welcome back - michigan · source: institute of medicine (iom) framework for patient and family...

Welcome Back

June 14, 2017

Day 2

1. Welcome 2. Lingering Questions

and Reflect 3. Review Today’s

Agenda

Yesterday, we…Had an orientation workshop for new participants, including a review of QI 101Had time to connect with CHIRsLearned from our peers and expanded our learning network through Storyboard RoundsTalked about different models to support changeLearned about a patient case

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Today, we will…Hear about best practices to link patients and achieve healthNetwork in “open space” conversationsAttend breakouts– Building will: Engaging patients as the core stakeholders in the

PCMH transformation– Measurement: Developing a Measurement Strategy– Journey to test and implement a SDoH assessment

screening toolLearn about population health managementLearn how to use Driver Diagrams to organize learningsParticipate in team time to work on storyboards and plan for the action period

4

Sites and Their Clinical Community Partners

Facilitator:- Trissa Torres, Institute for Healthcare

Improvement

Panelists:- Beth St. John, United Way of Michigan

(MiCHAP)- Lori Noyer, Ingham CHAP and Pathways - Robin Reynolds, Ingham CHAP and

Pathways

Open Space

Sue Gullo, DirectorSue Butts-Dion Improvement Advisor

Objectives

Capture energy and use it in self directed discussionShare learning from discussion groupsDescribe one task or test shared by a team that will aid in sustained practice changes required for practice transformation

Open Space

Harrison Owen wondered: why is most energy in a meeting in out of meeting time (breaks, social hour)?How to capture that energyCan work small groups to 500 peopleCan replace agenda planning and even span a 2,3 day conference

Principles

Let people decide and set breakoutsWho ever is here are the right peopleCan “bumble bee” and cross-pollenate between groupsDiscussion group reports are the meeting notes

How to do itAllow people a moment to think about what they are passionate about, want to or need to talk aboutA person stands, says name, and topic of interest. – Writes it on a piece paper and tapes it to the wall

Repeat until all are done, wait a little longer; someone usually comes up

Divide up into groups under area you want to discuss. Some may not be selected.

Each group

Has a leader – person who posted topicHas a recorder who takes notes as well and shares those at the end of the Open Space

Topics

1. Care managers/coordinators; physicians2. Billing and coding3.

4.

5.

Engaging Patients in Care and Care Redesign

June, 2017

5000 hours

Trevor

https://www.youtube.com/watch?v=cMGgoInt1Mo

CEO

Your TurnThink of specific experience where you were a patient or family member of a patient. Share with your neighbor:- Good parts of your experience- Things you would change about

your experience

What is Co-design in healthcare?

“Co-design is a process and mindset that brings together patients & families, staff & clinicians, performance improvement experts & other improvement stakeholders to design new care and service offerings or improve existing ones.”

Reference: Kaiser Permanente

Co-design Method

Explore change ideas & decide what to prioritize

Develop aims & plans around how to work effectively work together

Establish meaningful relationships between patients, families & staff

Understand patients & staff experiences, define metrics that matter & explore opportunities for improvement

Turn your improvement ideas into action through tests of change & prototyping

Implement strategies to ensure your improvements are sustainable

Engage

Plan

Discover

Generate Ideas

Test Ideas

Make changes

stick

MiPCT: Building the Patient Voice “In”

1. Program-Level Patient Advisory Council2. Patient and Caregiver Presentations at MiPCT Events

– Summit Keynote– Medicaid Health Plan/MiPCT Care Manager Synergy

Sessions3. Practice-Level Patient and Family Council (PFAC)

Support and Training4. Other Aspects

– “E-Councils”– “Michigan Pathways” (Stanford Self Management)

Awareness/Training

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Advisor RolesRole of patient and family advisors:

– Serve as sounding board for initiatives to establish balance with priorities of patients and families

– Generate new ideas to drive initiatives at all levels – Decrease barriers to patient engagement– Share best practices across regions– Participate in program planning and evaluation– Provide input on policies, programs, and practices– Evaluate and give input on PCMH transformation and

QI activities

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Characteristics of Great Patient/Family Advisors:

• Comfortable speaking publicly with candor• Able to use their own experience constructively• Able to see beyond their own experience;

concerned about more than one issue or agenda

• Able to listen and hear differing opinions

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Advisor Selection

Best Practices to Support Members

• Convene in-person meetings where possible to build relationships

• Use social networking web-based applications• Train advisors and “train the trainer” partners• Provide committee members with a contact list• Provide committee members with advisor to orient them

Remember, this type of collaboration is new for many people so preparation and orientation is important for care teams, as well as patients and family members.

