Population Health Management Defined

April 12, 2015

TIM MIKSCH, SECTION HEAD, APPLIED CLINICAL INFORMATICS

The Mayo Clinic

CLAUDIA BLACKBURN, SENIOR MANAGER

Aspen Advisors, Part of The Chartis Group

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest Disclosure

Tim Miksch, MBA

Has no real or apparent conflicts of interest to report.

Claudia Blackburn, MBA

Is employed by Aspen Advisors, Part of The Chartis Group, which provides services that are discussed as a part of this presentation.

© 2014 HIMSS

Learning Objectives

• Identify how to align an organizational healthcare model with a value-based reimbursement model to support the allocation of resources for high risk patients

• Explain definitions and concepts associated with Population Health and Population Health Management

• Summarize the role of analytics in developing and evaluating programs and processes

• Identify where your organization is on a Population Health Management (PHM) maturity roadmap

PHM Core

Competencies

Case StudyChallenges and Next

Steps

An Introduction to the Benefits Realized for the Value of Health PHM IT

http://www.himss.org/ValueSuite

Population Health Management (PHM)The Future of Healthcare Paradigm Shift

Today:Reactive andVolume-based

The Future:Proactive andValue-based

Drivers

Health Reform

Affordability Gap

Triple Aim

Weight of the Nation

Reimbursement

Encourageme!

Educateme!

Treatme

holistically!!

I will payyou!

Individuals are accountable for their health with the health system as their health advocate.

Population health management provides comprehensive

authoritative strategies for improving the systems and

policies that affect health care quality, access, and outcomes, ultimately

improving the health of an entire population

Engaged Communities • Proactive care processes• Identified patients• Focused on wellness• Community resource navigator

Engaged Patients• Identified and incorporated

patient goals• Focused on continuity and

coordination• Facilitated communication

channels• Improved access to care

Identified Opportunities to Reduce Waste• 4 Rights• Duplication avoided• Improved coordination/transitions• Used automation to reduce resource needs• Improved screening and prevention• Aligned incentives to drive value

7

Achieving SuccessMaking the “Triple Aim” Possible

Better Health for the

Population

Population Health Management Core Competencies and Key Pillars

Population Health Management (PHM)Core Competencies

The goal of population health is to transform care delivery practices and administrative support to deliver improved outcomes and lower costs across the continuum of care for a specified population. Success will depend on changes in care practices, business processes and cross-organizational communications, all supported by information technology.

Member Engagement

Cross-Continuum Care Delivery and Medical / Care Management

Quality Outcomes Management / Reporting

Operational Performance Management and BI

Accounting

Integration and Infrastructure

Key Pillars of Population Health Management

Workflows, role changes, people, care coaches,

wellness program development, heath risk

assessment process, population engagement

Business vision, population definition,

policies, modeling, financials, contracts, procedures, market analysis, and value

proposition

Integration and interoperability

including HIE, patient portal, analytics,

coaching tools and health risk assessment

Risk, incentives, payment management,

shared savings

Mayo Community Practices

MAYO CLINIC in the MIDWEST Community and Regional Health System75 communities in MN, IA and WI

• 4 regions

• 18 hospitals

• 525,000 patients/year

• 1,000+ physicians

Primary care

At risk for PC

Arizona

• 90,000 patients/year

• Approx. 400 physicians

Primary care

At full risk for PC

MAYO CLINIC in the SOUTHWEST MAYO CLINIC in the SOUTHEAST

Florida

• 90,000 patients/year

• Approx. 400 physicians

Primary care

At full risk for PC

Academic Medical CenterRochester, MN

• 500,000 patients/year

• 2,000 physicians

• 125 primary care providers

Primary care

At full risk for PC

Office of Population Health Management• Formed in 2012

• Developed a Mayo framework for PHM

– Strategy

– Phasing

– Oversight

– Coordination

– Standardization

• Focused on the community practices

• Initially focused on primary care

• Value-based care

– Patient-Centered Medical Home

– Risk based reimbursement

The Changing Market

2010 2015 20200%

20%

40%

60%

80%

100%

Fee-for-service

Episode care

Condition-based care

Partial population care

Full population care

Source: “The View from Healthcare’s Front Lines: An Oliver Wyman CEO Survey”

WHAT? MMoCC is an enterprise-wide, multi-year roll-out to achieve the TRIPLE AIM:

• Improve Population Health• Improve Individual Experiences• Lower Costs

While aligning with financial models

Changing isn’t just for survival

The new model allows us to thrive

The Mayo Model of Community Care (MMoCC)

Implemented in strategic phases

WHO?Office of Population Health Management(OPHM)

Created by MCCPC to TRANSFORM Community Care

OPHM establishes the STANDARDIZED ELEMENTS for clinics to implement with APPROPRIATE LOCALIZATION

A new way of practicing is needed

OPHM defines strategy for the new model

Costs are rising

Reimbursement is decreasing

The measure of PRODUCTIVITY is no longer VOLUME

It is VALUE =

Small changes are not enough

Outcomes + Service Cost

Our survival is at risk

WHY?

