Popula'onHealth…. OurJourney

BradCrosswhite,M.D.,FAAFPCentralRegionalMedicalDirectorACOMedicalDirectorPopula=onHealthPhysicianLeaderNorthMississippiMedicalClinics,Inc.SarahHammock,RN,BSN,CCMPopula=onHealthProgramDirectorACOChampionNorthMississippiMedicalClinics,Inc.

NorthMississippiHealthServices

Ø  650+bedregionalreferralcenterlocatedinTupelo,MS

Ø  5affiliatedhospitalsØ  BehavioralHealthInpa'entand

Outpa'entServicesØ Women’sHospitalØ  3NursingHomesØ  HomeHealthServicesØ  HospiceServices:Inpa'entandOutpa'entØ  ComprehensivePost-AcuteandRehab

ServicesØ WellnessCenters

ServingRuralMississippiandAlabama

Ø  700+employeesØ  150physiciansØ  60advancedclinical

prac''onersØ  600,000+visitsyearlyØ  40full-'meclinic

loca'onsØ  8RHCs

Ø  14medicalandsurgicalspecial'es

OurClinicSystem

Timeline1990 FirstClinic1999 Adop'onofElectronicHealthRecord

2003 Process/Outcomestrackingbegan

2009 Firstproac'vepa'entoutreachtools

2011 BestPrac'cesandInnova'onsestablished

2012 Fall–Popula'onHealthProgram

2016 Par'cipa'oninMSSPACO

WhyPopula'onHealth?

Ø  SoaringCostofHealthcare-Medicarespent$2.6Trillionin2014

Ø  PushtoReduceHospitalReadmissionsbeginningin2012

Ø U.S.rankslowestinqualityamongothercountriesandhealthcaresystemsareseenasproducingmarginalquality

Ø  Pa'entcaregrowingincreasinglyuncoordinated-riseinurgentcareprovideruseamongcommercialplanmembers

Ø  Burdenofchronicdiseaseiscon'nuouslygrowing

Whyarewepar'cipa'ng?

Popula'onHealthKeyItems

Health Information Technology

Prac'ceOrganization

Quality Measures

Patient Experience

“Teambased”PrimaryCare

Ø  IncreasedaccesstocareØ  Pa'ent-centeredØ  CoordinatedCareØ  Team-basedapproachØ Overallpa'ent

experience

Ø  “Value”drivencare

Howisthisdone?Ø  Requireschangeinprimarycaredeliverymodel;thechangeisnoteasy

Ø  Needsac've,engagedprovidersandac've,empoweredteam

Ø  Cri'caltohavecasemanagementembeddedinprimarycaresite

Ø  Linkagetoeverysystemofcareisneeded

Ø  Payor/providerpartnershipessen'altosuccess

TransformingCareDelivery

Today’sCare ACO/MedicalHomeCare

Mypa'entsarethosewhomakeappointmentstoseeme

Careisdeterminedbytoday’sproblemand'meavailabletoday

Careisdeterminedbyaproac'veplantomeethealthneeds,withorwithoutvisits

Ourpa'entsarethosewhoareseenwithinourACO/MedicalHome

Wemeasureourqualityandmakerapidchangestoimproveit

Apreparedteamofprofessionalscoordinateallpa'ents’

Aninterdisciplinaryteamworksatthetopofourlicensestoservepa'ents

Wetracktestsandconsulta'ons,andfollow-upaierEDandhospitaliza'on

Careisstandardizedaccordingtoevidence-basedguidelines

It’suptothepa'entstotelluswhathappenedtothem

IknowIdeliverhighqualitycarebecauseI’mwelltrained

Pa'entsareresponsibleforcoordina'ngtheirowncare

Clinicopera'onscenteronmee'ngthedoctor’sneeds

Carevariesbyscheduled'meandmemoryorskillofthedoctor

Employers§  Risingcostsofhealthcare§  Increased=meawayfromwork

InsuranceProviders§ Na=onalQualityStandards

§ Desiretoreducecosts

HealthSystems§  Pushtoreducehospitalreadmissions

§ DesireappropriateEDu=liza=on

Pa'ents/Caregivers§  Feelinglikea“number”§  Fragmentedcare§  Increasedout-of-pocketexpenses

