building resilient multi-channel care delivery for vbc
TRANSCRIPT
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Chief Analytics Officer, Castell
Andrew Sorens on MHCDS
DISCLAIMER: The views and opinions expressed in this presentation are solely those of the author/presenter and do not necessarily represent any policy or position of HIMSS.
William Daines MDMedical Director, Castell
Building Resilient Multi -Channel Care Delivery for VBCSes s ion 230, Augus t 12, 2021
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Welcome
Medical Director, CastellWilliam Daines MD
Chief Analytics Officer, CastellAndrew Sorens on MHCDS
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Andrew Sorenson MHCDSHas no real or apparent conflicts of interest to report.
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Conflict of Interest
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William Daines MDHas no real or apparent conflicts of interest to report.
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Conflict of Interest
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Agenda
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• Castell background• Creating Success in Value-Based Care• Data platforms and transformational analytics• The How: Creating tools and services• Data Meets Clinical Support: Care Traffic Control• Results & Key learnings• Q&A
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Learning Objectives
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• Identify critical requirements for implementing a data platform to support current, planned, and unanticipated value-based use cases
• Design a transformational analytics capability that makes work efficient and enjoyable, offers recommendations on best next steps instead of just recording the past, and provides useful, personalized performance information
• Explain the Care Traffic Control model Castell implemented to stitch together the continuum of care and drive the transition to value
• Explain how Castell’s resilient infrastructure and organizational agility enabled a rapid pivot in focus
• Assess reasons to accelerate a move to multi-channel care delivery
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The Evolution of Population Health at Intermountain
Castell builds on more than 10 years of learning
2010Shared Accountability
2016First phase of affiliated physician engagement
2017Intermountain Re-Structure
2018Reimagined Primary Care
2019Launch Castell
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Castell At a Glance
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Mission
Help people live the healthiest lives possible
Grow aligned lives through value-based care
Perform clinically and financially in value-based care
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Key objectives
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Castell At a Glance
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3 states
Multi payer value-based relationships
Custom data/analytics platform
Intermountain Healthcare’s Population Health Platform Company
UTID
NV~900klives under management
~$4 Billionin value-based care arrangements
860Employed providers
840Affiliate providers~350
employees
Full spectrum of value-based care arrangements
CMS BPCI Advanced
Medicare Shared Savings
Medicare Direct
Contracting
Managed Medicaid
Individual ACA CommercialMedicare
Advantage
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Creating Success in Value-Based Care
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Mutual Success Requires
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Aligned Incentives
Knowledge of the Patient
Empowered and Informed
Care Teams
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How Population Health Reporting Has Felt
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Retrospective and significantly lagged
Minimal predictive capability
Minimal visibility from macro to micro
Inaccurate, incomplete
One dimensional view of the patient
No “next action” identification
No one empowered to act
Another report on a stack of reports
All problems, no solutions
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How We Redesigned Population Health Reporting
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Created with patient and care team success in mind
Current and in-time
Predictive
Connected from macro to micro
Accurate and complete
Whole-patient oriented
Tied to clinical workflows that deliver value
Supported by workflows and personnel
Connected to daily clinical work
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Data Platform and Transformational Analytics
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Transforming Raw Data Into Actionable Insights
RAW DATA
DATA AGGREGATION
Collect and validateEHR, financial, SDoH,
network and other data from across the
enterpriseDATA CURATION, HARMONIZATION
& ALIGNMENT
Normalize, cleanse and map complex
unstructured data sets into useable data
DATA ENRICHMENT
Enrich and transform data to support quality
analysis, predictive analytics, and risk
calculations. Out-of-the-box algorithms and Castell’s proprietary
algorithms.INSIGHT DELIVERY
Surface expertly-derived insights within existing
workflows and allow for ad-hoc inspection
STAKEHOLDERS & END USERS
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UNLOCK AND INTEGRATE
DATA
Data from Insurance companies
Social Determinants of Health
Electronic Medical Record
Provider
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Enrich the Data
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Process data to make it meaningful
Establish relationships among data elements
Run data through predictive models and other algorithms
• Apply standard rules and ontologies
• Utilization Groupings
• Attribute patients to providers, providers to clinics, clinics to regions, etc.
