Population Management

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Presentation transcript:

Population Management November 2017

Take home points Quadruple Aim is the goal Primary care is vital to achieving these aims Empanelment, Panel Management, Health Coaching and High Risk Care Management are effective strategies for practice-based population management

Objectives Outline the concept of population management. Understand the fundamentals of empanelment and risk stratification.  Describe methods to initiate and sustain practice based population management.  Walk away with one idea to try out in your clinic.

Population Health Contributors From: RWJ

Population management 101 What is it? “the technical field of endeavor which utilizes a variety of individual, organizational and cultural interventions to help improve the morbidity patterns (i.e., the illness and injury burden) and the health care use behavior of defined populations” For a primary care doc it’s about improving the big picture while staying focused on the individual

Population management 101 What is it? “The science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.” CEA Winslow – an original definition of public health “the technical field of endeavor which utilizes a variety of individual, organizational and cultural interventions to help improve the morbidity patterns (i.e., the illness and injury burden) and the health care use behavior of defined populations” For a primary care doc it’s about improving the big picture while staying focused on the individual

The Big Picture What is the population management trying to achieve?

System designs that simultaneously improve three dimensions: Improving the health of the populations Improving the patient experience of care (including quality and satisfaction) Reducing per capita cost of health care

System designs that simultaneously improve three four dimensions: Improving the health of the populations Improving the patient experience of care (including quality and satisfaction) Reducing per capita cost of health care Care team well-being

Population management So where does population management fit into primary care?

It is one of the key building blocks of the PCMH Bodenheimer, et al. Annals of Family Medicine. 2014

Population management Practice-based strategies: Empanelment Panel management High risk care management Health coaching (for another time) Today we’ll focus on panel management Bodenheimer, et al. Annals of Family Medicine. 2014

Empanelment Who are our patients?

Empanelment A process of linking each patient to a care team and a primary care clinician A deliberate attempt to identify the group of patients for whom a clinician or team is responsible

Importance of Empanelment Establishing which patients are assigned to which physicians is important It makes patients happier It defines the workload Helps predict patient demand Necessary to measure provider performance Improves outcomes

Defining Clinic Populations Two Approaches: Community-wide population: Working in a defined geographic area to accomplish the Triple Aim for a community Defined population: A population that makes business sense around the Triple Aim Defined population is most relevant to UPI and other health systems. Business sense = sustainability.

Tools to help Patient panel size worksheet can be found here: www.aafp.org/fpm/2007/0400/p44.html More on our Resource Hub: resourcehub.practiceinnovationco.org/search/empanelment

*Not All Panels Are Equal Sex, age, illness burden, and socioeconomic status all can affect the “demand” of a panel on providers, teams, and clinics With even basic data (sex, age, visit numbers) a clinic can adjust panels more accurately More sophisticated systems can utilize more complicated factors like multi-morbidity, mental health, social determinants

Practice Reflections Who in the office is responsible for it? When does it get done? How is this information used in your clinic for operations and QI? Challenges you have faced when it does not get done properly. Audience questions. I may use these as prompts if the audience does not have questions: Is there an ideal panel size you shoot for? What do you do to fill up panels or shrink them? Do you work on distributing patient types (kids, adults, m/f, high risk, etc.)?

Questions on Empanelment? Audience questions. I may use these as prompts if the audience does not have questions: Is there an ideal panel size you shoot for? What do you do to fill up panels or shrink them? Do you work on distributing patient types (kids, adults, m/f, high risk, etc.)?

Panel Management Once you have a list of patients, what do you do with it?

Registries Gaps In Care +Team Based Workflows Panel Management

Registries Can focus on particular subpopulations Disease specific (ie DM, HTN) Prevention (ie immunizations, cancer screenings) Utilization (ie Frequent ER users, recent discharges)

Registries Can focus on particular subpopulations Or panel-wide Disease specific (ie DM, HTN) Prevention (ie immunizations, cancer screenings) Utilization (ie Frequent ER users, recent discharges) Or panel-wide Key indicators and needed services for all empaneled patients

Registries Lumping patients with similar needs to streamline work and evaluate outcomes Start with the basics, advance to predictive risk stratification Subpopulation vs. Intervention – which comes first?

Gaps In Care Goal is to perform all recommended services for a patient regardless of their reason for visit Can be carried out at the point of care or through asynchronous communications

Registries alone don’t improve care. Teams do! Team based workflows Registries alone don’t improve care. Teams do!

Practice Reflections Panel reflections Include how you choose the patients, who does the work, any metrics you track to see that you are making progress Associates – DM outreach using A1C; closing gaps of care during flu visits AFW – MA workflows and protocols; ambulatory health promotion Audience questions How did your teams pick these populations to focus on? How did you engage your teams to participate? Clinic vs health system – pros and cons?

Questions on Panel Management?

High Risk Care Management

Why Target Complex Patients Kyle What’s the big deal about complex patients? Why are people focusing on this now?

of patients account for 50% of Costs Top 5% of patients account for 50% of Costs Kyle Allows clinic to focus on those in most need Prioritize resources Structure interventions

Another way to demonstrate the same idea. Kyle Another way to demonstrate the same idea. This also shows that the high cost patients are becoming even more expensive. Haas, et al. American Journal of Managed Care. Sep2013, Vol. 19 Issue 9, p725-a735. 11p.

Who are the 5% ? Most Intense Intense Moderate - Homeless, Schizophrenia, etc Intense Multiple unstable chronic illnesses Depression + anything else High Utilization - Other issues (frail, social, financial, etc.) Moderate Well compensated multiple diseases Single diseases Bio-psycho-socially stable Kyle

Identification Methods Thresholds – Certain number of visits or medications or biomarkers Algorithms – combinations of diagnoses or assessment results Provider identification – just ask the clinicians

Developing a complex care management system Summary: Define the business case Determine outcomes for success Identify and stratify patients Develop model of care delivery Structure care management services Enroll patients Learn, adapt, grow More on our website at: http://resourcehub.practiceinnovationco.org/search/risk+stratification

Practice Reflections Panel reflections Include how you chose these groups to intervene on; how you find the patients (is it something in the EHR, some prompt from the hospital, provider input, etc); who on your team is involved; how much time to you give the team to do the work? metrics of success; Associates – transitions of care from ER, polypharmacy, social determinants AFW – TOC from hospital, complexity index, social determinants

Questions on high risk care management?

Wrap up Panel suggestions

Practice Reflections In closing, what are your suggestions to practices that aren’t doing any of this – knowing what you know now, where would you start?

Take home points Quadruple Aim is the goal Primary care is vital to achieving these aims Empanelment, Panel Management, Health Coaching and High Risk Care Management are effective strategies for practice-based population management

Resourcehub.PracticeInnovationCO.org