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Program-Wide Patient and Family Council

Patient Advisory Council

June 17, 2016 1:00 PM

Dial 888 330-1716; Access 7403249

Agenda

1:00-1:05 Welcome

1:05-1:10 Minutes and Agenda Review 1:10-1:20 MiPCT National Evaluation Results: Good news for Michigan!

a. Michigan led the other states in success for cost savings for Medicare b. Michigan and Vermont are the best performers of the eight states overall c. Key stakeholders interviews in the reports reflected themes that were consistent with

expectations, including: o Successes in embedding Care Managers within practices; diabetes self-management

education initiatives and preventive care; and providing Admission, Discharge and Transfer (ADT) notifications to primary care practices.

o Observations about the importance of sustained multipayer support, the time required to change practice patterns and workflow and embed Care Managers in practices to generate improvements in patient outcomes, and the key role of the Physician Organization in implementation.

o Challenges noted in interviewee responses included desires for growing participation to include all payers and to increase the number of care management services delivered to patients who would most benefit.

1:20-1:30 Transition of MiPCT from a demonstration to an ongoing program

• Partnership with the State Innovation Model (SIM) and SIM “101” for PAC Members at next meeting

• Expansion to 100 to 150 additional primary care practices in 2017!

1:30-1: 40 ICAN Tool (I Can!) reviewed at the last PAC and the challenge to try it out for yourself! (It is attached below for easy reference)

• What did you think of the tool? • How could it be used to help patients establish a relationship with providers? • Are there other tools that you or your family members use to prepare for a medical appointment?

1:40-1:50 Upcoming Opportunities for Patient Advisory Council input

• Your favorite user-friendly websites (we are on the hunt as we are redesigning and refreshing the mipct.org website and would love your suggestions)

• Summit agenda design • Medication reconciliation project • Medicaid Health Plan/MiPCT Care Manager coordination • Growing Patient input within practices, the MiPCT design and State policy

1:50-2:00 Other Patient Advisory Council Sharing

• Provided patient and family input into program design and operations during the MiPCT Demonstration

• Examples of issues taken to the PAC:

– Patient experience survey question review

– CAHPS-CG aggregate findings review

– Community Health Worker integration

• All patients and family members had experience with MiPCT practices and care management servicing

The “Voice of the Patient” MiPCT/GDAHC/IPFCC Partnership

A “Train the Trainer” Approach to Supporting PFAC Development in Michigan Practices

• Step One - Engage and Identify “Voice” Practices• Develop and host a joint webinar, explain options and offerings, benefits

and expectations • Request interested practices to submit a response form for practices that

wish to participate in the initiative

• Step Two – Train the Trainers• Train MiPCT and GDAHC staff• Offer trainings to responding practices

• Step Three – Initiate Program Implementation at the Practice Level

• Step Four – Collect outcomes and robustly share lessons through a learning network (MiPCT Practice Learning Credits awarded for participation)

March 17, 2015

MiPCT/GDAHC/IPFCC

Starting a Patient and Family Advisory Council requires some work – and a continued commitment. If you give up too soon, you “throw the baby out with the bathwater”. The value that a council can return value to the practice builds over time.

Use your advisors to get a sense from a patient’s perspective when your practice struggles with an area of patient engagement, or with a pattern of feedback/complaints from patients

Tools provided to practices should be sculpted to the beginning small practice. Often many tools are geared toward large systems or inpatient environments.

Practice “Celebration” Report Out -Example

What We Learned

Supporting Practices for PFAC Success• Are you also a CPC+ practice? PFACS are a CPC+ requirement

• Prepare and position for success– Collect patient/practice interaction “frustration points” for a week or two

– From the practice perspective (“I don’t know why patients can’t….”; “We have done all we can”; “ patient won’t comply”; etc.)

– From the patient perspective (what do you hear the most concern about from patients? What annoys them? Catch yourself saying “that is just the way we do it”, etc.)

