Population Health Innovations Deliver Significant Cost Savings and Improved Health Outcomes

Shauna ThomeExecutive Director

Crowfoot Village Family Practice (CVFP), Calgary, AB

Session 28:

Dave Jackson Chief Technology Officer

Airdrie & Area Health Cooperative (AAHC), Airdrie, AB

Agenda• The importance of the medical clinic environment:

“What gets measured, gets treasured.”

Setting the stage for success: leadership, culture, process, and change.

Plan, Do, Study, Act.

Outcomes and results.

• The importance of the community environment:

”All-in” community approach.

Social determinants of health.

Developing a “smart” community.

Outcomes and results.

Learning Objectives

Understand the importance of

environment and culture in affecting

change.

Demonstrate the importance of strategy and

defining outcomes.

Express the importance of

collaborations and identifying

potential partners.

Promote awareness of

social determinants of health.

Model the approach at both

the clinic and community levels.

Solicit ideas and incite change.

Poll Question #1

On a scale of 1 to 5, how effectively is your organization positioned for population health and accountable care?

a) 1-Not at all effectiveb) 2-Somewhat effectivec) 3-Moderately effectived) 4-Very effectivee) 5-Extremely effectivef) Unsure or not applicable

CVFP

Large publicly funded, physician-owned primary care clinic located in Northwest Calgary.

Provides care to 25,000 citizens from Calgary and surrounding areas.

Measurement

Engaged Leadership

• Share the halo.

• Model behavior.

• Constant feedback loop.

• Engagement.

• Plan for the future.

• Communicate often.

Conditions (Culture)

• Supportive context:– Performance is recognized and reinforced.– People have access to resources.– Information and training are available when

needed.

• Policies, procedures, and incentives align.

• Leadership demonstrates a commitment to teamwork.

Role Composition and Clarity

Scope of Practice

Legislated/Regulated

Competence

Individual Skill Set

Task

Patient Needs Driven

ROLE

AUTONOMYConfidence in Self

Confidence in OthersCOLLABORATION

QI Process

Set goalsMeasure

Create a cadence of accountability

Communicate:– Huddle– Debrief– Meet (monthly, annually)

Don’t Forget the Change

Change management is

a critical component of

QI.Define

success: set a goal.

Create buy-in: involve the entire team in planning

stages; communicate

often. Decide how you will measure

success.

Get started (don’t over-

commit).

Plan, Do, Study, Act.

Theory of Ones. Measure,

evaluate, sustain, and recognize.

Plan, Do, Study, Act

Act Plan

DoStudy

Act Plan

DoStudy

Act Plan

DoStudyPLAN

DO

STUDY

ACT

Micro Measure: Access• Alberta AIM (Access Improvement Measures).

• Goal: “To offer any patient an appointment on their preferred day with their primary provider by April 30, 2013.”

43% reduction in short delay80% reduction in long delay

Micro Measure: Population Management Diabetic Screening• Identify the patient group.

• Determine the overall care goals.

• Establish targets and risk stratification components.

• Use the EMR to access a list of patients who fit the criteria.

• Physician reviews patient list with team to determine the appropriate intervention.

Risk Stratification (simple) and Intervention

Patients with HbA1C => stratify high risk, receive in office HbA1C monitoring, appointment with Certified Diabetic Educator (CDE) and regular follow up with pharmacist. Initial goal is to reduce HbA1C below 9.

Patients with HbA1C between 7-9 stratify moderate risk, receive in office HbA1C monitoring, appointment with Pharmacist and on-going follow up, goal to reduce HbA1c below 7.

Patients with HbA1C between 6-7 stratify low risk receive teaching from Registered Nurse or appointment with the Health Management Nurse and on-going follow up, goal to reduce HbA1c below 6.

Micro Measure: Population Management Diabetic Screening• Used an in-office HbA1C monitor to obtain levels on patients opportunistically, which

increased values collected by 50%.

• High risk diabetics were contacted and booked with CDE─31% of those patients were moved to moderate risk category within one year.

• Moderate risk diabetics were contacted and booked with a Pharmacist or Chronic Disease Nurse─30% of those patients were moved to the low risk category.

HbA1c

Mar-13 Mar-14

Number of Patients Percent of population Number of Patients Percent of population

<=7.0 190 52% 258 70%

7.1 – 9.0 88 24% 62 17%

>9.1 23 6% 16 4%

No Value 65 18% 30 8%

Micro Measure: Health Screening

Macro Measure: Outcomes

Macro Measure: Outcomes

Poll Question #2

How would you quantify your organization’s engagement in community/preventive health outside of the clinic/hospital?

a) Noneb) Minimal–less than 10%c) 10 - 50%d) 50 - 75%e) Main focus–greater than 75%f) Unsure or not applicable

Background Information

• Vision: To be Canada’s healthiest community, individually and collectively, and to create a health information sharing culture.

