HI-FIVE (Health Informatics For Innovation, Value & Enrichment) Training is a 12-hour online course designed by Columbia University in 2016, with sponsorship from the Office of the National Coordinator for Health Information Technology (ONC). The training is role-based and uses case scenarios. Also, it has additional, optional modules on other topics of interest or relevance. Although we suggest to complete the course within a month's timeframe, the course is self-paced and so you can start and finish the course at anytime during a month's time period. No additional hardware or software are required for this course. Our nation’s healthcare system is changing at a rapid pace. Transformative health care delivery programs depend heavily on health information technology to improve and coordinate care, maintain patient registries, support patient engagement, develop and sustain data infrastructure necessary for multi-payer value-based payment, and enable analytical capacities to inform decision making and streamline reporting. The accelerated pace of change from new and expanding technology will continue to be a challenge for preparing a skilled workforce so taking this training will help you to stay current in the dynamic landscape of health care. This course is one of three related courses in the HI-FIVE training program, which has topics on population health, care coordination and interoperability, value-based care, healthcare data analytics, and patient-centered care. Each of the three courses is designed from a different perspective based on various healthcare roles. This first course is from a clinical perspective, geared towards physicians, nurse practitioners, physician assistants, nurses, clinical executives and managers, medical assistants, and other clinical support roles. However, we encourage anyone working in healthcare, health IT, public health, and population health to participate in any of the three trainings. If you would like to obtain continuing medical education (CME) or continuing nursing education (CNE) credits, you will need to have eligible credentials, complete the entire course, and complete the evaluation survey at the end. The HI-FIVE team verifies after each month that these requirements have been met and then a separate certificate (fee may apply) is distributed to you from our accreditation office. Please allow time for processing. If you have any further questions about continuing education, please see our website at www.hi-fivetraining.org. Accreditation Statement The College of Physicians and Surgeons of Columbia University is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. AMA Credit Designation Statement The College of Physcians and Surgeons designates this enduring material for 12.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The planning committee members are: Rita Kukafka, DrPH, MA, FACMI; Bruce Forman, MD; Gil Kuperman, MD, PhD; Virginia Lorenzi, MS, CPHIMS, FHL7, and Victoria Tiase, MSN, BN. None of the members of the committee, who planned this CME Activity, have any relevant financial relationships to disclose. The release date is 2/1/17 and the expiration date is 1/31/18. This activity is eligible for 12 continuing nursing education (CNE) credits. Columbia University School of Nursing, Continuing Nursing Education Program is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Structural "Accountable" Care Approaches for Target Population: Population-Based Care Management
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Del curso dictado por Columbia University
HI-FIVE: Health Informatics For Innovation, Value & Enrichment (Clinical Perspective)
107 calificaciones
Columbia University
107 calificaciones
De la lección
Role-Based Content (OPTIONAL) - Physicians / Nurse Practitioners / Physician Assistants / Clinical Executives / Clinical Managers / Public Health Professionals
This module is optional, but has additional topics that you may be interested based on your role. We encourage you to explore any of these topics and there are also quizzes to test your learning.
Conoce a los instructores
Rita KukafkaAssociate Professor
Biomedical Informatics
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.
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