Welcome to Population Health, Structural, quote, Accountable, end quote, Care Approaches for Target Population. This is lecture B, population-based care management. The objectives for this session are to, one, differentiate denominator-focused care from current primary care delivery that is patient-centered and episodic. Two, explain challenges of chronic care management in populations, including the role of social and community factors. Three, analyze the ways that health IT can be useful for accountable population health management. This graphic displays a movement from patient-centered care to population healthcare. Our health system of yesterday and today is represented by our caring for individual patients. As we move out in terms of shifting from individual patient care to population health management, we are potentially in a transition between yesterday and today. Moving toward the future of accountable care In population health. And in this transition, physician groups in the healthcare system become responsible for coordinating care, management of disease, and management of very complex, high-risk, high-cost, patients. And finally, in accountable care in population health, our health care system and primary care physicians, in particular, become incentivized to care for the entire population of patients. Not just providing care for one individual or coordinating care for that individual but moving to coordination of care in achieving population health management objectives. Patient-centered medical homes, as discussed in a previous lecture, is really the maximal model for the transformation of primary care. The key benefits of a patient-centered medical home include enhanced access to the medical home, to physicians, and to other providers and practitioners within the medical home. There is more comprehensive care. Patients become more engaged in their care, and the care is more coordinated. Generally, there is a physician-led team of providers, not one physician caring for one patient at a time. There may be additional non-physician providers who support the medical home's ability to provide additional services. PCMHs and what this team of providers is able to provide in terms of additional services to patients are covered in greater detail in other units in this curriculum. Often, there are disease registries that provide the ability to track patients over time and monitor patients for improved management. An example of this would be patients with diabetes, having their blood checked for measures of diabetes control. And if patients with diabetes are not having their blood checked for measures of diabetes control, can we reach out to them and make sure that they are having the appropriate tests and the appropriate preventive care? Key benefits of patient-centered medical homes include improved clinical quality through better chronic disease management, through better preventive care for patients, and through reduction of preventable chronic disease admissions and emergency department ED visits. We will see improved clinical quality outcomes across a population of diabetics or across a population of children with asthma. There is stronger incentive, economic gain, to primary care providers in patient-centered medical homes and to accountable care organizations. So there are generally stronger profitability margins for PCPs from improving their productivity. When a primary care provider has a team of interdisciplinary practitioners such as nurse case managers and health educators, they often have more time and can improve their productivity by seeing patients who they then can refer to this other team of individuals. Often, there are also reduced hospital readmissions and less of a negative incentive or penalty for readmissions. And often, this results in improved physician satisfaction. So it is easier to recruit physicians who are part of a team and working and who have the support they need. And it's easier to retain physicians because they have less burnout in their daily jobs. Primary care physician responsibilities are shifting from traditional primary care providers of yesterday to accountable care primary care providers. The traditional primary care provider reactively treated acute conditions. For example, as a patient awoke in the morning and had a fever, a sore throat, and chest tightness, etc., they would come in to be treated by the physician. In accountable care, the primary care providers are proactively providing preventative care. They are reaching out to offer flu shots and reminders for flu shots during the flu season so that their patients aren't coming in with acute conditions. Traditional primary care providers often employ case managers or nurse practitioners as assistance. In accountable care, they manage and lead multidisciplinary teams. So not only do they have nurses in their practice, but they're also working together around a comprehensive care plan and working together to provide self-management and education support to their patients. In traditional primary care, patients are often referred to specialists, and there's minimal follow-up. A primary care physician may or may not know what happened after you were referred to a pulmonologist or an allergist. In the accountable care provider system, there is a coordination with specialists and follow-up to provide better continuity of care as the primary care physician will feel more responsibility for care that is received outside of their domain. There are myriad of challenges for chronic care management in populations including the role of social and community factors. As our health system, and as our physicians and hospitals move toward population management, there are some unique challenges in caring for patients with chronic disease. What are the common characteristics of people with chronic disease? Often, these people are high cost. They have very high health care needs. In terms of health factors, many patients who have chronic disease do not present with just one chronic condition but often with multiple chronic conditions. They rate their health as very poor. Often, they know that they are not as healthy as they could be, given their heart