Population Health at Ochsner. Pursuit of Value Programs in GI/Hepatology. Population Screening initiatives- Hepatitis's C & CRC

Transcription

1 Population Health at Ochsner Pursuit of Value Programs in GI/Hepatology Philip M Oravetz, MD, MPH, MBA Medical Director, Accountable Care 1 Agenda Introduction Population Health Framework & Registries Population Screening initiatives- Hepatitis's C & CRC Pursuit of Value Colonoscopies and GI Lab Care Pathways & Bundles: GI Bleeds & Bowel Surgery 2 1

2 Ochsner Health System New Orleans, LA Who We Are: Louisiana s largest nonprofit, academic, health care system 25+ owned, managed and affiliated hospitals, group practice physicians and 600+ APP s in an integrated delivery system State and Region-wide Clinical Integration network Significant value based portfolio #1 ranked Liver Transplant Program Transition to Populationbased delivery Ochsner Risk Based Populations Full risk 35,000 Medicare Advantage seniors (Humana) 19,000 employees + dependents (self-insured) Shared Savings 27,000 Medicare ACO (MSSP ACO Track 1+) 9,000 Medicare Advantage (PHN) 47,000 BCBSLA commercial 7,500 CIGNA commercial 15,000 United commercial Focus on risk based narrow network insurance products 2

3 Ochsner Population Health Framework ENVIRONMENTAL Increasing Health care Expenditure Suboptimal Quality Cost-Shifting to Consumers Clinical and Cost Variation Increased Price & Quality Transparency Explosion of Information Employer Aggregation/Force P O P U L A T I O N H E A L T H Taking responsibility for the health and well-being of a population as defined by: HEALTH POLICY Shift to Value-Based Care MACRA legislation/apms Bundled payments MSSP & commercial shared savings Cost-shifting/HDHPs Health exchanges New reporting requirements IMPROVED QUALITY REDUCED COST BETTER PATIENT EXPERIENCE Safety Disease Management/Clinical Programming Medication Management Behavioral Health Wellness/Prevention Care Transitions/Post-Discharge Intervention ED, Admission/Readmission Avoidance Complex Care Management Standardized Care Pathways Referral Management Community Partnerships/SNF Access Care Coordination (Ochsner On Call, LPN-CCC) Patient Activation/Satisfaction HCAHPS, CGCAHPS Team-based Care Palliative Care FACILITATING CAPABILITIES Governance Leadership Commitment & Priority Transparency Advanced Analytics (Clinical + Financial) Connectivity Coding/Documentation Excellence Panel Management Aligned Incentives/Comp Model Resource Optimization Training & Development 2017 AMERICAN Culture of ASSOCIATION Performance Improvement FOR THE STUDY OF LIVER DISEASES 6 3

4 Targeted Risk Stratification for Population Health COMPLEX CARE Manage top 3% of the current population Complex Care Management Primary Care Lead Connected Care Team IP-OP continuity & collaboration Advanced Care Services CARE COORDINATION DISEASE MANAGEMENT PREVENTATIVE HEALTH Manage 20% of the population Primary Care coordination Specialists (e.g. ortho) Registries Care pathways Ancillary support staff (CDEs, behavioral health) Select disease-specific programs Manage rising risk population PREVENTATIVE HEALTH 7 Population Health: No Regrets Grow Primary Care Utilization Management On Demand Access Reduce OPE & Manage Referrals Care Pathways Palliative Care Chronic Disease & Preventive Care Develop Relationships with Post-Acute Providers Evolve Comp Plan to Align With Pop Health Behavioral Health & Primary Care Links Communication Platform Error Reduction 8 4

5 Population Health Scorecard Measure Total Cost of Care PMPM Total Medical PMPM Total Pharmacy PMPM UTILIZATION Admits/1000 ED visits/1000 (incl. obs) Readmits/1000 Readmit % Imaging Radiology/1000 MRI/1000 CT/1000 Outside Provider Expense QUALITY Quality Rating HbA1c < 8.0 BP Control <140/90 Mammography 12 mos. Roll Sept 12 mos. Roll Sept MSSP Humana MA PHN % Change 12 mos. Roll Oct mos. Roll Oct 2016 % Change June 2016 YTD 9 BIG 7 Quality Metrics 10 5

