20 July 2018

Obtaining Results in Population Health Management




THREE FUNDAMENTAL ELEMENTS

True population health management requires at least three fundamental elements to drive transformational change and meaningful results:

  1. Aligned incentives across payers, health systems, post-acute care providers, and physicians.
  2. Technology and framework fit for engaging an entire community that leverages resources for care coordination and addressing social, economic, and behavioral needs
  3. Personal engagement to drive activation, behavioral modification, and create a foundation for shared decision making.

HOW ASTHMA AFFECTS POPULATION HEALTH

While this framework is required for managing all populations, it becomes critical and complex when managing chronic disease. For example, asthma is a common disease, but it’s rarely recognized as one of the most common chronic diseases for children under the age of 18 with 6.2 million affected individuals. Over 8% of children have asthma, most with symptoms occurring before five years of age. Asthma disproportionately affects low-income, minority, and inner-city populations with African-American children being at the highest risk. It is a significant driver of school absenteeism, with an estimated 12-15 million school days lost per year.

Asthma impacts both families and the healthcare system financially as well as socially. Childhood asthma is the cause of nearly five million physician visits and more than 200,000 hospitalizations each year. Medical expenses for a child with asthma are almost double than those for a child without the disease. Given these statistics, there’s a compelling need for early identification and effective intervention to control this disease.

PCCI’S POPULATION HEALTH FRAMEWORK

The Parkland Center for Clinical Innovation (PCCI) has developed sophisticated predictive models to proactively identify children at risk for asthma exacerbations and has combined this powerful engine with a comprehensive population health framework to:

  • Reduce asthma emergency department visits and hospitalizations
  • Increase patient adherence to medication and clinic visits
  • Increase evidence-based leading practices at the provider level

 

Figure 1 Highlights the PCCI Pediatric Asthma Framework

Figure 1. PCCI Pediatric Asthma Framework

PCCI’S PEDIATRIC ASTHMA MODEL AT WORK

Through tailored clinical workflows, monthly provider reports, point-of-care EHR integration, and patient-centric mobile messaging applications, the framework can engage providers, communities, patients, and their families to optimize care, drive engagement, and reduce unnecessary utilization.

Within three years, deployment of the program in the Dallas metro-area by a large health plan resulted in:

  • 32-50% increase in the appropriate use of controller medications
  • 31% reduction in ED visits
  • 42% reduction in asthma-related inpatient admissions

This framework has resulted in more than a 40% drop in the cost of asthma care with the health plan saving over $18 million for both patients and healthcare providers.

ENGAGEMENT IS KEY

The key to PCCI’s pediatric asthma framework is that the clinicians, patients, and health systems are all engaged which generates value for all parties involved. With a foundation in literature-based evidence, the framework aligns with national and international guidelines. It is also both modular and patient-friendly – offering different levels of interventions based on patient risk score, needs, and available resources.
By utilizing our sophisticated predictive model to identify children at risk for asthma proactively, we are able to combine it with a comprehensive population health framework to:

  • Increase patient adherence to medication and clinic visits
  • Educate patients in care and self-management
  • Optimize health plan to care manager outreach and workflow
  • Engage physicians via direct EHR alerts
  • Reduce preventable asthma ED visits and hospitalizations

CURRENT DEPLOYMENT

Twenty-one community clinics in the DFW area receive real-time alerts embedded in their EMR and monthly progress reports. These activities resulted in 32% to 50% improvement in asthma controller medication prescriptions and a 5% improvement in the asthma medication ratio (a HEDIS metric). Some clinics are using the reports to redesign asthma care delivery programs and roll out shared medical appointments as needed, while others use the reports to guide spirometry scheduling.

ENGAGEMENT WITH THE POPULATION HEALTH FRAMEWORK

High and very high-risk patients can engage through succinct, precise, and educational text messages delivered by a simple effective mobile platform. Patients are surveyed about their condition, emergency inhaler usage monitored, and they are reminded of upcoming appointments and medication refills. These innovative features allow continuous symptom monitoring by the clinician to ensure continuity of care and positive outcomes. Patients have displayed satisfaction with the program, with over 70% top box satisfaction and an attrition rate of less than 15% on mobile engagement over a two-year period.

Community engagement is a critical element when trying to ensure not only coordination of care, but referrals and connections to community resources. Providers at either hospitals or the clinics, receive best practice alerts and utilize technology to identify SDOH needs. They can also refer families to community-based organizations (CBO) for assistance with critical daily needs. Currently, we’re in the process of expanding interactions and engagement with local schools, so that school nurses concurrently receive alerts on high risks children and can help coordinate care in those settings.

