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Optimizing Population Health through Risk-Stratification &
Team-based Primary Care
Clemens Hong MD, MPH Medical Director, Community Health Improvement Los Angeles County Department of Health Services
Oregon Primary Care Association
March 7, 2016
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Outline
• Overview of Population Health & Care Management in Primary Care
• Using population risk-stratification to drive improved outcomes
• Los Angeles County
– Care Connections Programs
– Upcoming Opportunities
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The Opportunity
• Move from units of care to episodes, people, & populations
• Focus on things shown to improve outcomes
• Continuously Improve
• Support Innovation – improve by leaps
• Use team-based approaches
• Engage the community
• Rapidly share learning
High-Risk
Patients
Rising-Risk
Patients
Low-Risk
Patients
Population health management approaches are at the core of this
delivery transformation effort
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Inpatient Spend (Acute, Rehab, SNF) Outpatient
Spend
Traditional
Fee for
Service
Outpatient Spend Inpatient
Spend
Population Health
ManagementSpend
With
Enhanced
Coordination
Conceptual Strategy for Population Health Management
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High-Risk
Patients (5%)
Rising-Risk Patients
(15-35%)
Low-Risk Patients
(60-80%)
Three Population Foci
Low Touch/High Volume • “Surveillance” • Wellness & Health
Coaching • Tools – Patient
Portals/Virtual Visits, Social Media
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High-Risk
Patients (5%)
Rising-Risk Patients
(15-35%)
Low-Risk Patients
(60-80%)
Three Population Foci Med Touch/Med Volume • Face-to-Face
engagement • Chronic disease &
Health Coaching • Tools – Enhanced
Primary Care
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High-Risk
Patients (5%)
Rising-Risk Patients
(15-35%)
Low-Risk Patients
(60-80%)
Three Population Foci High Touch/Low Volume • Frequent interaction • Chronic
Disease/Intensive Care Coordination
• Tools – Complex Care Management Teams
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Challenges for Population Health & Care
Management Interventions: Drops in Potential
Adapted from J Eisenberg JAMA. 2000
Engagement
Finding opportunities
for improvement
Intervention
Identification
Potential opportunity
Realized improvement
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Family/Caregivers PCMH/CCM Team
CM Patient
Trusting relationship between a patient & a proactive care team the foundation to care management
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Health Delivery System Acute & Post-acute Facilities
Specialty Care
Providers
Behavioral Health
Home Health &
VNA
Social Service
Agencies
Government Service
Agencies
Public Health
Agencies
Payers & Purchasers
Family/Caregivers PCMH/CCM Team
CM Patient
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Patient- Centered Medical Home
PCMH Team CCM Team
PCP CM
A strong relationship between care management & primary care teams critical for care management
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Patient- Centered Medical Home
PCMH Team CCM Team
PCP CM
As is a strong relationship between the care team & other health system and community partners
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Patient- Centered Medical Home
PCMH Team CCM Team
PCP CM
Acute & Post-acute Facilities
Specialty Care
Providers
Behavioral Health
Home Health &
VNA
Social Service
Agencies
Government Service
Agencies
Public Health
Agencies
Payers & Purchasers
Health Delivery System
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Patient- Centered Medical Home
PCMH Team CCM Team
PCP CM
Care Management Structure
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Patient- Centered Medical Home
CM Hub
PCMH Team CCM Team
PCP CM
Care Management Structure
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Challenges for Population Health & Care
Management Interventions: Drops in Potential
Adapted from J Eisenberg JAMA. 2000
Engagement
Finding opportunities
for improvement
Intervention
Identification
Potential opportunity
Realized improvement
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Challenges for Population Health & Care
Management Interventions: Drops in Potential
Adapted from J Eisenberg JAMA. 2000
Engagement
Finding opportunities
for improvement
Intervention
Identification
Potential opportunity
Realized improvement
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• To align population, intervention, & outcomes
• Select a population at risk for future poor outcomes for which planned interventions can improve outcomes
• Tools: Quantitative, Qualitative, Hybrid
• Key Challenges
– Dynamic nature of risk
– Lack of full picture
– Care sensitivity is patient & program dependent
Goals of Population Risk Stratification & Segmentation
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Effective Targeting of Care Management
Population Volume
Healthy
Chronic Illnesses
Medically Complex/ High Utilizers
Area of Greatest Opportunity?
