Population Health in Nebraska: Why Now and Steps for Moving Forward Dave Palm College of Public Health Nebraska Rural Health Association Annual Conference September 19, 2018 Population Health in Nebraska: Why Now and Steps for Moving Forward

Outline of Presentation The key elements of population health Rational for moving forward now and key success factors Some barriers and challenges Examples of population health successes Next steps in moving forward Outline of Presentation

What is Population Health? Focus is on improving population health outcomes Usually defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” (Kindig and Stoddard, APHA, 2003) This definition has been interpreted in different ways What is Population Health?

Views of Payers, Providers, and Public Health Professionals Payers tend to view the defined population as their current enrollees or covered lives Providers tend to think of the defined group as their organization’s panel of patients – often called Population Health Management Public health professionals tend to view the defined group as the entire population living in a geographical area (e.g., a city or county) Views of Payers, Providers, and Public Health Professionals

Public Health Perspective Continued It addresses the major determinants of health and health disparities Policies and interventions should target the determinants and reduce rural/urban disparities

Social Determinants of Health

“Loneliness and isolation is as negative a health effect as heart disease or cancer.” - Dr. David Feinberg, CEO of Geisinger Health

“If medical schools and residency programs are serious about burnout, they have to teach us about collective action – teach us to ask, what can we do? To fight burnout, we should never worry alone about the social determinants of health that patients face. To fight burnout, organize.” - Leo Eisenstein, “To Fight Burnout, Organize,” NEJM, August 9, 2018.

Why Now??? New goals for the health system – The Triple Aim HCE are unsustainable There are many drivers of change for both health care providers and public health officials There is a growing recognition that better health outcomes involve improving individual care and creating a healthier environment in communities

Triple Aim

U. S. Spending by Disease Condition (2016 JAMA Study) Diabetes Heart Disease Lower Back and Neck Pain Hypertension Treatment Falls Depressive Disorders $101 Billion $88 Billion $84 Billion $76 Billion 71 Billion

Reducing Preventable Deaths The CDC reported that these percentages of all deaths are preventable: 30% of heart disease deaths 15% of cancer deaths 43% of unintentional injuries 36% of chronic lower respiratory disease 28% of strokes

Preventable Heart Disease Deaths, 2016 CDC reported that 80% of heart-related deaths are preventable Total expenditures for these events were $32 billion Risk factors most responsible were obesity, physical inactivity, and diabetes

Drivers of Change – Medical Care Triple Aim – better patient care, improved population health, and lower per capita cost The shift from volume to value payments (e.g., MACRA, bundled payments, Medicaid managed care) New models of health care delivery (e.g., PCMHs and ACOs) Drivers of Change – Medical Care

Drivers of Change – Public Health Greater focus on disparities and the social determinants of health The shift to and opportunities for BIG DATA Greater emphasis on collaboration and planning/policies (Chief Health Strategist) New areas of concentration: chronic vs infectious diseases, behavioral health, and aging Budget and workforce declines Drivers of Change – Public Health

Challenges of Population Health What populations should be targeted (broad versus narrow)? What prevention/health promotion strategies and services should be emphasized? What are the potential funding sources? Challenges of Population Health

The cultural divide between medical care and public health individual treatment vs whole populations Short-term vs long-term results Shortages of medical and public health professionals Difficult to share information Willingness and ability to form collaborative partnerships Challenges Continued

Population Health and Care Coordination Examples Federal programs and policies State CMMI initiatives (Vermont, Oregon, Ohio) Medicaid reforms at the state level CDC’s Three Buckets Nebraska initiatives Population Health and Care Coordination Examples

New Federal Programs and Policies Value-based purchasing programs (e.g., ACOs) CMMI projects Accountable Health Communities Medicare’s Chronic Care Management Program and Pre-diabetes Program Chronic Care Act – 2018 (Allows Medicare to pay for social services) CDCs 6/18 Initiative New Federal Programs and Policies

State Level CMMI Projects Vermont – Blueprint for health includes advanced practice medical homes and community health teams Ohio – Focus on value- based payment and care coordination Oregon – Established Coordinated Care Organizations receive a global payment and address social factors State Level CMMI Projects

Medicaid Reforms Many examples of ACO value-based payment models Support for providers that focus on the social determinants Health Homes option under the ACA (21 states but not NE) Nebraska requires MCOs to have staff trained on the social determinants and be familiar with community resources Medicaid Reforms

CDC Three Bucket Approach CDC has developed the three bucket approach to think about improvements in health outcomes These buckets involve increasing the use of clinical preventive services, providing services that extend care outside of the clinical setting, and implementing interventions that reach whole populations CDC Three Bucket Approach

