community pathways to health: bridging the gap · population health informatics •advanced...
TRANSCRIPT
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Community Pathways to Health: Bridging the Gap
Session 161, February 14, 2019
Rhonda Medows, MD, President and Dora Barilla, DrPH, Group Vice President
Going Deep into Our Communities with Advanced Data Platform
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Rhonda Medows, MD
Dora Barilla, DrPH
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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• Introduction to Providence St. Joseph Health
• Bridging Health Care & Public Health
• Community Pathways to Health
• Medicaid
• Value-Based Care
• Health is a Human Right
• Community Partnerships and Improvement
• Homelessness: Case Study
Agenda
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• State the key steps to building a data platform that effectively
handles today’s population health initiatives
• Describe the data sets that are essential for developing an
effective population health data platform
• Adapt the core recommendations of this presentation to harness
AI and other new technologies to meet population health
objectives
Learning Objectives
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Providence St. Joseph Health
Our footprintProvidence Health & Services
Western Washington, including Swedish Health
Services and Pacific Medical Centers
Providence Health & Services
Eastern Washington/Western Montana, including
Kadlec Regional Medical Center
Providence Health & Services
Alaska
Providence Health & Services
Oregon
Providence Health Plan
St. Joseph Health
West Texas/Eastern New
Mexico, including
Covenant Health and
Covenant Medical Group
FirstCare Health Plans
St. Joseph Health
Northern California
(Humbolt, Napa, Sonoma
Counties), including St.
Joseph Heritage
Healthcare
Providence Health
& Services
Southern California (Los
Angeles County), including
Facey Medical Foundation
St. Joseph Health
Southern California (Orange
and San Bernardino Counties),
including Hoag and St. Joseph
Heritage Healthcare
AK
WA MT
OR
NM
TX
CA
“ We have to be big –
“ and small – at the same time.”
– Rod Hochman, MD, President & CEO, PSJH
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T O G E T H E R , W E P R O V I D E A N A B U N D A N C E O F D I V E R S E C A P A B I L I T I E S A N D S E R V I C E S T O O U R C O M M U N I T I E S
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Population Health Management Services for PSJH Regions:Enterprise Care Management, Contracting, Value Based Care Performance & PH Informatics
Providence Health Plan: Risk bearing health insurance products for Employers, Commercial, Medicare, Medicaid, DSNP, ASO, PBM, Workers Comp and TPA Services
Ayin Health Solutions: Non-risk bearing, “go to market”population health management company
Mike Cotton Susan Klarner Linda Marzano
Value Based
CareContracting
Population Health
Informatics
Sr. Executive Assistant
Tammy Wintrode
PHP Health Plans
• Medicare Advantage
• Medicaid & DSNP• Commercial/
Exchanges• ASO products for
- State Employees- PSJH Employees
New Product Lines: - New MA Plans- MSO Services
PHP Health Plans
• Medicare Advantage
• Medicaid & DSNP• Commercial/
Exchanges• ASO products for
- State Employees- PSJH Employees
New Product Lines: - New MA Plans- MSO Services
Contracting with Payers & Providers
Contracting Strategy • Contract negotiations• PayersValue Based Contracting• Risk Sharing
Partnerships• Performance
Incentives
Contracting with Payers & Providers
Contracting Strategy • Contract negotiations• PayersValue Based Contracting• Risk Sharing
Partnerships• Performance
Incentives
Value Based Care
• Value Based Care • Models of Care &
UM • Caregiver ACO PlanMedicare Programs : MACRA, Medicare Shared Savings Program, MAPacMed Multi-Specialty Group Tricare Plan: US FHP
Value Based Care
• Value Based Care • Models of Care &
UM • Caregiver ACO PlanMedicare Programs : MACRA, Medicare Shared Savings Program, MAPacMed Multi-Specialty Group Tricare Plan: US FHP
Population Health Informatics
• Advanced Analytics• Predictive
Modeling• Collaboration with
EPIC, HI, Regions,• PHI Capital &
Procurement • Government
Programs
Population Health Informatics
• Advanced Analytics• Predictive
Modeling• Collaboration with
EPIC, HI, Regions,• PHI Capital &
Procurement • Government
Programs
Rhonda Medows, M.D.
Karen Boudreau, M.D.
Care
Management
Enterprise Care Management
• Care Management• Training &
Support for Practice Based Care Coordinators
• Medicaid Improvement for Complex Patients/Populations
Enterprise Care Management
• Care Management• Training &
Support for Practice Based Care Coordinators
• Medicaid Improvement for Complex Patients/Populations
Deepak Sadagopan
President
Population Health Management
Ayin Health Solutions
Population Health Management Services for • Payers• Providers• Government • Employers
Ayin Health Solutions
Population Health Management Services for • Payers• Providers• Government • Employers
CEO: R. Medows
Pres: M. Cotton
Chief of Staff
Angela Marith
Providence Health Plan
Ayin Health
President Providence St. Joseph Health
Rod Hochman, M.D.