VisionPatient centered, integrated care delivery modelbased on:• Aligned incentives• Coordinated, collaborative processes • Evidence-based prevention and disease

management protocols• Seamless sharing of information

Supported by wellness and continuity care programs that focus on:

• Patient engagement

• Community integration

• Prevention and health promotion

Driven by analytics to support quality outcomes and value-based accountable reimbursement

Office of Population Health Management

Geographic Operations

Arizona Office

Florida Office

Midwest Office

Functional Subgroups

Change Mgmt./ Communications

Data Analytics

IT Tools and Application

OPHM Advisory

Group

Programs

Prevention

Community Engagement

Wellness

Care Coordination

Chronic Condition Management

Palliative Care

Care Transitions

Team-based Care

Patient Engagement

Access

Health & Wellness Continuity Care

Executive Team

Mayo Clinic Clinical Practice Committee

MMoCC Focus Areas

50% 15%

35% 35%

15% 50%

C O S T

% of communityP O P U L AT I O N

•Wellness•Prevention

• Disease Management

• Care Coordination

• Care Transitions• Palliative Care

P H M F O C U S

2010 data from Mayo Clinic Health Sciences Research

Care teams

Patient engagement

Community engagement

Access

MMoCC Impact

80% of costs

Lifetime

Abi

lity

to im

pact

Complexactive illness

Symptomaticillness

High riskEarly riskSituational risk

• Family Hx• Environment

• Diet• Exercise

• Cholesterol• BP• Blood sugar

• Active Dz• Diabetes

HEALTH STATUS

HEALTH CARE SPEND

Act on opportunities

Identify opportunities

ASSESS STRATIFYPopulation Identification Health Assessment Risk Stratification Enrollment / Engagement Strategies Management / Interventions

1DEFINE

2 3 4ENGAGE

5MANAGE

Tailored Interventions—

Care Coordination—

Disease / Case Management—

Health Risk Management—

Health Promotion / Wellness

Meeting patients where they are

…physicallyhome | school | work | shopping | in the clinic

…in the way that works best for thememail | text | internet | phone | video | face-to-face

MMoCC Process

Phased Implementation

MMoCC 2Laying the foundation while

living in FFS

• Introduces value-based (TCOC) concepts and model (change management)

• Emphasis on team-based care foundation and care coordination introduction

• Standardized disease management and prevention recommendations

• Focus on decreasing high utilization where it makes sense (30 d readmits…)

MMoCC 4Requires value-based contracts to succeedMMoCC 3

More site resource investment – mixed

volume/value

• Shifts from individual practice to team-based panels

• Continues focus on high utilization and expanded analytics and care management

• Increases focus on patient important outcomes

• Strong shift to total cost of care drivers

• Adds specialty integration to care team concept

• Community engagement

• Full alignment of incentives

Diffusion Timeline

MMoCC Limited Implementation 2013 2014 2015 2016

MMoCC Previous

MMoCC 2 Foundation

MMoCC 3 Mixed

MMoCC 4 TCOC

PILOT 4-6 Sites

2015 Status

• All sites are actively engaged

• Standardizing across sites and regions is a challenge

• For many, fee-for-service remains a driver

• Data management processes are maturing

• Keys to our success:

– Engaged leadership at local levels

– Institutional support

– Strong physician leaders in each program

– Excellent business analysis, project management and informatics support in place

Demand for healthcare

Supply of resources to meet demand

VALUE = Outcomes + ServiceCost

Our pay will be based on

We need to utilize our staff wisely through

Identify opportunities to impact health earlier and act on those opportunities

We need to think differently about how to activate our patients and communities

And how we interact with them

TEAM-BASED CARE

ANALYTICS CARE MGMT SYSTEMPREVENTION DISEASE MGMT

PATIENT ENGAGEMENT COMMUNITY ENGAGEMENT WELLNESS

ACCESS PALLIATIVE CARE CARE TRANSITIONSCARE COORDINATION

Structure

Analytics and Reports Examples

Report DescriptionRegistration• Unassigned and wrongly assigned patients• Unassigned Emergency Department high utilizersCare Coordination• Diabetic Mellitus (DM) patients who are most likely to be readmitted

• Congestive Heart Failure (CHF) patients who are most likely to be readmitted

• 30 day readmission reports are located within the Care Coordination dashboard with DM and CHF 20%. Follow instructions from section 2.1 and 2.2

Patients by Disease Evidence Type• Patients with no Diabetes diagnosis but have other evidence of Diabetes• Patients with no CHF diagnosis but have other evidence of CHF

Example Use from Care Coordinators

• Care Coordinator identified a patient based on ER visits and reached out to her. She was very interested in COMPASS and did the PHQ9, and it was 17.

“She was very interested in changing her life so that she could be around for her granddaughter. I have sent her a letter and will keep her on my watch. It was a good connection to at least let her be aware that services are available if and when she is ready.”

• “I have a patient who, because of care coordination, has improved her health to move from the PHM tool CHF “most” to the “more” list. The PHM tool still identifies her as higher risk, but she has done well with care coordination.”

• “It mostly has been helpful to me to identify patient populations that might be eligible for care coordination to reach out to the providers to get them on board with care coordination, pointing out that the PHM tool has already identified them as being higher risk.”

2015 NEXT STEPSCHALLENGES

Challenges and Next Steps

• Practice standardization

• Resources – Can’t stop processes and can’t add

resources to change

– Needed to understand practice variation and standardize

– Informatics knowledgeable in in EMR support teams

• Challenge to implement tools to free up resources when processes and data aren’t standardized(IT, informatics)

• Rapid cycle iteration is challenging for practice tools without significant resource involvement

• Decision rights – “who says this is the new process….”

• Enterprise metrics

• Point-of-care registry and care management

• Patient consumer engagement utilizing EMR patient portal

An Introduction to the Benefits Realized for the Value of Health IT

http://www.himss.org/ValueSuite

Claudia BlackburnAspen Advisors, Part of the Chartis Groupcblackburn@aspenadvisors.net@cblack67

Questions?

Thank You!Tim Miksch The Mayo Clinictmiksch@mayo.edu@tmiksch