failure or cardiac disease or other chronic diseases. Often, these patients are overweight, have diagnosis of mental illness and substance abuse, or have functional limitations that impact their ability to go to work, go to school, maintain their household, or other self-care activities. In terms of demographic factors, those with high cost and high needs are often less educated, have health literacy and general literacy issues, are low income, are non-English speaking, or have unstable housing or are homeless. So increasing attention is being paid to improving the health in all the communities across the US, particularly in regards to those with high costs and high needs. And as we know, in terms of health outcomes, the US lags behind most developed countries by a wide margin, despite spending substantially more than other developed countries. Within the United States, there is significant geographic variation in terms of morbidity, mortality, and other risk factors. And in the last several years, there's been worsening of mortality rates in many US counties. Health outcomes are produced by multiple factors, or health determinants, including clinical care or medical care, health behaviors, social and economic factors, and the physical environment. The contribution of clinical care to health outcomes is very modest, only 20%, a fact that many health care leaders often find surprising. Physical environment factors account for 10% of health outcomes, and include environmental quality, the quality of the water, the quality of the air, the built environment. In other words, are there walkways? Are there pathways where we can achieve our physical activity goals? Social and economic factors represent the biggest input, or biggest contribution, to health outcomes at 40%. These factors include education, employment, income, family and social support, and community safety factors. As we discussed, clinical care or medical care is access to care and the quality of care that is received. Are patients and the population getting appropriate preventive care and good disease management care? Finally, health behaviors account for 30% of health outcomes, and are things like tobacco use, diet and exercise, alcohol use, and sexual activity. In light of these factors, there's no single entity that can be held accountable for achieving the goals of improved population health. We need collective effort by many sectors, who are not necessarily accustomed to working together. And by stakeholders, who may not be aware of how actions affect population health. We need new incentives, new public and private resources in order to ensure that plans across these multiple determinants of health are coordinated. In order to achieve population health, there has been an evolution of a concept called the Triple Aim. In 2008, it was introduced by Don Berwick, who was, then, the CEO of the Institute for Healthcare Improvement. Later, the Triple Aim was adapted by Don Berwick for the National Quality Strategy, when he was the administrator for the Centers for Medicare and Medicaid Services in 2011. This chart compares 2008's Triple Aim with 2011's National Quality Strategy Three-Part Aim, both concepts introduced by Mr. Berwick. In terms of the goals of the Triple Aim, the Triple Aim sought to improve the individual experience of care, improve the health of populations, and reduce the per capita of cost of care. The National Quality Strategy aimed to have better care, healthy people and communities, and affordable care. The Triple Aim model can be compared to a more comprehensive model called the MATCH model. To achieve our broad population health goals, we need to understand and intervene across multiple determinants, health behaviors, social and economic factors, physical environment, and healthcare. However, this requirement for intervention across multiple sectors is not seen as clearly in the Triple Aim model as it is in the MATCH model. The two legs in the Triple Aim, experience of care and per capita cost of care, are indicative of this determinate of health, which is the quality and the access to healthcare. But in that population, health is influenced by these multiple determinants. They seem to be lacking in the Triple Aim model. Population health is really a product of multiple determinants of health, including healthcare and medical care. But also, including public health, genetics, behaviors, social factors, and environmental factors. This model seems to represent more broadly population level mortality and morbidity outcomes, and the influence of these factors on population health and morbidity outcomes. Although you will likely see the Triple Aim model as a model that's used to define population health improvement. This model is one that was designed at Johns Hopkins by Melissa Sherry and colleagues at the School of Public Health. And this accounts for the inclusion of individual factors, family and social support factors, healthcare and community organization and infrastructure, and policy and environmental context. It allows for that ecosystem and also allows for a service and accountability integrator. A healthcare organization could be an integrator, where all of these different factors and organizations are coming together, sharing data, sharing finances, sharing leadership even. In order to produce an empowered community of health, where there is reduced duplication and inefficiency in services, and improved quality, coordination, and communication. This model helps to bridge the silos between healthcare, and between social and individual factors of health, to produce better health in communities. Our final objective is to explore ways that population health is supported by IT. What are the accompanying IT requirements? In the framework for IT-enabled population health management, there are two main processes that are supported by health IT. One is the engagement of patients in their care, and the other is the administration, monitoring, and reporting of population health processes and outcomes. Identifying populations is a key process that can be supported by population health IT. Identifying populations of patients with chronic disease. Or identifying