A Conversation on Population Health & Wellbeing Mark Carroll, MD Brian Gregory, PhD, MBA Nathan Jones, JD, CHC May 15, 2017

Health care is moving from “volume to value”

The “4th Aim” = Clinician satisfaction or “joy”

“The health outcomes of a group of individuals, including the distribution of such outcomes within the group.”   Kindig and Stoddart American Journal of Public Health March 2003

“The health outcomes of a group of individuals, including the distribution of such outcomes within the group.”   Kindig and Stoddart American Journal of Public Health March 2003

Patient Risk Stratification “High risk” “Rising risk” “Low risk” Goal: Monitor & manage Goal: Identify & intervene Goal: Engage & empower

Geography

Other Characteristics Age or other demographic feature Examples: Children, elders Common need or concern Examples: People who are homeless or without food Common experience Examples: Veterans, employees Some combination of considerations Example: Adults with behavioral health needs

Population health is about improving the health & wellbeing of groups of people.

Together, we decide what groups of people should be our priority.

And then build solutions through partnerships

“Every year, more than 11 million people move through America's 3,100 local jails, many on low-level, non-violent misdemeanors, costing local governments approximately $22 billion a year. ln local jails, 64 percent of people suffer from mental illness, 68 percent have a substance abuse disorder, and 44 percent suffer from chronic health problems. Communities across the country have recognized that a relatively small number of these highly-vulnerable people cycle repeatedly not just through local jails, but also hospital emergency rooms, shelters, and other public systems, receiving fragmented and uncoordinated care at great cost to American taxpayers, with poor outcomes.”   June 30, 2016 The White House Office of the Press Secretary Fact Sheet for the Data-Driven Justice Initiative

“Every year, more than 11 million people move through America's 3,100 local jails, many on low-level, non-violent misdemeanors, costing local governments approximately $22 billion a year. ln local jails, 64 percent of people suffer from mental illness, 68 percent have a substance abuse disorder, and 44 percent suffer from chronic health problems. Communities across the country have recognized that a relatively small number of these highly-vulnerable people cycle repeatedly not just through local jails, but also hospital emergency rooms, shelters, and other public systems, receiving fragmented and uncoordinated care at great cost to American taxpayers, with poor outcomes.”   June 30, 2016 The White House Office of the Press Secretary Fact Sheet for the Data-Driven Justice Initiative

AHCCCS Targeted Investments Program https://www.azahcccs.gov/PlansProviders/TargetedInvestments/

“Social Determinants of Health” Source: CHCS Brief, Dec 2016; adapted from McGinnis et al, Health Affairs 2002: 21(2)

Comprehensive Care Management AHCCCS Care Coordination Development Work Session Resource Network Community Medic Program Child Care Services Transportation Food /Meal Assistance Financial Assistance Agencies Needs Spiritual Supports Assistance with Daily Needs Permanent Supportive Housing School-based svcs Social Service Agencies Physical therapy & rehab Patient & Care Team Shelters & Transitional Housing Supports for Life Instabilities Behavioral Health Services Behavioral Health Treatment Family Supports Case Management Crisis Response Services Substance Abuse Care Palliative Care Peer supports Collaborative Care Processes Transition Clinics Home Health Services Specialty Care Telehealth & eHealth Pharmacy services Community Health Workers Primary Care & Medical Homes Post-Acute Care Adapted from model developed with the Care Management Team at Northern Arizona Healthcare

Outcomes Hospital readmissions Avoidable ED visits Ambulatory visits Satisfaction Stable housing Risk screening Clinical condition outcomes Cost Integrated care plan development Linkage to community supports Health insurance status

Outcomes Repeat incarceration Avoidable ED visits Ambulatory visits Satisfaction Stable housing Risk screening Clinical condition outcomes Cost Integrated care plan development Linkage to community supports Health insurance status

Interdisciplinary collaboration works.

Two Expert Perspectives

Thank you