AZ Rural & Public Health Policy Forum Population Health: The Path from Volume to Value Mark Carroll, MD January 14, 2015
International Comparison of Spending on Health, 1980 2010 Average spending on health per capita ($US PPP) Total health expenditures as percent of GDP Notes: PPP = purchasing power parity; GDP = gross domestic product. Source: Commonwealth Fund, based on OECD Health Data 2012.
Moving from volume to value
Triple Aim
What is the path forward?
Payment Modernization
POPULATION HEALTH
New Partnerships
A Difficult Crossing, by Jules Daubeil
Working together working together differently - to bring care to our patients and communities when, where, and how that care is needed
To improve the health of specific populations of people.
How are we to work together differently?
Care Traffic Control Shelters & Transi9onal Housing Family Supports Permanent Suppor9ve Housing Social Service Agencies Crisis Response Services Counseling Services 081414 Community Medic Program Financial Assistance Agencies Supports for Life Instabili:es Home Health Services PHNs/Tribal CHRs Resource Network Pa#ent Needs Assistance with Daily Needs AHCCCS Care Coordina9on RN Care Development Manager Work Session Grand- Aide Program Transporta9on Structured Medical Care Processes Primary Care & Medical Homes Child Care Services Post- Acute Care Food /Meal Assistance Behavioral Health Services Pharmacy services Legal Assistance Spiritual Supports Payer Case Managers Behavioral Health Services Pallia9ve Care & Hospice Telehealth & Remote Monitoring Transi9on Clinics Specialty Care Physical therapy & rehab Func:oning as a care traffic controller, a Care Manager coordinates service connec9ons for each pa9ent s diverse needs - over 9me with an emphasis on what each pa#ent needs to get and stay well
Care Management
Community- Based Collabora9ons
Care Process Models (CPMs)
A Definition Care Process Model (CPM): A guideline for delivering consistent, evidence-based care for a patient with a specific diagnosis Not cookbook medicine! Practice patterns grounded by evidence Physician judgment always trumps the CPM when there is a conflict, because no two patients are exactly the same
CPM Goals To improve quality of care by reducing unnecessary variation Reduce mortality, readmissions and complications Provide the best, evidence-based, appropriate care to our patients
Provider References Osteoarthri9s CPM
Guidelines for the Diagnosis and Management of Heart Failure 7/1/14 Suspect Diagnosis of HF Echo I,C/BNP I,A Heart Failure Confirmed If isolated Cor Pulmonale, refer to Cor Pulmonale CPM Consider Cardiology Consult for all HF patients Mandatory Cardiology Consult: Newly diagnosed HF When prescribing spironolactone Ischemic Evalua9on Considera9on for device therapy Considera9on of changes to an9- arrhythmics or requiring two diure9cs Tip Box Known heart failure with acute exacerba9on New signs or symptoms of heart failure including: dyspnea, fa9gue, exercise intolerance, weight gain, pulmonary edema, orthopnea, peripheral edema, elevated BNP, hyponatremia with volume overload Tip Box In ambulatory pa9ents with dyspnea, measurement of BNP or N- terminal pro- B- type natriure:c pep:de (NT- probnp) is useful to support clinical decision making regarding the diagnosis of HF, especially in the se_ng of clinical uncertainty. (I,A) *ECHO indicated for ini9al evalua9on of pts presen9ng with HF, pts who have had significant change in clinical status, pts who have received treatment that might affect cardiac func9on or for considera9on of device therapy. (I,C) Repeat ECHO in the absence of clinical status change or treatment interven9ons should NOT be performed (III,B) Tip Box Labs: fas9ng lipids (only if new onset HF), CBC,CMET, Troponin, Mg, U/A, TSH (all are class I,A) Table a ICD 10 diagnoses Classification EF (%) Description Table b ACCF/AHA Stages of HF (37) NYHA Functional Classification (38) Labs, EKG, CXR review (class I,A) If suspected ischemic disease: Cardiology consult Consider cardiac cath if angina present (IIa,C) or