COMPETING POPULATION HEALTH FRAMEWORKS

While there are multiple and broad initiatives occurring in every market, results have displayed limited to incremental progress. PCCI has demonstrated that transformational change and meaningful results are achievable. Meaningful results require concurrent engagement and coordination of payers, providers, community, and patients via advanced risk-predictive stratification algorithms and deployment of information via new/updated workflows at the point of interaction. Figure 2 highlights the difference and impact our comprehensive program has across a market.

 

Figure 2. PCCI Pediatric Asthma controlled analysis. Comparison 1: DFWHC Medicaid <18 yo: 5% drop in asthma ED visits. Comparison 2: All Health Plan Members <18 yo: 10% drop in asthma ED visits. PCCI Asthma Program: 31% drop in asthma ED visits

Additional Innovations

Despite tremendous success, opportunities still exist to improve results and continue to further engage providers and patients. We are designing and rolling out two additional innovation pilots:

  1. Testing the effectiveness of disease-specific in-home personal assistance devices (Amazon Echo) to engage groups of homogeneous, high-risk, pediatric asthma children in a gamified home environment.
  2. Integrating within a home or community to allow remote monitoring of asthma medication adherence and in-home air quality by using “Internet-of-Things” integration.

The framework is designed with adaptability in mind and is ideal for environments where providers hold risk-based contracts. Future applications will include other patient populations and health conditions. PCCI’s Pediatric Asthma Population Health Framework has not only reduced unnecessary utilization and costs, but it has also improved the healthcare experience for hundreds of pediatric patients and their parents.

Central to the work of PCCI is its strength in predictive analytics/modeling and building connected communities using intelligent, integrated, electronic information exchange platforms. Our state-of-the-art programs and advisory services deliver exceptional value to Parkland Health & Hospital System, the local community, and the broader healthcare market.

Learn more about PCCI’s collaborations, or stay up-to-date with our recent news by following us on Facebook, Twitter and LinkedIn!

12 June 2018

The Increasing Importance of Social Determinants of Health




IMPACT ON HEALTH OUTCOMES

Over the last few years, it has been very clear from research that Social Determinants of Health (SDOH) variables have a major impact on health outcomes. It is estimated that close to 80% of health outcomes are impacted by SDOH. With the rise of population-based risk contracts in both the commercial and government sector, it is essential for both providers and payers to collaborate in the identification of best practices to address these SDOH variables. This is especially relevant as providers such as hospitals assume greater risk in arrangements with plans throughout the country such as Accountable Care Organizations (ACO) and bundled payments.

NATIONAL INTEREST AND PROGRESS

Many national associations such as the American Hospital Association (AHA) and America’s Essential Hospitals have developed resources and launched learning collaboratives for hospitals and health systems to address these variables such as food insecurity, housing, and transportation. Health system innovation and care-redesign models driven by organizations such as Healthbox and AVIA have launched collaboratives and forums to educate and address SDOH initiatives. The May 3, 2018, Healthbox forum discussion on “Challenging the Status Quo of Social Determinants” visually captured the opportunities and challenges ahead into one image (Figure 1):

Social Determinants of Health

Figure 1: Image captured during Healthbox Executive Panel Discussion, May 3, 2018. Chicago, IL

These variables have always been a focus of many health systems in terms of articulating their benefit to the community, but now they have particular importance given the rise of more population risk contracts.

Several major barriers have impeded the industry’s progress in addressing SDOH variables: funding and regulations. Fortunately, we have begun to see opportunities in both areas emerge in 2018!

MEDICARE UPDATES AND THE BENEFITS OF SOCIAL DETERMINANTS OF HEALTH DATA

Medicare Advantage (MA) has a regulation titled “Uniformity Standard” that requires all of the plan’s benefits, including cost-sharing, be the same for all plan enrollees. On April 2, 2018, the Centers for Medicare & Medicaid Services (CMS) outlined several widespread changes in this regulation that both providers and plans have advocated for over the last several years in their 2019 Medicare Advantage Call Letter. CMS expanded the flexibility of lifting the uniformity of supplemental benefit to allow different segments of an MA plan to offer specific benefits to a targeted population like diabetics. This can begin in CY 2019 (January 1, 2019) after the plan designs are approved by CMS. An example could be reduced cost sharing for foot or eye exams. In their official bids that were submitted by the June 4, 2018 deadline, the MA plans can include any of these supplemental benefit elements. Hopefully, providers will see many of the plans deciding to include these additional benefits in their MA bids to address the SDOH variables.

