population health in the mhs -...

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Population Health in the MHS

Regina Julian, MHA, MBA, FACHECh, Primary Care, Access, Experience and Integration Defense Health AgencyPast Deputy Director of TMA Medical Management and Population [email protected]

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Disclosures

• Presenter has no financial interests to disclose.

• This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with the MedExcellence Program. PESG, and MedExcellence Staff, and accrediting organization do not support or endorse any product or service mentioned in this activity.

• PESG and MedExcellence Program staff has no financial interest to disclose.

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Learning Objectives

1. Attendees will understand the six key steps in the execution of a successful population health program through an integrated medical management program and its impact on the Quadruple Aim.

2. Attendees will understand the resources available to help clinical teams understand who their patients are, what needs they may have and how to forecast demand to meet access to care and clinical needs in order to maximize positive outcomes.

3. Attendees will understand what demand management entails, why it is important to increase capacity and how to leverage PCMH staff members and MHS tools to effectively management demand while maintaining high patient satisfaction.

4. Attendees will understand the roles and responsibilities of and how to leverage case, disease and utilization management in the population health model of care.

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• Population Health Model and Principles

• Proactive Management and Prevention

• Population Health PCMH in the MHS

• Leading Practices and Way Ahead

Outline

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Medical Officer Functions

Misconceptions as to the functions of the Medical Department are not uncommon even in the Army. Since, in the time of peace, the medical officer is best known through his relation to the sick, his more important duties may be overlooked. His prime function is, in peace or war, not the cure, but the prevention of disease… The care of the sick, essential though it is from ethical and political considerations, thus assumes relative insignificance from the military standpoint.

Military Hygiene (1914) by Frank Keefer

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Spectrum

Clinical Medicine Epidemiology Population Health

Focus Individuals Populations Populations

Main Goal Diagnosis and Treatment

Prevention and Control

Improving population healthDecreasing health

disparities

Questions

What is wrong with this patient?What treatment is

appropriate?

What are the leading causes of death or disability in this population?What can be done to reduce them?

How do we increase years of life and quality of those

years?How do we

decrease disparities among population

subgroups?

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Presenter

Presentation Notes

This DOD model looks very linear – depicts in one graph: Population Health and Medical Management. This spans the entire spectrum/continuum. New model (as shown) replaces the Broad Spectrum Case Management Model in Medical Management Guide. Emphasize spectrum/continuum of health and care. As the focus moves toward illness/impairment, a more individualized approach is required (i.e. CM) Also added: color shift, Prevention, and Palliative Care – many WII SM have chronic pain & issues requiring palliative care. It includes a health continuum which emphasizes the role of Case Management, Primary, Secondary, and Tertiary Prevention, and Outcome Measures in Broad-spectrum Case Management. It includes a health continuum which emphasizes the role of Case Management, Primary, Secondary, and Tertiary Prevention, and Outcome Measures in Broad-spectrum Case Management.

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Why do we care?

• Because leadership is tracking it…• Gaps exist in quality of care• Variance exists in how we provide care (HRO)• Persons with disease/risk cost more and we work

in a financially constrained environment• Improves outcomes, productivity, satisfaction• Increases the VALUE we provide our patients

and our stakeholders

Presenter

Presentation Notes

Leadership: eMSM dashboards Gaps: Institute of Medicine’s report on Quality Chasm Financially constrained: reference Mike Dineen’s lecture

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Population Identification and Assessment

• Who are… • The eligible

beneficiaries?• Who is…

• Enrolled to the MTF?• Who is…

• Enrolled to your clinic?

• Who is… • Being seen in your

clinic?

• Who is NOT being seen but should be?

• What is the health status?

• What are the lifestyle risk factors (behaviors)?

• Who needs clinical preventive services?

• What is the prevalence of chronic disease?

• Who are the high utilizers of services?

Identification Assessment Data resources

• Medical record reviews• Health risk assessment• Health related behavior

survey• MHS Population Health

Portal• M2

SCENARIO:Who is the

population at each of the

three MTFs?

Presenter

Presentation Notes

The first question to be answered in identifying the population is “Who is the population?” - Look at age, gender, ben cat, risk factors, disease burden Assessment: do you have tobacco users? Heavy alcohol users? Depression diagnosis – could benefit from CM?, High utilizers - 10 or more outpatient visits, an ER visit or inpatient admissions? Sub-questions include…… who is an eligible beneficiary? NOT JUST WHO SHOWS UP FOR APPTS IN THE CLINIC! WHAT ABOUT THOSE YOU DO NOT SEE? They may have undiagnosed, or poorly managed chronic illnesses! Tools to help identify the population: DEERS M2: MHSPHP Dental Navy - DENCAS: Dental Common Access System Army - CDA: Corporate Dental Application Air Force - DDSW: Dental Data System-Web (moving to CDA)

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Demand Forecasting• How Many? (4.1 x 1000 = 4100 appts/208 days = 20/day)• Health care needs of the population (Prevalence of

disease/conditions within the population)• UTILIZATON PATTERNS

• What type? Acute or routine?• Gender, Bencat and age?• Time of day/day of week?

