maryland association of healthcare executives...
TRANSCRIPT
Maryland Association of Healthcare Executives presents:
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Today’s Expert Panel
Moderator:
Michael Cetta, MD FACEP, Chief Strategy Officer US Acute Care Solutions
Charles W. Callahan, DO, Vice President Population Health, University of Maryland
Lynell Medley, Vice President Programs Healthcare Access Maryland (HCAM)
Joseph Meyers, Chief Strategy Officer St. Agnes Healthcare
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Overview of the issue by Dr. Callahan
Maryland Association of Healthcare Executives presents:
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Population Health – The Third Revolution:Capital and Lower Case “P”
Chuck Callahan, DO, FAAPVice President, Population Health
University of Maryland Medical CenterBaltimore MD 21201
Healthis a human right.
Basic assumptions::
Population healthis a strategic problem.
Basic assumptions::
Medicine is intrinsically tactical.
Basic assumptions::
Public health:efforts to assure conditions where
people can be healthy.
Population health:the health outcomes of a group of
individuals.(Includes the distribution of outcomes
within the group.)
Basic definitions::
“What is the optimal balance of
investments (e.g., dollars, time, policies) in the multiple determinants of health
(e.g., behavior, environment, socioeconomic status, medical care,
genetics) over the life course that will maximize overall health outcomes and
minimize health inequities at the population level?”
Kindig D. Understanding Population Health Terminology. Milbank Q. 2007.;85:139-161
Why now?
Basic questions::
Value = Outcome / Cost
Need for Population Perspective
World Health
Organization
2000
USAGlobal
Ranking:
37th
http://www.who.int/whr/2000/en/whr00_en.pdf
Behind Colombia, Chile,
Costa Rica & Cyprus
2013
Life Expectancy at Birth
68.4 years
Under One Mortality
15.4 / 1,000
Under One Mortality
1.5 / 1,000
Life Expectancy at Birth
84 years
Poppleton vs. North
Baltimore/Guilford
2015 Data
7 miles apart
http://bniajfi.org/
“All models are wrong…
but some are useful.”
George E. F. Box
First Revolution:
Communicable Disease
Lester Breslow, MD“Breslow Third Revolution in Health”
First Revolution:Communicable Disease
1882
19431935
Second Revolution:
Non-communicable Disease
Lester Breslow, MD
Second Revolution:Non- Communicable “Chronic” Disease
Second Revolution:Affluence and Chronic Disease
Third Revolution:
Building health*
Lester Breslow, MD
*More than just the absence of disease.
“Am I well?”
AssureInsure
RestoreWell-being
Ecology of Health Care:The patients aren’t “in” the hospital
9 inpatients vs. 330 outpatients 1000/month
Green LA et al. The ecology of health care revisited. New Engl J Med 2001;344:2021-2024.
Where Health Decisions Happen
Baltimore:ER:
60/1000/monthHospitalization:
15/1000/month
UMMC Approach to Patient PopulationsUpdated HSCRC Risk Definitions December 2016
Midtown Campus
University Campus
“BED’D ENC”
“Bedded Encounter”
(Inpatient or observation
hospital stay.)
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A Simultaneous Approach:
small “p” and capital “P” Population health
population health (small “p”)• Peak of the pyramid
• Health & well-being of population affects healthcare institution
• Short-term imperatives and ROI
• Requires investment in the healthcare system
• Healthcare system-based interventions and metrics
• Seen through the lens of the healthcare provider
• Tendency to be “pejorative”
Population health (capital “P”)• Base of the pyramid
• Healthcare institution affects health & well-being of population
• Long-term imperatives and ROI
• Requires investment in community
• Community-based interventions and metrics
• Seen through the lens of the healthcare recipient
• Tendency to be “restorative”
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Inpatient / Emergency Care
Patient-Centered Specialty Care Practice
Patient-Centered
Primary Care Medical Home
Population Health and the
“Three Block” Medical Neighborhood
1.
3.
