how to build a scalable and effective population health ... justice healthcare... · • safety...
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Taylor Justice
P: 239-823-5895
How to Build a Scalable and Effective Population Health Program to Drive ROI
Taylor JusticePresident
• Addressing the Social Determinants of Health since 2013
• Community Coordinated Care Networks• 30+ Networks Deployed• Operating in 16 States• Interconnecting Public, Private,
Non-profit Providers
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Agenda
• Population Health Definition• Goals of Population Health• Population Health, its not a manual process• Tactical & practical implementation models
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1st Polling Question
What stage is your Population Health Initiative?
a.) Already implementing a modelb.) Will launch within 3 monthsc.) Launching in 3 – 6 monthsd.) Launching within 12 monthse.) Just Exploring. Here to learn!
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Defined as health outcomes of a group of individuals, including the distribution of such
outcomes within a group.
Population Health (internet definition)
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Health starts where you live, learn, work, and play.
Population Health (RWJF definition)
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Health, not just Healthcare
Source:SchroederSA,“WeCanDoBetter– ImprovingtheHealthoftheAmericanPeople,”NEJM,357,(2007):1221-8;“HealthCare’sBlindSide,”RobertWoodJohnsonFoundation,http://www.rwjf.org/en/library/articles-and-news/2011/12/health-cares-blind-side-unmet-socialneeds-leading-to-worse-heal.html;PopulationHealthAdvisorresearchandanalysis.
Examples of Social Determinants that influence Health:• Income and employment status• Housing • Transportation• Hunger and access to healthy food
options• Social Integration and support• Safety
Closing the Gap on Social Determinants of Health
80-90% 85% 20%Health status attributable factors other than clinical care
Physicians reporting that unmet social needs lead directly to poorer health outcomes
Physicians who are confident in their ability to address unmet social needs
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Population Health Visualized
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Population Health Current Reality
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Population Health Current Reality
EHRs
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Population Health Current Reality
EHRs
Census DataHeat Maps
Resource Directories
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Population Health Visualized
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Population Health Goals
CLINICALGOALS
ENGAGEMENT GOALS
FINANCIAL GOALS
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Get Tactical
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Goals Population Health
CLINICALGOALS
Process Improvement• How do we know we actually
improved overall patient health?Outcome Metrics
• Can we quantify improvement & prevent avoidable spend?
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Goals Population Health
ENGAGEMENT GOALS
Empower patients to manage their own care.• Do we have appropriate resources &
information?• Are we improving their process as
well?
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Goals Population Health
FINANCIAL GOALS
Reduce Unnecessary Utilizations:• Preventable ED visits• Avoidable Readmissions
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Return On Investment
Source:SchroederSA,“WeCanDoBetter– ImprovingtheHealthoftheAmericanPeople,”NEJM,357,(2007):1221-8;“HealthCare’sBlindSide,”RobertWoodJohnsonFoundation,http://www.rwjf.org/en/library/articles-and-news/2011/12/health-cares-blind-side-unmet-socialneeds-leading-to-worse-heal.html;PopulationHealthAdvisorresearchandanalysis.
Addressing Non-Clinical Barriers to Care
$8k 25% 2.9xAnnual per-person health care savings as a results of offering housing or supportive services to high cost homeless indiv.
Missed Appointments or rescheduling needs due to transportation issues.
Increased likelihood of poor overall health status if a member of a food insecure household.
25%High utilizers will readmit into the Hospital within 4 days of discharge for non-clinical reasons.
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2ND Polling QuestionsOn average how much time does it take organizations to send referrals to partners? (example: organization A to send organization B a referral)
a.) Within 4 Daysb.) 16 -18 Daysc.) Within 24 hoursd.) Longer than 30 days
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Time is Money
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Real World Example
Time is Money
New York City has a housing shortage• Only 10% of the demand can be serviced
by the supply• Housing resources are therefore
competitive• Hospitals and Payors must develop
relationships to secure resources for their patients
• You must develop a direct line to services
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You Need INFRASTRUCTURE
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THE SOLUTION:A COMMUNITY COORDINATEDCARE NETWORKAccountable, inter-connected networks of clinical and non-clinical social services addressing ALL social determinants of health
Process Documented
Process followed and automated
Process Metrics Measured
Continuous Improvement
Regressive Repeatable Consistent Quantitative OptimizingUnrepeatable &
ReactiveFunction
Dimension
Opportunity: Creating value for community providers
Opportunity: Holistic view of patients needs
Opportunity: vibrant interconnected community model
Opportunity: Real-time data;Patient & community
Opportunity: Elimination of avoidable spend
Community Engagement
Patient Journey
Technology Infrastructure
Data/Reporting
Return on Investment
Little to none, providers unaware
of their involvement
Transactional
Resource Directories, Heat Maps, manual
follow-up
Freshness of Service Provider Data &
Searches of Service Providers
Unrepeatable & Reactive
Community organization
buy-in, intakes & workflows defined
Community providers measuring success & recruiting
others
Real-time capacity updates, best
practices, & multi-provider service
Patient Journey defined and consent process established
Community organization
buy-in, but no technology yet
Process Documented
Target Population Identified and initial community partners
engaged
Process followed, automated, data
updated in real-time
Process measured, gaps identified,
recruitment initiated
Predictive Analytics
User adoption measured, SLA’s
met, external integrations initiated
Majority of external systems integrated
via API infrastructure(EHRs, SFDC, etc.)
