Optimizing Population Health through Risk-Stratification &

Team-based Primary Care

Clemens Hong MD, MPH Medical Director, Community Health Improvement Los Angeles County Department of Health Services

Oregon Primary Care Association

March 7, 2016

Outline

• Overview of Population Health & Care Management in Primary Care

• Using population risk-stratification to drive improved outcomes

• Los Angeles County

– Care Connections Programs

– Upcoming Opportunities

The Opportunity

• Move from units of care to episodes, people, & populations

• Focus on things shown to improve outcomes

• Continuously Improve

• Support Innovation – improve by leaps

• Use team-based approaches

• Engage the community

• Rapidly share learning

High-Risk

Patients

Rising-Risk

Patients

Low-Risk

Patients

Population health management approaches are at the core of this

delivery transformation effort

Inpatient Spend (Acute, Rehab, SNF) Outpatient

Spend

Traditional

Fee for

Service

Outpatient Spend Inpatient

Spend

Population Health

ManagementSpend

With

Enhanced

Coordination

Conceptual Strategy for Population Health Management

High-Risk

Patients (5%)

Rising-Risk Patients

(15-35%)

Low-Risk Patients

(60-80%)

Three Population Foci

Low Touch/High Volume • “Surveillance” • Wellness & Health

Coaching • Tools – Patient

Portals/Virtual Visits, Social Media

High-Risk

Patients (5%)

Rising-Risk Patients

(15-35%)

Low-Risk Patients

(60-80%)

Three Population Foci Med Touch/Med Volume • Face-to-Face

engagement • Chronic disease &

Health Coaching • Tools – Enhanced

Primary Care

High-Risk

Patients (5%)

Rising-Risk Patients

(15-35%)

Low-Risk Patients

(60-80%)

Three Population Foci High Touch/Low Volume • Frequent interaction • Chronic

Disease/Intensive Care Coordination

• Tools – Complex Care Management Teams

Challenges for Population Health & Care

Management Interventions: Drops in Potential

Adapted from J Eisenberg JAMA. 2000

Engagement

Finding opportunities

for improvement

Intervention

Identification

Potential opportunity

Realized improvement

Family/Caregivers PCMH/CCM Team

CM Patient

Trusting relationship between a patient & a proactive care team the foundation to care management

Health Delivery System Acute & Post-acute Facilities

Specialty Care

Providers

Behavioral Health

Home Health &

VNA

Social Service

Agencies

Government Service

Agencies

Public Health

Agencies

Payers & Purchasers

Family/Caregivers PCMH/CCM Team

CM Patient

Patient- Centered Medical Home

PCMH Team CCM Team

PCP CM

A strong relationship between care management & primary care teams critical for care management

Patient- Centered Medical Home

PCMH Team CCM Team

PCP CM

As is a strong relationship between the care team & other health system and community partners

Patient- Centered Medical Home

PCMH Team CCM Team

PCP CM

Acute & Post-acute Facilities

Specialty Care

Providers

Behavioral Health

Home Health &

VNA

Social Service

Agencies

Government Service

Agencies

Public Health

Agencies

Payers & Purchasers

Health Delivery System

Patient- Centered Medical Home

PCMH Team CCM Team

PCP CM

Care Management Structure

Patient- Centered Medical Home

CM Hub

PCMH Team CCM Team

PCP CM

Care Management Structure

Challenges for Population Health & Care

Management Interventions: Drops in Potential

Adapted from J Eisenberg JAMA. 2000

Engagement

Finding opportunities

for improvement

Intervention

Identification

Potential opportunity

Realized improvement

Challenges for Population Health & Care

Management Interventions: Drops in Potential

Adapted from J Eisenberg JAMA. 2000

Engagement

Finding opportunities

for improvement

Intervention

Identification

Potential opportunity

Realized improvement

• To align population, intervention, & outcomes

• Select a population at risk for future poor outcomes for which planned interventions can improve outcomes

• Tools: Quantitative, Qualitative, Hybrid

• Key Challenges

– Dynamic nature of risk

– Lack of full picture

– Care sensitivity is patient & program dependent

Goals of Population Risk Stratification & Segmentation

Effective Targeting of Care Management

Population Volume

Healthy

Chronic Illnesses

Medically Complex/ High Utilizers

Area of Greatest Opportunity?

