PQP & Social Determinants of HealthNC Medical Society

Population Health Collaborative

9/14/2017

Amy Messier, MD, Medical Director

Lydia Newman, MPP, Executive Director

physician Quality Partners

Physician Quality Agenda

• PQP – Who We Are

• NHRMC Strategic Plan

• MSSP Population

• System Efforts in a Shift Towards Value

• PQP’s Efforts to Address Social Determinants for MSSP

• NHRMC’s Broader Efforts Around Health Equity

Physician Quality Partners

PQP - Partnering with providers to navigate through value based

payment reform. Providing the organization, infrastructure, support

and education to make it easy for providers to put patients at the

center of care. Providing the right care to the right patient in the right

setting.

NHRMC 5 year Strategic Plan

Access

Mission: Leading our community to outstanding health

Success Measures

Focus Areas

Value Health Equity

- Engage providers to standardize care

- Create personalized experience for patients

- Establish post-acute network

- Create focused facilities that are highly reliable

- Innovate payer contracts and utilize bundles

Strategic Initiatives

Service & Operational

Excellence

Quality

Financial Health

Patient Engagement

Culture of Innovation & Engagement

Organizational Design & Infrastructure

Analytics

Governance

Provider Alignment

- Capitalize on and expand community partnerships, including long term support services and behavioral health

- Manage employee risk

- Build out care continuum

- Create healthy business opportunities

- Increase our understanding of and capabilities to manage risk

- Enhance cultural competency

- Expand access for sick and healthy patients

- Build out network (sites,distribution, primary care and specialty)

- Increase price and cost transparency

- Partner with retail

- Establish digital strategy & virtual platform

X # consumer touches Total system savings of $X

X # of covered lives

--Opportunity to rethink our role in population health, social determinants of health/health

equity

--New efforts being developed through entire NHRMC system, via PQP, and with other

strategic partners

Physician Quality Partners

NHRMC/PQP Population Health Initiatives

2013: BCBS Com/MA SS

9,000 Lives

2014: PQRS GPRO

2015: HQEP

5 Service Lines

2016: MSSP

17,000 Lives

2017: MIPS/MACRA

2019: Medicaid Reform

??? Bundled Payments

Employee Health

Physician Quality Partners- Providers

MSSP:

• Track 1, 2016

• 426 Providers

• 3 Tax IDs

– NHRMC’s Residency programs & NHRMC

Physician Group Practices (2 TINS)

– 1 External Private Practice

• Practice Composition

– Family and Internal Medicine traditional

and residency programs

– Surgical residency

– Cardiology

– Oncology

– Rheumatology

– Psychiatry (IP)

– Ob/Gyn

– Gastroenterology

– Urology

– Neurology

CIN:

• 591 Providers

• 5 HQEP programs

− Surgical Services

− General Surgery

− Orthopedic Surgery

− Neurosurgery

− Pathology

− Anesthesia

• Pediatrics

− Neonatology

− Pediatric Surgery

− Specialty Practice

− Hospitalists

• MSSP Providers

PQP MSSP Patient Characteristics

Attributed lives “less Risky” from demographics perspective

• 6% ESRD vs 8% for all MSSP

• 9% Disabled vs. 13% for all MSSP

• 3% Duals vs. 7% for all MSSP

• 87% Aged Non-Dual vs. 78% all MSSP

However, practice composition matters:

• 5X higher incidence of HIV (have an HIV clinic)

• 30-33% higher rates of Lymphoma, Breast, Prostate, and other

Cancer rates (have Oncology practice)

• 10X higher normal rates of diabetes with acute complications

• 30% lower rate of diabetes with chronic complications

• Average rate of diabetes without complications

• Low Obesity, Depression… REAL or HCC problem?

PQP MSSP Utilization

• Lower than average on Hospital/SNF Utilization

– Hospitalization Rates (260 vs. 313)

– Readmit Rates (147 vs 163)

– SNF Use (42 vs. 56)

– ED use (566 vs. 698)

– Lower than average admission rates for COPD and CHF

• Higher Average on

– CT Utilization

– Procedure Spending per Patient

– Laboratory and Other Test Spending per Patient

– Part B drugs per patient (but higher HIV and Cancer)

Can you shift site of service? Large primary care group - FFS

System Wide Efforts for Pop Health

Readmission Reduction Efforts – Hospital Perspective

• Improving Care Transitions from Hospital to Home “Must

Haves”

– Pharmacy medication review, education, and filling of Rx before discharge

– Discharge phone call within 48 hours

– Leave with appointment to PCP scheduled

• Complex Patient Management

– NHRMC Community Paramedics

– Community Care of the Lower Cape Fear for Medicaid and MSSP

– Transition Care Managers

• Improving Care Coordination with SNFs

– Discharge Telehuddle

– Preferred Partnership

– SNF Geriatrician partnership project

System Wide Efforts

ED Patient Assistance Center

• Located in the PAC office in ED Lobby

• Staffed 7 days a week from 8a-8p by 2

nurses, Licensed Social Workers and Case

Manager.

