population health learning network convening december 5, 2019 · 2019. 12. 2. · Ø medicare: 5%...

Population Health Learning Network Convening

December 5, 2019

•  FQHCinSanJoaquin,Solano,andYoloCountiesØ WeServe36%ofourentirecommunityin

SanJoaquinCountyand9%inSolanoCounty

•  Medical,Dental,andBehavioralHealth•  21Locationsin7Cities•  MembershipPopulation:

Ø Medi-Cal: 81%Ø Uninsured: 15%Ø Medicare: 5%

•  Hispanic67%,Asian13%,White13%,andAfricanAmerican7%

•  NextGenandi2iPatientRegistry

Who We Are

PHLNYear2ProjectAim MeasuresforSuccess

CommunityMedicalCenters,Inc.PHLNYear2ProjectAim

ServiceDeliverytoaHigherPercentageofOurAssignedMembershipConsistentWithOrganization’sMission:Focusingonoutreachstrategies,weaimtoimproveaboveourHealthPlanofSanJoaquinassignedmembersseenbyreaching80%membershipengagementbyDecember31,2019.

MeasuresforSuccessProcessmeasures:•  ImplementapopulationhealthbasedrostersystembyApril30,2019•  IdentifynumberofmemberswhohavenothadavisitwithCMC•  Outreachallmembersnewlyassignedpermonth(last90daysand

91-120days)andscheduleappointmentsforanannualwellnessvisit(newpatientphysical)

OutcomesMeasures:Runspecificreportstotrack:•  NumberofmembersreachedAndofthosemembersreached:•  Howmanyresultedinappointmentsscheduled•  Howmanyofthoseappointmentswerekept•  Howmanyofthosekeptappointmentswereannualwellnessvisits

ChangesTestedChanges

•  Developed an Outreach In-Reach Activity Matrix to help clearly identify what items teams are to work on.

•  Cultivate and sustain Tiered Approaches for outreaching members.

ImplementedChanges•  Implemented Enrollment Manager, a

new roster management tool through eMedApps, which identifies newly assigned and established members who have received or not received services; and documents outreach efforts and results.

•  Mailing Welcome Letters to newly enrolled members on a monthly basis.

•  Sending Text Message Campaigns and Post-card follow-up communications.

CENTER FOR CARE INNOVATIONS | 4

1

2

3

4


OUTREACH/IN-REACHACTIVITYMATRIXWho'sResponsible? In-Reach(Patients)Tasks Outreach(Members)Tasks

ClinicCareTeams

Fornewandestablishedpatients---Generatei2iHuddlereport;Huddle;conductrobustconfirmationcalls;managepatientpanels;

performannualwellnessvisit(physical)/CHDP;useappropriatecodes;performSHA(age-appropriate,annually);printoutanticipatory

guidance;recallno-showpatients;recallpatientswithabnormallabs/clinicallysignificantfollowup

DesignatedCareTeamStaff:ScheduleNon-EngagedMembers(notnewmembers)bydocumentinginEnrollmentManagerasdirectedbyCenterManager,Supervisors,Leaders.CenterManagerswillprovidefeedbacktoMembershipServicesDirectoron

O&Estaffprogressatsites.

HealthEducators

Conductgroupclasses;recallpatientswithgapsincarefordiabeticlabsCDC-HT;CDC-N;MPM-ACE;andMPM-Diuretics(standingorders);Recallpatientswhohavenothadanannualwellnessvisit(prioritizeCHDPs)inthepast12months(listsretrievedfromHealthPlans)

Note:DocumentationinNextGenonly.

N/A

PatientServicesCenter Scheduleappointmentsinatimelymannerforallpatients

Conductoutreach;scheduleappointmentsfromtheEnrollmentMangerlistfromdesignatedhealthplansformembersassignedwithinthelast0-90days.Ifall0-90

dayNewMembershavebeencontacted,availablestafftimeshouldbeconcentratedonNon-Engagedmemberswithafocusonsitesthathaveavailable

access.

