SNP Alliance Annual Leadership Forum Integrating Policy into Practice Improving Health Equity and Building Solutions Urban Service Area Focus Amy Helwig, MD, MS Chief Quality Officer and Vice President, Quality Performance, UPMC Health Plan November 3, 2017

Data Collection and Analysis for SNP Population Large Network Anchored by UPMC UPMC Clinical Enterprise UPMC Health Plan Contracted Network and Partners More than 3.2 million members strong

Developing Quality Disparities Analytic Tools

What is the impact of Shared Savings on Quality and Disparities? Shared Savings (SS) scores higher than non-Shared Savings for every race & ethnicity

All Races and Ethnicities: Shared Savings (SS) vs All Races and Ethnicities: Shared Savings (SS) vs. Rest of Network (RON) Shared Savings scored higher than non Shared Savings for every individual metric for all races & ethnicity

How does Shared Savings affect the Urban and Rural Disparity? Shared Savings reduces the urban / rural disparity +0.7 +3.0

Using Analytics to Target Lead Hot Spots Identifying Pediatric Members At Risk for Lead Exposure Lead Hot Spot Census Blocks in Central Pittsburgh Identifying Opportunity Disparities in the diabetes eye exam were found to be driven primarily by members clustered in practices with low compliance, as opposed to by socioeconomic characteristics. Using Analysis to Tailor Strategy To address the DM eye exam gap in care… Target providers/provider groups with current low compliance Educate providers and assist with data collection and member tracking to help identify low compliant members Facilitate partnerships between medical home practices and eye specialists for easy referral

Using Analytics to Identify Opportunities and Tailor Strategy Distribution of Poverty and HEDIS Diabetes Eye Exam Gaps within Allegheny County PCMH practices Identifying Opportunity Disparities in the diabetes eye exam were found to be driven primarily by members clustered in practices with low compliance, as opposed to by socioeconomic characteristics. Using Analysis to Tailor Strategy To address the DM eye exam gap in care… Target providers/provider groups with current low compliance Educate providers and assist with data collection and member tracking to help identify low compliant members Facilitate partnerships between medical home practices and eye specialists for easy referral

Community Human Services and HUD Initiative Solutions to Improve Urban Health Equity Having a Home Matters Community Human Services and HUD Initiative Program to provide stable housing and an assigned medical home to those who qualify. PCP and specialist visits doubled after program enrollment Unplanned medical costs decreased after housing was established Need paper citation here

Solutions to Improve Urban Health Equity Special Needs Program (SNP) Serious Mental Illness (SMI) High-Risk Model Community care team provides member-centric enhanced and community-based care management to vulnerable population, especially those with high medical expenses, through an integrated whole health population management approach that addresses both medical and behavioral conditions and needs In urban counties, a team of high-risk care managers focused on this population Engages members with complex behavioral health, physical health and psychosocial needs Member-centric services Intensive care/service care management coordination Promote optimal engagement, coordination and continuity of care Service delivery focuses on providing tools, education, and resources that activate individuals to be more informed and effective managers of their health and health care

Solutions to Improve Urban Health Equity Enhanced Care Program (ECP) for Vulnerable Population Multidisciplinary team works to address the medical and psychosocial needs for special needs patients Intensive case management Social work Mental health intervention Increased accessibility to a primary care provider Outcomes for first 2.5 years – Improvement in Quality of Care Emergency Department utilization and unplanned care encounters fell Decreased trends in admissions and total medical costs Significant increase in pharmacy due to improved adherence Improvement in quality metrics related to diabetes, hypertension and preventive cancer screenings

DISCUSSION QUESTIONS