no known CAD (IIa,C) Non- invasive cardiac imaging if h/o CAD and angina absent unless not eligible for cath/stent or CABG in which case NO imaging (IIa,C) Indicate cause of HF, if known (valvular, ischemic, non- ischemic) Classify Type of HF a Classify HF based on stage and NYHA symptom severity b Obtain prior Dry Weight (I,A) Management Systolic heart failure, specify acute/chronic Diastolic Heart Failure, specify acute/chronic Diastolic heart failure combined with systolic heart failure, specify acute/ chronic No ICD-10 dx, consider systolic heart failure, chronic/improved, +/- acute exacerbation I. Heart failure with reduced ejection fraction (HFrEF) II. Heart failure with preserved ejection fraction (HFpEF) a. HFpEF, borderline b. HFpEF, improved 40 50 41 to 49 >40 Also referred to as systolic HF. Randomized controlled trials have mainly enrolled patients with HFrEF, and it is only in these patients that efficacious therapies have been demonstrated to date Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified. These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patients with HFpEF. It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients. Jus9fica9on of classifica9on: Correct recogni9on of the type of heart failure (preserved EF vs. reduced EF ref) allows appropriate tailoring of guideline- directed medical therapy and, as a result, beeer clinical outcomes with the poten9al for reduced morbidity and mortality and improved HRQOL A B C D At high risk for HF but without structural heart disease or symptoms of HF Structural heart disease but without signs or symptoms of HF Structural heart disease with prior or current symptoms of HF Refractory HF requiring specialized interventions TIP: Dry Weight can be obtained from pa9ent, PCP, Cardiologist, Dialysis unit, or on Health Summary for all IHS pt s. **Use recent lowest value** None I I II III IV No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest. Final Version 6.2014 22
Guidelines for the Diagnosis and Management of Heart Failure 7/1/14 STAGE A At high risk for HF but w/o structural heart disease or symptoms of HF Management STAGE B Structural heart disease w/o signs or symptoms of HF STAGE C Structural heart disease w/prior or current symptoms of HF Symptoma:c Heart Failure STAGE D Refractory HF e.g., Pa9ents with: HTN Atherosclero9c disease DM Obesity Metabolic Syndrome Or Pa9ents Cardiotoxins (meth) with family h/o cardiomyopathy Structural Heart Dz e.g., Pa9ents with: Previous MI LV remodeling including LVH and Low EF Asymptoma9c valvular disease New sxs of HF e.g., Pa9ents with: Known structural heart disease and HF signs and symptoms Treatment for ALL Stage C and D pts: Daily weights (I,C) Con:nue outpa:ent medica:ons unless Dry weight teaching (I,B) new contraindica:on iden:fied(i,b) Exercise training or regular physical Low Sodium Diet (IIa,C) ac9vity HFpEF diastolic HFrEF systolic Refractory symptoms of HF at rest, despite GDMT e.g., Pa:ents with: Marked HF symptoms at rest Recurrent hospitaliza9ons despite GDMT Cardiac rehab referral inpa9ent (IIa,B) Aggressive Care Coordina9on (IIa,B) HF specific educa9onal Components Appropriate treatment for OSA Sta9ns if ischemic HF or other indica9on both THERAPY Drugs ACEi or ARB in appropriate pa9ents for vascular disease/htn or DM Sta9ns as indicated(i,a for h/o MI) Control condi9ons that contribute to development of HF (DM2, HTN, obesity, smoking, cardiotoxin exposure) (I,A- C) THERAPY Drugs ACEi for all reduced EF, ARB if ACEi intolerant (I,A) ACEi or ARB for all pa9ents with MI+ reduced EF (I,A) evidence- based beta blockers for low EF+/- h/o MI (I,A) Avoid verapamil & dil9azem aner MI or low EF (III,C) Sta9n if CAD or hyperlipidemia Selected Pa:ents: CRT g ICD h THERAPY Strategies Iden9fica9on of comorbidi9es Control sbp and dbp(i,b) Coronary interven9on if indicated (IIa,C) Guideline- directed care for Afib (IIa,C) Treatment Diuresis as needed (I,C) Use beta blockers, ACEi or ARBs to control BP ARB may decrease hospitaliza9ons(iib,b) Omega 3 faey acids