alisa haushalter, senior director, dept. of pop. health, nemours (us)
DESCRIPTION
Linking Primary Care and Public Health: Achieving the triple aim through innovation in community based pediatric Primary CareTRANSCRIPT
Linking Primary Care and Public Health: Achieving the triple aim through innovation in community-based, pediatric primary care
Alisa Haushalter, DNP, RN
Senior Director, Department of Population Health
Nemours Health and Prevention Services
A.I. duPont Nemours Pediatric Health System
November 18, 2014
Acknowledgement and Disclaimer
The project described was made possible by Grant 1C1CMS331017 from the Department of Health and Human Services, Center for Medicare and Medicaid Services.
The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the views of the Department of Health and Human Services or any of its agencies.
Nemours Integrated Child Health System
Goal: To improve child health and wellbeing, leveraging clinical and population health expertise.Strategy: Nemours focuses on child health promotion and disease prevention to address root causes of chronic disease and unhealthy behaviors in addition to clinical care.
Connecting Clinical Care and Population Health An Integrated Health System
Our Community Our Health System
Resources, Policies and System Change
Health Care Organization
Health PolicyHealth Promotion Practice Change
Self-Management Support
Delivery System Design Decision SupportClinical
Information Systems
Productive Interactions & Spreading Change
Informed, Activated Patient, Family and Community Partners
Improved Health Among PatientsImproved Health for Delaware’s Children
Source: Chang, Hassink, Werk, October, 2011
Organized, Prepared, Proactive Health Team with patient/family
Common Agenda•Leadership and Partnership Engagement•Spread, Scale and Sustainability•Continuous Learning and Improvement to Promote Population-Level Solutions
Business Community
Public Health/ EBH
SchoolsHousingChild
Care
Transportation
Courts
Families
NeighborhoodsNon-profits/ foundations
Hospitals/primary care
State agencies
Other integrators
Integrator
Working Across and Within Systems in a Community
Faith-based
Other partners
Other partners
Approaches to Population HealthExamples of 3.0 Transformation
Two ways to approach population health:
– Start from the Community
– Start from Clinical Approach
Start from Community:Obesity Prevention in Delaware
Strategy• Defined the geographic population and a shared outcome
– Reduce prevalence of overweight and obesity by 2015 for children in DE, ages 2-17
• Established multi-sector partnerships where kids live, learn and play
• Pursued policy changes in multiple sectors – Systems changes, licensing and regulation requirements
• Pursued practice changes to assist in implementation of policy changes– Established learning collaboratives in various sectors (e.g. schools, child care and
primary care)– Developed and/or adapted tools to promote practice change and adoption of new
policies in multiple sectors– Provided tools and technical assistance to providers, and state professional
associations, including train-the-trainer model
Center for Medicare and Medicaid Innovation Award
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• Funding through the Affordable Care Act (ACA)
• Center for Medicare and Medicaid Innovation
• Funding to applicants for innovative ideas to achieve the CMS Mission: “As an effective steward of public funds, CMS is committed to strengthening and modernizing the nation’s health care system to provide access to high quality care and improved health at lower cost.”
Start from Clinic:Health Care Innovation Award:
The Nemours/AIDHC Model• Nemours expanded its population-based strategy to explicitly link to primary
care
• Project Goals
– To reduce asthma-related emergency department use among pediatric Medicaid patients in Delaware by 50% and asthma-related hospitalization by 50% by 2015, with incremental declines in 2013 and 2014
– Other goals include:• Reduce asthma-related admissions and readmissions. • Improve the rate of flu counseling and/or vaccinations• Increase complete clinical adherence to evidence-based asthma guidelines• Increase the number of children reached by implemented policy, systems
and environmental change strategies to support asthma-related child well-being from baseline of 0 to 50,000
CMMI Population Health Model
Black text: Targeted populationRed text: Interventions
CMMI Population(s)Delaware: The First State
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Seaford, SussexSeaford Pediatrics Zip Codes: 19973, 19956
Wilmington, NCCJessup Street Pediatrics Zip Codes: 19801, 19802
Dover, Kent Dover Pediatrics Zip Codes: 19901,19904
The Nemours/AIDHC Model: Primary Drivers of the Project
•Enhancement of family-centered medical home
•Development of “integrator” model surrounding each site
•Deployment of “navigator” workforce
•Use of technology
Changes to the EHR• Same Day Appointment Access in Scheduling • Well Child 12 Months Bright Futures• Adolescent STI High Risk Notification• Patient Lists for Chronic and Preventive Conditions • QI Measures for Chronic and Preventive Conditions • PEDS • Adolescent Depression Screening • Tracking Community and/or External Specialty Referrals • Pre-Visit Contact Form (Telephone Encounter)• Pre-Visit Contact Assessment (Office Visit)• Self Care Plan • Self Care Plan Snapshot Report: In progress • Outpatient Care Plan available in Inpatient encounters: In progress • Add "Discussed transition of care - Yes/No" to all Adolescent • Add "Transportation" as a cancelation reason• Overdue Result Routing Scheme for Internal Consults • Urgent Care Referrals: In progress.
