2013 Institute for Quality Leadership Annual Conference ......Analytics to Action Population...
Transcript of 2013 Institute for Quality Leadership Annual Conference ......Analytics to Action Population...
Analytics to Action
2013 Institute for Quality Leadership
Annual Conference
September 2013
Analytics to Action
How to Stay Ahead of the Cost Curve
Analytics to Action
Wendy Oberdick, MD
Family Medicine Board Certified
Joined HMG November 2010
Medical Director
HMG Patient-Centered Medical Home
HMG Value Based Operations
Co-Medical Director
ACO - Qualuable Medical Professionals
Analytics to Action
Jason Tipton, MBA
Joined HMG July 2012
Director of Informatics
HMG Decision Support
HMG Analytics
Chair of Data Aggregation & Analytics
ACO - Qualuable Medical Professionals
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The correct answer is:
Open the refrigerator, put in the
giraffe and close the door.
This question tests whether you tend to do
things simple or in an overly complicated way.
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8
The wrong answer is:
Open the refrigerator, put in the
elephant and close the door.
This question tests your ability to think
through the repercussions of your actions.
The correct answer is:
Open the refrigerator, take out the
giraffe, put in the elephant and close
the door.
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10
This question tests your memory.
The correct answer is:
The elephant. The Elephant
is in the refrigerator.
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O.K., even if you didn’t
answer the first three
questions correctly you
still have one more
chance to show your
abilities.
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13
Correct answer:
You swim across. All the
crocodiles are attending the
Animal Meeting.
This question tests whether you
learn quickly from your mistakes.
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Analysis:
Approximately 90% of adults
tested get all the questions wrong.
But when Kindergarten students
were tested, they answered several
questions correctly.
What did we learn?
Analytics to Action
How to Stay Ahead of the
Cost Curve
Analytics to Action
Holston Medical Group - Overview
Established in 1977
Multispecialty, physician-owned group
8 principle sites
150 primary care physicians, specialists and mid-
level providers
200K patient population
Analytics to Action
Analytics to Action
Core Belief: In the changing world of Healthcare, organizations that can stay
ahead of the curve will succeed. The problems arise in identifying the curve,
understanding what that means, identifying the changes that must take
place, deploying the resources to make the change and measuring if the
change is successful.
One of the first questions we at HMG had to ask ourselves is “Can we get there from here?”
The obvious answer was “NO”.
“Insanity: doing the same thing over and over again and expecting different results. &
Without changing our patterns of thought, we will not be able to solve the problems that we created with our current patterns of thought.” Albert Einstein
Analytics to Action Paradigm Shift
Definition of an Organizational Paradigm Shift:
Fundamental change in an organization’s view of how things work .
Analytics to Action Audience Interactive Activity #1
Questions to answer
Who (or what) is driving your organization?
Do you “do” data?
What data is more important: Clinical or Financial?
Are you more data reactive or data proactive?
This determines where you are in the curve.
Who (or what) determines the majority of your encounters?
Do you control the direction of your organization?
Analytics to Action Paradigm Shift
Goal – Answer the following 4 questions
Do you know your population?
Have you developed your assets?
Does your workflow support performance?
Can you measure your compliance?
Analytics to Action
How to Stay Ahead of the Cost
Curve
Do you know your
population?
Have you developed
your assets?
Does your workflow support
performance?
Can you measure
your compliance?
Analytics to Action
Do you know your
population?
Step 1
At HMG we looked at 3 determining factors for our population: Population Demographics vs. Population Characteristics Population Risk Levels (i.e. population stratification by chronic conditions) Population by Contract
Commercial Medicare Advantage Medicare/Medicaid
Analytics to Action
Do you really know
your population?