6 Healthy Planet Dashboard 11 Healthy Planet Registry Tiers Tier Registry Low Complexity/Resource Requirement to High Complexity /PMO involvement Tier 3 Tier 2 Tier 1 Chronic Kidney Disease Diabetes Hypertension Wellness (Peds) *Well Child 15 months Breast Cancer Screening Cervical Cancer Screening Colorectal Cancer Screening Osteoporosis Lung Cancer All Wellness (Adults) ACO ALS Asthma Chronic Liver Disease COPD CJR CHF HIV Headache Obesity OPCM Opioid/Chronic Pain Tobacco Readmission MS IBD Rheumatology 12 6

7 EPIC Healthy Planet: Chronic Liver Disease Registry Ochsner's Chronic Liver Disease Registry Inclusion Logic Chronic Liver Disease Registry: Patient Status Patient is Alive Inclusion Criteria AND ProblemList diagnosis Disease of Liver Atleast2 Encounter Diagnosis HepatitisB Surface Antigen Lab Value (LAB471) Disease of Liver OR OR Equal to "Positive" or "Reactive" OR Hepatitis C Antibody Lab Value (LAB868) Equal to "Positive" or "Reactive" OR Hepatitis C RNA Lab Value (LAB887) Equal to "Positive" or "Detected" 14 7

8 Chronic Liver Disease: SNOMED Concept Type SNOMED Concept Logic DISEASE OF LIVER More Precise Concepts (under Disease of Liver [D ]): Diagnoses Grouper: EDG CONCEPT LIVER DISEASE [100024] 15 Chronic Liver Disease: Registry Metrics Over 900 Metrics Demographics Current PCP ED Visits Last GI Visit Social History First BMI Alcohol Abuse Tobacco Use Labs ALT AST Hep C (Ab & RNA) Radiology Abdominal Ultrasound Date Doppler portal vein blood flow date Rx Prescribed Folic Acid Prescribed glucocorticoids Diagnoses Has NAFLD Has NASH Procedures Liver biopsy performed Liver transplant in history 16 8

9 Population Health Framework: Wellness and Prevention Leadership Population Health Committee Primary Care Council Other (POV, IT, CCC, etc.) IT Functionality (EPIC) Health Maintenance Healthy Planet Patient Portal Kaboodle Dashboards 17 The Population Health Cycle LPN-Clinical Care Coordinators (CCC) Program Written Order Guidelines Care Touch (Call Center) Population Health Framework: Wellness and Prevention Operations My Panel Dashboards (Registry Driven) Physician Compensation (Value-Based) 18 9

10 Evolution of Primary Care at Ochsner 19 Population Health Cycle Pre Visit Work Population Work Visit Work 20 10

11 Population Health Registries Bulk Orders and Bulk Outreach Registry Patients Bulk Orders Outreach Outreach Type Disease Management 71,854 Weekly Quarterly MyChart/ Mail Mammogram 50,000 Weekly Monthly MyChart/ Mail Disease Mgmt. Program Chronic Kidney Disease Colorectal Cancer Screening 604 Weekly Weekly Engagement Specialists 26,623 Weekly Weekly MyChart/ Mail 50,000 Weekly Weekly MyChart/ Mail 2017 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES 21 Concierge Service at the Lab 2017 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES

12 MyChart: Ochsner Patient Portal 24 12

13 Hep C Screening Program 2014 YTD 2015 YTD 2016 YTD 2017 YTD Total Pts tested for Hep C Antibody 20,171 21,053 33,939 29, ,841 Pts with A Pos AB Test 968 1,092 1, ,673 % of Positive Hep C AB 4.80% 5.19% 4.04% 4.18% 4.46% Pts w/a Subsequent RNA Test ,846 % of Positive Ab Pts 80.37% 58.06% 55.39% 54.31% 60.90% Pts w/a Positive RNA Test ,415 % of Positive RNA Test 63.62% 57.89% 41.58% 35.16% 49.72% % of Positive RNA to Total Population 2.45% 1.74% 0.93% 0.80% 1.35% 2017 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES 25 Fit-Kit Colorectal Cancer Screening Program Fit Kit- Colorectal Cancer Screening Program Clinics Orders Dispensed In Process Negative Positive Dispensed/Not Returned Not Dispensed/ Opportunity Baptist Baton Rouge Jeff Hwy Kenner Northshore West Bank St. Anne Total 16, ,921 % positive 8.8% % resulted 64% % returned 65% % dispensed 25% 26 13

14 Suggestions for Success Get to know your LPN CCCs- they can help identify patients who need help closing care gaps Explore use of the Digital Health Programs for patients with Chronic Disease Look at your My Panel Dashboard and compare your performance with your peers Use Complex Case Management for patients with complicated medical and socioeconomic barriers Provide feedback to your leaders about which resources make the biggest impact on patient care Pharmacy Assistance Program offering support for patients having difficulty affording meds. 27 Pursuit of Value DRIVING VALUE THROUGH CLINICAL PRACTICE VARIATION REDUCTION 14

15 Cost and Quality efforts (Value) have traditionally taken place in silos 2017 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES 29 Pursuit of Value Our Mission: Highest Quality Care at an Affordable Cost Our Approach Our Structure 1 2Our Approach 3 Physician Led Project Mgmt. Cost/Quality Engineering Variation Reduction Process Improvement Clinicians Supply Analytics 30 15

16 Deployment Strategy: Cost/Quality Engineering 1 Cost /Quality Engineering Review Cost by DRG/Service Line Select highest cost inpatient DRG Set Savings Targets Reverse Cost Engineer Target Cost Accounting (EPSI) Utilization Data (Milliman LOS) Quality Metrics Challenges Standardizing metrics that would be used to capture quality metrics or cost savings Most efficient way to process and provide data Creating a datadriven culture 32 16

17 1 Cost /Quality Engineering Review Cost by DRG/Service Line Select highest cost inpatient DRG Set Savings Targets Reverse Cost Engineer Target DRG 029 DRG 469 DRG 237 Challenges Narrowing focus of the organization, from diving into all DRGs to selecting the highest impact DRGs. Understanding the the overlap in supply costs between common DRGs. Top Costing DRGs selected were in Spine, Orthopedics, Cardiology, and GI Service Lines 33 Colonoscopy Dashboard 34 17

18 Deployment Strategy: Variation Reduction Case Study 1: Colonoscopy Sedation Utilization 2017 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES Variation Reduction Identify High Variation Areas Facilitate Analysis of Alternatives to Minimize Variation Deploy Variation Reduction Strategies OMC K OMC NS OMC BR OMC WB OMC SS Case Study: Colonoscopy Sedation Utilization 9% 7% Propofol Use by Campus 98% 83% 53% CRS GI Propofol Use by Specialty 46% 67% Challenges Physician preference for moderate vs. deep sedation varied by site and specialty Moderate and deep sedation approaches would need to be agreed upon by surgeons and anesthesiologists 36 18

19 1 Variation Reduction Identify High Variation Areas Facilitate Analysis of Alternatives to Minimize Variation Deploy Variation Reduction Strategies Case Study: Colonoscopy Sedation Utilization Challenges Avg. CM Per Case Avg. Procedure Time Avg. Recovery Time Patient Satisfaction Deep Sedation (w/propofol) 10% Higher No Difference Moderate Sedation (Fentanyl, Versad, Mepiridime) No Difference 30 Minutes Minutes 20% Higher Changing physician practice in choosing between deep and moderate sedation Obtaining buy-in from anesthesia for the new approach 37 1 Variation Reduction Identify High Variation Areas Facilitate Analysis of Alternatives to Minimize Variation Deploy Variation Reduction Strategies Case Study: Colonoscopy Sedation Utilization Challenges Currently Deploying Project Plan Deploying the project plan system wide required local site operations and physician leader by-in to implement and sustain standards 38 19

