1. 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

2. 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

3. 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?

4. 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

5. 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

7. Social Determinants of Health

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

9. “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.

10. 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

11. Triple Aim

13. 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

14. 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

15. 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

17. 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

18. 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

19. 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

20. 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

22. 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

23. 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

24. 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

25. 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

26. 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

28. Bucket 1: Focus on Preventive care

29. Indicators – The Clinical Components

30. Bucket 2: Focus on Preventive Care

31. To address asthma:

32. Bucket 3: Focus on Preventive Care

34. 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

36. 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

38. 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

40. 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

41. 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

49. 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

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

53. 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

54. 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

55. 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

56. 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

57. 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

58. Dave Palm UNMC, COPH Department of Health Services Research and Administration
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