Area of Greatest Opportunity?

Area of Greatest Opportunity?

Complexity defined by Charlson & estimated Physician-defined Complexity (ePDC)

Complex

by

Charlson

24%

Complex

by

ePDC

37%

Complex

by

Both

39%

Total

Complex = 27,531 (19.2%)

Source: Hong CS JGIM 2015

0%

5%

10%

15%

20%

25%

30%

Not complex Charlson Only PDC Only PDC_Charlson

Primary Care Measures

Colon Cancer Screening DM A1c>9

Source: Hong CS JGIM 2015

*All p-values <0.05

0.00

0.10

0.20

0.30

0.40

Not Complex Charlson Only PDC Only PDC_Charlson

Acute Care Utilization (per person year) Over 4 Years

Admissions ED Visits

Source: Hong CS JGIM 2015

*All p-values <0.05

Clinical Outcomes by No Show Propensity Group

Source: Hwang AS JGIM 2015

Acute Care Utilization by No Show Propensity Group

Source: Hwang AS JGIM 2015

Challenges for CCM Programs: Drops in Potential

Adapted from J Eisenberg JAMA. 2000

Engagement

Finding opportunities

for improvement

Intervention

Identification

Potential opportunity

Realized improvement

Importance of Continuous Quality Improvement

• Design + Implementation = Effectiveness

• Track Quality Measures – Process & Outcome

• Example – IT Enabled, Team-based Care

– Embedded advanced analytics paired with role delineation

– For program management & quality improvement

• Rosters are all role-specific • Rosters are all actionable

• A user can send a task to another user

• A population-oriented care plan enables the user to see all that is happening with a patient

• A care team can be set up to include members that are typically not part of a care team

Important concepts for program planning

• Build strong relationships

• No perfect model

– Start with the best approach for the context/population

– Then use continuous quality improvement to improve

• Keys to efficient population management

– Work in multi-disciplinary teams

– Complement existing services

– Allocate resources to high-yield activities

– Focus on mutable issues (know your system’s assets)

– Use HIT infrastructure to enhance CM efficiency

Los Angeles County Care Connections Program & Beyond

Clemens Hong MD MPH

GIH Annual Conference

March 11, 2016

Using complex care management teams to improve care & reduce costs

Specially-trained, multi-disciplinary care teams

32

One proposed solution

to address healthcare cost problem

CCP

Admit/ ED

Care Connections Program (CCP) Aims

$

Serving ≈5% of LAC DHS’s Patients

≈20,000 out of 400,000 primary care patients

• Complex biopsychosocial needs

• Hard to engage • High utilization of

health care • High cost of care

Panel within a Panel

Patient- Centered Medical Home

PCMH Team CCM Team

Current Model Acute & Post-acute Facilities

Specialty Care

Providers

Behavioral Health

Home Health &

VNA

Social Service

Agencies

Government Service

Agencies

Public Health

Agencies

Payers & Purchasers

PCP CM

Patient- Centered Medical Home

Central CCM Hub

PCMH Team CCM Team

CCP “Enhanced” Model Acute & Post-acute Facilities

Specialty Care

Providers

Behavioral Health

Home Health &

VNA

Social Service

Agencies

Government Service

Agencies

Public Health

Agencies

Payers & Purchasers

PCP – CHW – RN

PCP

Care Connections Team

CHW PCMH

Embedded

Acute Event or Status Change

CCP Program Overview

Comprehensive Needs Survey

Care Transition Work if needed

Patient Engagement

Care Plan Development

Accompaniment/Routine FU

visits

Follow-up Assessment

Face-to-face: Hospital, Clinic Or home visit

“Step Down”