20 1 Variation Reduction Identify High Variation Areas Facilitate Analysis of Alternatives to Minimize Variation Deploy Variation Reduction Strategies Results Lessons Cost Savings Results: Shift Case Volumes to Deep Sedation using Propofol Enables an increase in throughput of 12 additional cases per day due to time savings for recovery Resulting in a Total Annualized Incremental Margin of $600K Engaging physicians across the region and in different specialties resulted in clinical standards that improved the quality of care and reduced cost 39 Deployment Strategy: Process Improvement Case Study 2: Vendor Management 20

21 2 Process Improvement Identify Areas of Opportunity Deploy guidelines and standards across the system Case Study: Vendor Management Vendor Physician Supply Chain Previous Process: Vendors would meet with physicians, advise them to use new technologies, and Supply Chain would find out after the fact Challenges Physician / Vendor relationships No standards to eliminate nonapproved products from entering Ochsner facilities 41 2 Process Improvement Identify Areas of Opportunity Deploy guidelines and standards across the system Case Study: Vendor Management Supply Chain Results Improved alignment between Supply Chain and physicians Vendor Physician Elimination of unapproved products from entering OHS facilities New Process: Supply Chain and Physicians Aligned. Vendor Management Guideline implemented eliminating unapproved products from entering OHS facilities 42 21

22 Deployment Strategy: Process Improvement Case Study 4: Value Stream Mapping 4 Process Improvement Identify Areas of Opportunity Deploy guidelines and standards across the system Case Study: Care Mapping Challenges Different care processes in each region Patient LOS expectation set at 4-5 days Minimal to no pre-operative care planning 44 22

23 4 Process Improvement Identify Areas of Opportunity Deploy guidelines and standards across the system Case Study: Care Mapping Results.5 Day reduction in Length of stay system wide Reduced supply expense through shorter hospital stays Standardized Patient Care and LOS as 3 days for typical Total Knee and Total Hip Replacement through Care Mapping 45 GI Bleed Dashboard 46 23

24 Pursuit of Value Extensions: Care Pathways and Bundles 2017 Development Timeline Jan Feb Mar April May June July Aug Sept Oct Nov Dec Go Train Live Go Train Live Develop. Cont. Advanced Heart Failure Evaluation Upper G.I. Bleed Epic Build & Testing Train Go Live Ischemic Stroke Content Development Content Development Content Development Content Development Content Development Major Bowel Heart Failure Epic Build & Testing Content Development Train Go Live STEMI Epic Build & Train Go Live Hip Fracture Testing Epic Build & Train Go Live Lower GI Bleed Testing Epic Build & Train Go Live CABG & Heart Valve Testing Epic Build & Train Go Live Spine 1 Testing Epic Build & Content Development Train Go Live Renal Failure Testing Epic Build & Content Development Train Go Live Testing Epic Build & Content Development Train Go Live Testing Spine 2 Epic Build & Content Development Train Go Live Testing Determine 2018 ONE Paths Epic Build & Testing Train Go Live NSTEMI 48 24

25 ONE Path Completed Patient Volume ONEPath Go-Live Date # of Initiated Pathways # of Completed Pathways Average of Length of Stay Average of Length of Pathway LARYNGECTOMY WITH FLAP PATHWAY 1/28/ LARYNGECTOMY WITHOUT FLAP PATHWAY 1/28/ TOTAL HIP REPLACEMENT WITH EPIDURAL 8/9/ TOTAL HIP REPLACEMENET WITHOUT EPIDURAL 8/16/ TOTAL KNEE REPLACEMENT 8/16/ COPD EXACERBATION 11/29/ ADULT ELECTIVE CRANIOTOMY 12/9/ STABLE UPPER GI BLEED 1/16/ ADVANCED HEART FAILURE EVALUATION 1/16/ ISCHEMIC STROKE 3/13/ Total for all ONEPaths Example View: Eligible Patients 50 25