2.Specialty Care
Primary Care
hospital Care
Home
Family
Community
Schools
Congregations
Transitional Care
Coordination (TCC)
Connect &
coordinate
home
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Inpatient & Transitional Care Coordination
Complex Specialty-Based
Chronic Disease Management
Primary Care
Well-Care
Chronic Disease Management
Specialty Care
Primary Care
hospital Care
The “Cross Sectional” ApproachTendency to Focus on the Capital “P”
• Housing
• Health literacy
• Transportation
• Employment
• Communication
The “Universal” ApproachApproaching the Lower Case “p”
Impact of the Social DeterminantsApproaching the Lower Case “p”
Dru
g-F
ree H
om
e
Marital Support
Fair
Housi
ng
Meanin
gfu
l W
ork
Living Wage
High School Diploma
Health Literacy
Lit
era
cy
Stu
dy S
kills
Pro
ble
m S
olv
ing S
kills
Parenting Mentors
Good p
are
nti
ng
0-3 Programs
Preschool30 Million Words
Smoking Cessation
Developmental Milestones
Well-child visitsImmunizations
Reading
Adequate
Incom
e
Em
plo
ym
ent
Family
CommunityThe C
hance t
o S
erv
e
Faith
Vocati
on
Hobbie
s
Healthy Weight
EtOH in Moderation
Tobacco F
ree H
om
e
Vitamins
Good Sleep
Musi
cSport
Em
oti
onal
Inte
llig
ence
Nutritious Food Fresh Food
Aerobic Exercise
Parenting Classes
Traum
a-F
ree
Reproductive Health
Fin
ancia
l Acum
en
Hope
Justice
Rest
Relaxation
True F
riends
Vid
eo M
odera
tion
Safe
Neig
hborh
ood
Civ
ic-S
ense
Play
Health and Well-Being
Educational Success
Good B
ody Im
age
Safety
Ability to Dialogue
Violence Prevention
Honor
Good Public PolicySecure Attachment
Equal Opportunities
Self
-Dis
cip
line
Support Systems
Housing
TransportationH
igher-
Educati
on
Vocati
onal Tr
ain
ing
Greenspace
Access
to N
atu
re
Culture
Environmental SafetyWater
Fruits & Vegetables
Healt
hcare
Access
BaltimoreVisits
Integrity
Healthy Delivery
Pre
nata
l
To love and be loved…
…longitudinal approach
Com
munic
ati
on/In
tern
et
Population healthis a strategic problem.
Basic assumptions::
Horst Rittel, 1973
• No definite formula
• No stopping rule
• Many players
• Solutions “good or bad”
not “true or false”
• Unpredictable
• Unique
• Problem symptom of
another problem
• Complex
• Ambiguous
• Uncertain
Population health is a strategic problem:
Solution requires:
Basic conclusions::
…coordinated, integrated care,
one person at a time.
“…to leave the world a better place,
whether by a healthy child,
a garden patch or a redeemed social condition;
to know even one life has breathed easier
because you have lived,
this is to have succeeded.”
Ralph Waldo Emerson
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Introduction by Lynell Medley
Facebook: /HealthCareAccessMaryland Twitter: @hcamaryland Website: www.hcamaryland.org
HealthCare Access Maryland
Lynell Medley, RN, VP, Programs
HCAM’s History
501-C3 established in 1997
Overseen by a committed, diverse board of directors
HCAM plays a critical role in strengthening Maryland’s health care delivery system
Funding from both Public and Private Sector
200 Total Employees/ $18M Budget
Serve 145,000 people per year
Experienced and Tenured Management Team/Staff
Experience with health insurance enrollment and system navigation
Care coordination focused on social determinants of health
Core Services
Eligibility/Enrollment
System Navigation
Case Management/Care Coordination
Public Policy and Advocacy
Social Determinants of Health
Job Readiness
Recovery Support
Health Insurance
Legal Assistance
GED
TCA, Food Stamps
Transportation
PCP
Mental Health Services
Our Model
Assess Identify Develop
Care Plan
Refer Follow
up
Programs
• Connector: Baltimore City/County, AA County, Howard, Carroll, Frederick
• Eligibility Unit for Baltimore City LHD
• Behavioral Health Outreach Programs
– Care Coordination (State, MDRN, BBI, Pregnant Women)
– Information and Referral Line
• Care Coordination Program (ACCU)
– Managed Care Organizations/PCP/OB providers
• Baltimore City Foster Care: MATCH
• Population Health Programs
– 911/Operation Care
– Hospitals : St. Agnes and West Baltimore Collaborative: University of Maryland, Midtown, Bon Secours and St. Agnes
Client Impact
The client is a 56 year old woman who often came to the ED for non-emergency reasons, such as a stomach ache. The Coordinator met with her in the ED and the client agreed to program services. Her goals were to obtain a new PCP and a home aide.
