1. Population Health Management Innovation Community Final Webinar! August 31, 2015

2. Today’s Agenda What worked and didn’t work with the Innovation Community Participant Population Health Management Project Focus Breakthroughs/ Breakdowns Surprises Advice to Providers Doing Population Health Management

3. Summary Learnings Gathered from: Work Plans Small group calls Webinars Submitted Evaluation Forms

4. Overview of Participation in Evaluation 21 of 35 Members Participated 60% Participation

5. What worked with the Innovation Community Webinars One-on-one Consultations & Reading Materials Step-by-step process for conducting PHM PHM Readiness Checklist Data Fluency Book

6. What didn’t work with the Innovation Community Need calendar of webinars and touch-base/coaching times in the beginning Need more interaction between members Accept fewer members and focus on grouping organizations based on their level of PHM readiness or stage of implementation

7. Member Service Focus 2% System level Provider (e.g., state entity, hospital system, regional network, or managed care) 76% Behavioral Health Provider Adult Focus 20% Behavioral Heath Provider Pediatric Focus.5 % Residential Services Provider.5% Primary Substance Abuse Services Provider.5% Homeless Residential Provider

8. Member PHM Project Focus Pediatric Integration (e.g., autism services, anxiety) Adult Integration (e.g., high blood pressure, diabetes, obesity, tobacco use) Dashboard Implementation Using Data to Inform Clinical and Administrative Work

9. Breakthroughs! Realized need to step back, take time to focus on what is possible Learned need to take smaller steps/goals Everyone in organization has different perspective on what PHM is…get it confused with other projects we’re engaged in… We tried to do too many projects…leadership finally figured this out! Realized we need to hire someone to specifically focus on PHM Can’t wait for our EMR to work must jump in without it

10. Surprises! We were further ahead with PHM/IH that we gave our selves credit for… Our board really embraced PHM How hard it is to get staff to change a little bit How hard it is to get our EMR to support PHM The importance of leadership driving the change Limited resources on PHM…esp. concerning pediatrics

11. Breakdowns… Hard to link all projects together Overshot our targets…should have made project goals more realistic Not enough staff time to dedicate to this project due to all other projects No funding to support PHM (e.g., EMR improvements or hiring staff specifically for PHM) Getting multiple departments or organizations to buy-in to process of change EMR is not supportive of PHM needed to use Excel

12. Advice to Others Wanting to PHM Leadership must drive change…C-suite must be in work group…also good to have variety of disciplines on team Start with what feels like small project charter but will soon see it is bigger than you think! Start with data that is available, clean, and meaningful to staff Start with “Why” then move to “What” Make sure there is clear alignment on the targets/goals of your PHM project Use Plan-Do-Check/Study-Act cycles to monitor rollout Find organizations that have done this already and talk to them

13. Advice to Others Wanting to PHM Make sure terms like PHM are defined and understood Easy to get distracted by many needs/avenues for improvement…stay focused until project is complete then take on next project Start with one set of data that you can work with then scale up from there Engage staff early and often regarding the definition of PHM and provide training Don’t talk about it just do it

14. Theory U Otto Sharmer, PhD, MIT, 2007 ProblemSolution Focus Deepening Creativity, new thinking Creativity, New processes Creativity, New structures Broadening

15. Overall Themes Take time to find out what is a realistic project target Clearly define terms Leadership Must Drive Change Talk with others doing this work EMR’s may not support effort must be creative Organizations should take inventory of all time staff have available to engage in PHM. May require other projects are put on back burner…

16. Closing Comments?

17. Thank YOU for participating! Different perspectives are a gift to innovation