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Session #24: Allina: How this ACO Is Using Actionable Data and an Integrated Care Program to

Improve Outcomes

Ensor Transfeldt, MD, Spine Program Medical Director

Allina Health

Pre-Session Poll Question

On a scale of 1-5, how effectiveis your organization’s ability to deliver coordinated care for complex conditions?

1) Not at all effective2) Somewhat effective3) Moderately effective4) Very effective5) Extremely effective6) Unsure or not applicable

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About the Organization

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• Dedicated to the prevention and treatment of illness and helping people live healthier lives in communities in Minnesota and western Wisconsin

• Not-for-profit integrated delivery system, Pioneer ACO

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The Problem

Low back pain (LBP) is a common and expensive medical problem

• The estimated annual associated costs for patients, employers, and insurers resulting from LBP exceed $100 billion per year in the United States, two-thirds of which are a result of lost wages and reduced productivity

• LBP is one of the most common reasons for missed work

• There are marked variations in spinal surgery internationally and between regions in the United States

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The ProblemIn 2010, Allina Health noted a poor grade for their spine surgery performance at some of their facilities on publicly reported data

• The accuracy of the rating was unclear, but Allina did not have good control of or access to their data to determine whether the report was accurate

• Analysis of available data indicated significant variation in outcomes

• Allina lacked a truly integrated, multidisciplinary approach to the treatment of patients with low back pain

• There was a significant lack of physician awareness and engagement in performance and outcomes

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Our Approachand

Results

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Surgical Spine Quality Council

Chair: Dr. Mehbod

Medical Spine Quality Council

Chair: Dr. Hillman

Spine Program Development Group

Chair: Dr. Transfeldt

Allina Health Group Executive Committee

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West Region Committee

East Region Committee

North Region Committee

CKRI Spine Ops Committee

IP Spine Nursing Group

PATIENT DRIVEN

Objective: recommend, prioritize, set goals, strategy, capital, performance oversight, communication

TBD: OP Spine Nursing Group

Allina Health Spine Program Governance

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CONTINUED SPINE CARE PATHWAYACUTE SPINE CARE

PATHWAY

Coordinated Spine Care Model

PREVENTION

Allina Health Spine Care Model

Consumer Education• Payer organizations• Employment groups

Community Education• AH “Back School”• Community Health Fairs

Wellness Organizations• YMCA• Life Time

Primary CareEmergency/Urgent CareSpecialty Care (MD)Specialty Care (non MD)

Return to Primary Care Provider with After Care as needed

Excellian Order:Ambu Consult to Spine Center

No Improvement or lack of resources

Spine Surgery Consult

(if indicated)

Medical Spine Specialist Consult

(MD or Non MD)

Clinical Triage / Care Navigation

Evidence-Based Spine Treatment

Further DX Workup

• Imaging• Labs

Conservative Treatment

• Sx management • Physical therapy• Chiropractic• Integrative medicine

Interventional Treatment

• Injections• Surgery

Chronic Pain Management

• Psychology• Medication

NO

NO

80-90% OF Acute LBP responds to:• Reassurance• Education• Exercise• Physical Therapy

Red Flags:• Suspected Cauda Equina

Syndrome• Suspected Myelopathy• Recent Trauma• Suspected Cancer• LMN Weakness• Suspected Infection

Community wellness programs

Fitness/Activity Programs

Episodic physical therapy or home

program

Self Referral(Telephone or Web Based)

Improved?

YE

S

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NO

Clinical Care Guidelines for LBP

Initial Evaluation Evaluation Elements:History and ExamReview Red/Yellow FlagsPain Rating (VAS)Quality of Life Instrument

Core Treatment Plan:Education & ReassuranceEncourage activityPT or Chiropractic Care

YESRed Flag Protocol

Radiculopathy CPGYES

NO

Core Treatment PlanReassess in 2-4 weeks

Continue Core Treatment Plan• Encourage ongoing exercise• Reassess in 4-6 weeks

Low RiskDetermine risk of developing chronic back pain:• Assess Yellow Flags• Keele STarT Back Screening Tool

Re-evaluation

Improving?

Re-evaluation

YES

YESImproving?

Core Treatment Plan, PLUS:• Physical Therapist with clinician trained in

addressing psychosocial issues• Mental Health Screening/Psychology• Consider Spine Center referral• Reassess in 1-3 weeks

Moderate/High Risk

Core Treatment Plan, PLUS:• Reassure & Address Psychosocial Factors• Consider Spine Center Referral• Consider Integrative Medicine Referral• Reassess in 1-3 weeks

Core Treatment Plan, PLUS:Shared Decision Making:• Further workup (Imaging, Labs)• Medications• Spine Center Referral

Self ManagementEncourage fitness/activity program(s)Or PT Home ProgramFollow up as needed

Re-evaluation

Improving?