OutreachandEnrollmentStaff Recallpatientswhoareidentifiedasuninsuredandpursueenrollmentofhealthcoverage

Conductoutreach;scheduleappointmentsfromtheEnrollmentMangerlistfromdesignatedhealthplansformembersassignedwithin91-120daysandNon-

Engagedmembersasasecondpriority.Healthcoverageschedulesareblockedfor4hoursweekly.DocumentationwillbedoneinEnrollmentManager.Thistimecommitmentwillbeallocatedinfullorpart

bytheO&ETeamLeader.O&ETeammemberswillalsocommunicatewithCenterManagersonweekly

progress.

UsingDataforImprovement

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

#HPSJAssignedMembersOutreached

1.#HPSJmembersoutreachattempts(phone,mailer,text-membersassigned0-120days)Target(100%ofmembersnewlyenrolledthatmonth,0-30days)


13%19%

26%

35% 37%41%

44%48% 47%

51%

26%

44%49%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Jan-19Feb-19Mar-19Apr-19May-19Jun-19Jul-19Aug-19Sep-19Oct-19 Q1 Q2 Q3

%HPSJAssignedMembershipEngagement

3.OfTotalHPSJAssignedMembership,%apptskept Target80%


67%

33%

HPSJPreventiveVisitsSeen2019(Assigned&Not-Assigned)

TOTAL#HPSJmembersSEEN(48595)

HPSJPreventiveVisitsKept(24458)

41389

48595

36000

38000

40000

42000

44000

46000

48000

50000

1

TOTAL#HPSJmembersSEEN(Jan18-Dec18)

TOTAL#HPSJmembersSEEN(Jan19-Oct19)

1

2

3

4

Creating an Interdisciplinary Team

DevelopedanOutreachIn-ReachActivityMatrix

Improvereportingonprogresswhereresultsarereadilyavailable

Tieredapproachestooutreachmemberengagement

StrategiesforSuccess


Ineffortstoexpandouroutreachgoalstoalsohelpwithmeetinginreachofournon-engagedmembers,wehaveupdatedourmatrixtoincluderesourcesfromourdirectClinicalCareTeams.

KeyTools&Resources


StafftrainingonnewEnrollmentManagertool.TrainingmaterialsonusingtherosterproducthavebeendevelopedbyourApplicationsDepartmentwiththesupportofsuperusersfromourPatientServicesCenter.

WeaddedTextReminderstocomeforcareviaintegrationfromourestablishedAppointmentReminderSystem,WellApp.WeusedaSpecialTextCampaign.

NextSteps

Add2newhealthplanstotheEnrollmentManagerrosterprocess,bringingourtotalparticipatingpercentageto92%.

Integrateourunassigned“members”intothisprocess,primarilyourUninsuredandStandardMedi-CalandMedicare.

IncorporateEnrollmentManagerintoHealthEducatoroutreachefforts

UtilizetheEnrollmentManagertofacilitateappointmentstoimproveHEDISoutcomesandmemberengagement.

Hardwireanongoingprocessbyrefiningandlearningonwhatworksanddoesnotwork.


Spreading Sustaining


Outreaching

100%ofnew

ly

assigned

memberswithin

30days

Todate,wehaveseen5%moreHPSJMembersforPreventiveVisits

ImplementedEnrollmentManagerthatwillhelptrack

outreach/inreachdocumentationefforts

Learnedhowtoimproveourdataanalyticstowork

forus

Wenowhavebettertoolsandastrongerunderstandingofhowtocontinueengagingourmembers!

1

2

Whatrelationshiptoolsandtechniquesarethemosteffectivemethodstoengageourmembersinreceivingourservices?

Membershipchangesmonthlywhichcreatesamovingtargetfortrackingoutreachresults.Whattacticsmaybeutilizedtohelpmitigatethis?


CurrentChallengesorBarriers

Questions?


Alyssa Arismendi-Alvarez, Director of Quality Improvement [email protected] Ginger Manss, Chief Nursing Officer [email protected] Javier Romo, Data Analyst [email protected] Laura Thao Vang, Operations Special Projects Manager [email protected] Marc Smith, Director of Member Services [email protected]

population health learning network convening december 5, 2019 · 2019. 12. 2. · Ø medicare: 5%...

Documents