• Care coordination at the “front door”

• Work to link Familiar Faces with the right

care/medical home

• Community partners stationed in PAC office

(BH – Coastal Horizons, Hospice)

• Next steps – center for communication

(SNF, outside MD)

System Wide Efforts for Pop Health

Building practice capacity to manage complex patients

– Notification to PCP of ED, hospitalization and SNF

visits

– Post Discharge Transitional Care Visits with Providers

– CCM programs for chronically ill patients

– PharmDs embedded in practices to work on

Medication Reviews, counsel patients on adherence,

etc.

– Largest practice also embedding LCSWs to provide

patient care

System Wide Efforts for Pop Health

Expanding Access to Care

• Expanding primary care capacity

– CFM open access to pediatrics

• Trying to move to “call or come” philosophy to reduce

unnecessary ED use

• Implementing process for direct referral from ED to practices

with indicator of urgency level (0-3 days, 4-7 days, etc.)

• E-visits

System Wide Focus on Quality

Driving Quality in the Ambulatory Care Setting

• Using AWVs to Sustain Attribution and Drive Quality Initiatives

− Rooming Standard Work to close care gaps

− AWV standard work to drive at all preventative measures

− Purchased Retinal Camera

− Developing standard work of report retrieval and upload from HIE

• Using EMR tools and Quality Reports to drive continuous

improvement

− Point of Care Alerts, Care Gap reports, Choosing Wisely, Healthy

Planet

• Clinical Pathways

− CHF

• Tying provider and staff compensation to quality metrics

− Peer Performance Committee

• Achieved Level 3 PCMH for Largest Practice

• HCC Education

System Wide Focus on Quality

Driving Quality in the Ambulatory Care Setting

PHYSICIAN QUALITY PARTNERS

SOCIAL DETERMINANT STRATEGIES

Introduction

Lydia Newman, MPP

Executive Director of Clinical Integration &

Physician Quality Partners

1. PQP’s Efforts to Address Social Determinants for MSSP

2. NHRMC’s Broader Efforts Around Health Equity

Why SDOH Matters so Much

• ACOs Accountable for Total Cost of Care

• But only 10% of Health Outcomes Driven by Care We Provide

• 80% behaviors, environment, and social/economic factors

Patients Carry Many Heavy Burdens

Big effort to address each patient’s needs

Even bigger efforts required to solve them at

population/community level

Social Determinants Journey

Building on NHRMC Work on Access and Quality

• PQP Adding Predictive Analytics/Risk Segmentation

• Complex Care Management to Address Patient Needs

• Beginning Journey Upstream to Address Root Causes

Risk stratifying patients

Applying Interventions to address each patient’s barriers

Beginning work in community to address health equity

PQP Risk Segmentation for MSSP

Data Driven Interventions1. Segmenting Risks at Granular Level with CCNC Tools

1. Admission Risks

1. 30 Day Admission Risk & 12 Month

2. Pharmacy Risks

1. Adherence Risk

2. Drug Interaction Risk

3. High Risk Medication Risk

4. Opioid Fill Risk

3. 90 Day Mortality Risk

4. Impactability Scores

1. Transitional Care Impactability Score—ROI for TC Services

2. Care Management Impactability—Rising Risk population

2. Putting Actionable Information in Hands of Many

A. Data in CareImpact (CCNC Tableau Tool) and Scores in Epic

3. Tailoring Interventions to Address Individual Risks

Care Impact Tool

Care Impact Tool

ADT of ED and Admit Info. Married to All Risk Data

Depicted Infinite Ways, Sortable for Number of Purposes

Risk by

PCP

Actionable Data In Many Hands

• Schedulers

• Practice Visits to Address Care Gaps

• Address HCCs

• Sustain Attribution of Patients

Low Risks

Patients Not Seen/

Needing AWVs

• Schedulers, Providers, PharmDs, CCMs

• Proactive MD Appointments to Prevent Admissions

• Medication Reviews with PharmDs in practices

• CCM Engagement

• Complex Care Management as Needed

High Admission Risks

30-day and 12-Month Admission Risks

• Schedulers, PharmDs/Providers

• Proactive Appointments to Prevent Admissions

• Adherence Risk--Affordability and Side Effects

• Discrepancy Risk--Med Review/Reconciliation

• Treatment Therapy and Opioid Risks-

• Review and discuss with providers and patients,

High Pharmacy Risks

Adherence, Discrepancy, High Risk Medication, and Opioid

Risks

Actionable Data Drives Interventions of Many

• CCMs/ PAC Nurses/Inpatient Care Managers

• CCMs/Providers review and refer to palliative/hospice

• CCHIE pings RNs in PAC in ED to review/refer to palliative care/hospice team (Driving a lot of new engagement)

• Inpatient Care Managers discuss on provider rounds/Refer to inpatient palliative care

Mortality Risk

Probability of Mortality

in Next 90 Days

• CCMs/PQP review

• Rising Risk indicator– can use proactively to engage those not necessarily in ED or hospital

• Get in for appointments

• Link care management

Complex Care Management Impact Score

Provides ROI for Complex Care Management Interventions

• Paramedics/CCLCF Complex Care Managers

• Community Paramedics or CCLCF based on geography, diagnosis, etc.

