Integrating Population Health Management into Patient-Centered Medical Home Meeting NCQA MHP Recognition Requirements CDR Patricia Taylor, NC, USN Deputy Director Medical Services Naval Hospital Bremerton, WA

Defining the Medical Home Care Coordination Specialist care is coordinated, and systems are in place to prevent errors that occur when multiple physicians are involved. Follow-up and support is provided. Team Care Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals (including BH specialists). Duplication of tests and procedures is avoided. Patient Feedback Patients routinely provide feedback to doctors; practices take advantage of low-cost, internet-based patient surveys to learn from patients and inform treatment plans. Superb Access to Care Patients can easily make appointments and select the day and time. Waiting times are short. eMail and telephone consultations are offered. Off-hour service is available. Patient Engagement in Care Patients have the option of being informed and engaged partners in their care. Practices provide information on treatment plans, preventative and follow-up care reminders, access to medical records, assistance with self-care, and counseling. Clinical Information Systems These systems support high-quality care, practice-based learning, and quality improvement. Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments. To understand the health risks and information needs of patients/families, requires a comprehensive health assessment. Uses this patient information to proactively remind patient and clinicians of preventive and follow-up care needed. -Implementing evidence-based guidelines through point of care reminders for patients. Care team performs pre-visit preparations, assess & addresses barriers when patient has not met treatment goals, follows up with patients/families not keeping important appts. Activities to support patients in self-management Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs. Publically available information Grundy (2012) Source: Health2 Resources 9.30.08 8

Investing in Primary Care Patient Centered Medical Home Group Health Cooperative of Puget Sound (Seattle, Washington) • Cost: $10 PMPM reduction in total costs 16% reduction in hospital admissions 29% reduction in ER visits Return on investment 1.5: 1 • Quality: 4% more patients achieving target levels on HEDIS quality measures 10% of pilot clinic staff reporting high emotional exhaustion at 12 months compared to 30 percent of staff in control clinics Improvement in recruitment and retention Geisinger Health System (Pennsylvania) 18% reduction in hospital admissions 7 % reduction in total PMPM costs Return on investment 2:1 74% improvement in preventive care 22% improvement in coronary artery disease care 34.5% improvement in diabetes care Resource: Grumback & Grundy. (2010) BUMED Team visited Group Health Cooperative (BUMED Comptroller, MHP PMO, etc)

Population Health - Do this right & it will have a positive affect on readiness, patient experience & per capita cost

Population Health Translating Strategy into Action Focus on Better Health Partnership between primary care and population health Prevention and Chronic Care Management IT tools allowing for actionable, near time data Embedded training and population health support -Culture of Change for patients & medical staff: Focusing on health while treating illness. Shifting the control and power out of the hands of those who give care and into the hands of those who receive it. Population health someone else’s job? Think prevention & chronic disease management IT tools that actually give the needed information Embedded training and population health support

Correlation to 2011 NCQA MHP Standards Identify and management patient populations (PCMH 2: Elements C & D) Plan and manage care (PCMH 3: Elements A-C) Providing self-care support and community resources (PCMH 4: Element A) Standard Two: Electronic systems used to identify patients who need service Standard Three: (3C-Must Pass) Care team performs care management through pre-visit planning, developing plan, and treatment goals Standard Four: (4A-Must Pass) Assess self-management abilities Document self-care plan; provide tools and resources Counsel on health behaviors Provide community resources

Integrating Planned Care into Primary Care Planned care for chronic conditions and preventive care Patient and caregiver engagement This is all about integrating planned care into the primary care setting. Planned care for chronic conditions & planned care for preventive health needs Requires patient and caregiver involvement in the healthcare delivery processes

Planned Care for Chronic Conditions & Preventive Care Primary care practices will proactively assess patients to determine need Provide appropriate and timely preventive care Use disease registries to track and appropriately treat chronically ill patients What are your patient’s needs? The population and the individual patient. Can’t provide planned care until you know what your patient population looks like Focus on preventive care Identifying and aggressively managing your chronically ill patients with a focus on maintaining health

Patient & Caregiver Engagement Primary care practices will engage patients and families in active participation in goal setting and decision making Patients will be full partners in truly patient-centered care No matter what we do, we’ve got to engage our patients & their families in the healthcare. Sometimes that means actually having a conversation about what they are willing to do & developing a plan that assists them in the behavior changes that will make a positive impact. Making patients full partners in their care requires understanding what patients want to know & how to help them know it. Patients and families can bring useful knowledge to care if they are invited to do so.

