Welcome to Population Health unit seven, Population Health Management Interventions. This is Lecture b, the learning objectives for Lecture b are to one, delineate interventions and staff who are deployed for high risk, rising risk, at risk, and low risk populations. Two, describe three types of deployment strategies models for population health management. Three, articulate successful strategies for human resource recruitment, retention, and training for population health staff. Traditional healthcare is seen when a person becomes ill or maybe even acutely ill. And goes to the local hospital or clinic, and is treated by a group of healthcare professionals, who often collaborate and determine the best care for the patient. So patients often enter the healthcare system when they're already sick. A different model of care with the goal of keeping people healthy, so that they can stay that way and have reduced risk for disease. Things of help needs and opportunities on a continuum. There are though portions of the population with risk factors for disease. With this different model of care, the goals in this part of the population, or this segment of the population is to help control risk factors to prevent and delay disease onset. And then of course, there are those in the population who have already contracted chronic disease or have complex healthcare needs. The goals in this portion of the population are to maximize the disease control, provide efficient and effective care and minimizing complications. In lecture A of unit seven, Population Health Management Interventions, you were introduced to Johns Hopkins Medicines Population Health Conceptual model. Which begins with prioritizing the population for interventions and ends with the evaluation of those population health interventions. We will continue to walk through this conceptual model for the remainder of today's lecture. In lecture A, we looked at population assessment, prioritizing health needs, and risk stratification and segmentation according to population needs. In the highlighted portion of the population health model, you'll see that we then began to develop primary and secondary prevention disease management interventions. And a supporting infrastructure to meet the needs of each population segment. And then after that planning and development, we began to implement customized health interventions. On the chart of the model appearing on this slide, the circle of intervention includes the health systems. Which falls within a larger circle that includes public health systems, community based partners and social services. Within health systems are pharmacists, who often lead medication management interventions. And clinical case managers, and health coaches who often coach patients on self-care management. Those providers engage health and social system navigation services health education, outreach, and engagement services, transitional care, and community partnerships. What do we mean by population health intervention? We mean programs, policies, resources, resource distribution approaches that impact people, numbers of people. By changing the underlying conditions of risks and by facilitating health improvement or maintenance for the population as a whole. And we do that either within the health sector, or within the health system, or outside the health system in communities and in homes. We allow for a comprehensive, multi-faceted approach to planning and delivering programs and interventions. What of the characteristics of population health interventions? We would like for all of our interventions to be well-planned, well-placed, and well-conducted, meaning highly specific. We hope that our interventions will lead to increased efficiency and effectiveness by allocating the right resources to the right sub-groups of the population. In other words, we dont want to apply a very intensive or high cost intervention to a lowc ost or low risk sub-group of the population. We want our interventions to adhere to the RE-AIM framework. RE-AIM was originally developed as a framework for consistent reporting of research results. But more recently, the RE-AIM framework has been used to translate research into practice and to help plan programs and improve their chances of working in real world settings. The frame has been used to understand the relative strengths and relative weaknesses of different approaches. From health promotion all the way to chronic disease management. Approaches, such as in-person counseling, group education, telephone counseling, etc. The overall goal of applying the RE-AIM framework is to encourage program planners, evaluators. And funders of interventions to pay most attention to the program elements that would help sustain adoption and implementation of effective generilizable and evidence based intervention. There are five steps to the RE-AIM framework. One for each letter of RE-AIM, RE-AIM is an acronym. The first step is to reach the target population and the question is, quote, how do I reach the targeted population with the intervention, end quote. We want to understand the number and proportion of the individuals who are willing to participate in a given intervention initiative and program. For the E, efficacy or effectiveness. We we want to know quote, how do I know that my intervention is affective, end quote. Especially with high cost interventions. We want to know that the intervention is reaching the number and the people that it should. As well as whether the intervention is having an impact on out comes. Whether we have any potential negative effects, and whether we're improving the quality of life and economic outcomes. The A in RE-AIM is adoption. We want to understand how to develop organizational support to develop and intervention. The number, the proportion, the representativeness of settings, and intervention agents, or the people who will deliver the program, who are willing to initiate a program. We want to know how well these people will adopt the program that we've outlined. The I stands for implementation. Implementation refers to the interventionists fidelity to the various components or elements of the protocol. Including how consistently it's being delivered and at the individual level, we want to understand for people enrolled in the program. Whether