Area of Greatest Opportunity?
Area of Greatest Opportunity?
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Complexity defined by Charlson & estimated Physician-defined Complexity (ePDC)
Complex
by
Charlson
24%
Complex
by
ePDC
37%
Complex
by
Both
39%
Total
Complex = 27,531 (19.2%)
Source: Hong CS JGIM 2015
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0%
5%
10%
15%
20%
25%
30%
Not complex Charlson Only PDC Only PDC_Charlson
Primary Care Measures
Colon Cancer Screening DM A1c>9
Source: Hong CS JGIM 2015
*All p-values <0.05
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0.00
0.10
0.20
0.30
0.40
Not Complex Charlson Only PDC Only PDC_Charlson
Acute Care Utilization (per person year) Over 4 Years
Admissions ED Visits
Source: Hong CS JGIM 2015
*All p-values <0.05
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Clinical Outcomes by No Show Propensity Group
Source: Hwang AS JGIM 2015
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Acute Care Utilization by No Show Propensity Group
Source: Hwang AS JGIM 2015
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Challenges for CCM Programs: Drops in Potential
Adapted from J Eisenberg JAMA. 2000
Engagement
Finding opportunities
for improvement
Intervention
Identification
Potential opportunity
Realized improvement
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Importance of Continuous Quality Improvement
• Design + Implementation = Effectiveness
• Track Quality Measures – Process & Outcome
• Example – IT Enabled, Team-based Care
– Embedded advanced analytics paired with role delineation
– For program management & quality improvement
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• Rosters are all role-specific • Rosters are all actionable
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• A user can send a task to another user
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• A population-oriented care plan enables the user to see all that is happening with a patient
• A care team can be set up to include members that are typically not part of a care team
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Important concepts for program planning
• Build strong relationships
• No perfect model
– Start with the best approach for the context/population
– Then use continuous quality improvement to improve
• Keys to efficient population management
– Work in multi-disciplinary teams
– Complement existing services
– Allocate resources to high-yield activities
– Focus on mutable issues (know your system’s assets)
– Use HIT infrastructure to enhance CM efficiency
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Los Angeles County Care Connections Program & Beyond
Clemens Hong MD MPH
GIH Annual Conference
March 11, 2016
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Using complex care management teams to improve care & reduce costs
Specially-trained, multi-disciplinary care teams
32
One proposed solution
to address healthcare cost problem
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CCP
Admit/ ED
Care Connections Program (CCP) Aims
$
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Serving ≈5% of LAC DHS’s Patients
≈20,000 out of 400,000 primary care patients
• Complex biopsychosocial needs
• Hard to engage • High utilization of
health care • High cost of care
Panel within a Panel
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Patient- Centered Medical Home
PCMH Team CCM Team
Current Model Acute & Post-acute Facilities
Specialty Care
Providers
Behavioral Health
Home Health &
VNA
Social Service
Agencies
Government Service
Agencies
Public Health
Agencies
Payers & Purchasers
PCP CM
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Patient- Centered Medical Home
Central CCM Hub
PCMH Team CCM Team
CCP “Enhanced” Model Acute & Post-acute Facilities
Specialty Care
Providers
Behavioral Health
Home Health &
VNA
Social Service
Agencies
Government Service
Agencies
Public Health
Agencies
Payers & Purchasers
PCP – CHW – RN
PCP
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Care Connections Team
CHW PCMH
Embedded
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Acute Event or Status Change
CCP Program Overview
Comprehensive Needs Survey
Care Transition Work if needed
Patient Engagement
Care Plan Development
Accompaniment/Routine FU
visits
Follow-up Assessment
Face-to-face: Hospital, Clinic Or home visit
“Step Down”
Revise Care Plan if needed
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Patient Engagement
CHW Role
Social Support
Comprehensive Assessment
& Care Planning