Before and After: Chronic Asthma CareBefore After
Identification of Needs
During scheduled well child visits, clinician tries to remember to ask about flu vaccine, environmental allergens, psychosocial needs, etc and also complete all the requirements of a health maintenance visit.
Children with asthma who are at high risk receive a call from a CHW to ask specifically about their asthma related needs, including assessment of asthma control, flu vaccine, environmental exposures, psychosocial needs. Follow-up with home visits and office visit, psychology and community service referrals are made as appropriate
Asthma Action Plan Clinicians use a variety of different ways to produce Asthma Action Plans. These are found in various places in the electronic medical record, and often not easily visible between specialties. Each time the patient comes, a new Asthma Action Plan needs to be created from scratch.
Clinicians across the Nemours Enterprise use one common asthma action plan (SmartForm) that is visible to everyone on the “Snapshot” screen of Epic. Rather than start a new plan each time, the Asthma Smart Form can be updated at each relevant visit.
School Asthma Management
School nurses call the office asking for clarification of child’s asthma treatment
School nurses access child’s Asthma Action Plan via Nemours Link.
Medication Use Patients have no way of knowing whether their rescue inhaler is full or empty.
Patients with Medicaid have access to a rescue inhaler with a counter so they always know how many doses are left.
Asthma Education Clinicians try to educate patients quickly during office visits. Parents feel uncomfortable taking up the clinician’s time and do not get opportunity to reinforce what they have learned (ex- spacer technique).
CHWs assess patient understanding of how to use their medications/devices during home visits, correct misunderstandings, and connect patients with nurse coordinator for further teaching.
Before and After: Acute Asthma CareBefore After
Accessing Care Parent takes child straight to the ED. Parent calls KHOC first. KHOC checks asthma action plan, provides home management advice, calls the patient back for follow-up. Calls MD on call if needed. Refers to ED appropriately for exacerbations that would not respond to home management.
Communication between ED and Practice
Patients are treated in the ED and discharged or admitted to the inpatient unit. Often, the PCP is not aware of the admission until the next time the patient comes to clinic.
The ED clinician sees on the “ED Dashboard” that the patient belongs to the “Asthma Registry”. The clinician reminds the patient of the asthma action plan and contacts the PCP and CHW to ensure follow-up.
Care Coordinators receive an automated report of ED visits by patients on the registry, so they can contact the patient for follow-up.
Readmission Risk Patients are treated and released without a systematic assessment of readmission risk and potential strategies to reduce them.
Registry patients receive an assessment to understand what led to the admission, so that appropriate interventions can be made. (for example, smoking ban in public parks; healthy homes assessment, etc.)
Community Level Policy and Practice Changes
• Medicaid Formulary change• Smoke Free Wilmington Ordinance• Healthy Housing and Integrated Pest
Management • Student Health Collaboration • Community Partnerships– New partnerships– Evolving relationships
ED Visits for Asthma registry patients from 2012 to 2013
Next Steps/Sustainability – Year 3 and Beyond
• Maintaining momentum • Add Population to the Model - 30 day readmissions • Evaluation• Dissemination• Capacity Building • Spread and Scale• Sustain
– Cultural Shifts– Systems and Structural Changes– Policy Changes– Practice Changes– Community Level Changes
Spread, Scale and Sustainability
Accelerating Population Health Innovation• Designed to accelerate the cultivation and national spread
of innovative system redesign strategies focused on improving population health.
• Nemours/UCLA Center for Healthier Children, Families and Communities effort, funded by Kresge Foundation
Exploring Financial Sustainability through Medicaid • “Medicaid Funding of Community-Based Prevention- Myths,
State Successes Overcoming Barriers and the Promise of Integrated Payment Models” http://www.nemours.org/content/dam/nemours/wwwv2/filebox/about/Medicaid_Funding_of_Community-Based_Prevention_Final.pdf)
Population Health Lessons Learned
• Focus on child well-being outcomes for a geographic population and intervene early to prevent problems;
• Develop a shared measurement system focused on improving child and family outcomes;
• Reach children where they live, learn and play;
• Coordinate programs and connect services so that program silos are eliminated and children are better served;
• Create policy and systems change/development to impact populations with sustainable change - essential elements of a comprehensive children’s system in addition to practice changes;
• Identify the integrators and support them.
• Consider sustainability at front end and throughout the life of the project
• Be intentional about harnessing lessons learned to inform spread, scale and sustainability; and
Acknowledgement and Disclaimer
The project described was made possible by Grant 1C1CMS331017 from the Department of Health and Human Services, Center for Medicare and Medicaid Services.
The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the views of the Department of Health and Human Services or any of its agencies.
www.nemours.org
Alisa Haushalter, DNP, RN Senior Director, Department of Population Health
Nemours Health and Prevention Services2200 Concord Pike
Applied Bank Building, 7th Floor Wilmington, Delaware 19803