Analytics to Action Population Demographics:
Approx 500,000 people in the region (3% growth rate)
Median Age of 44 20% over 65 20% under 18
94% of the population is Caucasian Gender: 55% Female, 45% Male Median Income $25,194 17% below the poverty line
24.9% under 18 13% over 65
Employment: Private – 82% Government – 10% Self-employed – 8%
Population Characteristics:
70% Urban, 30% Rural Majority do not leave area where
they were born. 98.4% drive to work
Independent Small town USA attitude 25% have a college education 18% have less than GED Employment: 50/50 split between
white & blue collar. Life Expectancy – 75.4 years Factors of Death:
19% Tobacco Use 14% Diet/Activity 5% Alcohol
VS
Population Risk Stratification by Chronic Condition
STEPS • Identify a list of specific
conditions to apply to patient population
• Identify a specific timeframe to query population
• Get a distinct count of how many conditions each patient has diagnosed in history
• Apply logic based on how many conditions are diagnosed as to risk level associated with each patient
Chronic Condition
% of Prevalence in
Total Population
HTN 34.6%
Diabetes 18.2%
Depression 17.6%
Asthma 14.0%
CAD 5.5%
COPD 4.6%
Osteoporosis 3.8%
AFIB 2.0%
Gout 1.7%
Kidney Dysfunction 1.7%
Pneumonia 1.7%
CHF 1.6%
Osteoarthritis 1.2%
Stroke 0.9%
ASCVD 0.8%
MI 0.1%
Schizophrenia 0.1%
Population Risk Stratification by Chronic Condition
• This process allowed for immediate action on Level 3 patients • Since the Level 3 patients are a small segment of the population, a manual
chart review on each patient was performed to identify care gaps and needs. • Level 2 patients are actioned by those with the highest chronic count
including Hypertension and Diabetes.
Population by Contract
Analytics to Action Lessons learned from Population Analysis:
Patient outreach needs to be local where trust can cultivated between doctor and patient.
Outreach needs to be simple and consistent.
High risk patients, regardless of insurance, need to be addressed repeatedly with higher level of care.
Chronic Conditions of Hypertension, Diabetes and COPD need a more dedicated focus and plan of action.
Patient’s behavior needs to change to more proactive approach where a hospital admit is not the 1st step in their medical care.
Analytics to Action
One of the next questions we at Holston had to ask
ourselves is “Where do we focus first?”
The obvious answer was “Where we can make a difference.”
“When eating an elephant, take one bite at a time. 4 star Army General Creighton Abrams
Analytics to Action
Who (or what) determines the majority of your encounters? BEFORE – uncontrolled patient flow with complete
seasonal variance AFTER – structured patient flow driven by care
models and decreasing seasonal variance
Are you data reactive or data proactive?
BEFORE – data reactive and dependent on payor format
AFTER – data proactive and building independent care models to decrease cost and improve quality
Who (or what) is driving your organization?
BEFORE – no one = retail business model AFTER – internal Data Mining to identify target
patient groupings
Analytics to Action
Have you
developed your assets?
Step 2
What resources are needed to affect the level of change desired?
Analytics to Action
Audience Interactive Activity #2
Questions to answer
Who (or what) are the top 3 focus points of your organization?
What do you measure?
What do you repeat?
How do you determine your organization’s needs and match resources ?
Analytics to Action Scope Iceberg Typical Action Typical Roles
Events – what we see happening
Tip React & Respond Firefighter, Impatient leaders
Trends – what has been happening
Just under the surface
Anticipate, Plan and Prepare
Architect, Contemporary Leader
Structure – why is it happening, how and what is the thinking that created it
At the Core Design, Create, Reengineer,
Innovate
Planner, Innovator, Designer, Servant Leader
Analytics to Action
Resource Preparation
Visualize the End Product
Asset Evaluation
Determine Change “agents”
“Low Hanging Fruit” first
Driver Diagram
Coordina onofCare
IncreasePa entCompliance
DecreaseHighCostSpend
ImprovePopula onWellness
AIM PrimaryDrivers SecondaryDrivers Interven ons
ClinicalWorkflows
StrategicOutreach
Predic veAnaly cs
TeamAc va on
ConvenientAccess
InformedDecisions
AccurateCarePlans
SOPs
Ac onLists
Pa entStra fica on
Educa on
ExtendedServiceLines
Team-basedCare
PerformanceImprovement
Transi onofCare
Diagram1–DriverDiagram
HMG Needs:
Improved technology to identify needs and
improve patient care.
Improved technology to measure success
and reduce cost.
Services to address high risk population
needs.
Analytics to Action
Analytics to Action
Diagram'8'–'Subcontrac1ng'Management'and'Procurement'System'Model'
HMG IT Landscape EMR: Allscripts Enterprise
Practice Management: GE Centricity (changing to Allscripts PM in 2014 1st Qtr.)
Data Mining & Analytics Tools: Humedica MinedShare
Precision BI by Origin Healthcare
OnePartner ATAC datacenter
www.onepartnerhie.com
Tier 3 Data Center
Health Information Exchange
Population Health Tool Sets
dbMotion
EHR Agent
Collaborate Engine
Performance Clinical Systems
Quire
Diagram11–HITImplementa onPlanModelDiagram
Professional Health Information & Analytics Exchange
One Partner Architecture Professional Health Information & Analytics Exchange
Quire – Population
Management
• Population Management Intelligence Tool
• Applies artificial analytics intelligence and queries to extract actionable health information from unstructured text in medical records.