Partnerships & Collaborationwith PSJH Regions:
• Population Health Roundtable• MACRA Steering Committee• Payer Contracting Regional Strategy councils• Medicaid Market/Region Strategy • Community Health Improvement• Population Health Data Coordination Council
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Bridging Health Care & Public Health
KNOW Our PopulationsIMPROVE Health Outcomes
Population Health Management
Social Determinants
of Health
Population Health Informatics &Community Pathways to Health (CPH)
A multi-source, integrated data platform
CPH DATA HUB
Health System Info
Hospital
ED
Community Health Data (CHNA)
Culture & Demographics
Clinical Info
Systems
Community health factors
Hot spot analysisTarget Intervention strategy Predictive Admission Status
Real-time data linking through geographic technology
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Care Management of Complex Patient Populations
Understand the problem
Develop interventions to
target the problems
Identify and engage patients
needing intervention
Evaluate the impact of the
solutions
Targeting patients with 5+ factors in the last 6 months
Targeting patients with 5+ factors in the last 6 months
AED: Avoidable ED
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Utilization•4+ ED visits•2+ AED visits OR 1+ AED in last month•2+ IP admits OR 1+ Avoidable IP
Clinical•2+ Chronic Conditions•10+ Distinct Medications•Lack of Primary Care “Home”•Mental Health Diagnosis•Active Substance Abuse
Social•Homeless Indicator•Lack of Social Support
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Maps and overlays make data visible, actionable
Medicaid enrollees, by zip of residence with 1+ avoidable ED visit in 2016
PSJH care facilities
Walgreen’s Locations
Starbucks locations (proxy for foot traffic)
Other overlays in development, including community resources, FQHCs, and more
Population Health Informatics Informs Strategy
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Two pronged approach focused Financial Sustainability & Complex Patient Management
Financial Improvement (Pillar #1) Complex Patient Management (Pillar #2)
Review of revenue cycle, finances & contracting Regional assessments, Strategic Playbook & Implementation
Denial Management
Underpayment Reduction
Eligibility Verification
CDI
DSH
Contracting Effectiveness
Access
Hospital & Transitional Care
Care Management
Caring for Special Populations
Policy & Advocacy
Strategy & Innovation
Process improvement & operational efficiencies to ensure financial
sustainability
PSJH Medicaid Strategy
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PSJH Value Based Arrangements Across All Payers
1.3 Million Lives In VBC PSJH Contracts with VBC Terms: $3.5 Billion
1. Includes PH&S Caregiver ACO2. Includes Medicare Advantage and Medicare Assigned
Capitated Hospital
Capitated Professional
HospitalQuality
Incentive Programs
SharedSavings (upside-
only)
Shared Risk
(upside & downside
risk)
Bundles
Commercial1 6 11 6 13 3 4
Medicare2 14 13 2 8 4 0
Medicaid 2 1 0 4 1 0
Direct toEmployer
0 0 0 0 3 0
Total 22 25 8 25 11 4
Note: Contracts with Quality Incentives & Shared Savings or Shared Risk were counted once in the Shared Savings or Risk category.
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PSJH Population Health Roles & Goals
Improving outcomes of our populations by providing services and support to our Regional Health Systems and Community Partners through• Enterprise Care Management• Contracting• Value Based Care Performance • Population Health Informatics
Improving Providence Health Plan integration with our network providers in Oregon, Washington, and California. Growth in new markets.
Ayin Health Population Health Management company providing services for external clients: sharing what we have learned with providers, payers, employers and government programs.
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Community PartnershipsWe align the influence of our system to create strongercommunities, raise awareness, and illuminate a pathwaythat inspires all to serve.
ENVIRONMENTALSTEWARDSHIP
COMMUNITY HEALTHINVESTMENT
GLOBALPARTNERSHIPS
COMMUNITYPARTNERSHIP FUND
GOVERNMENT &PUBLIC AFFAIRS
MENTAL HEALTH &WELL-BEING
PHILANTHROPY EDUCATION
Community Partnerships
HEALTH
2.0
Social Determinants of Health – A Paradigm Shift
CULTURE
• Mission
• Executive Sponsorship
• The External Environment
STRUCTURE
• Organizational Infrastructure
• Workflow Integration
• Scope of Work of Upstream Interventions
• Data
v
INCENTIVES
• Perceived Value of Moving Upstream
• Quality Improvement
CAPABILITIE
S• Staff and Team Roles
• Project Management of Upstream Interventions
• Financial Readiness
COMPETENCIES
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Community Health Improvement
5 year Regional Community Health Plans for each of our 7 states with focus on location population
Use Community Health Needs Assessment (CHNA)
Use Community Pathways to Health
Align efforts with strategy, community health investment, mental health initiative and population health
Assess intervention effectiveness
Each regional plan built by asking …
For example …
What are our top community health needs?
