management services.
…enhance appropriate care and reduce unnecessary health system utilization.
Learning Session cycle –Jan ‘14 - April ’15
Access models + New patient on-boarding –
July ‘14
Population management through high functioning
care teams – Oct. ‘14
Patient/Family partnership in care and
design – Jan. ‘15
Understand your patient; improve their
care – April ‘15
Learning Session Deep Dives
Learning Session cycle –Oct ‘15 – Nov ‘16
© Oregon Primary Care Association
APCM Learning Session - January 2018 9
![Page 10: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/10.jpg)
APCM Learning Session - January 2018 10
![Page 11: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/11.jpg)
APCM Learning Session - January 2018 11
![Page 12: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/12.jpg)
12
APCM Learning Session - January 2018
![Page 13: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/13.jpg)
APCM Learning Session - January 2018 13
![Page 14: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/14.jpg)
APCM Learning Session - January 2018 14
![Page 15: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/15.jpg)
Quality
Population Health Equity
Access
Cost
APCM Learning Session - January 2018 15
![Page 16: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/16.jpg)
APCM Learning Session - January 2018 16
![Page 17: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/17.jpg)
Anchoring the Day
APCM Learning Session - January 2018 17
![Page 18: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/18.jpg)
18
![Page 19: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/19.jpg)
High level care
Elements of Value
APCM Learning Session - January 2018 19
Deliver care to patients in different formats
Re-distribute power so that patients become equal partners in co-creating their care
Synthesize and utilize population data to uncover gaps in community health
![Page 20: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/20.jpg)
High level care
Elements of Value
APCM Learning Session - January 2018 20
Test out appropriate, upstream interventions for groups segmented using bio-psychosocial data
Continue to make strategic care connections involving community partners
Document, document, and document so you know who you are serving!
![Page 21: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/21.jpg)
![Page 22: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/22.jpg)
APCM Learning Session - January 2018 22
![Page 23: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/23.jpg)
APCM Learning Session - January 2018 23
![Page 24: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/24.jpg)
APCM Learning Session - January 2018 24
![Page 25: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/25.jpg)
APCM Learning Session - January 2018 25
Quality
Clinics report performance for Seven Quality Metrics aligned with Coordinated Care Organization (CCO) Incentive Metrics and a Patient Experience Measure.
Cost
In 2018, clinics and OHA will clearly define what data to track in cost/utilization, and determine how health centers will access such data.
Access
Report Care STEPs quarterly. OHA will remove patients from clinics’ APCM lists if they have not had a visit or Care STEP in eight quarters.
Population Health Equity
Clinics will identify a population and use tool to learn and track bio-psychosocial needs. Improve quality through segmentation.
*One metric to be added in 2019 (SBIRT).
QUADRUPLE AIMOREGON APCM METRICS AND ACCOUNTABILITY PLAN
![Page 26: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/26.jpg)
Access
Report Care STEPs quarterly. OHA will remove patients from clinics’ APCM lists if they have not had a visit or Care STEP in eight quarters.
Population Health Equity
Clinics will identify a population and use tool to learn and track bio-psychosocial needs. Improve quality through segmentation.
Clinics report performance for Seven* Quality Metrics aligned with Coordinated Care Organization (CCO) 2016 Incentive Metrics.
Access
Report Care STEPs quarterly. OHA will remove patients from clinics’ APCM lists if they have not had a visit or Care STEP in eight quarters.
Clinics will identify a population and use tool to learn and track bio-psychosocial needs. Improve quality through segmentation.
Population Health Equity
Data…
Skills…
Design…
…that informs current and future modes of care and services?
…that uncovers population health disparities at the clinic level?
…that make the vision tangible for front line staff?
…that encourages empathic inquiry and partnering between patients and staff?
…that weaves in the patient voice?…that incorporates community
partnerships?
How may we use…APCM Learning Session - January 2018 26
![Page 27: APCM Learning Session - January 2018 1 F2F - Intro Slides.pdf · APCM Transformation Goals APCM Learning Session - January 2018 27 Foundational Intermediate Advanced Population Health](https://reader030.vdocuments.site/reader030/viewer/2022041122/5f3751b5231eeb15021d5552/html5/thumbnails/27.jpg)
APCM Transformation Goals
APCM Learning Session - January 2018 27
Foundational Intermediate Advanced
Population Health
Equity Goals:
Segment patient populations
to a target set of patients and
conduct a SDH screening to
learn more about their bio-
psychosocial needs.
Pull and routinely analyze
data related to SDH issues for
target populations.
Incorporate SDH data into panel
management activities and use it
to inform care-plan decision
making.
Foundational Intermediate Advanced
Access Goals: Use the Care STEPs categories
to develop one new mode of
access/service delivery.
Evaluate patient engagement
or satisfaction with new
modes of access/service
delivery.
Use Care STEPs categories to
create one new patient-driven
mode of access/service delivery
for target populations identified
through the PHE quadrant.