• Population Management Activities:
• Identification of pre-diabetics
• Risk stratification of patients with multiple indications
• Highlighting patients who would benefit from a new standard of care
HMG has developed 2 program services that are designed to
improve patient centered quality for High Risk patients at a
reduced cost - Alternative Outreach Services (AOS) and
the Extensivist Clinic (e-clinic).
These services offer non-traditional opportunities for patients
to be taken care of in an outpatient setting and have patient
care and convenience at the core of their design.
Analytics to Action
Alternative Outreach Services
(AOS) –
Utilizes Nurse Practioners and
Providers
Reaches out to provide full
service healthcare for highest risk
patients
Proactively treats high risk
patients in facilities, at home and
includes end-of-life transitions
Analytics to Action
Extensivist Clinic –
Transitional high acuity care clinic
Care team includes:
ICCAs
C3s
Infusion services support
“Extends the walls” to stage appropriate care plan strategy
Analytics to Action
Analytics to Action
Does your workflow support
performance?
Step 3
Are your processes built to succeed?
Analytics to Action
Audience Interactive Activity #3
Questions to answer
How do you engage providers and support teams to determine and develop workflow?
Do you use “just in time” tools?
Do you develop performance support mechanisms?
How do you measure the change going forward that you determine is necessary and then effect?
• Primary Care Physician
• Specialists
• Hospitalists
• Transitional Care Team
• Extensivist Clinic
• Adopting “best practice”
• Performance Potential
Analytics to Action
Building a functional team:
Load%%%%%Drive%
&/or
PCS
Patient
Eval
Compliance
Hospital
Facility
Home Care
Acute Observation
Infusion Center/Post
discharge clinic
HMG Extensivist
Office Clinics & Urgent Care
The Master Plan (Table of Pathways)
• Pathway 1 (Pre-Emptive Care): Patient of Primary Care office, Urgent Care facility, or other non-hospital facilities – Provider assesses need for
Extensivist program for patient.
• Pathway 2 (Ex-Post Facto Care): Patient discharged from Hospital with plan of care orders for Extensivist program
Menu for Services
• Infusion Clinic
• Laboratory
• Pharmacy Services
• Radiology
• Respiratory Services
• Physical Therapy/Wound Care
• Same Day Consultative Services
• AOS (Alternative Outreach Services)
Patient Workflow
Coordina onofCareServices
Load%%%%%Drive%
&/or
PCS
Patient
Eval
Compliance
Load%%%%%Drive
Patient
Eval
Compliance
Diagram12–CapacityforMonitoringandMeasurementofOutpa entClinicalServicesModelDiagram
PROCESS RESOURCEACTION
PEOPLE
LOCATION
SYSTEM
TIMELINE
Alternative7Outreach7Services7(AOS)7Initiative7I>Chart
PROCESS PROCESS PROCESS PROCESS PROCESS
Identify7Patient7List
Decision7Support
Admin
PBI
Quarterly
Load%%%%%EHR%
&/or
PCS
Schedule7Patient7Visit
C37Facility7
Facility7"Home"
PM
1>27weeks
Patient
Eval
Patient7Facility7"Home"Visit
C3Nursing7SupportProviderBack
Facility7"Home"
M>Modal
EHR
1207min
Follow7
UP
+7
CPOE
Patient7Action7Items
C3Nursing7SupportProviderBackCodersAncillaryDiagnosticRehab
Facility7"Home"
Symphony
EHR
PM
1>27days1>27weeks
Compliance
Cohort7Capture7Reporting
Decision7SupportOps
Admin
PM
PBI
Humedica
Quire
Symphony
4>67weeks
Humedica
PM
Facility
Humedica
Symphony
AOS Workflow
AOS will encompass Nursing Home, Assisted Living, and Home Visits.
Each of these three types of visits will require an individual mapped process.
All orders written or verbal will be faxed to a C3 fax line.
Hospital Coordinators
- Receives copy of face sheet from NH and Assisted Living facilities
- Update insurance information/demographics in Centricity - Build the patient account in Symphony/Centricity
- Place the patient under the appropriate tab (AOS/Prep)
- Bill all charges for all facilities.
- Bill all flu vaccines administered.
- Bill CMN for all providers. - Any call changes or scheduling assistance with be coordinated with Beverly
Shull.