– Talk about the big “why”, “what” and “how” – Recruit (staff, prospective patient reps)– Plan the agenda and logistics for the first meeting– Incorporate things that advisors want to discuss– Repeat again, review and improve, adjust if necessary

• Find early “quick win” areas that allow practices to reap benefit from patient and family input as a hook for expansion and greater adoption and let members see how their input becomes action that benefits other patients

Your Turn: Turning Pain Points into Progress!

Part One: From the Practice/PO/CHIR Perspective• Do you ever think or hear “I don’t know why patients can’t….”; “We have done all we

can, but they won’t comply”….– When? – What did that look like?

Part Two: From the Patient Perspective• What do you hear the most concern about from patients? What annoys them? Catch

yourself saying “that is just the way we do it”, etc.)

Share your thoughts with your neighbor!Explore your aspirations!

Brainstorm 1-2 new ideas to try!

Source: Institute of Medicine (IOM) Framework for Patient and Family Engagement: Care, Scheduling, Delivery, and Follow-Up (Released July 13,2015 in “Transforming Health Care Scheduling and Access: Getting to Now)

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Consumers’ Use of the Healthcare System and Level of Engagement by Segment

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Developing a Measurement StrategyMeasures for Accountability and Measures for Improvement

Katherine Commey, MPHSIM PCMH Initiative CoordinatorSue Butts-Dion, Improvement Advisor, IHI

Objectives

Review the purpose and operational definition of Clinical Community Linkages (CCL)Differentiate between measures for accountability and measures for improvementDiscuss outcome, structure, process, and balancing measures for the MI SIM requirements and for improvementBegin thinking about measurement strategy for your team

2

US Dept of Health and Human Services AHRQ

Langley, et al, The Improvement Guide, 2009

A Model for Learning and Change3

CCL-Operational Definition/Objective—What are we trying to accomplish?

Develop documented partnerships between a Practice (or PO on behalf of multiple Practices) and community-based organizations which provide services and resources that address significant socioeconomic needs of the Practice’s population following the process below:

1. Assess patients’ social determinants of health (SDoH) to better understand socioeconomic barriers using a brief screening tool with all attributed patients.

2. Provide linkages to community-based organizations that support patient needs identified through brief screening, including tracking and monitoring the initiation, follow-up, and outcomes of referrals made.

3. As part of the Practice’s ongoing population health and quality improvement activities, periodically review the most common linkages made and the outcome of those linkages to determine the effectiveness of the community partnership and opportunities for process improvement and partnership expansion.

4

With Focus on Patient Centeredness

Oriented towards the whole personCreated by partnering with patients and families through an understanding of and respect for culture, unique needs, preferences, and values

US Dept of Health and Human Services AHRQ

5


A Model for Learning and Change6

Data for Improvement, Accountability and Research in Health Care

Aspect Improvement Accountability or Judgment

Research

Aim: Improvement of care processes, systems and

outcomes

Comparison for judgment, choice,

reassurance, spur for change

New generalizable knowledge

Methods: Test observable No test, evaluate current performance

Test blinded

Bias: Accept consistent bias Measure and adjust to reduce bias

Design to eliminate bias

Sample Size: “Just enough” data, small sequential samples

Obtain 100% of available, relevant data

“Just in case” data

Flexibility ofHypothesis:

Hypothesis flexible, changes as learning takes

place

No hypothesis Fixed hypothesis

Testing Strategy: Sequential tests No tests One large test

Determining if a Change is anImprovement:

Run charts or Shewhart control charts

No focus on change Hypothesis, statistical tests (t-test, F-test, chi square, p-

values)

Confidentiality ofthe Data:

Data used only by those involved with improvement

Data available for public consumption

Research subjects’ identities protected

Frequency of Use: Daily, weekly, monthly Quarterly, annually At end of project

Source: The Health Care Data Guide: Provost and Murray, 2011. Developed from Solberg, Leif I., Mosser, Gordon and McDonald, Susan. “The Three Faces of Performance Measurement: Improvement, Accountability and Research.” Journal on Quality Improvement. March 1997, Vol.23, No. 3.