the implementation is being used effectively by the client or by the program participant. So how do I ensure that the intervention is delivered properly, and how do I ensure that those enrolled in the program are uptaking the intervention appropriately? And finally, the M is for maintenance. The extent to which a program or policy becomes part of the routine organizational practice and policy. So within our framework, it applies not only to the program level, but also to the individual level. Maintenance can be defined as how well a client or participant in the program is able to carry out the intervention in the long term. This public health intervention wheel shows the merger of public health and clinical intervention frameworks to be applied the population health. The term population health management is really a merger of public health interventions and clinical intervention frameworks. The intervention wheel is a population-based practice model that encompasses three levels of practice. The community level, the health systems level and the individual and family level. There are 16 separate public health interventions that are listed on the outer ring of the wheel. Each intervention, at the practice level, contributes to improving population health. Disease and health event investigations and surveillance are all part of what we call the case finding process. And in Lecture a, we talked about using available data to help us find cases of diabetics, and then to help us outreach and screen the population, and then apply specific interventions. In the clinical intervention framework, we have a level of specificity and appropriateness for each level of intervention. If we start at the bottom of the pyramid, we find primary prevention. We want to apply population health interventions to protect people who are healthy from developing a disease or a health condition. In secondary prevention, we want interventions that are aimed at halting or slowing a progress of disease, at its earliest stages, in people who may have a disease or be at risk for a disease. And then finally, in tertiary prevention, we want to target our interventions for population health, to manage care for people with complicated or chronic health problems, such as diabetes, heart disease, cancer and chronic pain. We're aiming to improve disease control, to prevent further physical deterioration and prevent complications. In other words, for people with chronic diseases to maximize their quality of life. And so you can see that both the public health framework and the clinical intervention framework add a level of specificity, and appropriateness to various subgroups of the population. Let's look at key elements of population health intervention. Collaborative, team-based care is often integrated into primary care. And coordinated care often involves including transitions from inpatient to outpatient care. We have case management, individual patient assessments and care plans. And patient self-management support, which often includes health education, health coaches and sometimes includes assessments and care plans and interventions. We have a variety of clinical delivery modalities options. For example, health education can be delivered in the clinic, over the telephone or through web-based interactive designs. All of these modalities can be employed in population health. We often have clinic and community partnerships, such as community-based surveillance or health promotion and support using lay health support and lay health agents. Design and implementation of risk behavior protocols and programs are flexible, adapted to address patients at different risk stratification levels. This table summarizes care management models both sites and modalities of care. And this is a summary of evidence-based on care of patients with complex health care needs reported by McCarthy, Ryan and Klein. In terms of site of care, when care management and population health is included in primary care, we often find that we have improved quality of care. And in terms of the impact of those programs on hospital use and cost, we find some reduced utilization of hospital services. When we have care management services that are delivered by telephone often vendor supported, many health plans and many employers will hire vendors to deliver population health and care management interventions by telephone. In terms of the impact on quality, there is some improvement. But there is inconclusive evidence that those type of interventions, which are delivered by telephone, are impactful on hospital use or on other costs of clinical and medical care. When we have primary care integrated with multi-specialty care and care management is included as part of that model. So for example, having health educators in clinics we find that we have improved quality of care and some reduced costs in hospitalization. When we have models that include hospital to home transition, so for patients who are hospitalized and then transition to home, we have care managers deployed in those types of interventions and programs. We often find improved quality and reduced cost, and utilization. As for care management programs that are delivered in the home, there is no clear evidence that those programs improve quality. And there is no clear evidence that there is impact on hospital use or cost, and utilization. Let's now talk about integrated, team-based primary care. Often, we have primary care that includes, in addition to medical care, behavioral health services that more fully address the spectrum of problems that patients often bring to primary medical care. There is an integration of a new discipline, a behavioral team into the primary care team. We have community based health workers that extend services into patients' homes and into their neighborhoods. It helps lift some of the burden from the primary care team, particularly the primary care physician. We have to adjust the workflow of the primary care team because when we add additional interventionist or additional clinicians to the primary care setting, there is less required of the primary care physician in terms of face-to-face interaction with patients. So if primary care physicians know that they can, after their interactions with their patients, refer those patients to