• Apply both out of the box algorithms as well as Castell’s proprietary predictive models• Prioritizing engagement
opportunities
• Assessing organizational opportunities and issues
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Deliver Information and Insights with Analytics Tools
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Tools for Executives
Tools for Care Teams
Tools for Providers
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Tools for Executives
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Tools for Care Teams
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Workflow Tools for Providers
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Point of care analytic insights
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Data Meets Clinical Support:Care Traffic Control
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How “Bedside" Population Health Has Felt
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Providers are not pop health experts
Clinic caregivers are overburdened
Pop health conversations were sporadic and reactive
Pop health conversations add work to providers and caregivers
Good intentions lacking know -how and resources
No connection between pop health metrics and clinical vital behaviors
No one watching a clinical team's pop health "blind spots"
No one offering a menu of solutions
No one is helping me and my clinical team succeed in pop health
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How We Redesigned “Bedside" Population Health
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Create a population health support ecosystem
Providers supported by a dedicated, knowledgeable pop health team
Involve clinic caregivers, but also take work off them
Regularly scheduled pop health discussions ("huddles")
Constant surveillance of "blind spots"
Pop health metrics and clinical care behaviors connected meaningfully
Offer a menu of solutions to complicated clinical problems
Provide eyes, ears and hands to succeed in pop health
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Care Traffic Control
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Care Coordinator• Collaborative care plan development and
support• Comprehensive psychosocial assessment
and support• High risk transition management• Chronic disease support• RN or SW focused on highest risk patients
• Preparation of population health huddles• Pre-visit planning• Care gap closure • Social determinants of health support• High value outreach and scheduling• Administrative support for transitions, high
value referrals, mental health coordination• Lay personnel focused on low-risk patients
Care Manager
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Bringing Insight to Providers and Care Teams
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Data/Analytics Platform
Huddle Preparation
Value-Based Care Huddles
Workflow -based Tools
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Data/Analytics Platform
Huddle Preparation
Value-Based Care Huddles
Workflow -based Tools
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Data/Analytics Platform
Huddle Preparation
Value-Based Care Huddles
Workflow -based Tools
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PATIENT AND CARE
TEAM
Practice Transformation
Care Pathways
Network Engagement
Care Traffic Control
Post-Acute Care
Coding and Documentation Support
Care at Home
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Covid Wellness Calls• Early in the pandemic, Castell supported high risk patients in need
• Executed a patient-support outreach process across our service area
Hospital Level Care at Home• Rapidly deployed capabilities in multiple geographies to offload hospitals
Affiliate Clinic and Rehabilitation Facility Support• Provided PPE and enhanced clinical support across our network
A Solid Platform Enables Rapid Pivots
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A Solid Platform Enables Rapid Pivots
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COVID Vaccine Support
Castell was tapped to provide
text-message-based outreach to
patients
Initiated text messaging
campaign months faster using Castell platform than was
possible with legacy infrastructure
Outreach to 1.1M patients in March and
April
Roughly 20% of messages sent
resulted in a visit to scheduling site
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Results and Key Learnings
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Reimagined Primary Care: 2020 Current State
$9.40 PMPM savings vs FFS network providers
RPC panels 58% higher risk (RAF)
Financial Success
2020 Performance
>1 year in RPC: 40% higher quality score
Marked improvement in coding and documentation
Clinical Success
Quality
PG Caregiver Engagement:>1 year in RPC: 98th Percentile
Non-RPC: Bottom decile
Caregiver Experience
Experience
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Key Learnings
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• Analytics must be clinically relevant and clearly actionable
• The entire human network is critical to success
• Organizational agility is enhanced by a sound technological infrastructure and strong partnerships
• Patients will increasingly demand that healthcare is delivered in a way that is tailored to their preferences. Healthcare organizations need to adapt quickly to deliver care in this way or they risk disruption.
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Questions
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Thank you!
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Andrew Sorens onMedical Director, Castell
William Daines , MD
Chief Analytics Officer, Castell