C3
- Receives a patient list for each facility daily from NH and Assisted Living. - Assigns each provider their patient list daily.
- Receives all home health certificates and coordinates provider approval
- Receives death certificates from Vickie Belcher and will get provider
signatures and return to Hospital Coordinator.
- Receives phones calls/faxes with various reports throughout the day and insures that providers are notified and that documents are scanned into the
patients EMR.
- Home visits are to be coordinated through Brittany in which she will place
under Home visit tab and schedule with patient
Symphony
- Nursing Homes/Assisted Livings will send a face sheet of patients needing to be seen by AOS Team to Cheryl George/Brittany Eichmann
- Cheryl will build the account in Symphony and Centricity.
- Verification of Insurance
- Cheryl will place patient under appropriate facility
Nursing Homes
Holston Manor
Brookhaven
Nova
Assisted Living
Crown Cypress
Elmcroft
Emeritus
Preston Place I Preston Place II
Village at Allandale
Home Visits
Triaged and scheduled by C3 Once scheduled, the patient will be placed under that appropriate tab with
provider assignment in the patient detail screen.
Once patient has been seen/treated at home, the provider will complete their
checklist and will assign to the C3 for 48 hour phone call and continued
education.
At the completion of visit, the 30 day, 60 day, 90 days alerts will be set.
AWV’s will be tract in Symphony
Symphony Clinical Scenario
Nursing Home Visit Types New/Established Initial Nursing Facility Visit
New/Established Subsequent Nursing Facility Visit (will have a drop down for 30/60/90
day follow-up)
Nursing Facility Discharge (at end of checklist, red light that will have option to select greater or less than 30 minutes.)
Annual Nursing Facility Assessment (AWV)
Assisted Living Visit Types New Assisted Living Visit
Established Assisted Living Visit
Home Visit
New Home Visit Established Home Visit
!!!!!!!Import!
List!
for
Action!!
Medication
?s
Pharm&D
Compliance!
&
31+!d
claim
2013 Initiative
Transitional Management Services Medicare Patient in Transition – facility to home
•Established patient requiring moderate or high complexity decision making •Service period – 29 days from day of discharge
• Billing not submitted til day 30 • Can not be readmitted during timeframe
•Both F2F and non F2F services required • F2F – first visit - is not billed separately • Communication within 2 days of discharge
• Telephonic, electronic or direct contact • Communication F2F
• within 7-14 calendar days of discharge • If more than 1 required, bill separately
• Non F2F services • Aspects of care • Communication with Home Health • Education on Self Management • Med Adherence & management
•Med Rec required and must occur no later than F2F visit
2013 Initiative
Transitional Management Services (cont.) Medicare Patient in Transition – facility to home
•Documentation requirements • Date/ timing of post discharge communication (within 2 days) • Date of F2F • Complexity of Decision Making
•Only 1 provider can bill • Claims paid on the first received by the payer
•Codes • 99495
• 2 day communication with patient/ caregiver • Moderate complexity decision making + • F2F within 14 calendar days • Estimated Medicare allowable based on 2012 RFS = $142.96
• 99496 • 2 day communication with patient/ caregiver • High complexity decision making • F2F within 7 calendar days • Estimated Medicare allowable based on 2012 RFS = $231.11
Analytics to Action
Can you
measure your compliance?
Without measuring performance, how do you know if you are succeeding?
Step 4
Analytics to Action
Audience Interactive Activity #4
Questions to answer
How do you reward providers, support teams and patients?
Do you use a “carrot” ?
Do you use a “stick” ?
How do you measure success and facilitate sustained compliance that drives effectiveness?
HMG Population Quality Measures
Hospital Admits – all populations
Transition of Care – all populations
Extensivist – Prevented Hospital Admits
Primary Care visits – all populations
HCC coding – all populations
Wellness programs – Medicare & Medicare Advantage populations
Total Medical Cost – Commercial, Medicare Advantage and MSSP
populations.