§  Poormanagementofchronicdiseases

PrimaryCareProviders§  Frustratedwithcurrentdaytodayopera=ons

§  Limited=mewithpa=ents

PCMH/ACOStakeholders

PrimaryStakeholders

StakeholderBenefits

Ø  FortheBolomLineØ  Moreefficientuseofprac'ceresources,resul'ngincostsavingsØ  Opportuni'estopar'cipateinpaymentincen'vesØ  Prac'cesbelerpreparedforfuturepaymentreformandvalue-based

paymentmodels

Ø  ForthePa'entØ  Engaged,happier,andmoresa'sfiedØ  Belercoordinated,morecomprehensive,andpersonalizedcareØ  ImprovedaccesstomedicalcareandservicesØ  Improvedhealthoutcomes,especiallyforpa'entswhohavechroniccondi'ons

Ø  ForthePrac'ceØ  Increasedphysicianstaffmembersa'sfac'onØ  Physiciansandstaffmemberswhoprac'ceatthetopoftheirlicensesØ  Improvedsafetyandqualityofcare

OurGoal:TripleQuadrupleAim

Ø QualityCareØ  Long,healthy,andproduc'velivesØ  Access,efficiency,equity

Ø  CostØ Moderatemedicalexpense

Ø  Pa'entexperience

Ø  Providerexperience

What’sinaname?

CareManager

CaseManager

DiseaseManager

CareCoordinator

HealthCoach

HealthNavigator

Popula'onHealthManager

Prac'ceCoach

Transi'onCoach

Pa'entAdvocate

GuidedCareNurse

HealthAdvocate

Ø  Focusonhighrisk/highcostpa'ents,whichwillensureappropriatealignmentinuseofhealthcareservicesØ  “Therightpa=entgetstherightcareattherightplaceandright=me.”Ø  10%ofMedicarebeneficiariescontributeto60%ofcostsØ  20%ofMedicarebeneficiariescontributeto80%ofcosts

Ø  Buildtrus'ngrela'onshipswithpa'entsandfamilies

Ø  ClosethegapsincaredeliveryØ  Reducecostofcareby20%

Ø  Ensureeffec'vemobiliza'onofresourcesandappropriatealignmentØ  Avoidduplica=veservicesØ  Ensureasmooth“hand-off”andtransi=onofcarefromoneenvironmenttoanotherØ  Ensureadequatefollow-upand“closingtheloop”

WhoReceivesHealthManagement/CareCoordina'on?

AmbulatoryCaseManager-Thenextgenera<onofcarecoordina<on--“HybridGeisingerModel”

Ø  AcuteandChronicdiseasemanagement

Ø  Transi'onsofCareØ Wellnessanddiseasepreven'on

Ø  Engagementofpa'entstodriveownership

Ø  Pa'enteduca'on/resourcesØ  LeveragingEHRtodatamineandfillcaregaps

Ø  Trackqualityandoutcomes

HealthManagementataGlance

Iden'fyingOurTargetPopula'on

Ø  Co-MorbidCondi'onsAsthma SmokingCessa'on CADHyperlipidemia Hypertension COPDDiabetes WeightManagement CHF TOCEnd-of-LifeCare

Ø  Transi'onsofCare

Ø  PhysicianReferral

Ø  InternalChartRevieworRiskModel-manualwork

Ø  HospitalReferral/SNFReferral

Ø  Predic'veModelingSoiware

Predic'veModeling

Ø  Technologythatallowspayorsandcaremanagementorganiza'onsto:Ø  Proac'velystra'fyinsuredindividualsatriskØ  Iden'fycost-driversfortheirhigh-riskpopula'onØ  ForecastfuturehealthplancostsØ  Evaluateinsuredindividualpalernsover'meØ  Improveclinicalandfinancialoutcomes

**Formostpayers,iden'fyingandmanagingabout1%oftheircoveredlivescangeneratesignificantsavings.**

Ø  Customizedcontainersforiden'fying“atrisk”individualsØ  Filterbasedonclinic,provider,payor

Ø  AcclaimandMedicarePopula'onHealthViews

Ø  Filterbasedonspecificdiseasestatesandquality,suchas: Ø  Diabetes:A1C>9,Eye/FootExamsØ  Hyperlipidemia:LDL>150Ø  CAD:BP<150/90Ø  TobaccoAbuse:Smokingcessa'onmaterialgivenØ  Preven'veWellnessNeeds:Flu,Mammo,Colonoscopy,