Integrating Planned Care into the Primary Care Setting Key components Leadership support and buy-in at all levels Roles/Responsibilities defined for entire team Ongoing training for targeted preventive care and chronic conditions Information tools for point of care and outreach efforts Delivery system process redesign Embedded population health/health educator -Leadership support at all levels -Define roles and responsibilities for every member of the team (clerks, medical assistants, corpsmen, nurses, providers, case managers, etc) Staff training – what, when, & why do they need to focus on specific preventive care & chronic conditions Tools that will assist staff in maximizing point of care & outreach efforts Delivery system redesign: not just “vital signs” techs, but integral members of the healthcare team Embedded specialists should include population health/health educator in a clearly defined supportive role to staff & patients

Planned Care Management Process Point of Care Preventive Health Assessment Proactive Office Encounter Preparation Process Planned Care Management at Point of Care – patient appt Using the Preventive Health Assessment, a tool to assist in preparing for the patient’s office visit

Preventive Health Review Part I: Patient Appointment Information Part II: Preventive Health Screenings Part III: Disease and Condition Management

Preventive Health Review Patient action lists are downloaded from CarePoint into our SQL server. This is done manually every Monday AM. Every morning the appointments for today & tomorrow are automatically downloaded from a CHCS adhoc report into SQL. SQL then automatically batch generates & automatically emails to each Medical Home Team each AM Thus most appointments are covered by one of these batches: If appt made greater than 24 hours before If appt made within the last 24 hours

Part I: Patient Appointment Information Part II: Preventive Health Screenings Part 1: Patient Appointment Information -Patient Name & identifiers, Clinic being seen in, Provider seeing patient, Appt Date & time Part 2: Preventive Health Screenings -Cancer Screening Recommendations (color coded indicates whether action is required. Meaning an order, consult, or appts is made (cervical cancer screenings can be done the day of the appt if patient agreeable) - Key indicates the specifics about the screening, i.e. CRC screening begins at age 50. 3 screening options (FOBT, Flex sig, colonoscopy)

Part III: Disease and Condition Management Part 3: Disease and Condition Management: Asthma – Read items in column

Proactive Office Encounter Preparation Staff Roles/Responsibilities Review PHR during huddle/team meeting If screenings are flagged “red or due” take appropriate action (colorectal CA, breast CA, or Cervical CA screenings) If patient has specific chronic conditions review & take appropriate action (Asthma, diabetes, dyslipidemia) Gather appropriate educational resources

Office Encounter Process Staff Roles/Responsibilities Support Staff Review PHR with patient If screenings are flagged “red or due” take appropriate action (colorectal CA, breast CA, or Cervical CA screenings) If patient has specific chronic conditions review & take appropriate action (Asthma, diabetes, dyslipidemia) Provider Review/reinforce tests/screenings needed Patient Takes home PHR Leaves clinic with appropriate orders, consults, f/u appts Has appropriate educational resources Acts on orders and consults Achieves self-management goals

Planned Care Management Process Outreach Efforts Use CarePoint for Outreach efforts

Point out various elements

Point out various elements in view

Planned Care Management Staff Training Components CarePoint Familiarization with various features Patient Population Management (PPM) Preventive Care Chronic Care CarePoint Skills competencies/PPM knowledge exam Patient Communication Scripts Documentation/Exclusions Staff Trained to use CarePoint effectively

Planned Care Management Process Outreach Efforts Support Staff use CarePoint to identify patients who are overdue or due for tests/screening Contacts via phone Unable to contact Address all patient needs in one phone call Place appropriate orders/consults /schedule appointments Document in CarePoint (Notes, exclusions, ordered tests/screenings Documents in CarePoint. Enters AHTLA t-con with reason for notification Patient returns call, Communication Room staff can address issue with patient Three attempts – Letter sent Review diagram ( may also use secure messaging system)

Embedded Population Health/Health Educator Population Health responsibilities Streamline CarePoint account application process Established and conducts CarePoint and Population Management staff training Clean up data: outside reports, coding corrections, amending records Provide team updates on HEDIS Captain’s Cup Challenge Strengthen partnership between Medical Home team and Population Health department Embedded Population Health/Health Educator extremely valuable to MHP team & patient care processes. Population Health responsibilities include:

HEDIS Captain’s Cup Challenge

Embedded Population Health/Health Educator Health Educator responsibilities Provides individualized patient education in support of PCMH team Created standard objective-based education curriculums for use by MH team support staff. (Pathways for brief point of care education) Provides clinical support staff training for specific health conditions and risk factors (PCMH/HEDIS) Documents self-management plans and goals This individual also serves as a Health educator. Extremely valuable to the team

Impact of Integrating Planned Care into Primary Care Enhanced Team-based approach Maximized Provider/patient time Enhanced patient/caregiver engagement Improvements in HEDIS measures

NH Bremerton Points of Contact CDR Patricia Taylor patricia.taylor2@med.navy.mil Dr. Dan Frederick daniel.frederick@med.navy.mil Aimee Aldendorf aimee.aldendorf.ctr@med.navy.mil