Measures for Accountability

SIM PCMH Initiative Semi-Annual Practice Transformation Report– Social Determinants of Health

– Screening Plan, Procedure, and Tool

– Clinical Community Linkage Methodology – Roles and Responsibilities, Information Sharing, Training

Approach, Partnerships, Documentation

– Quality Improvement Activities – Process Reviews, Documentation Reviews, Addressing

Gaps

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Reporting requirements and improvement…not mutually exclusive!

Reporting requirements

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What Are We Trying To Accomplish?

The AIM isNot just a vague desire to do betterA commitment to achieve measured improvement– In a specific system—for whom?– With a definite timeline– And numeric goals

– E.g. % of patients screened, % of patients appropriately linked to follow up (e.g., feedback loop closed)

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• Brief description of your organization: ________________________________________________________________________________________

• With regard to Clinical-Community Linkages:What do you hope to accomplish related to this objective?____________________________________________By how much do you hope to improve?

______________________________________And by when do you want to improve?

______________________________________

Organization Name: _______________________Location: ________________________________

LS1 Pre-work

Reporting requirements and improvement…not mutually exclusive!

Reporting requirement

“For Whom”—what population?

Time frame?

What changes will you test to close gaps?

Workflow/flow chart?

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Cont…

Workflow/flow chart?

14

Measures for Accountability15

Measures for Improvement

Sue to insert various graphs for how data for improvement might be looked at.

16

Your Turn

Take time to think through your report for July 2017What questions do you have?

17

June 13-14, 2017

Breakout C: Journey to test and implement a SDoH assessment screening tool

ObjectivesDescribe the process of the SDoH assessment in your organization

Identify one area that could make assessment most purposeful

Discuss your test of change and what you have learned

Identify changes that have been tested across organization

Overview

Building a reliable framework- training and education (Marie and Lauren)Building the key components one step at a time (Sue)Building your plan (All)Sharing the plan- report out

Michigan Care Management Resource Center

Social Determinants of HealthCare Management Resources

SIM PCMH Initiative – Initial Required Training

MiCMRC Complex Care Management Course – Social Determinants of Health (SDOH) Expanded Curriculum

MiCMRC Complex Care Management Course offered monthly• Blended learning activity: live webinar, self study recorded webinars and 2 in

person course days– Registration: http://micmrc.org/training/micmrc-complex-care-management-

course/registration

NEW . . . Starting June 19 – 22, 2017 the CCM course will include expanded SDOH content:• Self study recorded webinar

– “SDOH Introduction” • In Person

– “SDOH Implications for Care Management”– Group activities – case study, community mapping, care mapping

• Resources – Sample SDOH screening tools – Community mapping tool

http://micmrc.org/training/micmrc-complex-care-management-course/registration

SIM Initial Required SDOH Training – OnlineThe SDOH online required training includes:• Recorded Webinar

– Introduction to SDOH– Clinical Community Linkages and Community Mapping

• Interactive web based module– Implications of SDOH for Care Management – Case study

• Resources– Sample SDOH screening tools, community mapping tool

NOTE: The SDOH online initial required training is to be completed by:– Care Coordinators and Care Managers who took the Complex Care

Management course prior to July 2017– Starting end of July 2017, access the SDOH online required training at

http://micmrc.org/training/supported-programs/sim-pcmh• For the SDOH online required training “go live” date - Look for announcement in the

SIM PCMH Initiative Monthly Newsletter

http://micmrc.org/training/supported-programs/sim-pcmh

SIM PCMH Longitudinal Learning Credits for Care Coordinators and Care Managers

Opportunity for Longitudinal Learning Activities: Social Determinants of Health – Webinar Series

To provide examples of how integrated care teams identify roles and communicate in order to effectively provide care to clients and address Social Determinants of Health. Webinar panelists will present information about their roles on the care team, team communication strategies, and addressing SDOH.

To enhance the understanding of how Social Determinants of Health impact chronic conditions. The presenter will describe potential strategies and interventions for addressing SDOH as a care management team, and the importance of addressing SDOH to improve patient outcomes.

