co community pathways to health - cha
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Co
Community Pathways to Health Innovations in Data, Technology and Financing
Presented byDora Barilla, DrPH, Group Vice President, Community Health Investment
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Providence St. Joseph Health – Our Footprint
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Population Health Connections within the CommunityRelevance of Social Determinants of Health
An initiative facilitated by: Key partners: AHA/HRET, IHI, NRHI, PHI, Stakeholder Health
Funded by: Robert Wood Johnson Foundation
Pathways to Population Health
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Distribution of Health Care Expenditures
Source: AHRQ https://meps.ahrq.gov/data_files/publications/st497/stat497.pdf
Top 1%
Top 5%
Top 10%
Bottom 50%2.8%
66.2%
50.4%
22.8%
Percentage of Population
Percentage of Health care Costs
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There is an opportunity to align community benefit distribution to areas of greatest need
As a nation, we spend a lot on access to healthcare But it’s only part of the nation’s health challenge!
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Most Frequently Prioritized Community Needs
Mental health
Substance abuse Nutrition/Food Insecurity
Access to affordablehealth care
Chronic Conditions/Obesity
Housing
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Social DeterminantsHealth Status IndicatorsService Utilization Primary Care Network DesignCommunity AssetsPeople Potential
Community Pathways to Health – Future CHNA Framework with Multi Source/Integrated Data
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CHNA Data Collection & Analysis
Set Strategic Priorities
Connect Data to Overall Strategic Plan
Identify Strategic Priorities and Partners
Measure & Evaluate
Identify Best Practices and Interventions
Identify Key Metrics
Disseminate Results
Galvanize Community Toward Collective Action
CONNECTING COMMUNITY HEALTHTO STRATEGIC PLANNING
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We know Social Determinants of Health (SDH) are an essential element in risk stratification
According to the CDC, 70% of a person’s health comes from socio-economic environment (e.g. family structure, location etc.) Social and economic factors drive ~ 40% of
consumer health and behavioral elements account for another 30%.
Key elements that contribute to the sustained health of a patient often are not captured in EHR Need to look for external data
Source: http://barhii.org/framework/
Upstream Downstream
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CPH – A Multi-Source Integrated Data PlatformEPIC EHR data at the patient level
Clinical information (e.g. diagnosis of dementia) Social history (e.g. history of smoking) Demographics (e.g. age, gender, etc.) Resource utilization (including charges from Insights) Addresses for patients, clinics, and hospitals for geo-
coding
Social Determinants of HealthIncome and poverty
Population receiving SNAP benefits Population with housing assistance Population in poverty Median household income
Community and housing Overcrowding Units in substandard conditions Median home value
Community Demographics Population with disabilities Linguistically isolated population
Transportation Households without car Population using public transportation
Food Access
Air Quality
Transform raw data to actionable information
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Community Pathways to Health Goals A platform used to identify areas of need where patients are most vulnerable, allowing
us to provide proactive outreach and service before neighbors become patients. Our goal is to meet people’s health needs where they need it most, in their communities.
To build or strengthen community partnerships to address social determinants of health
By leveraging the predictive functionality and extensive curated datasets within this platform, we can help patients to avoid the ED, readmission, and extended length of stays.
For Providence St. Joseph Health, this means we can better more promptly meet care management needs, prioritize our resource allocation, and ensure high quality, timely care.