community health workers, health coaches or health behavior specialists. They can focus their time very specifically on medical care. Documented in the literature, both in Brown and from the Agency for Healthcare Research and Quality, are several features that make care management and care coordination successful. The care coordination intervention should happen at least one time per month, and should include face-to-face contact with the care managers or providers. In other words, there is not a lot of evidence that telephonic care management improves quality, or reduces cost and utilization of care. Care managers or care coordinators should be located near physicians, should attend appointments and should see the physicians on rounds. According to the literature, the care coordinator in successful programs often has communication hubs with the physician. Sometimes, those hubs are face-to-face. Perhaps touching base at the beginning of the day, and sometimes those communication hubs are within the electronic medical record. The fourth feature of successful care coordination is the provision of behavior change education. So self-management of diabetes is a good example of helping patients to change behavior around exercise, nutrition, medication, etc. Those would all be behavioral change education programs that were part of successful care coordination or care management programs. Care managers often contact patients when they're in the hospital, and they'll often look at or request a copy of discharge instructions. Knowing what happened while a patient was in the hospital helps clinic or community-based case managers, facilitate a smooth transition from hospital to home. Transition protocols are often used and monitored for compliance. So as a patient moves from hospital to home, it's important to know, for example, of any followup appointments with the primary care physician whether the patient has received all the necessary home care equipment and whether the patient has all necessary medications. Care managers often receive information about medications from sources other than patients. They often consult with the pharmacist or the physician, if there is a problem. So, mediation reconciliation or medication compliance is often a very large feature and factor in successful care management programs. What do population health interventions for high-risk members have in common? They often target patients who have been in the hospital or patients who have already had complications from their chronic diseases. There is often strong transitional care. There is medication management and a very tight focus on making sure that the patient has medications, and that their adherent to those medications. There's ongoing assessment monitoring of patients with chronic illnesses and chronic conditions. There's streamlined care plans that are often targeted to the most important priorities of the patient. There is close communication between care managers, patients, primary care doctors and specialists. And finally, there is personal fact-to-fact contact between care coordinators or care managers and patients. So, what have we learned from some of the medicare demonstration projects? Over the past 10 to 15 years, Medicare has funded demonstrations on disease management, care coordination and value-based payments and we've learned that some of the programs have been successful and some have not. When they put program fees at risk value-based payments, we learn that they did not save money or reduce admissions, but we saw that there had been very successful reductions in hospital admissions in programs in which case managers had significant interactions with physicians. We saw that there has been a 7% reduction in admissions where there is significant in-person interaction between case managers and patients and we found that programs that lacked personal interactions between care managers, doctors and patients showed no effect. In other words, telephonic programs in the disease management demonstration projects, programs that lacked face-to-face interaction showed no effect. We'd like to look at the experience of the patient who has enrolled in a population health program and we also like to know who the team members are who are interacting with patients. Let's examine the high-risk patient experience in a population health program called the Johns Hopkins Community Health Partnership or J-CHiP. In lecture a, we looked at target populations within the seven zip codes around East Baltimore around John Hopkins Hospital and we looked at whether or not members attended one of their participating clinics. Using a predictive model, they identified the top 20% of the population who were at high-risk of having either an inpatient admission or an emergency department admission and in a very high-risk intervention enrolled 3,000 people in East Baltimore. The intervention began with being outreached by clinic staff to make an appointment with a primary care doctor and nurse case manager. Next, a community health worker went into the community, into the patient's home and set up an appointment to discuss with the patient whether there were any barriers to care to getting to healthcare services. In other words, to getting to that primary care and nurse case manager appointment. Next, a nurse case manager would invite the patient to come to the clinic and they would talk about the patient's health needs both medical and behavioral. After that visit, the primary care physician, and the team of people at the clinic would meet with the patient to work on a care plan. And the care plan would identify goals and healthcare services needed, and ask patients to identify their most critical goals, and to identify the interventions that they wanted to begin to work on. Patients were then ask to prioritize their needs and choose three goals or interventions to work on together with the team. So for example, the patient may be obese, but they're not ready to lose weight. They may have other problems they'd like to solve, such as a lack of housing or transportation before dealing with issues like weight lose, smoking cessation or diabetes education. Often, a team had to acknowledge and deal with social problems and social interventions before dealing with things like maintaining a diabetic