Opportunity for Longitudinal Learning Activities: Social Determinants of Health – Webinar Series

Michigan Care Management Resource Center www.micmrc.org

NEW SDOH Resources – access via www.micmrc.org

• Goal: Provide care managers and coordinators with educational offerings, tools and resources to assist individuals and their families – Recorded Webinars– Articles– Tools – Videos

http://www.micmrc.org/

Questions? Contact us: [email protected]

mailto:[email protected]

Let’s start from the same understanding

https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1536&bih=760&q=on+the+same+page+&oq=on+the+same+page+&gs_l=img.3..0l7j0i30k1j0i24k1l2.64344.70885.0.72121.24.22.2.0.0.0.536.2706.0j13j1j5-1.15.0....0...1.1.64.img..7.17.2716.0..35i39k1j0i10i24k1.YTlsM_RHfxs#hl=en&tbm=isch&q=on+the+same+page+idiom&imgrc=JONW8JQKqGdPfM:

P u t t i n g p e o p l e f i r s t , w i t h t h e g o a l o f h e l p i n g a l l M i c h i g a n d e r s l e a d h e a l t h i e r a n d m o r e p r o d u c t i v e l i v e s , n o m a t t e r t h e i r s t a g e i n l i f e . 14

A Common Definition

“The social determinants of health (SDH) are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. “

SIM PCMH Initiative I www.michigan.gov/sim

http://www.michigan.gov/sim


SDoH Screening

Clinicians have long recognized the connection between unmet basic resource needs – e.g. food, housing, and transportation – and the health of their patients. More than 70% of health outcomes are attributable to the social and environmental factors that patients face outside of their PCMH.

“One of the first steps to addressing social needs is asking your patients about this aspect of their lives.”




Develop documented partnerships between a Practice (or PO on behalf of multiple Practices) and community-based organizations which provide services and resources that address significant socioeconomic needs of the Practice’s population following the process below:

1. Assess patients’ social determinants of health (SDoH) to better understand socioeconomic barriers using a brief screening tool with all attributed patients.

2. Provide linkages to community-based organizations that support patient needs identified through brief screening, including tracking and monitoring the initiation, follow-up, and outcomes of referrals made.

3. As part of the Practice’s ongoing population health and quality improvement activities, periodically review the most common linkages made and the outcome of those linkages to determine the effectiveness of the community partnership and opportunities for process improvement and partnership expansion.

PCMH Initiative CCL Objective




Image Credit: Eileen Clegg, Visual Insight

Future of Care Delivery?SIM PCMH Initiative I www.michigan.gov/sim


What do you need help with?

Provide linkages to community-based organizations that support patient needs identified through:

1. brief screening 2. tracking and monitoring the initiation3. follow-up, and 4. outcomes of linkages made.

18

Our Time Together

Identify where you are on the SDOH journey 0.5 - Intent to Participate 1.0 - Forming team 1.5 - Planning for the project has begun 2.0 - Activity, but no changes 2.5 - Changes tested, but no improvement 3.0 - Modest improvement Initial test cycles have

been completed and implementation begun. 3.5 - Improvement Moderate

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A Model for Learning and Change

Aim Statement for Improving ScDOH Screening (Insert your aim statement at what ever stage it is in)

• Brief description of your organization: ________________________________________________________________________________________

• With regard to ScDOH screening:What do you hope to accomplish related to this objective?____________________________________________By how much do you hope to improve?______________________________________And by when do you want to improve? ______________________________________

Organization Name: _______________________Location: ________________________________

Clarifying Knowledge of the Current Processes & Systems

What do you know about the problem you want to solve? What is working well?

What is known about the common “failures” in screening for the social

What are patients saying about their experience?

In this box or on another slide, insert picture(s) of any flow charts (Ecomaps, high level,

detailed, etc) you used to help you review your current process.

Insert answer here:

Insert answer here:

Insert answer here:

First PDSA....PDSA Planning Worksheet

Team Name:__________________ Cycle start date:_________ Cycle end date:__________

PLAN: Describe the change you are testing and state the question you want this test to answer: What do you predict the result will be? What measure will you use to learn if this test is successful or has promise? Plan for change or test: who, what, when, where Data collection plan: who, what, when, where DO: Report what happened after you carried out the test. Describe observations, findings, problems encountered, and special circumstances.

STUDY: Compare results from this completed test to your predictions. What did you learn? Any surprises?

ACT: Modifications or refinements for the next cycle; what will you do next? (Adapt Adopt Abandon)

A P

S D

Insert a description of a test you want to accomplish or have done.

•What did you predict would happen?•What did happen?•How was your next action was directed by your learning?