• Operationally defined & system-required demands (pre-deployment requirements, physical exams, overseas screening)

• High utilizers (PCMH – ER, Visits, CHUP, etc.)• Resources:

• Utilization Reviews (historical data such as chart reviews and M2 queries)

• Carepoint• Demand Forecasting models

Presenter

Presentation Notes

*Demand forecasting is an estimate the volume of care required by a given population. It requires accurate identification of the population in terms of size, age, gender, location and ID Health care needs of the population�(including immunizations & other clinical preventive services) - How many women greater than 42yo? – will need mammos - How many children? Will be able to forecast the needs for immunizations and well child check ups Prevalence of condition/disease within the population & clinical practices used to treat a given condition/disease Operationally defined & system-required demands (includes pre-deployment requirements, physical exams, overseas screening, etc.) Demand forecasting lets the medical management team determine the staffing and budgets required to provide acute care, chronic care, clinical preventive services, and health promotion programs for the population Demand forecasts help the disease manager determine: Prioritize programs Collaborate with leadership, medical management staff, and stakeholders on staffing and resource needs. Proactively prepare to meet needs of beneficiary population Establish budgetary requirements

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Your Panel

• Plan for:• Complex patients with multiple co-morbidities• Patients with low resilience, helath literacy or support• “At risk” patients• Higher ER utilizers• 10+ primary care visits per year• Chronic Pain/High Utilizer/Polypharmacy – 5% of

patients drive 25% of costs

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Demand Management

• Proactive interventions focused on reducing unnecessary health care utilization and encouraging clinically appropriate use

• Increasing SELF-CARE Strategies & Patient Education • PCM Assignments (Right patient mix & distribution) and panel balance• Nurse Triage and Nurse Advice Line• Message Center/T-Cons• Template scrubbing to see if “in person” visits can be better handled in other

ways• Pre-visit planning to making the most of every visit: Refills, Immunizations,

scheduling for preventive screens• Optimizing ALL team members (e.g. SSPs, nurse-run walk-in clinics for common

acute conditions, etc.• Embedded specialists: clinical pharmacy, behavioral health, etc.• Medical Management (CM, UM, and DM) SCENARIO:

How could the mother’s utilization have been better managed?

Presenter

Presentation Notes

Refers to proactive interventions aimed at reducing unnecessary healthcare utilization while encouraging the use of appropriate healthcare resources Demand Management strategies include…… Consider tracking who is calling for what types of appts, and when do they want them (pm clinics?), and possibly with which provider Evaluate PCM assignments to assess the right patient mix for the provider role and patient distribution among providers Encourage the use of effective decision support (CPGs) and self management tools, thus enabling beneficiaries to use healthcare resources appropriately. Use of demand management strategies will decrease the need for urgent episodic care. Focus is on prevention of illness and injury. Medical Management = Case Management + Utilization Management + Disease Management

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NAL BenefitsOverall NAL Results Jun 14 – Sep 15

• 45% of callers end up being seen in their own MTFs (49% Jul-Sep 15; most recent)

• 80% of MTF visits in Primary care and 20% in MTF ED/UC• MTF share is increasing; most recent data Jun-Sep 15 is 48%+

* M2 data on patient action obtained by SSN and analyzed by Kennell, compared to caller’s stated pre-intent and NAL RN recommendation

80% in primary care20% in MTF ER/UC

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NAL Transparency• DHA SharePoint site provides transparent results• https://info.health.mil/hco/clinicsup/hsd/pcpcmh/nal/SitePage

s/Home.aspx• PCM On Call Pilot• Global NAL in development for FY18

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• Case Management• Promote utilization of clinicalloy appropriate available resources • Facilitate appropriate access to care.• Collaborate with the patient/team to develop and implement a plan that meets the needs

and goals of the patient.• Develop individualized patient plans of care.• Offer objectivity, healthcare choices, and self-management solutions.

• Utilization Management• Supports patient to appropriate level of care.• Coordinating healthcare benefits.• Promoting the least costly, most effective treatment benefit.• Determining the presence of medical necessity

• Disease Management• Improve the quality of life for individuals by preventing or minimizing the impact of a

disease or chronic condition• Improve outcomes, increase provider/patient satisfaction• Use evidence-based interventions to reduce variation• Support patient with a self-care plan to manage his/her own health and prevent

complicationsSCENARIO:

How could the scenario patient have benefitted from Case Management?