Bucket 1: Focus on Preventive care

Indicators – The Clinical Components

Bucket 2: Focus on Preventive Care

To address asthma:

Bucket 3: Focus on Preventive Care

Nebraska Population Health Initiatives Nonprofit hospital CHNAs and Implementation Plans Integration activities between LHDs and primary care clinics Nebraska has several active ACOs, more than 200 PCMHs, and 22 clinics in CPC+ Nebraska Population Health Initiatives

Highest Priorities: Small Rural Nonprofit Nebraska Hospitals Specific Area % of Hospitals Behavioral health/mental health/substance abuse/suicide 76.5% Obesity/overweight/physical activity 73.5% Chronic disease prevention and screening (diabetes, hypertension, heart disease & stroke) 32.4% Access to care Cancer 29.4% Violence and injury prevention 8.8% Aging issues (arthritis, hearing, etc.) Family issues/parenting support Maternal and child health/prenatal care Breast feeding 2.9% Aging of primary care providers Increase number of visiting specialists Age of nursing home facilities

Evaluating the CHNAs and IPs Most nonprofit hospitals (70%) worked closely with their LHD and the priorities were consistent with the CHIP Most of the CHNAs met the IRS requirements Many IPs lacked specific action steps and did not identify the role of their partners For this process to be effective, the hospital, the LHD, and other community partners need to develop a cohesive implementation strategy that includes performance measures to track progress Evaluating the CHNAs and IPs

Linkages between LHDs and Physician Clinics in Nebraska Based on interviews with LHDs in 2017 and a survey of LHDs in 2018 Several linkage programs and activities have been identified In many areas, linkage partnerships and initiatives are becoming stronger and expanding to more clinics By mid-2019, expect to see several formal contracts or MOUs between LHDs and physician clinics Models and programs expected to vary across the state Linkages between LHDs and Physician Clinics in Nebraska

Linkages between LHDs and Physician Clinics Screening programs for diabetes and hypertension Work site wellness programs Cancer screening promotional campaigns Home visitation programs Helping patients enroll in Medicaid or insurance exchanges Medication assistance programs Analysis of EHR data Coordination of immunization programs

Some Options for Sustainable Funding Use some of the savings from keeping people healthy (e.g., diabetes and hypertension) and reallocate to prevention programs and addressing the social determinants of health Between 2017 and 2021, CDC is projecting 11,900 preventable deaths in Nebraska at a cost of $800 million dollars Better target community benefits spending - nonprofit hospitals in rural NE spent about $13 million on community health initiatives in 2014 Encourage Medicaid and private insurers to fund promising care coordination projects and evaluate their outcomes Some Options for Sustainable Funding

Funding Options Continued: Chronic Care Management Program Medicare Pre-diabetes program RHCs and FQHCs eligible Funding Options Continued:

Factors to Sustain Behavioral Change Requires joint organizational efforts In-person social support (64%) Virtual social support (48%) Improved access to preventive care (46%) Electronic reminders (45%) Financial rewards (41%) Personal technology devices (36%) More education about preventive conditions (25%) Financial penalties (13%) Source: NEJM Catalyst Factors to Sustain Behavioral Change

Building an Integration Model Define Define the roles and responsibilities of each partner Determine Determine the evidence-based clinical and population-based strategies that will be implemented Implement Implement standard protocols in clinics and hospitals Organize Organize a community coalition Develop a shared vision Select one to three high priority issues based on EMR data, CHIP, and CHNA Building an Integration Model

Building an Integrated Model Continued Advocate Advocate for policy changes at the local, state, and national levels Establish Establish an evaluation plan and key process and outcome measures Identify Identify funding sources (community benefits, CDC grants, Medicare programs, etc.) Develop Develop data sharing agreements Building an Integrated Model Continued

Keys to Long-Term Success Great leadership and trust among the partners Agreement and support for the priorities and intervention strategies It is better to start small with one or two initiatives Realign community benefit spending with the priority issues but all partners should contribute in some way Assess progress and modify strategies if needed Keys to Long-Term Success

Population health is an ongoing process that requires trust and commitment of key partners The focus and implementation of population health will not be the same in all parts of the state – Not a cookie cutter approach We need to document the success of population health strategies, including the cost and benefits We need to focus on the Triple Aim and use our resources more efficiently Conclusion

Dave Palm UNMC, COPH Department of Health Services Research and Administration david.palm@unmc.edu 402.559.8441 Contact Information