• Airdrie & Area is a community of around 70,000 citizens.

• Two years of public engagement (5 questions):– What are the health and healthcare strengths in the community?

Why?– What are the unmet needs? What are the priorities?– Who do you collaborate with? What are the linkages?– What should the health park be about and who should be there?

Out in the community?– What would it look like to “own your own health”?

Need for Change

• Per capita spending in AB is among highest in Canada (~$7K).

• Canada as a whole is lower performing in outcomes.• Strong need to focus on social determinants of health

(healthcare accounts for 10-25% of our health).

Community “All-in” Approach• Healthy communities are more connected, networked,

and data-driven.

• Community stakeholders, as part of an all-in effort to create smart, healthy communities, depend on open data and connected technologies to keep their citizens more informed, engaged, and empowered.

• 5 Major Projects (all supported by the Smart Community Project):1. The Airdrie & Area Blue Zones Project2. The Airdrie & Area Health Park Project3. Community Health Need-Based Networks4. The Airdrie & Area Health Cooperative Project5. The Airdrie & Area Smart Community Project

#1: The Airdrie & Area Blue Zones Project• Blue Zones are communities around

the world where people live healthier, happier, and longer.

• By changing the environment (workplaces, schools, etc.), Blue Zone communities make the healthy choice the easy choice, thereby nudging everyone in the community toward improved health.

• An open data platform and connected technologies facilitate the collection of data from the environment and from all participants, and then return customized content to enable informed efforts to improve the social determinants of health.

#2: The Airdrie & Area Health Park ProjectA one-stop shop for both health and healthcare:

• Team-based, co-located, and fully integrated from birth to death (family physicians, specialists, allied health, 24/7, outpatient, etc.).

• Healthy seniors living and housing.

• Hub to support health and healthcare in the community.

A mini-smart health community:

• Greenfield development: smart technologies built into all aspects, from the design stage.

• Smart solutions include building, housing, transportation, energy use, water and waste, food supply, safety, health and healthcare, education, social connectedness, etc.

#3: Community Health Need-Based Networks• Not everyone is the same when it comes to their

health and healthcare needs:– A personalized approach is required (precision

healthcare, analytics, etc.).• The community will be segmented into like groups of

individuals from healthy to living with health challenges, and from young to old.– Will determine health and healthcare needs for

each group, which will form the basis of health improvement efforts.

• Identify the Right Care, the Right Provider, the Right Time.

• Networks need to be supported by open data in support of effective planning and decision making. They will also require specific, smart, and connected technologies as tools to meet needs.

#4: The Airdrie & Area Health Cooperative Project• A health cooperative has been incorporated as the structure through which to secure

buy-in and cooperation between many stakeholders.

• All in the community can be members and owners in the health of their community; individuals and families can be members and owners in their own health.

• The Health Cooperative Project is the glue that brings the community together to achieve something that no single part could achieve on its own.

#5: The Airdrie & Area Smart Community Project• Utilizes data and connected technology in an effort to become Canada’s healthiest

community; supports all other projects.

• Empowers individuals, providers, organizations, and need-based groups to own their own health through portals, dashboards, applications, tools, devices, etc.

• Works with a range of vendors (through a standardized framework) that each contribute their part.

• The resulting smart solutions will be available to other communities.

Digital Health Ecosystem“It’s about supporting a whole ecosystem for

using these data and tapping into creativity and resources that are not available within any

single organization.”

Peter Speyer, Chief Data and Technology OfficerInstitute for Health Metrics and Evaluation (IHME)

Poll Question #3

On a scale of 1 to 5, how effective is your organization at creating connections to community applications and external tools?

a) 1-Not at all effectiveb) 2-Somewhat effectivec) 3-Moderately effectived) 4-Very effectivee) 5-Extremely effectivef) Unsure or not applicable

• Finalist in the Canadian Smart Cities Challenge (one in five chance for a $10M prize).• Potential to be the first Blue Zones Community in Canada (currently in evaluation phase).• Community excitement:

– Commitment from the Mayor and City Council.– Partnership committee with local businesses.– Preventive health (vs sick care) is becoming a regular discussion.

Results

Lessons and Recommendations

Health = Physical Health + Mental Health

+ Social Health, backstopped by

healthcare.

Need to establish the environment first. A

digital ecosystem needs to be the backbone and

facilitator of change; change won’t occur by

telling.

Needs to be an all-in community approach; cannot be achieved by

only one organization or person.

Need to be outcomes-driven. Identify the

vision and work backwards. Establish an

ecosystem that can support and accomplish

the vision.

Needs to be a win-win for individuals,

organizations, groups, stakeholders, etc.

(incentivize).

Questions and Answers

sthome@cvfp.ca

Shauna ThomeCrowfoot Village Family Practice

dave.jackson@aahc.ca

Dave JacksonAirdrie & Area Health Cooperative