Medical Management

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All Cause Readmissions –Current State

1

MHS

Army

WOMACK

Navy

Camp Pendleton

Air Force

Keesler

NCR

Ft. Belvoir WRNMMC

All Cause Readmission HEDIS Benchmarks:

Blue (90th) Green (75th) Yellow (50th) Red0.68 0.73 0.79 Greater than 0.79

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• Schedule follow up appointments for ‘high risk’ prior to discharge• Multidisciplinary Rounds at time of discharge• Capture medication reconciliation at time of discharge• Telephone reinforcement within 48-72 hours of discharge

Process Evaluation MeasuresPilot Locations

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* All Sites Selected by Services *

Womack Army Medical Center

Keesler Medical Center

Naval Hospital Camp Pendleton

Pilot Site Locations

Pilot Measures

Fort Belvoir Community Hospital

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HEDIS® All Cause Readmission Measure – MHS Dashboard Sample View

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Medical Admissions/Readmissions by MTF– MHS PHP Sample View

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Capacity Management

Balance panels and adjust based on needs of the population

Fully leverage the team!

Factors affecting capacity Management:

• Patient demand (utilization)• Appointment types

• Open Access• Group Appointments• Phone visits

• Provider availability• Provider type needed• Support staff• Ancillary support

requirements• Readiness requirements• Physical space• Equipment needs

Presenter

Presentation Notes

**THINK CLINIC MANAGEMENT MTF capacity must be linked to best clinical and business practices Capacity management includes: Implementing proactive vs. reactive strategies Managing the clinical processes—\clarify staff roles & responsibilities Controlling leakage to the network Optimizing supply and demand Reducing excess needs if possible Increasing throughput of the system by improving processes (i.e., do things right) Using evidence-based practices (i.e., do the right things) TOOLS: Template analysis tool (TAT) available in the TOC CPGs or decision support tools Coordination of referrals and utilization (UM and RM) Clinic Managers (trained – courses available) Clinic support staff to optimize clinicians time with patients Shared Appointments:

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Evidence-Based Care and Prevention• The provision of healthcare using a systematically developed,

research-based approach • Identifies people with or at risk for chronic disease• Improves Quality/Outcomes at Reduced Costs

• TSWF with embedded CPGs and Referral Guidelines (2.0 soon!)• Increased depression screening in primary care from 28% to 90% • Low Back Pain (LBP) standardized documentation compliance from

41% to 98%• Increased prescribing of medication (statins, aspirin, ACE-I) that

decrease morbidity/mortality in diabetics• Provides patients & families:

• Evidence-based information & tools (e.g. CPGs)• Multidisciplinary team to follow plan of care• Referral to resources, as needed (e.g., case management, disease

management)• Health promotion and/or patient self-management education

Presenter

Presentation Notes

The Foundation of Quality Care = Evidence-based Care Evidence-based prevention is provided at three levels. Primary: ****patient education, Health Promotion and Protection (e.g. PHA, immunizations) Example of diabetic: exercise and diet can help prevent secondary diabetes for those who have a family history or are otherwise predisposed Secondary: ***Screening, Early Detection an Case Finding (e.g. Hypertension, Caries, Cancer Screening) Example: predisposed, family history of diabetes – test blood sugars periodically Tertiary: Treatment, Keeping the disease/condition from worsening, and Rehabilitation (e.g. Diabetes, Asthma) CPGs are used here Diabetes: keep A1Cs under 9 CPGs – the foundation of a successful DM program.

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Leading Practices• Team-based demand management to enhance access beyond

face-to-face encounters with PCM (DEMAND MANAGEMENT)• Virtual health and Telephone Visits• Nurse-run walk-in clinics for common acute conditions• Proactive high utilizer outreach

• Simplified Appointing Guidance and First Call Resolution (Matching Supply and Demand)

• Commitment to PCM Continuity• Active Management of Access / Templates• Ensuring panels are balanced appropriately (empanelment) and

enrollment capacity is balanced against access, quality and safety

• Facility and physical support is adequate• Templates and other demand management techniques

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Standard Processes and Way Ahead

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Standard WorkPrevents

Backsliding

Onward!

Source: ThedaCare, Appleton, WI

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Obtaining CME/CE Credit

If you would like to receive continuing education credit for this activity, please visit:

http://medxellence.cds.pesgce.com

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Questions?

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Medical Management Guidance

• Department of Defense Instruction (DoDI) 6025.20 (dated Jan 2006)

• Population Health/Medical Management Guides• Available: www.tricare.mil/OCMO/publications.aspx• Medical Management Webinars available. Schedule at

www.tricare.mil/tma/ocmo/webinars.aspx• Service PCMH Instructions: BUMED Instruction 6300.19; AFI

44.171 and Army OPORD 11-20

http://www.tricare.mil/OCMO/publications.aspx

http://www.tricare.mil/tma/ocmo/webinars.aspx

population health in the mhs -...

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