populations who are over a specific age and require a certain preventive care, or under a specific age and require immunizations and vaccinations, can be very much enabled by population health IT, mapping and tracking patients over time. As we deliver care, and as we engage in self management support and health education, those processes can be mapped and tracked across the whole continuum of care. So that care is coordinated, and all people who are participating in that person's care have a care plan and mutual goals and deliver services that are very integrated and consistent. This slide outlines the framework of IT requirements for population health. We'll look more specifically at each of these different processes to identify how population health can be supported. In terms of population identification, what's required in managing large populations is the ability to acquire data and aggregate data. And for that, there is some kind of aggregation platform that is necessary. Electronic medical records, a clinical data repository warehouse, or a health information exchange data warehouse. Maryland has the Chesapeake Regional Information System for our patients, CRIS, which is a health information exchange that provides access to hospital data regardless of where a person is in the state. Analytics-based population definition often requires multiple sources of data. In terms of having algorithms to identify populations or even predictive modeling, it often requires aggregate data, across many different settings of care, using claims as a data source. We also need systems for statistical methods of modeling. For predicted modeling, algorithms are very helpful in population health management. So identifying which diabetics are currently out of control is helped by having algorithms for analytics. To the extent that we can have a variety of data sources, laboratory, pharmacy, clinical data. Then we can have more accurate algorithms and analytics. Patient-provider attribution is also a requirement. In other words, what provider is the patient seeing, so that that provider will be able to be rewarded for better quality outcomes? Processes and algorithms for attribution are necessary to have in place so that we can say Who provides the majority of care for this patient? We have high-risk, high utilizing patients with chronic disease, patients in the population who are in need of preventive care. And those population definitions require disease and population health registries. We can map against care guidelines, we can map care against the continuum of care overtime. We can get a sense of how our population is doing against our care guideline. In terms of care delivery, it's essential to have a clinical data view for the physicians and the team who is treating the person. Access to clinical documentation and communication tools and e-prescribing are essential for all team members. Another requirement is a patient-centered view of interventions that are due. If there is an interdisciplinary team carrying for a population of patients, it is imperative that they have access to the EMR or to a physician portal, or to a patient registry so that their decision is reported Decision making is supported by having access to data that supports intervention. Care managers need patient data access and clinical documentation across the continuum of care meaning that. If a patient who is typically seen at a primary care practice, has an urgent or emergent situation, and goes to seek care at a hospital that is local, and is then admitted, the care manager must have access to that clinical documentation. So care plans are sometimes developed across the continuum of care. It's important to have remote data acquisition, vital signs, lab values and definitely realtime capabilities. In terms of patient engagement, it's important to have documentation of patients contact information and update that in realtime. And really, providers should have multiple communication modalities with a patient, whether it's access to an electronic medical record, a patient portal, a text-based communication system, or a call center. For difficult to reach patients, or those who do not have a steady or reliable home address, providers can give patients cell phones with limited text or with limited phone numbers so the providers can get in touch with the patients and the patients with providers, if needed. And then, generally, for all of the interventions and all of the programs that have been mentioned, it's a requirement in terms of improving programs to have the ability to monitor performance and report back to funders. Or to those who are delivering the program. It's imperative to have the ability to produce performance data against care plans at the clinician, physician, and organization levels. To be able to do e-measure calculations and reporting using such systems as dashboards or contract management and financial systems. Revenue cycle systems and financial decisions supporting cost accounting systems. The past several slides have demonstrated that IT is a key element for population health management success. Population health leaders must focus on data and information that will increasingly power clinical decisions, complete data integration is a must. Getting the right systems in place to work together which each other. Leveraging data to redesign care so that ultimately we can achieve the Triple Aim. We want to advance clinical outcomes, improve quality, and lower costs. Getting information-powered care to patients in real time is the ultimate goal. This concludes Lecture b of structural accountable care approaches for target population. In summary, you'll have learned that patient-centered medical homes are the maximal model for the transformation of primary care. The traditional primary care provider reactively treated acute conditions. The challenges of chronic care management in populations include the role of social and community factors. The IT requirements for population management include population identification, population tracking, care delivery, cross curriculum care management, patient engagement, and administration performance monitoring and reporting.