26 Example View: Process Metrics 51 Mock-Up: Outcome Metrics 52 26

27 GI Bleed and Bowel Surgery Bundle Stable Lower GI Bleed One Path - Work Team Charter Core Team: Stable Lower GI Bleed Executive Sponsor(s): Chris White, MD / Nigel Girgrah, MD Project Lead(s): Brian Kann, MD In Scope: Admitted patients at OMC, Adults (18+) Patients presenting to ED Patients who develop a bleed in-house Patients who develop self-limited rectal bleeding, including: hematochezia, bright red blood (Rectum) who are hemodynamically stable Out of Scope: Non-admitted patients, transfer patients via Regional Referral Center, patients with melena, patients not actively bleeding (On and Off Bleeding), patients under 18 Expected Benefits: Increased Standardization of Care, Decreased Utilization, Reduction of Length of Stay, Reduction of 2-Day Readmissions, Reduction of 30-Day Readmissions, Reduced Mortality (RAMI), Reduction in Blood Use, Faster ER to CT Time, Faster CT NGO to IR Time, More Frequent Admit to Hospital Medicine vs. CRS. Targeted Start Date: April 3, 2017 Anticipated Go-Live Date: August 28, 2017 Resources Needed: PMO, Epic, Analytics Project Team Members: See Included List 27

28 Benefit Metric Description Decreased Utilization Decreased Utilization Decreased Utilization Improved Outcomes Decreased Utilization Improved Outcomes Improved Outcomes Reduction of Length of Stay (LOS) Reduction of 2-Day Readmissions Reduction of 30-Day Readmissions Reduced Mortality (RAMI) Benefits and Metrics Reduction in the overall duration of hospitalization Number of GI Bleed patients who return to inpatient care within 48 hours of initial discharge Number of GI Bleed patients who return to inpatient care within 30 days of initial discharge Reduction in the death rate associated with GI Bleeds (number of deaths/number with bleeds) Do we currently measure? Y/N Current State Goal Y TBD TBD Y TBD TBD Y TBD TBD Y TBD TBD Reduction in Blood Use Reduction in use of donor blood TBD TBD ER to CT Time Reduction in time from ER arrival to CT complete CT NGO to IR Time Reduction in time from CT to IR TBD TBD TBD TBD MSSP GI Bleed Bundle 28

29 Key Learnings Key Lesson 1: This is an effort in Physician Change Management Understand the Data: Review reports, dashboards, and scorecards for variation reduction opportunities. Educate Physicians: Highlight areas of cost / quality variation. Focus on avoidable practice expenses. Standardize best practice. Engage Physicians: Physician Champion to speak with other Service Line Physicians about variation reduction opportunities Hold Physicians Accountable: Continue to provide transparency around the data so physicians have an understanding of key drivers. Drive Sustainability: Track results and refine approach if necessary 58 29

30 Key Lesson 2: Do s and Don ts for Engaging Physicians Lead discussions with data. Continue to provide transparency around data. Engage physician champion to help lead discussions. Discuss best practices with other sites. Celebrate service line successes. Ensure discussion is value based (components of cost / quality). Do s Accept status quo. Don ts Abuse physicians time. Make sure you are prepared for meetings and discussions. Assume data is the 100% answer. There may be a good clinical reason for poor cost / quality performance that needs to be discussed with the physicians. 59 Key Lesson 3: Continuous Improvement is a Never Ending Journey 1 2 Cost Engineering Variation Reduction 3 Process Improvement The team iterated and repeated the cost/quality engineering, variation reduction, process improvement approach several times for each service line it worked with 60 30

31 In addition to cost and quality improvement, our team has driven a cultural shift Degree of organizational Support Understanding Awareness Commitment Acceptance Ending Point Starting Point Time 61 Philip M. Oravetz, MD, MPH, MBA Medical Director, Accountable Care poravetz@ochsner.org 31