1. A Town Hall Event by the C&BI Population Health-Accountable Care Task Force May 27, 2015 Population Health Management: Care Coordination and Data Workflow

2. HIMSS Town Hall Series This is an informal public meeting that gives the members of a community an opportunity to get together to discuss emerging issues and to voice concerns and preferences for their community.

3. Today’s Event: Population Health Management: Care Coordination and Data Workflow Town Hall speakers: Alan Gilbert, MPA, FHIMSS Chief Growth Officer TEAM of Care Solutions Alan.Gilbert@TEAMofCare.com Antonio Linares, M.D. Regional Vice President, Medical Director Anthem Blue Cross - Health and Wellness Solutions Tony.Linares@anthem.com Moderator: John Middleton, MD, MS Diplomate, Clinical Informatics, ABPM VP/CMIO, SCL Health System john.middleton@sclhs.net john.middleton@sclhs.net

4. Executive Summary 4 1.Population Attribution models were shared and discussed in the first HIMSS Town Hall Meeting 2.Population Health Management is the topic for today’s Town Hall Meeting and will cover the following topics:  Definition of population health and key determinants  Examples of population health improvement (Triple Aim, PCMH)  TEAM Coordination of Care to drive population health  Cost and quality data drivers  TEAM, data workflow to support providers  Impact of Non-medical determinants of health

5. What Is Population Health? Historically, the term “population health” has been more commonly used in Canada than in the United States A simple definition is “the health outcomes of a group of individuals, including the distribution of the outcomes within the group,”* The Triple Aim- defines 3 inter-dependent aspects:** - Improving the health of a population - Improving the patients experience of care - Reducing the per capita costs of care for populations * David Kindig, MD, PhD, and Greg Stoddart, PhD- Models for Population Health, AJPH 2003 **Don Berwick, Health Affairs – The Triple Aim: Care, Health and Cost, May 2008, vol. 27

6. Population Health Includes: 1.Health outcomes for a defined group that is at risk (based on agreement of metrics and measures of health) 2.Patterns of specific health determinants for the group at risk 3.Specific health policies and key interventions that link the above outcomes with the health determinants* *Policies, process and procedures are developed at the organization or medical group or ACO level

7. Key Considerations Determinants of health may be both medical and non- medical (important in attribution and risk assessment) Population health determinants create a framework to drive policy development, research focus and resource allocation Measurement of population health includes consideration of the relative cost-effectiveness of resource allocation to multiple determinants of health and outcomes.

8. Risks regarding access to health care and resources, housing, food and income, security, education, employment, and safety Underserved children are disproportionately impacted, widening medical and developmental outcomes disparities Early detection and mitigation of socioeconomic and environmental risks within a pediatric primary care practice has the potential to improve outcomes What are Non-medical Determinants of Health? Reference: Andrew F. Beck, MD, MPH, Cincinnati Children’s Hospital Medical Center and excerpts from the Meharry Medical College Journal of Health Care for the Poor and Underserved 24 (2013): 1063- 1073

9. CCHMC Cincinnati emergency room and hospital use rates and code violations

10. Objective 2 Cincinnati emergency room and hospital use rates and code violations HCVD significantly associated with asthma emergency and hospital utilization rates after adjust for poverty (p=0.01)

11. Population Health Management: Patient Centered Medical Home (PCMH) Case Study* PCMH Providers Outperform Peers on Quality Measure Bundles Data from Q4 2014 11 * Anthem Blue Cross year 1 results from 2013 to 2014

12. Population Health Management: Improves Patient Satisfaction Members get appointments for urgent care right away Physicians and staff are attentive, thorough and available Members feel more respected and satisfied PCMH Non-PCMH 12 Appointment for Urgent Care as Soon as Needed Providers Show Respect for What Patients Say Providers Spend Enough Time with Patient Provider Probed on Behavioral Health +11 +3 +5 +2 +4 +1 +11 +1 Change in member experience scores, (2013 -2014) * Anthem Blue Cross year 1 results from 2013 to 2014

