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Montana Integrated Care Learning Community Jeff Capobianco, PhD, LLP jeffc@thenationalcouncil.org Joan Kenerson King, RN, MSN, CS joank@thenationalcouncil.org October 4, 2016

Webinar Overview 1) Define the Terms Value-based Purchasing, Population Health Management and Risk Adjustment 2) Explain the difference between data, information, and knowledge. 3) Define population health management and identify the four steps required to conduct effective population health management. 4) Identify the internal mechanisms and staff competencies necessary to implement these concepts.

Why does data measurement matter? “If you are not measuring a process, you don’t know what you are doing.” “If you are not measuring processes, you can’t improve.” “If you are not measuring processes, you are operating blindly and therefore are at risk for delivering ineffective and wasteful care at best.” If you are not measuring your care provision and administrative processes, you cannot achieve the triple aim of population health management, cost containment and customer centered care … in other words, survive in the healthcare marketplace today.

Effective & Efficient Healthcare Effective Healthcare: – Right Patient Need(s) Identified – Right Treatment(s) Provided – By the Right Professional(s) – At the Right Time(s) – Producing the Right Health and Satisfaction Outcome(s) Efficient Healthcare: – Clinical and administrative work flow processes that operate within optimal time and cost specifications.

Aligning our Terms! Value-base Purchasing requires… Population Health Management which requires… Risk Stratification therefore… these concepts are not loosely linked but are structurally contingent on one another.

Value-based Purchasing An Old Term Getting New Life "The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. This strategy can be contrasted with more limited efforts to negotiate price discounts, which reduce costs but do little to ensure that quality of care is improved." Source: Theory & Reality of Value-Based Purchasing: Lessons from the Pioneer. November 1997. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality- patient-safety/quality-resources/tools/meyer/index.html

Data, Information, and Knowledge What is data? o Granular or unprocessed information (e.g., one A1c lab value or PHQ 9 measurement) What is information? o Information is “big data” that have been organized, measured and communicated in a coherent and meaningful manner (i.e., take multiple A1c lab vales or PHQ 9 scores) What is knowledge? o Information evaluated and organized so that it can be used purposefully (e.g., electronic medical record dashboards)

What is the ultimate purpose of collecting and sharing data? To turn it into action! (a.k.a. Continuous Quality Improvement) Data Information Knowledge Action

Defining Population Health Management • A set of interventions designed to maintain and improve people’s health across the full continuum of care— from low- risk, healthy individuals to high-risk individuals with one or more chronic conditions (Source: Felt-Lisk & Higgins, 2011) • Population management requires providers to develop the capacity to utilize data to choose which patients to select for specific evidence-based interventions and treatments (Source: Parks, 2014)

Population Health Management • Strategies for optimizing the health of an entire client population by systematically assessing, tracking, and managing the group’s health conditions and treatment response. • It also entails approaches to engaging the entire target group, rather than just responding to the clients who actively seek care.

Principles of Population Health

Components of Population Health Management: 1. Knowing what to ask about your population(s) 2. A data registry to describe/risk stratify your population(s) 3. Proficiency with quality improvement tools to respond to the findings 4. Using continuous quality improvement policies/procedures to sustain data specification targets

Quick Break for Questions & Comments?

Components of Population Health Management: 1. Know what to ask about your population(s) 2. A data registry to describe/risk stratify your population(s) 3. Proficiency with quality improvement tools to respond to the findings 4. Using continuous quality improvement policies/procedures to sustain data specification targets

What are the questions you want answers to about your populations? 1. Who are you serving? Who are you not serving but could / should be? 2. What are the costs for the average patient? 3. What kind of services are they getting; where, and when? 4. What is the patient’s response to treatment? 5. What is the patient’s opinion of his / her care?

Components of Population Health Management: 1. Know what to ask about your population(s) 2. A data registry to describe/risk stratify your population(s) 3. Proficiency with quality improvement tools to respond to the findings 4. Using continuous quality improvement policies/procedures to sustain data specification targets

Patient Registry “…an organized system to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes.” Source: Gliklich RE, Dreyer NA, eds. (2010). Registries for Evaluating Patient Outcomes: A User’s Guide. 2nd ed.

Registry Examples • Provider Excel / ACCESS DB (simplest) • Managed Care Portals • Electronic Medical Records • Health Information Exchanges (typically do not have registries)

Population Health Management Measures Must Have Measure Specifications Measure specifications provide the following: 1. Brief measure description explaining targets and procedure for collection. 2. Definition of measure numerator 3. Definition of measure denominator 4. Formula for calculating the measure 5. Exclusions to measure, if applicable 6. Description of report periods 7. Measure specific diagnosis & billing codes

PHM Measure Specifications

Components of Population Health Management: 1. Know what to ask about your population(s) 2. A data registry to describe/risk stratify your population(s) 3. Proficiency with quality improvement tools to respond to the findings 4. Using continuous quality improvement policies/procedures to sustain data specification targets

Rapid-Cycle Change for Process Improvement Rapid-cycle change is a systematic problem-solving approach to understand client needs, restructure processes, and make the most efficient use of available resources in response to data findings. Source: The Network for the Improvement of Addiction Treatment (NIATx)

Dashboards w w w . T h e N a t i o n a l C o u n c i l . o r g • A dashboard translates your work into metrics • It provides timely information & insights • It makes it easier for staff to monitor , analyze , & manage their work 24

Dashboard Data Elements • Cost: Service Utilization, Case Rates, etc. • Operations: No Shows, Insurance Mix, etc. • Staff Work Plan: Performance on Scope of Practice Tasks • Clinical: Labs, Assessment / Screening Results, Vitals, etc. • Care Coordination: Medication Reconciliation, etc. • Benchmark Comparisons: Between Organizations, Clinicians, Teams, etc. • Risk Cutoffs: Reveal when data are out of specification (e.g., A1c > 6)

Components of Population Health Management: 1. Know what to ask about your population(s) 2. A data registry to describe/risk stratify your population(s) 3. Proficiency with quality improvement tools to respond to the findings 4. Using continuous quality improvement policies/procedures to sustain data specification targets

Sustaining Improvements through CQI • Leverage Dashboards for staff, teams, supervisors, & senior leaders to see/understand progress/or lack there of! • Use Rapid-Cycle Plan-Do-Study- Act for problem-solving when benchmarks show need for improvement • Supervisors to coach and manage staff to maintain improvements!

An Example: The Population Health Management of Depression

Let’s look at Depression as an Example 1. Know what to ask about your population(s)  How are we doing with the treatment of our consumers who are depressed? 2. Using your registry to Risk Stratify the population of Depressed Consumers  Pull & Aggregate Consumer PHQ-9 Scores by Team and Clinician.