Machine Learning optimizing community workflows
Patient journey is empowered to
manage their own care
Patient journey is predictable based on
presented needs
Patient journey is trackable end to end
(clinical and non-clinical)
Driving Policy Change and SDoHReimbursement
Economic models defined and
expansion plans implemented
Resource Directories Community Engaged Pilot Coordination Care Coordination Predictive Care
Community engagement
measured
Quantifying financial impact; reducing ED visits & readmissions
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Population Health – Maturity Model
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3rd Polling QuestionPopulation Health Maturity Model, what stage are you?
a.) Resource Directoryb.) Community Engagedc.) Pilot Coordinationd.) Care Coordinatione.) Predictive Caref.) Hey remember me, I’m just here to learn!
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Start Small
Practical Implementation ModelWhere Do You Start?
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Practical Plan• Select a Population• Identify Community Partners,
gain buy-in and deliver value. • Technology partner
• Deploy technology infrastructure (Not EHR)
• Drive Community Ownership
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Select a Population• High-Need Adults• Military Veterans• Medicaid enrollees
• Vulnerable populations have co-occurring needs
• DO NOT SELECT JUST A SERVICE CATEGORY
Data:2009–2011MedicalExpenditurePanelSurvey(MEPS).Source:S.L.Hayes,etal.,High-Need,High-CostPatients:WhoAreTheyandHowDoTheyUseHealthCare?TheCommonwealthFund,August2016.https://www.oecd.org/health/ministerial/policy-forum/David-Blumenthal-Presentation-OECD-Health-Forum-2017.pdf
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IDENTIFY COMMUNITY PARTNERS
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Going Against the Grain, Less is More
• Quality vs. Quantity - you don’t need 1,000s of providers
• Start with an engaged group that all share the same goal
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First, meet community providers where they are…
Technology Infrastructure
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• Patient-centered• Consent Process• Data Reports
Technology Infrastructure
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Patient-Centered
• Philosophical decision? Referrals or Patient
• Duh, provide a holistic view of Patient Journey
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2/12: NCDVMA called to
refer client. File opened.
2/18-2/19: In need of
emergency housing.
Connected to HUD-VASH.
3/3: Reserved bed on
Veteran side of Men's
Shelter.
4/26: Referred to
Community Link.
5/10: Permanently housed
using HUD-VASH voucher.
7/13: Received funds to
move into unit. Case
closed.
2/12 — 7/13HOUSING
4/12: Employment Case
created.
4/21: Case referred to
Goodwill.
5/11: Case closed: unable
to contact.
10/19: Case reopened
and referred to
Goodwill.
4/12 —10/19 EMPLOYMENT
2/24 — 9/26 HEALTHCARE
2/24: Case created.
Enrolled in VA
Healthcare. Referred to
DSS for food stamps and
local food bank.
Requests new EBT card.
4/5-9/26: NCServes
worked with VA staff to
connect Veteran to
Mental Health Services.
9/26: Case closed.
10/10HOUSEHOLD GOODS
10/10: Case for
furniture request
for clients house.
7/14: Request for
assistance with
utilities.
7/25: Closed. Referred
out of Network.
7/14 — 7/25UTILITIES
4/12 —10/25BENEFITS
4/12: Case created.
Peer Support
Specialist has
Veteran's DD214.
5/24: Case closed.
10/25: Case created to
appeal VA denial for
compensation.
Client’s Total Health Journey
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Correlations in Service Requests - Trends
HEALTHCARE
61%EMPLOYMENTHOUSING
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Consent Process – Mitigate Risk
• Without patient consent, providers are not able to coordinate effectively
• Value for the patient
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Reporting Is Not...
Superficial Data:• Number of Searches• Freshness of Data• Free-text Outcomes• Heat Maps
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Reporting Is…
Meaningful Outcomes:• Patient journey• Timeliness• Effectiveness• Efficiency
CLIENT HEALTH PROVIDER
Tom needs assistance. Sue is a clinical provider and identifies Tom has additional
needs.
As Tom receives care, Sue works with Tom’s new “care team,” receives updates in real-time, tracking 100% of outcomes.UNITEUS.COM
With consent, Sue uses Unite US to refer Tom to multiple
community partners.
How it Works
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Final Thoughts Through our Learnings
ü Population Health is a long-term plan
ü To drive effective coordination & outcomes, clinical and non-clinical services need to be interconnectedü Get Tactical
ü Choose a technology partner, not a vendor or tool
