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Community Oriented Approach to Population Health
Ingredients for a value based learning health system
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Value Based Payment Models
Changing the Healthcare Landscape The objective of this session is to review and discuss strategies that are proving effective for a continuously improving value based health system, and how these strategies can be applied in a community oriented approach including: advanced primary care with well designed incentive models multi-disciplinary team based services tied closely to primary care coordination with community providers (medical, non-medical) to organize a more complete approach to population health use of health IT and data to support care management, measurement of comparative performance, and continuous improvement.
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Value Based Payment Models
11/13/2018 Value Based Payment Models Changing the Healthcare Landscape 11/13/2018 3
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Vermont Blueprint for Health Extended Community Health Team
Hospitals Specialty Care & Disease Management Programs Advanced Primary Care Community Health Team Nurse Coordinator Social Workers Nutrition Specialists Community Health Workers Public Health Specialist Extended Community Health Team Medicaid Care Coordinators SASH Teams Spoke (MAT) Staff Social & Economic Services Advanced Primary Care Home & Long Term Support Services Advanced Primary Care Mental Health & Substance Abuse Specialty Programs Advanced Primary Care Self Management Programs Public Health Programs & Services All-Insurer Payment Reforms Transformation Network Service Area & Statewide Collaboratives Data Infrastructure 11/13/2018 11/13/2018 Evaluation & Comparative Reporting 4 4
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Vermont Blueprint for Health
Data use cases Care management for people with complex needs Outreach and prevention for key populations Outcomes to evaluate program impact on core measures Comparative performance across settings (variation, drivers) Predictive models to meet health, quality, and cost goals 11/13/2018
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Vermont Blueprint for Health
Transformation Network 11/13/2018 31 Community Health Team Leaders 19 Blueprint Practice Facilitators 14 Blueprint Project Managers 4 ACO Clinical Quality Leaders 6 ACO Clinical Consultants 11/13/2018 6
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Vermont Blueprint for Health
Data utility to support transformation 11/13/2018 Onpoint Health Analytics Measurement Utilization Expenditures Unit Costs Quality Patient Experience Social, Economic, Behavioral Variation & Associations Products Practice Profiles HSA Profiles Learning System Activities Performance Payments Program Impact & Publications Predictive Models Provider Registry Claims data from APCD Clinical Registry BRFSS Data Process data sets Check data quality Address data gaps Link data sets Analytics Reporting Data extracts CAHPS Data Corrections data Other? 11/13/2018 7
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Framework for Effective Data Sharing & Use
Foundational Components & Technical Capabilities Technical Capabilities Analytics Services Reporting Services Expenditure Reporting Utilization Reporting Data Quality & Risk Adjustment Quality Measure Reporting Data Extraction Data Aggregation & Transformation Patient Identity Management Provider Directory & Attribution Security & Privacy Consent Management Foundational Elements Business Reason Governance Policy Financing Legal Agreements User Support / Learning Network Adapted from ONC Health IT-Enabled Quality Measurement Strategic Implementation Guide 2017
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Data Aggregation & Data Use Strategies Build a ‘data use’ culture
Meaningful stakeholder group that informs reporting & displays Provide information that directly supports care management (individuals) Provide information that directly supports outreach & prevention (populations) Display performance results that are linked with incentives Display comparative performance, highlight variation & drivers Support practices use of information to drive operations Evaluate and report program impact, culture of transparency 11/13/2018
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Practice Profiles Evaluate Care Delivery
Commercial, Medicaid, & Medicare 10
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Practice Profiles Evaluate Care Delivery
Using associations & comparative performance Total Expenditures vs. Utilization 11/13/2018 11
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Combining Data Sources for Population Health
11/13/2018 Combining Data Sources for Population Health Associations & predictive analytics In press, Craig Jones, MD1 Mary Kate Mohlman, PhD1 David Jorgenson, MS2 Karl Finison, MA2 Katie McGee, MS3 Hans Kastensmith3 AJMC 12
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Combining Data Sources for Population Health
11/13/2018 Combining Data Sources for Population Health Associations & predictive analytics Outreach Criteria Diabetes + BP ≥ 140/90 mm/Hg Diabetes + BP ≤ 90/60 mm/Hg Diabetes + BMI > 35 Diabetes + HbA1c ≤ 6% Diabetes + HbA1c > 9% Diabetes + Insulin Diabetes + Asthma Diabetes + COPD Diabetes + CHF Diabetes + CHD Diabetes + Renal Failure Diabetes + Depression Updated 1/24 NFL
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11/13/2018 11/13/2018 14
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Alignment on Performance, Payment, & Service Delivery
Core Measures & Health IT Drive a Value Based Health System AIMs Use of Measurement for a Value Based Learning Health System Measurement & Modeling Data Services to Facilitate Measurement Data Sources for Core Measures Core Measures Better Quality Better Health Cost Control Incentives for providers to work together to improve outcomes Initiatives to improve proactive outreach & preventive services Initiatives to improve coordination & quality of services Initiatives to improve integration of medical, social, behavioral services Initiatives to reduce variation, unnecessary, & harmful services Shared governance structure to oversee & improve data utility Payer measurement & reporting needs Data sent in native formats Most complete longitudinal patient record Link patients-services- providers-sites Apply attribution algorithms Create data extracts & access for users Analytic & reporting services Data quality process & assistance Payers, APCD, Claims Curators Quality Health Status Utilization Expenditures Medical Error Social Economic Behavioral Provider measurement & reporting needs EHR Systems Populate value based payment models HIE Networks Evaluate outcomes & impact of programs Specialty Registries Comparative performance & variation analyses Public Health Registries Predictive models & actionable insights State Data Systems
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Community Oriented Approach to Population Health
Key Ingredients Advanced primary care freed up by the right incentive model Multi-disciplinary team based services working closely with primary care Coordination with community providers (medical, non-medical) to organize a more complete approach to population health Use of health IT and data (medical, non-medical) to support care management and measure comparative performance Support for providers and practices to assist with transformation and data guided continuous improvement …. ‘Data use’ culture Learning network to share best practices and improve variable performance
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Community Oriented Approach to Population Health
Questions & Discussion Craig Jones MD CMO Privis Health
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