Mental health/substance abuse, obesity,high cancer, mortality rates
What population is our focus? Medicaid, home-bound elderly, foster kids, uninsured
Which Social Determinants of Health have the most impact on this population and their need?
Homelessness, food insecurity, transportation, social connections,substance use
Who are our relevant community partners that we can collaborate with for greater impact?
Local shelter, FQHC, low income housing authority, schools, food bank, transportation
What is the intervention? Temporary housing, respite care, care navigation, community resource desk, nutrition and physical activity programming, early childhood policy advocacy programs
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Disparities in ExpendituresAs a nation, we spend a lot on access to health care – but it’s only part of the nation’s health challenge!
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Distribution of Health Care Expenditures
Source: AHRQ https://meps.ahrq.gov/data_files/publications/st497/stat497.pdf
Top 1%
Top 5%
Top 10%
Bottom 50%2.8%
66.2%
50.4%
22.8%
Percentage of Population
Percentage of Health care Costs
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Strategically Connecting Top Needs to Top 1%
Chronic Conditions/Obesity
Chronic Conditions/Obesity
Mental healthMental health
Access to affordablecare/services
Access to affordablecare/services
Substance useSubstance use Nutrition/Food Insecurity
Nutrition/Food Insecurity
Housing Insecurity/Homeless
Housing Insecurity/Homeless
Social Determinants
Health Status Indicators
Service Utilization
Primary Care Network Design
Community Assets
People Potential
Community Pathways to HealthFuture Community Health Needs Assessment Framework with Multi Source/Integrated Data
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Re-Imagining our Community Health Needs Assessment Process
The CHNA becomes the core of our strategy with information
supporting decisions for:• The point of clinical contact• Populations at risk• Community health
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Modernizing the CHNA Process
State or County-Level
PDF/Static Documents
Public data lag
Inconsistent methodology
Inconsistent definitions
Informal qualitative input
Limited comparability
ZIP or census-block level data
Online hubs, “living” CHNAs
Embedded internal data
Modified MAPP framework
Standard definition
Mixed methods approach
Common core set of indicators
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Familiar Faces
1 High Social Needs / High Utilization
2 Post Hospital Discharge Follow Up
3 Avoidable ED Familiar Faces / High ED Utilization
4 LLOS Patients
5 Ambulatory Care-Sensitive Condition (ACSC) Patients (i.e. Avoidable IP Admissions) / IP High Utilizer
6 Pediatric ACES / High Risk
7 Trauma-Sensitive Conditions (TSC) Indicator
8 Pediatric CBT for Teens with Anxiety & Depression
9 Pediatric Chronically Ill
10 Families at Risk
11 Ambulatory CCM Chronic Care Management
12 Homeless and/or Homeless with Chronic Conditions
13 Disease Specific - i.e. Asthma, CHF, COPD
14 Palliative / End of Life / Pre-Hospice
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Population Profile Patient SnapshotPatient Attributes
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Social Determinants of Health DomainsFoundation System
1. Alcohol Use
2. Depression
3. Financial Resource Strain/Housing
4. Food Insecurity
5. Intimate Partner Violence
6. Physical Activity
7. Social Connections
8. Stress
9. Tobacco Use
10. Transportation Needs
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Move CHNA from a Static Document to a Living Actionable Document
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Homelessness
Using Geography
Anchorage Moves the Dialon Homelessness
Using Community Investment to Catalyze Systems Change
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Community Health Needs Assessment
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Anchorage Coalition to End Homelessness
1. United Way
2. Indian Health & Tribal
3. Mental Health Services
4. Community BasedOrganizations
5. Safety and LawEnforcement
6. Social Service Agencies
7. LocalBusinesses
8. Faith BasedOrganizations
9. Libraries & EducationalInstitutions
10. Municipality of Anchorage
11. Legislators & LocalPoliticians
12. City Planners & Land UseAnalysis
HUD Continuum of CareCommunity Partners
Anchored HomeUsing Community Investment to Catalyze Systems Change
“We are turning a corner, and we are using innovative and evidence-based methods to reach people, connect them with services and get them into housing. Our methods are working – andthe numbers aredecreasing.”
- Lisa Aquino, Executive Director Catholic Social Services and ACEH Board President
Long-Term Goals (Shared Data Model)
• Coordinated, client-centric model ofcare
• Reduce chronic homelessness by 20% by increasing permanent supportive housing
Example of Health System Outcomes
• Reduce emergency department visits and inpatient readmission rates of homeless persons
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Our Journey
“We expect Providence ministries to search for new ways to carry out the Mission, honoring Providence tradition, but not lettingpast practice constrict the vision of what is best for the future. Changing needs, social structures and institutions will require new and different responses. We expect that you will be open to the call of those who suffer by addressing emerging needs with wise and discerning responses so the poor and vulnerable may be served in new and more effective ways.”
- Sisters of Providence, Hopes and Aspirations Document40
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Contact info
Rhonda Medows, MD: [email protected]
Dora Barilla, DrPH: [email protected]
Please complete the online session evaluation
Questions
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