Pneumonia

DiseaseRegistry:Meridios

Ø  ImprovetheTripleAim:health,cost,andexperience

Ø  Reduceinpa'entadmissionsorreadmissions

Ø  ReduceunnecessaryEDvisits

Ø  Increasepar'cipa'onwithWellnessVisitu'liza'on

Ø  Increasepost-hospitalfollowupappointments

Ø  Increasegenericdrugu'liza'on

Ø  ReducePMPMcostacrosstheboard

PayerPartnershipProjectFocus

Inpa=entadmissions Readmissions

ERvisitsAvoidablevisits

PrimaryCare(HEDIS

measures)PMPMCostGenericRx

U=liza=on

WellnessVisitu=liza=on Biometrics

Postadmission

visits

ProgramPerformanceMeasures

Outreach,TrackingandFollowUp

Ø  Healthmanager“touches”

Ø  Registrymonitoring

Ø  RemotePa'entMonitoring(CHF,HTN,DM)

Ø  Dailyhospitaldischarge/EDdischargereportØ  Transi'onsofCareManagement

Ø  Pre/PostVisitPlanning

Ø  Medica'onManagement

TargetPopula'on&Outcomes

Ø 137membersenrolledinprogram121followedbyembeddedcaremanager16followedbycarecoordinator

Ø Averaged9.1contactsperpa'entwithover900pa'entcontacts

Ø Reducedpharmacycostsofover15%PMPMØ AllservicecategoriessawadecreaseinPMPMcostsexceptancillaryservices

PMPMCostComparisonsØ  Decreaseintotalmedicalcostsbynearly27.8%.Ø  Con'nueddecreaseby28%postPHMenrollment.

$0.00

$200.00

$400.00

$600.00

$800.00

$1,000.00

$1,200.00

0TO3MONTHS 3TO6MONTHS 6TO9MONTHS >9MONTHS TOTAL TOTAL,Excl<3Mos

PMPM

Cost

Baselinevs.CurrentMedicalCosts

Baseline

Current

$-

$200.00

$400.00

$600.00

$800.00

$1,000.00

$1,200.00

BaselinePMPM CurrentPMPM

PMPM

Cost

Baselinevs.CurrentCostsbyMajorServiceCategoryTotalPHCTargetPopula'on(N=100)

RX

Ancillary/Other

Prof

OP

ER

IP

Ø  ERcostsreducedbyover81%Ø Outpa'entcostsreducedbyover21%Ø  Professionalservicesreducedbyover18%

OverallCosts

Ø  AveragePMPMcostsdecreasedby25%.Ø  Decreaseininpa'entcosts(49%ofthetotaldecrease).Ø  AllservicecategoriessawadecreaseinPMPMcosts

exceptancillary/othermedicalservices

$-

$200.00

$400.00

$600.00

$800.00

$1,000.00

$1,200.00

$1,400.00

$1,600.00

0TO3MONTHS 3TO6MONTHS 6TO9MONTHS >9MONTHS TOTAL TOTAL,Excl<3Mos

PMPM

Cost

Baselinevs.CurrentTotalCosts

Baseline

Current

Cantherebeaposi'veROI?

FinancialImpact

$64,338 AcuteMembers

$151,035 ChronicMembers

25%or$271 PMPMReduc=onincosts

ImprovedHealthOutcomes

17% Membersmovedtolowerriskcategory

57% ImprovementinDiabetesControl

86% ImprovementinBloodpressure

Successthroughthe“ThreeE’s”

Ø  EngagementØ Whatarethepa'entgoals?Ø  BarrierstosuccessØ  BuildingRela'onship

Ø  EmpowermentØ  EncouragementØ  SupportØ  Self-managementAc'onplan

Ø  Educa'onØ  Treateachpa'entindividually

EverChangingWorldofHealthcare

Inearly2015,theDepartmentofHealthandHumanServicesannounceda'melinetomovetheMedicareprogram

towardpayingprovidersbasedonthequality,ratherthanthequan<tyofcaretheygivepa'ents.

2015

20162018

0%

30%

50%

VBP (us in future)

FFS (us now)

Ø  Partnershipsoverthelast4.5yearsØ  CommercialPayorØ  LocalIndustriesØ  Acclaim(NMHS’healthplan)

Ø  QualityDashboardsandPQRSØ  Popula'onHealthBasedSoiware

Ø  DiseaseRegistry-dataminingØ  OutreachCalls-pa'entengagementØ  Telehealthtechnology-increaseinaccessibility

Ø  GrowthMindset:ACO/PCMH

TheACOinfrastructurewasanessen'alsteponourpathwaytosustainabilityandourul'mategoalofachievingthe“Quadruple

Aim.”

