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Population Health Management, Access to Care and Patient Safety
COLLEEN KRAFT, MD HEALTH NETWORK BY CINCINNATI CHILDREN’S
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2
Faculty Disclosure Information:
In the past 12 months, I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) or provider(s) of commercial services discussed
in this CME activity.
I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.
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Learning Objectives
• Discuss the relationship between individual health, population health, and patient safety
• Provide tools and strategies for improving access and patient safety using population health as a framework.
• Share techniques for identifying populations where improved access could improve safety.
8/22/2014
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Population Health—not a new concept
"I swear by Apollo the physician, and by Asclepius, and by Hygeia and Panacea, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation ."
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Two of the daughters of Asclepius
• Hygeia = health, prevention of sickness, sanitation
• Public health
• Panacea = universal remedy, healing, treatment
• Personal health
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http://www.healthpolicyohio.org/wp-content/uploads/2014/11/WhatIsPopHealth_PolicyBrief.pdf
Population Health: Geography
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PHM Program Elements Population
Identification Health
Assessment Risk Stratification
Health Promotion and
Wellness Health Risk
Mgmt Care
Coordination & Advocacy
Care Mgmt
Program Outcomes and
Evaluation
Quality improvement reporting and feedback (loop)
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Population Identification
• Any inpatient admissions? • Inpatient and Emergency Department? • Primary Care practices who utilize your
hospital? • Specialty Care practices who utilize your
hospital? • Surrounding community
8/22/2014
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Population Distribution
% population
1%
35%
64%
Healthy
Chronic
Complex % expense
25%
70%
5%
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Patient Safety
population
inpatient
Inpatient/MH community
MH/Community
Healthy
Chronic
Complex
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Assess Stratify
Implement Solutions
Measure & Report
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Registry
• Database or spreadsheet • Contains fields
– relevant to the population – relevant to measuring quality of care
• More dynamic than periodic reports • Populate retrospectively or prospectively • Running/maintaining registry could be a hospital or
alliance/ACO function for associated primary care practices
8/22/2014
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Inpatient and SSEs
• Registries can organize: – Patient diagnosis – Risk for fall – Allergies – Cognitive capacity
8/22/2014
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Overview of serious safety events
• Serious reportable event (National Quality Forum)
• Never event (Agency for Healthcare Quality and Research)
• Sentinel event (The Joint Commission)
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Incident Reporting
• Majority of events are not reported through hospital incident reporting systems – Estimated 86% not reported – Staff misperception of patient harm – Staff reluctance to report – Nurses most often report events
• OIG estimates 27% of in-patients experienced at least one adverse event or temporary harm
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Incident Reporting
TYPE OF SYSTEM # OF HOSPITALS
WITH SYSTEM
General incident reporting system 189
Specialized incident reporting system 132
Infection tracking 98
Pharmacy or medication error tracking 43
Patient complaint tracking 40
Security issues 14
Harm to staff 7
Regulatory compliance 4
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Registries
• Allow for the denominator to be the number of patients;
• Serve as a reminder of patient concerns prior to a risk of a SSE;
• Reporting becomes part of the care of the patient and reportable on the registry;
• Leads to questions of “what happened” and “what can be improved”, supports a culture of safety
8/22/2014
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Building a Culture of Safety ERROR
ADVERSE EVENT
Huddle, registry review to prevent errors from being made in the first place Detecting and reversing
error before it causes harm
Repairing or minimizing the damage caused by errors that cannot be prevented or reversed
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Building a Culture of Safety “The single greatest impediment to
error prevention in the medical industry
is that we punish people for making mistakes.”
Dr. Lucian Leape
Professor, Harvard School of Public Health Testimony before Congress on
Health Care Quality Improvement
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Patient Safety
population
inpatient
Inpatient/MH community
MH/Community
Healthy
Chronic
Complex
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Care Management, Practice Partnerships, Data Sharing for Quality
ACTIVITIES THAT PROMOTE PATIENT SAFETY
Innovative Care Management
Practice Network Development and
Transformation
Data for Quality and Financial Management
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Care Management
• Most effective at the practice level • Face-to-face works best—relationships • Registry guides best practices • Care coordination and transitions most
important – Build in time for inpatient and outpatient care
managers to meet
8/22/2014
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• Measures – Patient Experience (Satisfaction) – Access to Care – Patient Function (ADLs, school attendance,
school performance, physical activity) – Quality/Evidence based guidelines – Cost of Care
Population health
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• Identify a population needing improvement • Define that population
– Patients with behavioral health disorders – Patients with chronic conditions (Asthma, BMI >95%) – Patients needing preventive care
• Measurement – Experience? – Function? – Evidence-based guidelines?
Population health and Access to Care
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• Registries – Preventive Care – Chronic Care Management
• Reports – Quality Metrics – Admissions, ED visits, Re-admissions
• Tracking – Huddle Sheet – Pre-visit planning
Tools of Practice-based population health
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Alina
• Third admission for status asthmaticus in 4 weeks
• Asthma is set off by fumes in her family’s apartment
• Family desperately wants safe housing
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Alina
• Team Alina – Inpatient Team – Nurse Case
Manager – Social Worker – Family
• Medical Legal Partnership
• Temporary Housing
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Population Health Management ACTIVITIES THAT PROMOTE THE PATIENT SAFETY
Practice Network Development and
Transformation
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HNCC and Community Physicians
• Health Network Practice Engagement – Practice Network Agreements – Accurate Attribution – Quality Incentives – Patient-Centered Medical Home – CCHMC inpatient/outpatient care manager
collaboration
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HNCC PCP Attribution Model Flowchart
No claims for member?
