Population Health in an Integrated Care Delivery System

Transcription

1 Population Health in an Integrated Care Delivery System Michael McNamara, MD Chief Medical Information Officer Northwest Permanente Medical Group Kaiser Permanente

2 Agenda KPNW Overview of Population Health Approaches to Intervention Centralized Initiatives Clinic Based Strategies Review of Tools Quality Outcomes Shared Decision Making OpenNotes Questions

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4 Population Health Population Health Stratification Wellness/Prevention Services Healthy At Risk Chronic Chronic/Complex Complex (Late Stage or Complex Chronic / Poly-Disease) Description Members without any major chronic conditions who are free of key risk factors Members without any major chronic conditions who exhibit one or more risks (high bp, cholesterol, obese, smoke/drink excessively) Members who have been diagnosed with a chronic condition that is well controlled and has not substantially progressed Members who have been diagnosed with one or more chronic conditions that are uncontrolled or advanced Primary Health Management Goals Patient Engagement Wellness support of lifestyle Wellness and prevention Patient Engagement Lifestyle modification Medication compliance (as necessary) Wellness and prevention Patient Engagement Lifestyle modification Treatment compliance Informed decision making Wellness and prevention Patient Engagement Joint treatment planning Adherence with EBM Care coordination Treatment compliance and support Primary Medical Impact and Timing Preventing deterioration of health (Longer-term) Preventing deterioration of health (Longer-term) Preventing deterioration of health (Longer-term) Decreasing Redundancy (Near-term) Avoidance of adverse events and reduction in unnecessary procedures (Near-term)

5 Population Health Current Population Health Picture

6 Population Health Organizational View Dental Medical Home is the functional system by which we deliver care. Population Health is the clinical framework for organizing a patient s care. Member Services Primary Care Provider (Care Integration Team) Prevention/ Wellness Programs Each supporting area needs to organize their services and connect those services with the Primary Care Provider (PCP team). Care Coordination PCP) is the leader/coordinator of patient s care, and other departments exist to support the PCP team in delivering care. NCQA

7 Population Health Patient s View Patient expects: Seamless care and services based on their level of acuity. A proactive approach to their care. That we know them regardless of where care occurs. Care focused on the whole person, not just the presenting problem or the primary health concern. Care that seamlessly crosses the care continuum to include ambulatory, urgent, emergent, sub-acute, inpatient, continuing care.

8 Population Health Requires a Strong Foundation of Information Enterprise Data Warehouse (EDW) Over 20 Years of Clinical Data from a Single EMR Integrated with Outside Claims Data Marts Subsets of EDW Designed to Support Specific Population or Disease Contains Only Necessary Data Elements for Relevant Issue Extract Frequency Ranging from Every 24 Hours Every 15 Minutes Visualization Tools Wide Variety of Standard Tools Including Cold Fusion, Tableau, SAS, etc

9 System Approaches to Patient Engagement Centralized Services Letters/Postcards IVR Outreach Calls Registries Clinical Quality and Pharmacy Service Involvement Clinic Based Services Inreach Using Patient Support Tool (PST) Outreach Using PST

10 Centralized Shared Services Prevention Outreach CHILDHOOD Initiatives Central Clinic Childhood Immunizations Unpaneled Lists Paneled Dtap Outreach PREVENTION Initiatives Central Clinic Breast Ca Screening Mamm Cards IVR Inreach WCC 1-6 IVR Inreach Imaging Outreach Appointing WCC 0-15 months WCC Cards Inreach WCC Adolescent Adolescent Immunizations WCC 1-6 IVR WCC Cards WCC IVR WCC Cards Inreach Inreach ADHD Initiation Centralized calls Inreach Cervical Ca Screening Centralized calls Pap Cards IVR Unpaneled lists Inreach Pap Opportunity Report BMI Children Inreach Colorectal Ca Screening Centralized calls CRC IVR Calls Follow Up Letters Centralized calls Unpaneled lists Inreach Unpaneled lists Chlamydia Screening Inreach Unpaneled lists Centralized calls

11 Centralized Shared Services Disease and Medication Management ADULT Initiatives Central Clinic Initiatives Central Clinic Adult BMI (Medicare) Controlling HTN IET Clinical Pharmacy outreach calls CVD/DM High Risk IVR Call Recode lists to quality liaisons Inreach Outreach for Elevated recheck due Inreach, MA BP clinics BPA/Inreach Monitoring Persistent Meds ALL 7-Day MH Follow Up COPD via Spirometry Rx booster outreach Centralized Clinical Pharmacy Med Management Central Outreach PST caregap MH Outreach Inreach,PST caregap Drug-disease Interaction Refill protocol BPA Inreach Lists to clinicians Osteoporosis Clinical Pharmacy Med Mgt Inreach, PST caregap Diabetes HbA1c Poor Control Diabetes BP 140/90 Clinical Pharmacy outreach, PCP huddles Diabetes Care Managers CVD/DM High Risk IVR Call Clinical Pharmacy Outreach calls CVD/DM High Risk IVR Call Outreach for Elevated recheck due Two minute diabetes encounter Outreach for Elevated recheck due Glaucoma Multiple Measure Outreach * Optiate Therapy Plan Osteo Outreach Outreach Birthday letters and calls Refill Protocol, STORM, Inreach, PST caregap Outreach lists

