The NCQA Population Health Management Resource Guide. Natalie Mueller, MPH Manager, Product Development NCQA

Transcription

1 The NCQA Population Health Management Resource Guide Natalie Mueller, MPH Manager, Product Development NCQA

2 OUR MISSION To improve the quality of health care OUR METHOD Measurement Transparency Accountability We can t improve what we don t measure We show how we measure so measurement will be accepted Once we measure, we can expect and track progress

3 Health Plan Accreditation (HPA) Our flagship product covers 70 % of people in HMOs, PPOs

4 Health plan accreditation is STRUCTURE & PROCESS HEDIS Performance Measures (Clinical) CAHPS 4.0H (Patient Experience) Performance-based accreditation

5 Improving Health Plan Accreditation Drivers Health Plans Clinically Integrated Networks Practices

6 PHM Category in Health Plan Accreditation QUALITY MANAGEMENT AND IMPROVEMENT MOVED FAMILIAR AND MODIFIE NEW D POPULATION HEALTH MANAGEMENT NETWORK MANAGEMENT PHM 1: PHM Strategy PHM 2: Population Identification PHM 3: Delivery System Supports UTILIZATION MANAGEMENT CREDENTIALING AND RECREDENTIALING MEMBERS RIGHTS AND RESPONSIBILITIES MEMBER CONNECTIONS PHM 4: Wellness and Prevention PHM 5: Complex Case Management PHM 6: PHM Impact PHM 7: Delegation of PHM

7 Population Health Management is

8 NCQA & Janssen Sponsorship

9 Why a PHM Resource Guide? Goal and Audience Educate health plans on PHM principles and provide examples of how PHM can be achieved in practice to inspire their own activities.

10 The PHM Strategy 5 Components Stratification & Resources Targeted Interventions Delivery System Support Measurement What s in the PHM Resource Guide? Commonly Asked Questions Relevant NCQA Programs In the Field Examples

11 If I m applying for NCQA Health Plan Accreditation, do I need to follow everything in this Guide? No- organizations undergoing Health Plan Accreditation are required to meet the requirements as described in Health Plan Accreditation ONLY. The Guide is a supplemental educational tool intending to support an organization s implementation of population health management.

12 PHM 1: PHM Strategy Element A: Strategy Description Element B: Informing Members

13 Keeping members healthy. Managing members with emerging risk. Patient safety or outcomes across settings. Managing multiple chronic illnesses.

14 Component 1 Four areas of focus Goals Pg Targeted Populations Health plan activities Direct member programs PHM Strategy

15 Component 1: PHM Strategy Pg

16 PHM 2: Population Identification Element A: Data Integration Element B: Population Assessment Element C: Activities and Resources Element D: Segmentation

17 Component 2 Data Integration Pg Social Determinants of Health Population Stratification and Resource Integration Population Assessment PHM Activities and Resources Risk Stratification

18 Component 2: Population Stratification and Resource Integration Data Integration Medical and behavioral claims* Laboratory data* Electronic health records* Clinical management programs, such as case management, wellness programs* Member-supplied data Pharmacy claims* Health appraisals* Advanced data sources such as health information exchanges, all-payer data warehouses* Demographic or census data Data supplied by providers or practitioners Pg

19 Component 2: Population Stratification and Resource Integration Pg

20 Component 2: Population Stratification and Resource Integration Pg

21 Component 2: Population Stratification and Resource Integration In-The-Field Examples and Tools: Pg Philips Wellcentive Health Leads ActiveHealth Management Kaiser Permanente Evolent Health BlueCare Tennessee UnitedHealthcare

22 Component 2: Population Stratification and Resource Integration Pg

23 Targeted Interventions PHM 4: Wellness and Prevention PHM 5: Complex Case Management

24 Component 3 Complex case management Pg Chronic condition management Long-term services and supports Wellness and prevention programs Targeted, Personcentered Interventions Behavioral health management

25 Component 3: Targeted, person-centered Interventions Pg

26 Component 3: Targeted, person-centered Interventions Pg

27 Component 3: Targeted, person-centered Interventions In-The-Field Examples and Tools: Pg Essentia Health University of Texas Medical Branch Cognizant Sharecare, Inc. Neighborhood Health Plan of Rhode Island Partners in Care Foundation

28 PHM 3: Delivery System Supports Element A: Practitioner or Provider Support Element B: Value- Based Payment Arrangements

29 Component 4 Delivery System Pg Health Plan Practitioners, ACOs, other care delivers Value-based payment arrangements Patientcentered medical home transformation Shareddecision making aids Data sharing Delivery System Support and Alignment

30 Component 4: Delivery System Alignment and Support Pg Value-based Payment Arrangements Pay-for-performance Shared savings Shared risk Two-sided risk sharing Capitation/population-based payment

31 Component 4: Delivery System Alignment and Support Pg

32 Component 4: Delivery System Alignment and Support In-The-Field Examples and Tools: Pg Washington State Health Care Authority Baylor Scott and White Quality Alliance

33 PHM 6: Population Health Management Impact Element A: Measuring Effectiveness Element B: Improvement and Action

34 Component 5 Clinical Measures Pg Measurement Cost/Utilization Measures Member Experience of Care Measures Tools to Set and Evaluate the Impact of the PHM Strategy

35 Component 5: Measurement Pg

36 Component 5: Measurement Pg

37 In conclusion: Resource Guide Aligns with Health Plan Accreditation Standards Frequently Asked Questions NCQA Programs Relevant Measures In-The-Field Examples and Tools

38 NCQA & Population Health Management HPA 2018 PHM Standards Category of standards in Health Plan Accreditation 2018 July 2018 PHM Prevalidation For health IT vendors performing discrete PHM functions December 2018 PHP Accreditation For population health organizations December 2018

39 Questions