Medical Expense Ratio – High Risk Patients & Medicare Advantage
populations
Medicare
Medicare Advantage
Commercial
20
40
60
80
100
120
140
Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13
Co
de
s B
ille
d p
er
Mo
nth
Transition of Care Codes billed by HMG in 2013 August Forecast
2013 2nd Qtr* 190 $1,938,000 $1,938,000
2013 3rd Qtr 194 $1,978,800 $3,916,800
2013 4th Qtr 198 $2,019,600 $5,936,400
2014 1st Qtr 202 $2,060,400 $7,996,800
2014 2nd Qtr 206 $2,101,200 $10,098,000
2014 3rd Qtr 210 $2,143,224 $12,241,224
2014 4th Qtr 214 $2,186,088 $14,427,312
2015 1st Qtr 219 $2,229,810 $16,657,123
2015 2nd Qtr 223 $2,274,406 $18,931,529
2015 3rd Qtr 227 $2,319,895 $21,251,424
2015 4th Qtr 232 $2,366,292 $23,617,716
2016 1st Qtr 237 $2,413,618 $26,031,335
2016 2nd Qtr 241 $2,461,891 $28,493,225
2016 3rd Qtr 246 $2,511,129 $31,004,354
2016 4th Qtr 251 $2,561,351 $33,565,705
2017 1st Qtr 256 $2,612,578 $36,178,283
*Actual performance
Extensivist
Program -
Forecast
Savings
Analysis thru
2017
Forecast
Prevented
Admits with
no program
expansion
Forecasted
Cost Savings
Generated
from
Prevented
Admits
Forecasted
Cumlative Cost
Savings
Generated from
Prevented
Admits
Extensivist
Population by
Insurance
% of
Population
Med Advantage 49%
Commercial 24%
Medicare 15%
Dual eligible 11%
Medicaid 1%
Extensivist Program Performance
Primary Care Visits
Population Risk Levels
Annual Wellness Process & Performance
Commercial 2013 Contract Performance
• 8.1% better than market in Total Medical Cost ($23/PMPM) • 3.2% better than market in Quality Performance
Market
Medicare Advantage 2013 Contract Performance
Performance Indications
High Risk Patients are increasingly being
seen in a Primary Care setting.
Appropriate coding is being documented.
Quality measures are improving.
Total Medical Cost is being driven down.
Hospital Admits continue to decline.
Analytics to Action
Conclusion - 4 Principle Transition Points
Analytics
Using Technology to enhance care and impact change
To Action
Clinical Integration & improving quality of care
How to Stay Ahead
Leading through change
Of the Cost Curve
Improving Operational Efficiency
How to Stay Ahead of the Cost
Curve
Do you know your
population?
Have you developed
your assets?
Does your workflow support
performance?
Can you measure
your compliance
?
Analytics USING TECHNOLOGY TO ENHANCE CARE
AND IMPACT CHANGE
Using data metrics to:
identify gaps in care, benchmark for organizational improvement
and build a foundation for population health analytics, allows
the development of predictive models that both identify cost drivers and facilitate wellness solutions via outreach, patient
engagement and workflow.
What we do today will not get us to tomorrow – we need an analytical & clinical transformation.
How to Stay Ahead of the Cost
Curve
Do you know your
population?
Have you developed
your assets?
Does your workflow support
performance?
Can you measure
your compliance
?
To Action CLINICAL
INTEGRATION & IMPROVING QUALITY
OF CARE
Predictive modeling involving disease burden, specifically chronic conditions that lend to hospitalizations, coupled
with development and implementation of standardized care
processes within a medical home model leads to total medical spend
reduction and improved quality metrics across multiple populations
and enables valued-based risk contractual arrangements.
Where we focus determines what we measure and repeat – we need to stratify patient need and
resource allocation.
How to Stay Ahead of the Cost
Curve
Do you know your
population?
Have you developed
your assets?
Does your workflow support
performance?
Can you measure
your compliance
?
How to Stay Ahead LEADING THROUGH
CHANGE
Identifying physician leadership and facilitating engagement is
what initially re-engineers the care team across the continuum.
How we engage providers and support teams determines how we develop workflow – we need to effect change with performance support to get ahead.
How to Stay Ahead of the Cost
Curve
Do you know your
population?
Have you developed
your assets?
Does your workflow support
performance?
Can you measure
your compliance
?
Of the Cost Curve - IMPROVING
OPERATIONAL EFFICIENCY
Transitioning from volume to value and aligning provider
compensation and support team financial incentives is the
foundation of moving from a productivity-based to a value-based model and successfully
fulfilling the obligations of risk-bearing contracts.
How we reward providers, support teams and patients determines the level of success we experience– we need to facilitate compliance to drive the effectiveness of the “triple aim”.
Why we do what we do….regardless of the waves or distance…
Analytics to Action
“I have been impressed with the urgency of doing. Knowing is not enough; we must apply. Being willing is not enough; we must do.” Leonardo da Vinci
“Do or do not. There is no try” - Yoda
Now is the time to act, it is not too late.