Collaboration between Healthcare Intelligence, Community Health Investment, and Population Health
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Social determinants from CHNA, combined with an individual patient’s medical history, create a more
comprehensive predictive model
EPIC EHR data at the patient level Clinical information (e.g. diagnosis of dementia) Social history (e.g. history of smoking) Demographics (e.g. age, gender, etc.) Resource utilization (including charges from Insights) Addresses for patients, clinics, and hospitals for geo-coding
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Example Model 1: Usage Of Services (Adult Medicaid) Less likely to use ER, Inpatient, or
Observation Older patients Females English speakers Married/Significant Other Medicaid HMO or Dual Eligible With PCP assigned Living in economically and socially stable area
(Highest quantile GEO score=117) vs 80 Having Work and cell phone documented in EPIC Had 1+ office visits in the last year
Increased risk of using ER, Inpatient, or Observation Housing instability With history of drug, alcohol, tobacco With dementia High BP Multiple mental health dx on problem list Increase in number of med orders, lab orders, and images
0.340.950.780.89
0.540.67
0.740.82
0.200.78
4.721.38
1.061.551.651.72
1.56
1.031.06
1.230.94
0.00 1.00 2.00 3.00 4.00 5.00
Age >=65 vs Young adults 18-25Gender: F vs M
Language: English vs SpanishMarital Status: Married/Sig Other vs…
PrimPayorType: Dual Eligible vs…PrimPayorType: Medicaid HMO vs…
CellPhone: Yes vs NoWorkPhone: Yes vs No
PatAssigned2PCP: Yes vs NoGeo Quality Quantiles Last vs First
HomelessLast2Yrs: Yes vs NoHXTobaccoUser: Yes vs NoHXAlcoholUser: Yes vs NoHXIllDrugUser: Yes vs No
Dementia: Yes vs NoHighBP >=140/90 vs <140/90
DXMentalHealth: 4+ vs 0
MedOrdersLast1YrLabsResultedLast1Yr
ImagesLast1YrOfficeVisitsLast1Yr
Patients with dementia are 65% more likely to be seen treated in a hospital ER, inpatient or observation in a hospital as compared to patients without..
Female patients are 5% less likely to be seen in ER, inpatient or observation as compared to
male patients
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Example Model 2: Charges ($) Among Users
0.971.22
0.721.03
0.951.04
0.940.95
1.151.10
1.091.161.20
1.04
1.191.10
1.551.16
1.65
0.00 0.50 1.00 1.50 2.00
Months on MedicaidAge >=65 vs 18-25
PatAssigned to PCP Dual Eligible vs Medicaid Traditional
Medicaid HMO vs. Medicaid…BMI Category: Obese vs. Normal
Language: English vs. SpanishMaritalStatus: Married/Sig Other vs.…
HomelessLast2YrsHXIllDrugUser
DXChronicMildLiverDXChronicMyocardialI
DXChronicCVDDXChronicCancer
AlcoholRelatedBipolar
IntentionalSelfHaOtherMentalHealth
Schizophrenia On average with lower charges Patients with longer coverage Assigned to PCP HMO-covered English speakers Married/Significant other With work phone
On average with higher charges With dx of schizophrenia Various mental health problems With suicidal ideations With Dx of bipolar With Dx of alcohol related mental health problems Dx of CVD, MI, Chronic Liver Being homeless With history of alcohol and drug abuseOn average, charges among patients
with CVD are 20% higher than among patients without CVD
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We also include community factors affecting patient’s health such as population density, average age, percentage of renters/home owners, as well as varied social determinants such as primary language, employment status, and members in household
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Maps and overlays make data visible, actionable
Medicaid enrollees, by zip of residence with 1+ avoidable ED visit in 2016
PSJH care facilities Walgreen’s Locations Starbucks locations
(proxy for foot traffic) Other overlays in
development, including community resources, FQHCs, and more
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CPH Patient SnapAvoidable ED
The Patient Snap helps us understand the care patterns and factors determining high risk for a given patient.
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CPH Patient SnapOverall Use of Hospital (IP, ED, Obs)
Young woman, managing chronic disability (41-64, Medicare & Medicaid)
Dealing with significant underlying medical conditions
Additional impact of underlying behavioral health issues (bipolar disorder)
Additional socialfactors
Population Profile Data
Insights:• Understand and
Know our Populations
• What do we know about this segment
• Different strategies• Different Touch
Points
• Strategically identify community benefit investments
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“Know Me”
WHAT WE DO
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”Care for Me”Patient Level Profiles Whole Person Care
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Proposed Immediate Next StepsCustomer Refinement• Community Health Investment• Operational and Clinical leaders, Health Plans• Strategic analytics
Growth•Evaluate for community partners
Platform•Scalability •Expand sources
Maintenance• Monthly Refresh