Revise Care Plan if needed

Patient Engagement

CHW Role

Social Support

Comprehensive Assessment

& Care Planning

Health System Navigation

Care Transition Support

HospitalReadmission

Earlydischargeplanning

Contactinpa entteam/CMin24H

ContactPCPin24H

ChecksinwithInpa entteam/CMdaily&par cipatesinD/Cplanning

GivePCPupdateswithchangesinpa entstatus

Ensurecoordina onwithfamily/caregivers

Hospitaltohometransi on

Visitpa entatdischarge

Reviewdischargeplan&transi onalcareplan

Performmedica onreconcilia on&addressesmedica onmanagement

Educatepa entonred-flags&createred-flagsac onplans

Ensurecoordina onwithfamily/caregivers

Schedulefollow-uphomevisitwithin72Hpost-D/C

Schedulefollow-upPCPvisitfor1weekpost-D/C

Homevisitswithin72Hpost-D/C–reviewtransi onalcareplan,medica on,&red-flags

Assessneedfordiseasemonitoringdevices/DME

Assessneed/desireforadvanceddirec ve/goals-of-careplanning

Updatecareplanasneeded

Accompanypa enttopost-D/CPCPvisit

Addressingriskfactorsforacutecareu liza on

Assessforunmetsocialandresourceneeds

Assessforbarrierstocare

Engagesclientinbehaviormodifica onusingMI

Assessforhome-health&community-basedcareneeds

Primary Drivers Activities Outcome

Readmission

Driver Diagram

Patient Engagement

CHW Role

Social Support

Comprehensive Assessment

& Care Planning

Health System Navigation

Care Transition Support

Chronic Disease Support &

Health Coaching

Patient Engagement

CHW Role

Social Support

Comprehensive Assessment

& Care Planning

Health System Navigation

Care Transition Support

Chronic Disease Support &

Health Coaching

Advanced Illness management

support

A Multi-faceted Program

Community Health Workers

Care Without Walls

Community Engagement

Social Needs Navigation

Care Transition & Acute Care Planning

Chronic Disease Management

Data-driven Improvement

Components

Advanced Illness Management

Pharmacy Intervention

Phase 1: Demonstration

March/April 2015 – March

2017

5 DHS primary care practices in South and

East LA

Hire 25 CHWs CHW training by WERC &

Anansi Health 1,250 patients

Phase 2: Expansion

Apply lessons from Phase 1 Replicate model across LAC DHS

Up to 15X expansion possible

Challenges

• Poor baseline health system infrastructure – Data Integration & real-time data access

• Implementation – Front-line provider engagement & patient selection

– Perception of program as “External”

– Poor understanding of intervention & CHW role

– Consistent delivery of intervention

• Culture “Clash” – Innovation vs “production engine”

Thank you!

Questions?

Contact:

chong@dhs.lacounty.gov clemensh@anansihealth.org Twitter:@clemenshong

CHW Training/Supervision

• Training Topics

– Motivational Interviewing/Harm Reduction/Trauma-Informed Care

– Chronic disease self-management support – health coaching

– Goal Setting/Care Planning

– Program protocols – emergency, medication review

– Disease specific topics

– Other core competencies – boundary setting, safety

• CHW Supervision

– Programmatic – CQI meetings, performance evaluation

– Clinical – Weekly one-on-one, Monthly group, case conferences

• Clinical Support – Primary care team

Patient Selection Approach

Hybrid Approach – quantitative gate 1. Primary care team refers patients based on criteria 2. Criteria verified through chart review 3. Randomly select subset of patients for the intervention 4. PCP Over-ride

High-risk criteria: – 2 Acute Care Utilization Equivalents (1 admit = 2 ED visits = 4 UC visits) – 1 Acute Care Utilization Equivalent PLUS 1 High-risk condition:

• CHF, IHD/Stroke/PVD, COPD, Asthma, DM w/ A1c>9, Uncontrolled HTN w/ cardiac/renal complications, ESLD, ESRD, progressive dementia/Anxiety/Depression/Bipolar disorder/psychotic disorder with functional impairment, Active Substance Use Disorder, or Age>90yo (HIV carved out)

– Poorly controlled chronic condition with co-occurring mental illness or substance use disorder independent of acute care utilization

• Rosters are typically disease-centric, not ideal for patient outreach

• 1-view – a roster of rosters centered around patients

• This roster is optimized for outreach • With 1 click on the arrow to the left…

• A row expands, and opens a pane displaying contact information, all the notes across all diseases pertaining to that patient, and a section for the user to enter a note