population health management: integration of process ...v. alue. b. ase. c. are. f. oundation. data...

Population Health Management:Integration of Process & Technology

1

CNYCC Annual MeetingNovember 6th, 2017

CNYCC Population Health Management Approach

Introduction

Delivery System Transformation

Preserve and transform the State’s fragile health care safety net system and prepare providers

for Value-Based Payment

VBP

Improve health outcomes and reduce avoidable

readmissions and emergency department

visits by 25%

Performing provider system (PPS) promotes

community-level collaboration and

Integrated Delivery of Services

IDS25%

DSRIP - GoalsTHERE ARE THREE PRIMARY OBJECTIVES OF THE DSRIP PROGRAM

Performance Management• Knowing the patients for which we have clinical and financial accountability• Scalable monitoring of utilization, quality and cost metrics •Generating actionable insights

Coordinated & Informed Service Delivery•Collaboration to facilitate transitional care and complex care management• Knowledge of a patient’s care team and their interactions with shared patients•Unifying efforts across the care continuum, as well as community based and social

services

Patient Centered Approach• Proactive identification and management of a patient’s unique clinical, social and

behavioral risk factors•Outreach and interaction with patients to ensure they are informed and engaged

in their care

DSRIP - GoalsIMPROVING OUTCOMES, INTEGRATING SERVICE DELIVERY AND PREPARING FOR VBP ALL HAVE

COMMON THEMES

CNYCC PHM Approach: OverviewPERFORMANCE MANAGEMENT, COORDINATED & INFORMED SERVICE DELIVERY AND A

PATIENT CENTERED APPROACH ARE ALL ENABLED THROUGH POPULATION HEALTH MANAGEMENT (PHM)

A strategy to provide a new model of care

An integrated infrastructure of people, process & technology

Delivery of evidence-based & consensus care to patients with complex clinical, social and behavioral needs

What is

PHM?

What does PHM

Require?

What Does PHM

Enable?


Process Overview

Managing Vulnerable Patients – A Population Level Approach

THROUGH THE DEVELOPMENT OF THE PPS NETWORK AND INFRASTRUCTURE, CNYCC IS WORKING TO ENABLE A STANDARD PROCESS FOR POPULATION HEALTH MANAGEMENT (PHM)

+

-

Risk

Clinical

Claims

SBDH

Complex Care Management

—Outcome & Disease

Management—

Care Coordination—

Health Promotion & Wellness

PHM

PR

OC

ESS

1COLLECTAggregate Data

2IDENTIFYPatient Cohorts

3ASSESS

Gaps, Needs & Risks

4STRATIFY

Prioritize

5ENGAGEOutreach & Awareness

6MANAGEIntervene & Collaborate

Collect: Aggregate DataFOUNDATIONAL ELEMENT THAT IS A CORNERSTONE OF A SUCCESSFUL PHM STRATEGY

KEY COMPONENTS

Data Sources

Data Types

Data Processing

Quality Assurance

Identify: Patient CohortsDEFINING POPULATIONS OF INTEREST BASED ON STANDARDIZED CRITERIA

KEY COMPONENTS

Patient Relationships

Patient Characteristics

Patient Monitoring

Program/Intervention Goals

Assess: Gaps, Needs & RisksGAINING AN ENHANCED UNDERSTANDING AND TARGETING OF OUR POPULATION

KEY COMPONENTS

Patient Disease States

Social/Behavioral Factors

Utilization Patterns

Care/Service Gaps

Sharable Data Summary

Assess: ChallengesTHERE IS LIMITED AVAILABILITY FOR SOME OF THE DATA THAT IS KNOWN TO

IMPACT ADVERSE HEALTH OUTCOMES

0% 10% 20% 30% 40%

Impact on Premature Death

• Availability: Low• Standards: Minimal• Quality: LowSome documentation in electronic medical record systems

Individual Behavior• Availability: Very Low• Standards: High• Quality: HighRecent growth in genetic testing and analysis, not widely spread

Genetics

• Availability: Very Low• Standards: Minimal• Quality: ModerateData is being captured, but may not be electronic and/or shareable

Social/Environmental• Availability: High• Standards: Moderate• Quality: ModerateDocumentation practices and EMR vendor differences impact quality

Health Care

Source: Schroeder, SA. (2007). We Can Do Better – Improving the Health of the American People. NEJM. 357:1221-8.

Stratify: Prioritize Patient Outreach and InterventionTRANSFORMING INFORMATION INTO ACTIONABLE INSIGHTS

KEY COMPONENTSUnderstanding the Full

Spectrum of Patient Risk

Defining & Utilizing Risk Criteria

Early Intervention

Resource Optimization

Engage: Outreach & Awareness

KEY COMPONENTS

Outreach Strategies

Timing

Scalability

Automation

INFORMING PATIENTS OF THEIR RISKS AND ENGAGING THEM IN THEIR CARE

Manage: Intervene & CollaborateTAKING PROACTIVE AND COORDINATED ACTIONS BASED ON DEVELOPED INSIGHTS