Additionally, in the Bipartisan Budget Act (BBA) that was passed in early 2018, Congress has taken it further by extending the lifting of the uniformity of the supplemental benefits to all chronically ill members of the MA plans effective January 1, 2020. This reinforces the need for us to gain valuable lessons during 2019 in order to determine what works and what doesn’t before it is transitioned to a broader population.

The Chronic Care Act of 2018 extended the Center for Medicare & Medicaid Innovation’s (CMMI) Valued-Based Insurance Design Model to all 50 states in 2020. This model was launched in 2017 to allow Medicare Advantage plans to offer supplemental benefits and reduced cost-sharing to seven conditions including Coronary Artery Disease or Congestive Heart Failure. The model focuses on four approaches:

  1. Reduced Cost Sharing for High-Value Services
  2. Reduced Cost Sharing for High-Value Providers
  3. Reduced Cost Sharing for enrollees participating in disease management
  4. Coverage of additional supplemental benefits such as transport or meal delivery

The creation of more supplemental benefits will enhance the quality of services we provide for our patients especially in terms of addressing the SDOH. Encouraging the inclusion of these targeted supplemental benefits will allow us to partner with payers to improve the health of the country in a more innovative way.

ADDRESSING SDOH WITH HEALTHCARE PROVIDERS AND COMMUNITY RESOURCES

At PCCI, we have been directly involved in national and state-driven education forums, presentations, and roundtables directed to design and deploy local models for the Connected Communities of Care program (previously known as the Information Exchange Portal) that bring together providers, payers, philanthropic organizations, community-based organizations (CBO), and local/state government entities. While most markets continue to be in a learning mode, significant and tangible activities are being initiated in a number of municipalities, including Dallas, Raleigh-Durham, Louisville, Detroit, Chicago, Phoenix, Salt Lake City, as well as across whole regions. For example, North Carolina recently requested proposals for the development of a North Carolina Resource Platform via the Foundation for Health Leadership & Innovation. The goal of this multi-year program is to connect over 3,000 statewide community-based organizations via technology, and facilitate SDOH. This will be completed through a programmatic coordination of referrals between healthcare providers and community resources to comprehensively identify and address the needs of individuals across the state. On a broader level, the Accountable Health Communities Model deployed in 2017 is engaging 31 organizations across the country to address a critical gap between clinical care and community services in the current healthcare delivery system. This is being done by testing the process of systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services to see if it will impact healthcare costs and reduce healthcare utilization.

SUCCESS IN SIX TRACKS

Our experience over the last five years across Dallas tells us that models will need to address six tracks to be successful: Governance, Legal, Technology, Clinical Workflows, CBO Workflows, and Sustainability (Figure 2). The maturity and evolution of the models need to develop and be staged within a multi-year deployment framework (concentric circles in Figure 2 represent the progression and evolution of the model with outer circles representing mature and more sophisticated models).

Social Determinants of Health

Figure 2: Connected Communities of Care program multi-year deployment framework

There is also a critical upfront readiness and deployment/implementation assessment that is important in order to stage the deployment of a Connected Community of Care program. This broad representation of the community’s fabric is critical to ensure that:

  1. A community is ready to undertake the operational and financial requirements associated with deploying a Connected Communities of Care program
  2. The healthcare and social needs of the community are at the forefront of the customized design of the platform (something most for-profit technology vendors offering an out-of-the-box solution either cannot do or fail to do properly)
  3. The design is sufficiently flexible to adjust as the healthcare or social needs of the community change

Addressing SDOH is finally moving from a “buzz” word to implementation pilots. While we talked a lot about population health over the last 10 years, doing population health without a truly engaged and “Connected Community of Care” is like focusing on rescuing people from drowning in a river vs. building a bridge so they can cross it safely. As we continue this journey, let us make sure we build a bridge that adapts to the needs of each community and has emerging local and national models of care to ensure sustainability. We don’t want to end up with a bridge like the Choluteca Bridge in Honduras, connecting nothing to nowhere.

Acknowledgments: Valinda Rutledge, PCCI Executive Advisor and Lindsey Nace, PCCI Marketing and Communications have contributed to this article.