SPINE CENTER REFERRAL

YES

NO

NO

NO

Red Flags?

Red Flags?

8

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The Need for Actionable Data

Implemented a late- binding enterprise data warehouse platform (EDW) to take advantage of available information and provide support for providers and managers.

The EDW aggregates clinical, financial, operational, experience and other data to create consistent views of the data to inform decisions.

The Spine dashboard is used to monitor and manage performance and to drive behavior change.

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The Spine DashboardThe Spine dashboard is used to monitor and manage performance and to drive behavior change

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The Spine Dashboard

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The Spine Dashboard

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Poll Question #2

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On a scale of 1-5, how effective is your organization at using data to drive behavior change and performance improvement?

1) Not at all effective

2) Somewhat effective

3) Moderately effective

4) Very effective

5) Extremely effective

6) Unsure or not applicable

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Results

Implemented a successful, highly collaborative coordinated care program for spine disorders including LBP

Significantly improved access to good data and toward a data- driven culture

Projected $2.7 million in implant savings achieved through standardization

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Results – LOS• Achieved a 16% reduction in LOS

Length of Stay

Year Average LOS Volume

2012 4.25 1246

2013 3.97 1146

2014 3.75 1172

Jan-Apr 2015 3.61 398

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Results – Post-Op Complications

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Year-to-Date 2015 (Jan-Feb)

Mar 14n=24

Apr 14n=18

May 14n=21

Jun 14n=26

Jul 14n=23

Aug 14n=24

Sep 14n=26

Oct 14n=28

Nov 14n=14

Dec 14n=20

Jan 15n=17

Feb 15n=7

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0% 10.6%

7.4%9.1%

10.8%9.7%

10.6% 10.3% 10.6%

6.3%7.7% 8.1%

3.6%

PPC Overall - 2014-2015

PPC Rate (N/D) Goal ≤ 9.3%

3.6% Reduction in post-op complications

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Future Plans

• Continue to develop a highly integrated, coordinated, multi-disciplinary, patient-centric approach to patients with spine issues

• Continue to improve quality and availability of data

• Continue drive toward value (high quality, low cost, appropriate care)

• Broadly introduce the fusion risk score (FRS)

• Measure the financial impact of the Spine program

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Lessons Learned

1. Data is not only critical for measurement; it can also influence behavior

2. Build an effective multi-disciplinary improvement team 3. Engage and effectively communicate with all stakeholders

involved in the care process you are trying to improve 4. Create a compelling case for change

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Analytic Insights

AQuestions &

Answers

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Choose one thing…

20

Write down one thing will you do differently after hearing this presentation

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Thank You

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Session Feedback Survey

1. On a scale of 1-5, how satisfied were you overall with this session?

1) Not at all satisfied

2) Somewhat satisfied

3) Moderately satisfied

4) Very satisfied

5) Extremely satisfied

2. What feedback or suggestions do you have?

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Upcoming Sessions

Breakout Sessions – Wave 4 (1:15 PM – 2:00 PM)

26) Panel – How Community Hospitals Thrive with AnalyticsJohn Wadsworth, Vice President, Technical Operations, Health Catalyst

27) Quality Improvement in Healthcare: An ACO Palliative Care CaseDr. Robert Sawicki, MD, Senior Vice President, Supportive Care, OSF HealthcareRoopa Foulger, Executive Director, Data Delivery, OSF HealthcareLinda Fehr, RN, Division Director, Supportive Care, OSF Healthcare

28) Clinical Standards Work To Improve Evidence-Based Care Delivery: A How-To WorkshopCharles Macias, MD, MPH, Chief Clinical Systems Integration Officer, Texas Children’s HospitalTerri Brown, MSN, RN, CPN, Assistant Director, Clinical Outcomes & Data Support; Research Specialist, Center for Research and EBP, Texas Children’s Hospital

29) Five Months to Improvement: How Stanford Built an Improvement Program the Gets ResultsSpencer H. Kubo, MD, Associate Professor of Radiology (Pediatric Radiology), Stanford University Medical Center

30) Breaking Down Silos: Resolving Academic, Medical, and Research Interests Once and for AllSamuel L. Volchenboum, MS, MD, PhD, Assistant Professor of Pediatrics, Director, Informatics Program, The University of Chicago Medicine)

Location

Imperial Ballroom B

Imperial Ballroom A

Grand Salon

Murano

Venezia