KEY COMPONENTSAlignment of Intervention and

Need

Coordination & Collaboration

Accessibility

Measuring Impact

Social & Community Based Services

Mental & Behavioral Health

SNFs & LTC

Care Management

Primary Care

InpatientFacilities

Home Care

Patient

BY ENABLING SHARED ACCESS TO PERTINENT PATIENT INFORMATION AND REDUCING BARRIERS TO COLLABORATION, PARTNERS CAN COORDINATE INTERVENTIONS TO ADDRESS PATIENTS NEEDS

Manage: Intervene & Collaborate


Technology Overview

Technology Overview: Watson Health PHM SuiteAN INTEGRATED SOLUTION THAT ALLOWS INSIGHT TO BE TRANSFORMED INTO ACTION

MODULE HIGHLIGHTS

Scalable Big Data Solution

Promotes True Interoperability

Ensures Accuracy & Quality of Data

Flexible Integration Strategy

Technology Overview: Value Based Care (VBC) Foundation

• Observe workflows & documentation practices

• Inventory critical status indicators

Data Discovery

• Create structured data

• Map to common standards

Data Harmonization

• Partner led• Ensures that

collected data maintains its context and meaning

Data Validation

VBC Foundation: Quality AssuranceENSURING THE ACCURACY AND QUALITY OF THE DATA WE COLLECT IS CRITICAL

MODULE HIGHLIGHTS

All Payer Quality/VBP Program Management

Identify and Track Patient Cohorts

Comprehensive Longitudinal Care Record

Technology Overview: Performance Manager

MODULE HIGHLIGHTS

Cross Continuum Collaborative Care Planning

CBO Participation & Engagement

Customizable Program Workflows

Technology Overview: Watson Care Manager

MODULE HIGHLIGHTS

Targeted Patient Outreach

Minimizes Resource Requirements

Customizable Protocols

Technology Overview: Engagement Manager

Managing Vulnerable Patients – Enablement Through Technology

VALUE BASE CARE FOUNDATION

Data Aggregation & Curation

PERFORMANCE MANAGER

ENGAGEMENT MANAGER

COLLECT

IDENTIFY

ASSESS

STRATIFY

ENGAGE

MANAGE

WATSON CARE MANAGER ENGAGEMENT MANAGER

Attribution & Registries

Care Gaps, Utilization & Cost

Risk & Disease States

Clinical & SBDH Risks

Patients & Care Teams

Care Plans & Referrals

Guided Pathways Cohort Driven Outreach

Campaign Management

Post Discharge Risks

ID Patients for CM

Quality & Performance


Use Case Scenarios

Managing DSRIP Program PerformancePERFORMANCE MANAGEMENT

Watson Health © IBM Corporation 2017 25

JunePopulation Health Officer

June is responsible for achieving value- based care goals linked to quality and cost. She works with the care management team on transitions and care referrals based on care goals. We will walk through each consecutively.

UNDERSTANDING PERFORMANCEJune navigates to her DSRIP scorecard.

Screen capture

Watson Health © IBM Corporation 2017

Navigate to DSRIP Scorecard

Note: Commercial Payer and other

scorecards

FINDING MORE DETAILSJune drills down to compare provider adherence to the measures scorecard

Screen capture

Compare providers on prevention

and screening


Cardiovascular needs work

Referral List to Watson Care ManagerPERFORMANCE MANAGEMENT

Watson Health © IBM Corporation 2017 28

JuneDirector of Care Management

MaryCare Management Supervisor

June shares her findings with the Mary to create engagement programs to address these measures. Mary spends most of her time identifying patients for care management.

VIEWING PATIENTS Mary navigates to the Registry performance management tool.

Screen capture

Navigation to Cardiovascular

Disease Registry

Navigation to Registries


FOCUSING ON HEART DISEASEMary selects the Cardiovascular Disease Registry to begin her search for appropriate care management referrals.


NARROWING THE SEARCHMary filters her registry to a hypertensive population based on the latest data received from all sources


AUTOMATING REFERRALS Mary creates a daily action to send the filtered list to Watson Care Manager as referrals for care management.


Sets action to daily to send new updates to WCM automatically

Preparing for a Patient Conversation CARE MANAGEMENT


MariaCare Manager

Maria identifies individuals who are the best candidates for care management and enrolls them into programs where she manages their care plan.

GETTING STARTEDMaria logs into Watson Care Manager and identifies the patients referred by Mary

ASSESSING PATIENT RISKMaria reviews each patient’s summary, assesses their clinical records and prioritizes outreach

Demographics including Insurance, and care team

Vitals • Body

Temperature• Heart Rate• Respiratory

Rate• Blood

Pressure• Body Weight• BMI

Recent and upcoming appointments

Recent Lab ResultsRecent Problem ListCurrent Allergies

Recent MedicationsWatson Health © IBM Corporation 2017

Digital CampaignsENGAGEMENT SERVICES


KathyAdministrator, Front Office

FOCUSING ON HEART DISEASEKathy navigates to the Cardiovascular Disease Registry and selects the patients she wants to send communications.


Selects patients & sends them for an hoc

campaign

PATIENT COMMUNICATIONJulie uses the ad hoc campaign interface to create an email message to patients with a call to action


Ad hoc campaigns

population health management: integration of process ...v. alue. b. ase. c. are. f. oundation. data...

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