diet. Members were then referred to the J-CHiP program for self-management education, behavioral support, specialty care, whatever was needed. The team developed an ongoing relationship with the patients. And often, this included telephone calls, visits to the home, visits to community centers, education, whatever was necessary. All with the goal of improving healthcare, improving the person's experience with the healthcare system and reducing cost and utilization. We talked about several different team members that were part of the Johns Hopkins Community Health Partnership program. One of the key members is a community health worker, a position that has become more and more prevalent in population health interventions. Often, they're deployed when there is low patient engagement, often in low resource urban centers. Community health worker programs effectively increase engagement. Often, community health workers are paraprofessionals. Meaning, they're high school graduates without any further education or training. The functions that community health workers are most appropriately deployed to are locating and engaging patients. Patients who have no home or transportation are difficult to locate. And so, community health workers go out into the community. Find patients and help them to get engaged in their healthcare. They assess barriers to care and any existing support that might be needed to improve access to healthcare. They mitigate those identified barriers through a number of different mechanisms and they often provide support, such as reminders, ongoing assessments and care coordination. Sometimes, community health works speak to J-CHiP patients several times a day. Sometimes, it's once a month. They provide very focused health education. Often, social support groups participate in the organization of volunteer support groups and just generally provide overall surveillance and monitoring of the patients in the community and in their homes. Neighborhood navigators also provide community support in the Johns Hopkins Community Health Partnership. Often, they are community support specialists who can, because they're neighbors provide social support to patients. They often provide a network of support that is supplemental to the community health workers work. What J-CHiP envisions is a multidimensional program, including existing caregivers as well as disease specific peers and mentors. So if a patient has diabetes, for example, J-CHiP pairs that patient with someone who's been successful at living with and monitoring their own diabetes or a mother who has successfully navigated the high-risk pregnancy may be a sign to a teen with the difficult pregnancy. When a community help worker does an initial assessment, they are often as we've described in previous slides Barriers to care that are identified. On this slide, is an example of a very brief survey that a community health worker might take to a patients home. So the questions most often asked are about transportation. Whether there is stable housing, stable telephone access, and access to the food they need. Many patients in urban areas, live in what we call food deserts areas where there aren't adequate grocery stores or fresh food, especially fresh fruits and vegetables. The survey also asks about whether the patient has difficulty paying for medications, doctor visits and utility bills. Difficulty with paying utility bills becomes particularly problematic for pregnant patients and for patients with chronic diseases. Such as heart failure, obstructive pulmonary disease, or asthma, who don't have air conditioning and live in urban areas with bad air pollution, or high heat and humidity. And patients are also asked about whether Whether they're caring for elders or children. When community health workers are in the community, they often have tablets or remote devices. So that they can keep in communication with case managers embedded in primary care clinics. The case managers embedded in primary care clinics are often part of a model called quote patient centered medical helm unquote. Generally, the case managers who are part of the patient centered medical helm focus on the most complex patients, and they work in close collaboration with the primary care physicians. Embedded case managers serve as the clinical supervisors of the care management team. So what do the embedded case managers do in a primary care clinic? Often, they're working with a very small percentage of patients. In the Johns Hopkins community health partnership, they were working with approximately 20% of the population many times it's a much smaller group of patients with whom they work. They perform very comprehensive patient assessments. Including assessments on any kind of health behaviors, nutrition, diet, exercise, smoking. Anything that might be improved with education assessing barriers to care and screening for mental health or substance use issues, is often part of that comprehensive patient assessment, including a patient history, patient medical history, family history. Many times this assessment has to be performed in multiple visits, because patients who have very complex health needs, or behavioral health, or mental health needs, and issues, often don't particularly adapt to J Chip's assessment appointment. So many times the case managers break their assessments into multiple sessions, or home visits with patients. After the patient assessment, embedded case managers generate a care plan in collaboration with the primary care team. Often in collaboration with the patient and their caregivers. To see what the patient's priorities are. They perform on-going care coordination, medication reconciliation, patient education, self-management training and support, and on-going monitoring. So this concludes Lecture B, Population Health Management Interventions. To briefly review, we delineated interventions and staff who were deployed to high-risk, rising-risk, at-risk, and low-risk populations. We described different types of deployment strategies, different types of models, such as patient-centered medical home and embedding staff in the community for population health management. And we articulated some successful strategies for human resource recruitment, retention, and training for population health staff, thank you.