Select the MCO assigned PCP
Attribute member to this provider
Most recent 12-24 months of historical claims1 analyzed for specialties of Family
Practice, FQHC, Internal Medicine, OB/GYN, Pediatrician and RHC
With which provider has the member
had the most visits?²
1. Visits defined on the following page. 2. If there is a tie in number of visits the provider with the most recent visit is chosen.
Attribution Flow Diagram
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Year 1 – Payout Timeline
Tasks 2015 2016
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Generate Membership/Physician/TIN data
Q1 Data Q2 Data Q3 Data Q4 Data
Format Incentive Reports for distribution
Q1 Data Q2 Data Q3 Data Q4 Data
Audit Incentive Reports for distribution
Q1 Data Q2 Data Q3 Data Q4 Data
Submit Audited Incentive Report Documents to AP
Q1 Data Q2 Data Q3 Data Q4 Data
AP sends checks to the Practices
Q1 Data Q2 Data Q3 Data Q4 Data
Network Team deliver each Practice’s Report
Q1 Data Q2 Data Q3 Data Q4 Data
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2015-06
ourn
Patient Centered Medical Home • PCMH Improvement Team
established by CCHMC. • PCMH Coaches provide
consultant and coaching resources.
• Engaging “Early Adopters” to enhance our own learning.
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Patient Safety
population
inpatient
Inpatient/MH community
MH/Community
Healthy
Chronic
Complex
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http://www.healthpolicyohio.org/wpcontent/uploads/2014/11/WhatIsPopHealth_PolicyBrief.pdf
Beyond medical care
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Avondale
Nationwide
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Beck (2013)
CCHMC has 90+% of all asthma admissions in county
Quintile 1: • 18 admits among 29,000 kids • 0.6 per 1000 • 17% of pop’n with 2% of admissions Quintile 5: • 299 admits among 17,900 kids • 16.7 per 1000 • 11% of pop’n with 35% of admissions
Children in highest rate neighborhoods more likely to be exposed to bad housing, have a depressed parent, lack transportation, and live in poverty, compared to lowest rate neighborhoods
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Who are the critical partners?
• Home health care • Pharmacies
• Legal Aid Society • Public Schools
• Health Department • Community health workers
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Cincinnati Asthma Admissions and Neighborhood Asthma Hotspots
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Legal Aid Housing Cases Mapped Against Neighborhood Asthma Hotspots
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Addressing Housing with Legal Help
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CCHMC – CPS Partnership Journey
Foundation built on trusted partnership
Strategic Plan to Increase QI Capability
FY ‘13 • 5%
CPS School RN Trained in QI
• METHOD: 2 Teams in Rapid Cycle Improvement Class (120 days)
FY ‘14 • 40%
CPS School RNs Trained
• METHOD: 1 Team in RCIC Class 13
• CCHMC-CPS Pilot mini learning collaborative
FY ’15 • 100%
CPS School RNs Trained (n=50)
• METHOD: Summer School RN Boot Camp
• Increase Learning in how to promote a “Asthma Friendly School”
• Co-Led Community- CCHMC Team working
FY ‘12 • <1%
CPS School RNs • METHOD:
One-off project with 1-2 RNs
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Avondale
Beck (2014)
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Avondale
Beck & D. Jones (2014)
“Heat map” of building
code violations
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Avondale
CHOICE Buildings to be refurbished by The Community Builders
Beck (2014)
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Network of care
Figure. Collaborations between agencies serving children with complex chronic conditions. Acad Ped 2012
schools pharmacy
community health worker
Health Dept home remediation
Legal Aid
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Injury rate per 1000 children aged 1-4 years, 3 year average
Additional conditions Prematurity Grade 3 reading proficiency Mental health
Toward an integrated health and wellness approach
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Primary Care and ‘toxic stress’ interventions
• Move from Patient Centered Medical Home to notion of a Community Centered Health Home
• Community system of partnerships
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Social Determinants a Clinic Will Detect Maslow’s Hierarchy of Needs
Hunger; homelessness; denial or delay of benefits;
utility shut offs
Domestic violence; mental health issues; inadequate education
services
Overwhelmed new parents; lack of
parenting role models
Unemployment; lack of high school degree;
ex-offender reentry issues
Potential Collaborations
Achieving potential
Esteem & Respect
Belonging
Safety
Basic Human Needs
A. Henize (2013)
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EHR social history screening
Benefits
Housing
Depression
Domestic Violence
All others
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Lessons
• Vision – change the outcome AND close the gap • Population denominator approach
– Otherwise great silos, lousy outcomes – Measurement and analytic capacity
• Effective network of partnerships – Span missions, but also operations, data
• Building improvement capacity – health care culture, capacity to bridge – community capacity for QI, EHR/measurement
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Thank you!
• Questions
8/22/2014