Sequence of Improvement

What follow up tests did you do? What did you learn? • ________________________________• ________________________________

Did you test for when the process might fail? If not why? And If so what did you learn? • ________________________________• ________________________________

Are you ready to implement any changes you have tested? Why or why not? • ________________________________• ________________________________

FlowchartsA Helpful Diagram for Exploring Systems and Understanding ProcessesSue Butts-Dion, Improvement Advisor

FlowchartsPictures of steps in a process Purpose– Examine the order of the steps– Identify inefficiencies in the process– Create common understanding of the process flow– Train workers in a process– Help clarify complex processes– Identify value and non-value added steps– Create shared understanding of process– Basis for designing new flow

Source: http://www.ihi.org/resources/Pages/Tools/Flowchart.aspx

Especially useful…Learning Community participants will apply the Model for Improvement to accelerate change in their local environments and learn to embed improvement methods into their day-to-day work.

• Aims (What are we trying to accomplish?)

• Measures (How will we know that a change is an improvement?):

• Improvement Ideas (What changes can we make that will result in improvement?)

Value of Flowcharts to you…

Sketch out a brand new process if you have nothing in place– If no process in place to do a brief SDoH assessment

Sketch out your existing process and look for improvement or ways to build improvement into existing processes– Already do an assessment but want to improve

High-Level Flowchart (Block Diagram)Simplest form of process description.

Helps establish boundaries for the process, see complexity, see handoffs and foster conversation.

Especially useful early in life of team—when trying to figure out their current process.

High-Level Flowchart (Block Diagram) – How

1. Get the right people in the room2. Identify the major process steps3. Write them in the order they occur (usually done

horizontally so information can be hung below the major process steps but not always)

4. If there are more than eight, process might be too complex

5. Choose another process or a subset of the major steps

High-Level Flowchart: Annual Physical

Patient Check in

Patient Roomed Provider

Visit with Patient

Patient Checks Out

Step 1: Identify big “buckets” or work—present them horizontally

Step 2: Hang specific steps related to the bigger “buckets” of work underneath appropriate step, vertically as well as initial barriers.


Patient Check in


Visit with Patient

Patient Checks Out



Step 3: For each step, ask: •Can it be eliminated?•Can it be done in a different order?•Can it be done by someone else-more appropriate person?•Are there unnecessary waits?•Communication breakdowns?•Is this value added for the patient?•Is this value added for the staff?


Patient Check in


Visit with Patient

Patient Checks Out



Step 3: For each step, ask: •Can it be eliminated?•Can it be done in a different order?•Can it be done by someone else-more appropriate person?•Are there unnecessary waits?•Communication breakdowns?•Is this value added for the patient?•Is this value added for the staff?

Can MA support?

Engage patient in

plan?

Report Out

Population Health ManagementTrissa Torres, MD, MSPHChief Operations and North America Programs Officer

Agenda2

DefinitionsApproachSegmenting your populationUnderstanding your population segment

Next step… redesigning care

What MattersIt’s scary when I can’t breathe.

Sometimes I’m just too tired to go to the doctor.

I miss my family.

Population Management

Lewis, Ninon. "Populations, Population Health, and the Evolution of Population Management: Making Sense of the Terminology in US Health Care Today." IHI Leadership Blog. Institute for Healthcare Improvement, 19 Mar. 2014.

The design, delivery, coordination, and payment of services for a defined group of people to achieve specified cost, quality and health outcomes for that group of people.

Population Health Management

The design, delivery, coordination, and payment of services for a defined group of people to achieve specified cost, quality and health outcomes for that group of people.

Lewis, Ninon. "Populations, Population Health, and the Evolution of Population Management: Making Sense of the Terminology in US Health Care Today." IHI Leadership Blog. Institute for Healthcare Improvement, 19 Mar. 2014.

Agenda6



Definition

System designs that simultaneously improve three dimensions:– Improving the health of the populations; – Improving the patient experience of care (including

quality and satisfaction); and– Reducing the per capita cost of health care.

Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health, and cost. Health Affairs. 2008 May/June;27(3):759-769

Whittington, John, Kevin Nolan, Ninon Lewis, and Trissa Torres. "Pursuing the Triple Aim: The First 7 Years." Milbank Quarterly 93.2 (2015): 263-300

Delivery of Services at

Scale

Community, Family and Individual Resources

Approach to Population Health Management

LearningLoops

Needs & Assets Assessment for

Segment

Service Redesign

and Coordination

Population Segmentation

Population Outcomes

LearningLoops

Approach to Triple Aim for Populations

Choose a relevant Population for improved health, care and lowered costConduct a Needs and Assets AssessmentDesign or Redesign Services to meet the needs of the populationDevelop a Portfolio (group) of projects that will yield Triple Aim resultsCreate a Learning System and Measures that will show improvement for the population Build a Team of individuals who can manage this workUse Improvement Methods to drive resultsDevelop a brisk and realistic plan for Execution and Scale

Whittington, John, Kevin Nolan, Ninon Lewis, and Trissa Torres. "Pursuing the Triple Aim: The First 7 Years." Milbank Quarterly 93.2 (2015): 263-300.

Agenda10



Total Population to Target Population11

Total PopulationEveryone in your reach

Target Population: People (with identified characteristics) who you will focus the next round of population management

How do you currently understand your total population?Choose a target population segment

Understand Your Total Population12

PHOX00,000 patients

CountyPopulation: X00,000

PracticeX,000

patients-Medicaid-Medicare

-Commercial-Risk Contracts

Community Services

Choose a Target Population Segment

Generally healthyAcute episode (expect full recovery)Behavioral risk factors and/or chronic disease(s) well managedHigh risk and/or high cost– Multiple chronic diseases

and/or social risk factors– Disability– Frail– End of life

ChildrenPregnant WomenYoung AdultsOlder Adults

Lynn, Joanne et al. “Using Population Segmentation to Provide Better Health Care for All: The ‘Bridges to Health’ Model.” The Milbank Quarterly 85.2 (2007): 185–208. PMC.

Stage of LifeDisease Burden

Considerations

o Prevalenceo Burden on the systemo Ability to identify and engageo Ability to track and measureo Ability to impacto Partners and resources to support

Know your AIM

14

Full population Population Segment

Specific Needs Interventions & PDSAs

Moving from Population Segmentation to Care Redesign

Know your AIM

Agenda16



Understanding Needs and Assets17

Needs and

Assets

Data

PatientCare Team

3 Part Data Review

1. Review available data on your selected target population segment (and/or individuals from that segment)

2. Interview care providers to learn their perspective

3. Interview patients in the select target population to learn their perspective

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Data Review: How-toReview available data from HIT systems*– Claims/utilization data from payer or

your own system (inpatient, ED, primary and specialty care visits, pharmacy)

– Behavioral health encounter/claims data

– EHR– Demographics

Generalized data in the literature and/or your county (countyhealthrankings.org)

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Needs and

Assets

Data

PatientCare Team

Ask the Care Team: How-to

For this target population:– What are the biggest challenges to

managing these patients?– What is working well?– What needs do these patients have that

are outside the scope of our services?– What do you think could have the biggest

impact on fostering better outcomes with these patients?

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Needs and

Assets

Data

PatientCare Team

Ask the Patients: How-to

Deep listening with patients– Use a semi-structured set of questions

to gain insight into patient perspectives• What is working well about how you engage with us?• What is most helpful in managing your condition(s)?• What do you need that you are having trouble accessing?• What do you wish we could do better or differently?

– Come together as a team to discuss what was learned

– Identify similarities, differences, and common themes

– Use an ecomap to map assets and needs

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Needs and

Assets

Data

PatientCare Team

Design with the individual…Learn for the population

Design for the population…Adapt with the individual

From one to many

Full population Population Segment

Specific Needs Interventions & PDSAs

Moving from Population Segmentation to Care Redesign

Know your AIM

Agenda24



MI SIM

Implement regular reviews of targeted patient population needs including access to reports that show unique characteristics of the Practice’s patient population. (data review)

Identify vulnerable patients and demonstrate how clinical treatment needs are being tailored, if necessary, to address unique needs. (interventions)

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Group WorkTo Do:

Choose a target population segment

Understand the needs and assets of your population segment

What possible interventions (including but not exclusive to clinical community linkages) could help improve outcomes for this population segment?

welcome back - michigan · source: institute of medicine (iom) framework for patient and family...

Documents