• Both entities do home visits, med recs, assessments, linkages to services, etc.

• Also use scores to impact ED visits

Transitional Care Impact Score

ROI for Complex Care Management Interventions for

Admissions/ED visits

Importance of Home Visits

Complex patients

--Needs not easily identified/addressed in office visit or by phone

--Requires relationship building, MI training, empathy and detective work

--PharmDs critical for complex med review

Mr. Jones- Patient with diabetes and falls/infections

– Lost his wife, children live in Florida, lives in rural NC/socially isolated

– Sold car to pay bills

– Can’t get to church, pharmacy, store, and MD practice too far away,

– Inherited home in Florida and has one in NC, 2x mortgages

– Financially stressed, food insecure

CM requires broad plan to manage complex needs

– Started with problem at hand: healing infection

– Diabetes education—nutrition, medication adherence

– Financial—help with prioritizing bills, getting help from children selling home

– Social/Spiritual--Getting church members to pick him up for church

– Nutrition--Linking to Meals on Wheels & church food boxes

– Transportation--Changing to VA practice closer to home/linking to community transportation

services

And he is more straightforward than many—dementia, lack of supports, many stories

SNF Strategies

Reduce SNF Utilization, LOS, and Readmissions

1) Hospital Mobilization Project

– Deconditioning during hospital stay cause of SNF admission

– Efforts to prevent falls contributing to lack of

mobilization/increased deconditioning

2) Family Medicine Residency Home Visits

– Target patients high risk patients who can’t come to clinic

– Physician, Pharmacist, and care manager

– Take practice visit to home that includes SDOH

H&P Falls Risks Care Giver Support

ADLs Environment Nutrition

Spiritual health Code Status Most Form

Reducing SNF LOS and Readmissions

3) SNF Discharge Pilot for MSSP

• Geriatrician reviewing high risk MSSP discharges to SNF

– Convey her expected plan of care and length of stay to SNF

• Use Care Manger Following Up with SNFs

– Calling SNF at transition to ensure effective transfer made

– Calling again at expected discharge date, ensure patient on

track, has home health, PCP appointment, PCP has discharge

paperwork, etc.

– Follow up with patient to confirm home health arrived, PCP

appointment in place, have transportation, etc.

Swimming Upstream: Health Equity

NHRMC Strategic Plan Focus on Health Equity

• Employees– Starting with Cultural Competency of own Employees

– Using workforce to impact community through volunteerism

• Community Gardens, Food Drives, Book Drives,

• Engaging Community

– Adding Needed Services

• Uber, NA and AA for inpatients, Diaper Bank, Meals on

Wheels

– Partnering with community organization formed to stop cycle of

youth violence in neighborhood

• Helping conduct community needs assessment

• Determining our role in filling identified gaps

Swimming Upstream: Health Equity

• Reducing Health Disparities

– Statistically significant differences between Blacks and whites within MSSP data

in disease burden and utilization

– Picked up by Priority Scores, but what do we do to change/do differently?

Population % of Total % of White Pop

% of Black Pop

Total MSSP 100% 86% 10%

Dual Status 8% 5% 30%

CHF 7.2% 6.9% 11%

Diabetes w/complications 8.24% 7.27% 17.2%

Diabetes w/o comp 13.8% 13.2% 19.1%

Renal Failure 2.4% 2.25% 4.14%

Admit rate per 1000 (per claims) 15.4 15.3 17.42

Readmit Rate per 1000 (per claims) 13.6 12.6 20.2

Palliative Care Indicator 5.4% 4.8% 11.24%

TC Priority 29.3% 28.3% 41.5%

Cost per beneficiary down $177 per paCost per beneficiary down $177 per patient ($3 M total) since

interventions began Q3 2016

All MSSP Cost up $221, FFS up 1,366 (FFS deducted non utilizers in

Q1 2017)

Cost per Dual down $3,572 ($1.85 MM), (In Part Due to SNF Pts out of

attribution 1/1/17)

All MSSP cost up $379, and FFS up $1,284

OutcomesComponent cost per beneficiary on short term hospital down $48

All MSSP up $73

All FFS up $395

Hosp. rate down 22 per 1,000 = 378 fewer per year

Admissions continuing to decline vs. all MSSP and FFS constant

Readmit Rate top quartile, 14.7%

Physician Quality Partners