12 Patient Support Tool This is a one-stop, one-page tool that provides a comprehensive look at both the provider panel as well as details for the individual patient Unique formats available for the following audiences: Adult primary care Pediatrics OB/GYN Immunodeficiency (HIV) clinic

13 Goals of the Patient Support Tool (PST) To help us achieve our regional quality vision by making the right thing easy to do To support exceptional in-reach at all member touch points To support Total Panel Ownership in Primary Care To facilitate regional outreach initiatives

14 PST - Outreach User-friendly outreach functionality. Complete Panel View displays key information on each panel member. Total care gap score is a summary of weighted care gaps for each panel member. All chronic condition, contact modality & utilization columns can be sorted by a single click. Color-coded flags indicate different care recommendations for each chronic condition as well as priority rank, so clinicians may focus on what needs to be done with a quick glance.

15 PST - Inreach Easy & efficient Inreach workflow. Simply select members with next-day office visits and batch printout Patient Detail View by MA to supplement pre-visit summaries. Currently Patient Detail View can be accessed for each member in the EMR. Specific recommendations for care gaps are displayed in red. Detailed patient information updated nightly from EMR and other clinical systems.

16 PST Care Gaps PST provides user-friendly functions to enable clinicians to customize their care gap queries. Currently, there are 134 care gaps addressed in the PST.

17 Birthday Outreach for All Members

18 Monthly Performance Feedback

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20 Pediatric Panel View

21 PST- Embedded in KP HealthConnect

22 Population Health Protocol: Batch Orders

23 Population Health Protocol: Batch Orders

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25 Patient Friendly Handout

26 Birthday Letter for Members with Care Gaps

27 Personal action plan available on kp.org

28 Controlling High Blood Pressure (ages 18-85) 86.00% 84.00% 83.45% 82.97% 84.43% 83.70% 82.00% 80.00% 78.00% 76.00% 76.64% National 90th Percentile, 75.13% 74.00% 72.00% 70.00% 2011 YE 2012 YE 2013 YE 2014 YE 2015 YE Rate National 90th Percentile

29 Drugs to be avoided in the elderly (one prescription) 14.00% 12.00% 10.00% 9.94% 11.75% 10.23% 8.00% 6.00% 7.61% National 90th Percentile, 7.56% 6.07% 4.00% 2.00% 0.00% 2011 YE 2012 YE 2013 YE 2014 YE 2015 YE Rate National 90th Percentile

30 Colorectal Cancer Screening 78.00% 76.00% 74.77% 76.74% 75.98% 74.82% 74.00% 72.00% 70.00% 71.76% National 90th Percentile, 72.02% 68.00% 66.00% 2011 YE 2012 Screening YE Rate National 2013 YE 90th Percentile 2014 YE 2015 YE

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33 Shared Decision Making: Population Health at the Individual Level All prior tools apply the same algorithm to the entire population Need mechanism to allow individualized care decision based on patient needs and preferences. Started with Initiation of Statins Already had 10 year CVD risk score readily available Well defined outcome data with regard to impact of starting Statins

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38 Breast Cancer Treatment Online PDF summarizing Individual background information regarding breast cancer Treatment options for that patient Pros and cons of treatment options

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44 Dynamic Tools Extract data from patient record to automatically populate the Shared Decision Making Tool Currently have tools from Health Decision for Treatment of Atrial Fibrillation Lung Cancer Screening

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55 Possible SDM Tools in the Future Knee/Hip Replacement Pre-Diabetes Treatment Treatment of Osteoporosis Chemotherapy in Stage IV Cancer Vaginal Birth After Cesarean

56 PATIENT ENGAGEMENT AFTER THE VISIT Open Notes provides ability to continue patient engagement beyond the visit Positive results have been well detailed and prior conferences and presentations Our approach Big Bang implementation April 8, Exclude mental health, addiction medicine and teenagers

57 OPEN NOTES EXPERIENCE AT KPNW Virtually seamless non event No demonstrable spike in patient s Occasional nuisance questions as a result Virtually universal adoption by medical group Many reports of positive intervention Increased patient awareness of underlying disease Patients reported feeling more listened to by physician and team Correction/clarification of drug regimen Clarification of risks of interventional procedures FIND A WAY TO JUST MAKE IT HAPPEN!

58 Questions? Michael McNamara