13. Impact on Personal Health Care Per Capita Costs $8.75 PaMPM (3%) Lower costs in the first program year Trends from providers indicate they are changing their practice behaviors. 13 1 Gross savings before provider gain share. Performance period (7/1/13 – 6/30/13). Per attributed member per month. 7.6% fewer acute inpatient admits per 1,000 4.8% PaMPM decrease in outpatient surgery costs 5.4% fewer inpatient days per 1,000 3.9% decrease in acute admissions for high risk patients with chronic conditions 1.5% increase in PCP office visits for members with high risk chronic conditions Anthem Blue Cross 2013- 2014

14. Part 2 Spotlight on Active TEAM Care Coordination and Data-Workflow Transformation

15. Air Traffic Controllers 15 Care Traffic Controllers Source: Care Traffic Controllers - John Halemka, MD - Professor of Medicine at Harvard Medical School and the CIO of Beth Israel Deaconess Medical Center (BIDMC) in Boston

16. TEAM Coordination Across the Full Continuum of Care 16 Patient Unified Coordination Plan Primary Care Med Rec Social Work Housing - Assessment Home Health Bed Set Up Transportation SNF to Home Transition of Care Transition Checklist Behavioral Health Assessment Program / Workflow Example: Transition from SNF to Home w/ Home Care

17. TEAM Coordination Actions are Defined and Routed by Program Algorithms 17

18. Source: Identifying and Quantifying the Cost of Uncoordinated Care: Opportunities for Savings and Improved Outcomes, Mary Kay Owens, R.Ph.,C.Ph, Institute of Medicine, 2009. 18 Lack of Care Coordination Drives Up Costs

19. 19 18%35% 7% 14% 9% 6% 9% Percentages Shown are the Share of Medicare Spending at Each Stage of Care Cost and Quality Control Occur at All Points Across the Continuum of Care

20. 20 Care Coordination Workflow Infrastructure Across All Points of Care

21. 21 Turning Data into Systematic Action Through Care Coordination Work Flow and Management

22. 22 Workflow & Content to Support Providers, Care Coordinators, Administrators, & Patients

23. In the Provider Workflow 23

24. In the Provider Workflow 24

25. Town Hall Discussion 25 How does population health management differ from the historical “capitation models”? Why is the attribution of the providers member panel so important in population health management? What are the greatest challenges for providers in care coordination and the use of technology to improve data workflow? Non-medical determinants of health were mentioned early in the presentation as being important for population health management. Can you elaborate more on this topic?

26. Next Steps Let’s continue the conversation and learning Blog posts Key findings and take-aways Articles

27. FY15 C&BI Leadership Information Committee Chair: JD Whitlock, MPH, MBA, CPHIMS Vice President, Clinical & Business Intelligence Mercy Health JDWhitlock@mercy.com Population Health-Accountable Care Task Force Co-Chairs: William Beach, MBA, MLA, PhDJennifer Jackson Regional Director, Regulatory Readiness, Northern Region, Senior Director, IT Population Health Data Solutions St. Joseph Health SystemBanner Health William.Beach@stjoe.orgWilliam.Beach@stjoe.org Jennifer.Jackson@bannerhealth.comJennifer.Jackson@bannerhealth.com Community Co-Chairs: Michael Brooks, BS, MBA, CPHIMS Mike Berger, PE, CPHIMS Specialist LeaderChef Analytics Officer Deloitte Consulting LLPAffinity Health Plan mibrooks@deloitte.commibrooks@deloitte.com Mberger@affinityplan.orgMberger@affinityplan.org HIMSS Community Organizers | Staff Liaisons: Shelley Price, MS, FHIMSSNancy Devlin Director, Payer & Life Sciences, HIMSSSenior Assoc., Payer & Life Sciences, HIMSS sprice@himss.orgsprice@himss.org ndevlin@himss.orgndevlin@himss.org

28. Thank you!