1. Moving the focus upstream: Teaching about (and caring for) patients with complex illness in the Family Medicine Center and across the continuum Allen Perkins, MD Ehab Molokhia, MD Curtis Gill, MD STFM Spring Meeting 2016, Minneapolis, MN

2. Drowning folks, upstream, etc 2

3. A different way of looking at patients 3

4. UHC profile of patients with chronic illness 4

5. Complex patients in the FMC How many of you see these patients in your practice? What would it take to provide better care? What efforts have you made to move care upstream? 5

6. Components of highly functioning primary care 6 Team based care Enhanced Access Self-management Support Population Management Planned Care Care Management Medication Management Referral Management Behavioral Health Management Communication Management Clinic-community connections

7. Residency Curriculum 7 Introduction of Population Health Knowledge Acquisition Knowledge Application

8. Description of curriculum IHI Modules 8 Triple Aim for Populations Improvement Capability Quality Cost and Value Patient Safety Person- and Family-Centered Care

9. Required Readings 9 D Kindig G Stoddart (2003). What Is Pop Health? American Journal of Public Health Community Tool Box: Addressing Social Determinants of Health and Development Using Public Records and Archival Data. Participatory Approaches to Planning Community Interventions. Defining and Analyzing the Problem. Analyzing the Root Causes of Problems National Public Health Data Resources. Dulin MF et al. (2010). Using geographic information systems (GIS) to understand a community’s primary care needs. J Am Board Fam Med Principles of Community Engagement, 2 nd edition. Bethesda, MD: National Institutes of Health, 2011 Primary Care and Public Health: Exploring Integration to Improve Population Health. IOM 2012 Population Health: Creating a Culture of Wellness by David B. Nash

10. Knowledge Application 10 Longitudinal Experience Rotation on QI teams weekly Rotate on population health team weekly Participation in monthly QI meeting 2 Block Rotation Rotation on all Teams Rotation with Medicaid patient care network (VIVA) Population study (geo- mapping) 1

11. Outcomes 18 months in…. 11 Significant improvements in HEDIS measures: Greater than 40% reduction in the number of uncontrolled diabetic patients as measured by Hemoglobin A1C, Near 100% improvement in screening for diabetic nephropathy and retinopathy, Near 200% improvement in screening for peripheral neuropathy Significant improvements in the delivery of preventive services like mammography, as well as screening for colorectal cancer and osteoporosis.

12. At a practice level 12 Greater than 50% reduction in 30-day all-cause readmissions. Improvement in transitioning care from one setting to another: Improved communication, Services utilization collaboration with interdisciplinary members of the care teams. Change of focus of these teams toward quality and performance improvement.

13. At a Resident level 13 Significant improvement in their knowledge base of population management as well as the social determinants of health. An improvement in resident and employment satisfaction as it relates to their level of preparedness to function and lead in the emerging healthcare delivery models.

14. Diabetic Mellitus 14

15. Hypertension 15

16. Prevention 16

17. Department adult readmissions (compared to cohort) 17

18. Getting paid 18 Current Readmission penalty reduction Mortality penalty reductio n HEDIS measure bonus Coming up CPC+ The Center for Medicare and Medicaid Innovation estimates that a practice participating in Track 1 of CPC+ that is similar in size to the average practice participating in CPCI will receive $126,000 annually plus performance payments of $21,000. For Track 2 the figures are $235,200 and $33,600 respectively

19. Where does the money come from? 19

20. 20

21. What’s in The Future ? 21 Improvement in data collection: EHR transition with a data analytics package Inclusion of inpatient data Inclusion of social determinants data Creation financial incentives for outcomes Creation of a complex patient care team Multidisciplinary Physician and provider team, behavioral health, pharmacy, care manager Food security? Housing security? Legal? Pest control? Community engagement Expanding the experience to medical students

22. QUESTIONS 22