if NYHA II- III and no ESLD, egfr>30, no chronic lung dz, no PAD (IIa,B) *Aldosterone receptor antagonist (spironolactone) is recommended in pt s with NYHA class II- IV HF with LVEF of 35% or less, unless contraindicated, to reduce morbidity and mortality, provided es:mated GFR>30mL/min and K+<5.0 meq/dl (I,A) Also indicated for post acute MI w/ EF 40% w/dm or symptoms of HF (I,B) Final Version 6.2014 NAH THERAPY Drugs for all pa:ents THERAPY DC all poten9ally harmful medica9ons including all NSAIDS, Goals thiazolidinediones,most an9- arrhythmics (cards c/s required Fluid restric9on 1.5L/ prior to cessa@on),calcium channel blockers (III harm, B/C) day esp if except amlodipine hyponatremic (IIa,C) Diure9cs for fluid reten9on (I,B) f Control symptoms ACEi or ARB if ACEi intolerant(i,a) f Improve HRQOL* Reduce hospital Evidence- based Beta Blockers if stable (carvedilol, metoprolol succinate (I,A) f readmissions Establish pa9ent's end Drugs used for selected pa#ents of life goals (I,B) Aldosterone antagonists* (Spironolactone) Op9ons for select pts Isosorbide dinitrate+hydral(nyha III- IV, AfricanAm w/ Advanced care persistent sxs in spite of ACEi &beta blocker)(i,a) measures Isosorbide dinitrate+hydral for any pt who cannot get ACEi Heart transplant or ARB (IIa,B) Chronic Digoxin (can reduce hospitaliza9ons)(iia,b) inotropes(iib,b) Omega 3 faey acid (same caveats as for HFpEF) Temporary or Add ARB to ACEI if persistent symptoms (non- African permanent MCS(IIa,B) American) if no aldosterone antagonist is indicated. (IIb,A) Experimental surgery **Do NOT use ACE- I +ARB +aldo antagonist (III:Harm, B) or drugs Add IV NTG, nitroprusside or nesiri9de if dyspnea persists Pallia9ve care/hospice (IIb,A) (I,B) Treatment In Selected pa:ents ICD deac9va9on CRT g 23 ICD h Revasculariza9on or valvular surgery as appropriate *HRQOL, health- related quality of life
THRIVE
Shi Hooghan Project
Care Beyond Walls and Wires
Regional Infec9ous Disease Council Collabora9ve council to include representa9ves from many organiza9ons across the region to help iden9fy opportuni9es for improved: Formulary alignment An9bio9c stewardship Diagnosis, treatment, and preven9on
Vision PathfinderHealth is a regional, clinically integrated care delivery system that empowers providers to enhance health while improving quality and lowering costs. Furthermore, the vision encompasses the Triple Aim of improving care, improving outcomes, and reducing costs. Guiding Principles In support of the ACO vision, the ACO guiding principles help provide direction on certain components of PathfinderHealth and include: Enhances patient- and family-centered care. Facilitates clinical and financial alignment to ensure a sustainable care model. Is physician-driven, with an emphasis on primary care and strengthening the provider community. Aligns like-minded providers and facilities with a shared vision. Partners with patients to enhance care through all stages of life. Uses best practices and IT to improve care. Provides timely access to appropriate care. Rewards quality care, creates new relationships. Clinical Integration/ACO Vision
NAH and the physician community determined the need for an ACO in March 2014. PathfinderHealth ACO was developed by a physician- led and physician- driven approach. PathfinderHealth ACO was rolled out August 6, 2014 to providers to become members. Within 3 weeks, over 300 providers had joined PathfinderHealth. Board was seated September 29, 2014. Executive Summary
PAYOR COLLABORATIONS Improved care management For adult members of the American Indian Health Plan with high need, high cost condi9ons Through collabora9on with key partners in behavioral health, primary care, and community- based services
FMC Readmission Reduc9on 35
Patient Risk Stratification High- risk Goal: Tools: Monitor & manage Registries Rising- risk Goal: Iden:fy & intervene Tools: Predic:ve analy:cs Low- risk Goal: Engage & empower Tools: Portals & educa:on
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Thank you mark.carroll@nahealth.com