Health System Navigation
Care Transition Support
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HospitalReadmission
Earlydischargeplanning
Contactinpa entteam/CMin24H
ContactPCPin24H
ChecksinwithInpa entteam/CMdaily&par cipatesinD/Cplanning
GivePCPupdateswithchangesinpa entstatus
Ensurecoordina onwithfamily/caregivers
Hospitaltohometransi on
Visitpa entatdischarge
Reviewdischargeplan&transi onalcareplan
Performmedica onreconcilia on&addressesmedica onmanagement
Educatepa entonred-flags&createred-flagsac onplans
Ensurecoordina onwithfamily/caregivers
Schedulefollow-uphomevisitwithin72Hpost-D/C
Schedulefollow-upPCPvisitfor1weekpost-D/C
Homevisitswithin72Hpost-D/C–reviewtransi onalcareplan,medica on,&red-flags
Assessneedfordiseasemonitoringdevices/DME
Assessneed/desireforadvanceddirec ve/goals-of-careplanning
Updatecareplanasneeded
Accompanypa enttopost-D/CPCPvisit
Addressingriskfactorsforacutecareu liza on
Assessforunmetsocialandresourceneeds
Assessforbarrierstocare
Engagesclientinbehaviormodifica onusingMI
Assessforhome-health&community-basedcareneeds
Primary Drivers Activities Outcome
Readmission
Driver Diagram
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Patient Engagement
CHW Role
Social Support
Comprehensive Assessment
& Care Planning
Health System Navigation
Care Transition Support
Chronic Disease Support &
Health Coaching
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Patient Engagement
CHW Role
Social Support
Comprehensive Assessment
& Care Planning
Health System Navigation
Care Transition Support
Chronic Disease Support &
Health Coaching
Advanced Illness management
support
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A Multi-faceted Program
Community Health Workers
Care Without Walls
Community Engagement
Social Needs Navigation
Care Transition & Acute Care Planning
Chronic Disease Management
Data-driven Improvement
Components
Advanced Illness Management
Pharmacy Intervention
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Phase 1: Demonstration
March/April 2015 – March
2017
5 DHS primary care practices in South and
East LA
Hire 25 CHWs CHW training by WERC &
Anansi Health 1,250 patients
Phase 2: Expansion
Apply lessons from Phase 1 Replicate model across LAC DHS
Up to 15X expansion possible
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Challenges
• Poor baseline health system infrastructure – Data Integration & real-time data access
• Implementation – Front-line provider engagement & patient selection
– Perception of program as “External”
– Poor understanding of intervention & CHW role
– Consistent delivery of intervention
• Culture “Clash” – Innovation vs “production engine”
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CHW Training/Supervision
• Training Topics
– Motivational Interviewing/Harm Reduction/Trauma-Informed Care
– Chronic disease self-management support – health coaching
– Goal Setting/Care Planning
– Program protocols – emergency, medication review
– Disease specific topics
– Other core competencies – boundary setting, safety
• CHW Supervision
– Programmatic – CQI meetings, performance evaluation
– Clinical – Weekly one-on-one, Monthly group, case conferences
• Clinical Support – Primary care team
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Patient Selection Approach
Hybrid Approach – quantitative gate 1. Primary care team refers patients based on criteria 2. Criteria verified through chart review 3. Randomly select subset of patients for the intervention 4. PCP Over-ride
High-risk criteria: – 2 Acute Care Utilization Equivalents (1 admit = 2 ED visits = 4 UC visits) – 1 Acute Care Utilization Equivalent PLUS 1 High-risk condition:
• CHF, IHD/Stroke/PVD, COPD, Asthma, DM w/ A1c>9, Uncontrolled HTN w/ cardiac/renal complications, ESLD, ESRD, progressive dementia/Anxiety/Depression/Bipolar disorder/psychotic disorder with functional impairment, Active Substance Use Disorder, or Age>90yo (HIV carved out)
– Poorly controlled chronic condition with co-occurring mental illness or substance use disorder independent of acute care utilization
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• Rosters are typically disease-centric, not ideal for patient outreach
• 1-view – a roster of rosters centered around patients
• This roster is optimized for outreach • With 1 click on the arrow to the left…
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• A row expands, and opens a pane displaying contact information, all the notes across all diseases pertaining to that patient, and a section for the user to enter a note