NMMCIMovesTowardAdvancedPaymentModels(APMs)

Ø NorthMississippiConnectedCareAllianceACOformedinJan2016Ø  ACOInvestmentModel(AIM)

Ø  Medicarepre-payssharedsavingsfor2yearsØ  Ifnosavings,thennorepaymentatlongastheACOcomplieswiththeprogramfor3years.

Ø MedicareSharedSavingsProgram

Ø  Requires5,000ajributedlivesinall3benchmark yearsØ  Ifsuccessful,Medicaresharesupto50%ofsavings.Ø  Ifnotsuccessful,nopenalty

Ø  Allexis'ngreimbursementstaysthesame.

Ø  18,000+alributedMedicarelives.

JourneytoACO

Ø  FocusonNMHSAcclaimmembersandMedicareACOØ  EmbeddedRN’slocatedinthefollowingclinics:

Ø  IMA-TupeloØ  BoonevilleØ  FultonØ  IukaØ  Sal'lloØ  WestTupeloØ  OkolonaØ  WestPointInternalMedicineØ  WestPointMedicalØ  Future–Eupora&Hamilton

Ø  Centrally locatedLPNteamcomple'ngini'alTCMcallandworkingoncaregapcoordina'on

Ø  IndustryHealthManagers-Franklin,MossyOak,HunterDouglas,Provia

NMMCIPopula'onHealthStrategy

CurrentACOIni'a'ves

Ø  HCCScoresØ  Con'nuedAnnualWellnessVisitfocuswithemphasisonthenew

GCodesforpreven'vecareØ  Transi'onalCareManagement&ChronicCareManagementØ  CareGapClosureØ  PostAcuteReview

Ø  Partnershipswithlocalnursingfacili'esØ  PartnershipsbetweenHealthManager/HomeHealthØ  ReferralLeakageReduc'onØ  RehabOpportuni'esinotheropenmarkets

Ø  Iden=fica=onofpa=entswithhighriskorchronicdiseases

Ø  Gapsandduplica=onofservicesincareexist

Ø  Poortransi=onsuponhospitaldischargeandincreasedriskforreadmission

Ø Naviga=onwithintheambulatorysekngcanbecomplex

Ø  Primarycareaccessmaybelimited,andexpansionandchangescanbechallenging

CurrentChallengestoPopula'onHealth

Management

Ø  Improvespa'entunderstanding&mutualcommitmenttohealthgoals

Ø  Improvescommunica'onbetweenclinicians&variouspointsofcare

Ø  Iden'fiesobstaclestoeffec'vepa'entcare,suchas:Ø  Medication adherence Ø  Psychosocial barriers Ø  Socioeconomic barriers Ø  Overutilization of ER, “easy access” urgent cares, and imaging Ø  Complex care coordination Ø  Transitions of care Ø  Assists with “end of life” care planning and referrals

BenefitstoProviders

KeystoSuccess

Ø  EmbeddedPopula'onHealthManagerswithinclinicsitesØ Medica'onreconcilia'on(paramounttoreducemed

errors)Ø  Follow-upappointmentscheduledwithin5-7daysof

discharge(capitalizeonTCMvisitreimbursement)Ø  Coordina'onofCare-Theteamunderstandscareplanand

caregapsiden'fiedquicklyandaddressedØ  Pa'ent/Caregivereduca'onandunderstanding(pa'ent

engagement)

Ø  Engagementofallstaffateachclinic

Ø  HealthManagersworkwithpa'entsandprovidersequally

Ø  Clinicalefficiencyteamadjustsworkflow-“hard-wired”prac'ces

Ø  Promoteclinicianengagementcon'nuouslytoimprovecare

Ø  Integrate“growthmindset”intocultureoforganiza'on

Ø  ACOworkisnot“extra”work(everypa<ent,every<me)

Ø  Purpose–growingbusinessandprovidingbelercareforpa'entsØ Maximizereimbursement-“Don’tleavemoneyonthetable.”

Ø MedicareWellnessVisits

Ø  CCM/TCM

Ø NewGcodes(e.g.depressionscreening,smokingcessa'on)

BestPrac'ces

“Withoutcon<nualgrowthandprogress,suchwordsasimprovement,achievement,andsuccesshavenomeaning.”

-BenjaminFranklin

ThankYou!

Ques'ons??

Contactusat:

brcrosswhite@nmhs.netshammock@nmhs.net