Stay up-to-date with PCCI’s data science work by checking our recent news and follow us on Facebook, Twitter and LinkedIn!

28 March 2018

HEALTHCARE DIVE: Payers use data to flag those at greatest risk of opioid abuse




12 March 2018

Trustee Mag: Information exchange portal closes the gap between health system and social services




Successful Dallas project reduces ED visits by 36 percent

21 December 2017

Becker’s Hospital Review: How Parkland Memorial cut ER costs through a ‘frequent flier’ program: 5 takeaways




2 November 2017

Hospitals and Health Networks: Information Exchange Portal Closes the Gap Between Health System and Social Services




30 October 2017

D Magazine: Dallas Group Honors CEO of Parkland Center for Clinical Innovation




12 October 2017

Advisory Board: How Parkland Health is using an information exchange to address social determinants




Read More

12 April 2017

Parkland Center for Clinical Innovation to serve as local ‘hub’




April 12, 2017

Parkland Center for Clinical Innovation to serve as local ‘hub’

One of 32 participants nationwide to link clinical, community services

DALLAS – The Parkland Center for Clinical Innovation (PCCI) has been named a recipient of the CMS Accountable Health Communities (AHC) grant by the Centers for Medicare & Medicaid Services. The Assistance and Alignment Tracks of the Accountable Health Communities Model will begin on May 1, with a five-year performance period.

PCCI is one of 32 participating sites in 23 states. UT Health Science Center Houston and CHRISTUS Santa Rosa are the only other Texas sites that will conduct and test interventions.

“We are poised to utilize the innovative and transformational capabilities of PCCI in an effort to reduce health disparities in the North Texas region and across the nation,” said Ted Shaw, chair of the PCCI Board of Directors. “PCCI is dedicated to designing solutions that bring together clinical care, public health and community services in a coherent strategy to meet the community’s healthcare needs.”

The grant was designed to specifically address the largest cost drivers that extend beyond the scope of healthcare alone including unmet health-related social needs such as food insecurity and inadequate or unstable housing which may increase the risk of developing chronic conditions, reduce an individuals’ ability to manage these conditions and lead to avoidable healthcare utilization.

“We are very proud that CMS has entrusted PCCI with an Accountable Health Communities Model Grant. This award recognizes the great work PCCI and the Pieces Technologies, Inc. teams have done over the last few years and is a great opportunity for PCCI, Parkland and the Dallas community to expand our mission of creating a world of connected communities where every health outcome is positive,” said Steve Miff, PhD, president and CEO of PCCI.

“We are thankful to our Dallas AHC grant partners, Parkland Health & Hospital System leadership and board, the W.W. Caruth, Jr. and Lyda Hill Foundations for their ongoing partnership, and for the letters of support from Dallas Mayor Mike Rawlings, the Dallas County Health Department, and Dallas County Judge Clay Jenkins,” Dr. Miff added. “We look forward to getting started and partnering with CMS and other leading organizations across the country to improve the health of every community.”

The AHC model was established to test innovative service delivery models and seeks specifically to test whether uniform screening of Medicaid and Medicare beneficiaries at risk for emergency department visits will reduce expenditures and enhance quality of care.

CMS launched the project by announcing the participants for two of the three tracks, the Assistance and Alignment Tracks. PCCI had been awarded the Alignment Track, the most intensive level which includes screening, education, referral, navigation and alignment of community resources to ensure responsiveness to high risk beneficiaries needs.

PCCI will be partnering with five healthcare providers in the Metroplex (Parkland, Methodist, Children’s, Baylor, Dallas Metrocare), 289 community based organizations and Texas Medicaid to design, implement and evalute this model.

To view a list of the assistance and Alignment Tracks bridge organizations in the Accountable Health Communities Model, please visit: https://innovation.cms.gov/initiatives/ahcm.

About PCCI:

PCCI is an independent, not-for-profit healthcare intelligence organization focused on creating connected communities through data science and machine learning. It combines deep clinical expertise with advanced analytics and artificial intelligence to enable the delivery of precision medicine at the point of care. PCCI is a recipient of more than $45 million in grants directed at developing and deploying patient centric cutting edge technologies connecting communities, Parkland Health & Hospital System and beyond.

# # #

Contact:

Lindsey Nace
214-590-3887
lindsey.nace@pccipieces.org

10 September 2014

In Dallas, Partnering with Social Services on Holistic View of the Patient




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