measure up pressure down: a team based approach

Copyright Geisinger Health System 2014

Not for reuse or distribution without permission

Measure Up Pressure Down: A Team Based Approach

Frederick J. Bloom, Jr. MD MMM Chief, Care Continuum Geisinger Health System

Heal • Teach • Discover • Serve Copyright Geisinger Health System 2014


Geisinger Health System Confidential and Proprietary

Topics for Discussion

Approach to population management

1

Advanced Medical Home Model 2

Care Management Model and staff support 3

Gap Analysis 4

Q&A 5




Population Management

Approach

Advanced Medical Home Care Management




Data Analytics: PM; Gaps in Care; Provider Profiling

Primary Prevention

Preventive Screenings Immunizations

Campaign Management Care Gap Closures

Health Alerts Patient Portals

Disease Management Self Management Education

Condition Screenings Symptom Monitoring

Medication Management - “Move to Control”

HTN, DM, Asthma, CAD, Osteo, Tobacco, Weight Management

Case Management Care Coordination Communication

Resources SMAP

End-of-Life/Life Planning Transitions of Care (TOC)

Telemonitoring HF, COPD, ESRD, Frail

Elderly

Population Management Approach

Well Complex

Conditions Chronic Conditions

Advanced Medical Home Team – Patient,

Provider, Payer

Behavioral Health

Hosp, ED, Specialist

Pharmacy, HH, NH

4




5 |

PRIMARY CARE REDESIGN IS THE FOUNDATION

OF POPULATION HEALTH IMPROVEMENT

Patient Centered

Primary Care

• PCP led team-delivered care, with all members functioning at “top of the license”

• Focus on consistent, high reliability care through systems of care approach

• Enhanced access, services guided by patient needs and preferences

• Enhanced member & family education & engagement

Value-Based

Reimbursement

• Fee-for-service with P4P payments for quality outcomes for 20-30% of total

compensation for PCPs and specialists

• Total cost of care (PMPM) targets

• Payments distributed on measured quality performance

Performance

Management

• Patient and clinician satisfaction

• Cost of care, utilization, efficiency

• All-or-none bundled quality metrics, unwarranted variation in clinical care

• Preventive services metrics

Medical

Neighborhood

• 360°care systems – SNF, ED, hospitals, HH, pharmacy, etc.

• Physician profiling, selective specialty/facility referral, transitions of care

processes, community services integration

• High value referral systems across full continuum of care

Integrated Population Health Management

• Population identification, segmentation and risk stratification drives team work

• Chronic disease & preventive care optimized with EHR, clinical decision support

• Case manager embedded directly within care team

• Automated interventions triggered by gaps in care, other needs




Hypertension Process Redesign

6

EHR • Plan Previsit – Huddle reports • Reminder Letters – Care Gaps Outreach

Clerical Clinic Nurse

Case Manager

• Scheduling of Testing, Follow Up appt. • Blood Pressure Follow-Up • High Intensity Coordination/Education

Nurses Providers

• Rooming Process, Process Measure Alerts • Alerts and Reminders for Complex

Decisions

Patients and Providers

• Patient Portal, Patient Report Cards

AUTOMATE

DELEGATE

INCORPORATE

ACTIVATE




Monthly Care Team Meetings

• Foundational to success

• Shared leadership

• Case review

– Missed opportunities

– Pattern recognition

• Workflow gaps and redesign

• Performance monitoring

• Review of patient ID reports & performance outcomes

• Care Team training

7




Care Approach by Patient Risk Status

8

Advanced Primary Care

• Practice redesign

• Automated prevention care gaps & interventions

• Health IT reinforces guidelines & best practices

• Patient education & activation

• Care team performance management meetings

Chronic Disease Care

• All of the above plus:

− Identify & stratify

− Self-management & education

− Close gaps in care

− Driving to goal

Concentrated Care

• All of the above plus:

- Embedded Case Manager

- Predictive analytics

- Transitions of Care

- Advanced clinical

management

- Care coordination

Well

At Risk

Chronic Complex




Population Risk Stratification

9

Health Management

Health Maintenance

RISK

MODEL High Risk

3%

Moderate Risk

27%

Low Risk

70%

Complex

Case

Management

Health Management

Health Maintenance

30 Patients

700 Patients

One targeted

chronic conditions

230 Patients

More than one targeted

chronic conditions

40 Patients




Staffing for Disease & Case Management

1

0

• Self management education & treatment

optimization

• Less complex, moderate risk

• RNs or health coaches for ongoing

monitoring, rx optimization, behavior change

• Caseloads 250 – 300 patients / HM

• 1 HM per 5000 – 10,000 lives

• Highest risk, complex co-morbid conditions • Care coordination and treatment optimization • Acute exacerbation management • RNs with CCM expected • Caseloads 125 – 150 patients / CM • 1 case manager per 1,000 Medicare; 5,000

commercial and 3,000 Medicaid lives

Health

Managers

DM

Case Managers Complex

CM

Additional staff include Social Workers, Care

Associates, Pharm D, Behavioral Health




Approach to Case Management

1

1

High risk

identification

Targeted

Populations

Comprehensive

assessment Team Care

• HF, COPD,

oncology

• Special

populations –

cystic fibrosis,

CP, MS, high

risk pregnancy

• Multiple trauma

• ESRD, frail

elderly

• TOC

• Predictive

modeling

• EHR data

• Medical claims

• Pharmacy data

• Health Risk

Assessment

(HRA) data

• Driving issue behind case

• Physical and psychosocial gaps

• Readiness to change

• Family/social supports

• Frequent follow-up with patient/family

• Daily interaction

with provider

• Active team

member

• Patient sees CM

in practice or

with specialist

• Pushes access

& exacerbation

management




Population Health Data Analytics




Data Enrichment Helps Drive Clinical Interventions

13

• Provider Data - Link different provider IDs for the

same provider

- Link location of practice and group

affiliations to provider IDs

• Patient Data - Link data for a given member from

different sources

- Attribute members to providers

- Stratify by financial and clinical risk

• Claims Data - Apply standardized pricing

- Apply third-party episode groupers

Data Enrichment

13




• Use advanced analytical techniques + clinical / care

management expertise to identify patients/opportunities to

focus on and associations between particular patient and

provider characteristics and particular outcomes - Construction of member and provider “profiles”

- Exploring use NLP to extract valuable information from unstructured

data in EMR and care management software

• Identification of specific, actionable

“gaps in care” - Design efficient gap closure pathways

• Provider profiling

– Disease Registries

- Quality of care

- Cost of care

• Reporting - Executive dashboards

- Clinical overview for CMO, other leaders

- Physician- and patient-specific profiles

Clinical Data Analytics

14




ID of Patients not at LDL Goal and Not on

Maximum Statin Therapy

Provider Profile

Patient Intervention Report

Prov01 PrimaryCareSite01






PrimaryCareSite01

PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 PrimaryCareSite01 15

15




Facilitated Referral to Hypertension Specialist

• Patient list obtained from EHR extract

– Systolic BP > 160 at last visit at selected clinic sites and no BP within goal in previous 6 months

• Clinical agreement that the health manager or Care Gaps team can reach out to schedule appointment with nephrology




Clinic Flow

– Each patient was seen 45 minutes with Nephrologist, 15 minutes with health manager

– All patients were given patient education information, educated on dietary measures, lifestyle modifications, appropriate exercise program

– All patients contacted initially weekly for BP results, with adjustments in medications as needed




Clinic Flow

– Once targeted BP achieved patients will be placed in monitoring plan • Twice daily BP/pulse for the first week of each month

for minimum of three months: then twice daily BP/pulse for the first week of the month every 2 months

– At 2 month intervals patients were re-educated on lifestyle modifications • Diet

• OTC medications

• Aerobic exercise

• Smoking cessation




Infrastructure Support

• Marketing materials for patient developed

• Guiding expectations for case managers and health managers developed

• Phone script for schedulers enhanced – incorporated into EPIC

– EPIC encounter sent to me on scheduling contacts with patients

– Weekly update on status of patient scheduling




Infrastructure Support

• Biometric Home Monitors obtained and available for use

• Health Managers and Providers trained on new workflows

• Monthly database being generated by Innovations and reviewed for suitable additional patients




HTN from 1/2011 – 3/2014




Making Progress to Goal

22 |

Number of

HTN PatientsControl

<140/90

Male

Age 18-64 14,489 76%

Age 65-85 12,287 79%

Female

Age 18-64 12,308 80%

Age 65-85 15,344 77%




Questions?

[email protected]

23 |

measure up pressure down: a team based approach

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