Population Health in The Berkshires

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Presentation transcript:

Population Health in The Berkshires October 21, 2016 Mark Pettus MD and Gray Ellrodt Berkshire Health Systems

The term “population health” has been used to describe both a clinical perspective focused on delivering care to groups enrolled in a health system and a broader perspective that focuses on the health of all people in a given geographic area and emphasizes multisector approaches and incorporation of nonclinical interventions to address social determinants of health. N Engl J Med 2015; 372:109-111 January 8, 2015

Quadruple Aim Health of a Population Experience of Care Per Capita Cost Care of the Provider Adapted from: Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759–769. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med, November/December 2014 vol. 12 no. 6 573-576.

Health Outcomes

County Health Rankings Model of Population Health

Population Health QALYs3 Primary Prevention Disease Management Creating Health - 2016 Creating Health Primary Prevention Disease Management End of Life E.g. Wellness at Work, Canyon Ranch Institute/ Berkshire Health Systems, PCMH1 E.g. Prevention Wellness Trust Fund, PCMH1 E.g. CHART2 , PCMH1 E.g. Compression of Morbidity, Palliative Care, Hospice Ideal 6 Quality of Life / Health Reserve Primordial prevention Primary prevention Disease management QALYs3 Life’s Slippery Slope Population Health Hospitalization MET Call End of Life Time in Years 1 PCMH=Patient Centered Medical Home 2 CHART=Community Hospital Acceleration, Revitalization, & Transformation 3 QALY=Quality-Adjusted Life Year

Clinical-Community Integration! Partners Berkshire Medical Center (Coord. Partner) Northern Berkshire Community Coalition Berkshire County Boards of Health Association BRPC/ Berkshire Public Health Alliance Fairview Hospital Tri-Town Health Dept. YMCA (Pittsfield/ N.A.) Community Health Programs (central) Volunteers in Medicine Berkshire South Clinical-Community Integration!

Neighborhood for Health The Neighborhood for Health PCP Adult NP Diabetic Support SUD Day Treatment Smoke Cessation CHF Behavioral Health Support Nutrition Counseling Community support Care Navigation Team

Thank You