After initial enrollment, the client was unresponsive to follow up.
The coordinator was able to reestablish contact and the client now has a new PCP, receives pain management, and has a therapist. HCAM is in the process of obtaining a home aide. The client has been compliant with her appointments so far.
Prior to enrollment, the client visited Sinai’s ED 14 times within a 4-month period. Since development of a care plan, the client has returned to the ED only once.
Baltimore City
Thank You! Lynell Medley, VP Programs
HealthCare Access Maryland
201 E. Baltimore St., 12th floor
Baltimore, MD 21202
Phone: 410-864-2344
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Introduction by Joesph Meyers
POPULATION HEALTH JOURNEY
Saint Agnes HealthCare
F. Joseph Meyers
Chief Strategy Officer
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Business Proposition for Large P Population Health Profile of Medicare Spending in Maryland
Phase 2 of Maryland’s CMS Waiver will place hospital industry at
financial risk for Total Cost of Care (TCOC).
Business Case for Saint Agnes for Population Health
• Global Revenue Budget (GBR) = $440M
• Major volume increases in Bedded Care and ED following GBR.
• Potentially Avoidable Utilization (PAU) = 5,000+ admits (readmission & ambulatory sensitive conditions) and $60M+ charges.
• PAU Penalties = $4-7M annually.
• Waiver Progression Plan and shift to Total Cost of Care.
Population Health Journey for Little p to Big P
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Deg
ree o
f F
inan
cia
l R
isk
Degree of Patient/Provider/Community Engagement
Fee For
Service
Total Cost
Of Care
Discharge
Planning
Care Managers
Utilization Review
RN Navigators
30-Day Readmits
Patient Center
Medical Home
Community-based
Care Management
Transitions of
Care Programs
Strategic Partnership
Post Acute Providers
Strategic Partnership
Community-based Organizations
Global Revenue Budget (GBR)
Home *Saint Agnes
Medical Group
Saint Agnes Hospital
Skilled Nursing Facilities
Home Care
Acuity
E-visits
Community-Based Care Acute Care
Post-Acute Care
UMMS
Transitional Care Programs (CCC, COPD, CHF) Complex Care Management
Seton Imaging Center
Community-Based Physicians
Gibbons Commons
Transportation
Strategic Direction Vision Map – Creation of Integrated System of Care Current State
*Some care management in PCP practices
Total Cost of Care
Ambulatory Care Center(s)
Retail Pharmacy
Home Saint Agnes
Medical Group
Saint Agnes Hospital
Preferred SNF Network
Home Care
Acuity
E-visits
Community-Based Care Acute Care
Post-Acute Care
UMMS
Transitional Care Programs (CCC, COPD, CHF) Complex Care Management
Ambulatory Surgery Center
Seton Imaging Center
Community-Based Physicians
Behavioral Health
Wellness and Fitness
Gibbons Commons
Community-based Care Management
Transportation
Strategic Direction Vision Map – Creation of Integrated System of Care
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Moderated questions….
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Question #1
Patient attribution – how do we track and
manage the at risk population?
There are often several care providers –
who is ultimately responsible?
What technology has been successful?
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Question #2
What is the role of the health care systems
in populations health?
Should we expect our hospitals to address
housing and education needs?
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Question #3
What is a “high utilizer”? Who are we to say
that a patient is using too many resources.
Do we need to change our definition?
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Question #4
Integration of Baltimore City –
what have we learned?
How does East and West
Baltimore differ?
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Pearls of Wisdom