San Francisco Jail Population Management Plan: Solutions ...
Building an Integrated Population Health Culture in San ... · Building an Integrated Population...
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Building an Integrated Population Health Culture in San Diego County
"The views expressed are solely those of the author(s) and do not reflect the official policy or position of the US Navy, the Department of Defense, or the US Government."
Sunny Ramchandani MD MPH
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2
The “Same Way” Syndrome
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A Few San Diego Facts
3- 2012 San Diego County Comprehensive Annual Financial Report
Employer # of Employees
1. US Navy / Federal Government 45,500
2. State of California 42,900
3. University of California, San Diego 27,391
4. County of San Diego 15,687
5. Sharp HealthCare 15,231
6. San Diego Unified School District 14,603
7. Scripps Health 14,097
8. Qualcomm 11,400
9. City of San Diego 10,057
10. Kaiser Permanente 7,731
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Military/Veterans Chronic Disease Prevalence
Conditions %Hypertension (HTN) 48.9
Diabetes 23.6Depression 22.6
Lower Back Pain (LBP) 22.2Asthma 5.9COPD 3.7
Serious, persistent mental illness 3.4Ischemic heart disease (IHD) 2.6
Post Traumatic Stress Disorder (PTSD) 2.0Stroke 1.0
4* MHS Conference, 2011
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Population Health Determinants
Individual traits
Biology of Disease
Institute of Medicine: Committee on Public Health Strategies to Improve Health – Jan 2011
Community, Social, & Health
Services
Health Care Services
Macro-System Breakdown
Bridge
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Healthcare Services vs. Social Services
0
10
20
30Social Service Expenditures as %
of GDP, 2005*Healthcare Service Expenditures as % of
GDP, 2005*
0
2
4
6
8
Infant Mortality (deaths per 1,000 live births)
74
76
78
80
82
84
USA Sweden France Canada Japan UK
Average life expectancy, 2007
*Bradley EH, et al. Health and Social Services Expenditures: Associations with Health Outcomes. BMJ Qual Saf (2011). *McGinnis JM, Russo PG, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21(2):78–93
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Other Community Based Approaches
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Sabermetrics, Anyone?
• Sabermetrics: The empirical analysis of baseball, especially baseball statistics that measure in‐game activity. – Derived from the acronym SABR:
• Society for American Baseball Research. 8
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Population Snapshot
3° Prevention Population(17X Avg. $) 1.5K
2° Prevention Population(2X Avg. $)
21K CVD, COPD
32K Diabetes, HTN, Dyslipidemia
95K HTN Risk, Pre-Diabetes, Elevated Cholesterol
1° Prevention Population(1X Avg. $)
Obese or OverweightTobacco Use
Advanced Disease
Disease
Sub-Clinical Disease
Behavioral Risk Factors
Environmental Risk Factors
Lack of EducationPoor Air Quality
Low Physical ActivityStress/Anxiety
Food DesertUnsafe/Inaccessible Environment
250K
400K San Diego County TRICARE Beneficiaries
23% Ages 0-17
63% Ages 18-64
14% Ages 65+
37% Direct Care / MTF Enrolled
Total Costs: $1.125 B
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Strategy and Approach
Source: [A Population Approach] CDC, Prev Chronic Dis 2012;9:11 http://www.cdc.gov/pcd/issues/2012/11_0116.htm
TertiaryPrevention
Secondary Prevention
PrimaryPreventionBehavior
FocusPersonFocus
ConditionFocus
High-Intensity Medium-Intensity Low-Intensity
Initiation: Nov 2012
Coordinated CareAmbulatory ICU
Medical Home IntegrationAdvanced Analytics
EmpowermentClinical Pharmacists
Health CoachingHealth / Wellness Programs
Wellness Technologies
EngagementHealth / Wellness Programs
Wellness TechnologiesCommunity Partnerships
Outreach & Education
Initiation: Feb 2013 Initiation: Jan 2015
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Medical Home
Community / Social Services Health / Wellness
Services
Metrics• HEDIS• PCM Continuity• Missed Visits
• ER Use• Inpatient Admissions
Healthcare Delivery Model
Personal HealthRecord
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IntensiveServices
Metrics• Physical Activity & Nutrition• BMI
• Controlled Chronic Diseases• Patient Activation Score
• Smoking Cessation
New Model
Community / Social Services Health / Wellness
Services
Medical Home
Personal HealthRecord
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Wellness,Community,
and Social ServicesPrimary Care Team
PCM / RN / LVN / MA
Intensive Services- Case Manager - Care Facilitator
Health Services- Behavioral Health- Pharmacist- Health Coach- Social Worker
Virtual Health Services / Technology
Admin
Patient-Centered Medical Home
Healthcare / Community Model
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Valuation Periods: NHCP 1: Dec 2012 – Nov 2013, 10 patientsNMCSD 1: Nov 2012 – Oct 2013, 50 patients NHCP 2: Feb 2013 – Jan 2014, 16 patientsNMCSD 2: Jun 2013 – May 2014, 135 patients NHCP 2.5: Jul 2013 – Jun 2014, 51 patientsNMCSD 3: Nov 2013 – Oct 2014, 74 patients NHCP 4: Nov 2013 – Oct 2014, 61 patientsNMCSD 4: May 2014 – Dec 2014 (4 mo. Projected), 86 patients NHCP 5: May 2014 – Dec 2014 (4 mo. Projected), 16 patients*Projections are through December 2014 because of the M2 data delay
4,413
3,243
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
5,000
Annual Avg. for 2Years Prior
1 Year PostIntervention
Total ER Visits(Direct and Purchased Care)
Actuals Projected
910 Fewer Visits
929
621
0
100
200
300
400
500
600
700
800
900
1,000
Annual Avg. for 2Years Prior
1 Year PostIntervention
Total Inpatient Admissions(Direct and Purchased Care)
Actuals Projected
257 FewerAdmits
3° Intervention Impact n = 499 (as of Apr 2015)
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Valuation Periods: NHCP 1: Dec 2012 – Nov 2013, 10 patientsNMCSD 1: Nov 2012 – Oct 2013, 50 patients NHCP 2: Feb 2013 – Jan 2014, 16 patientsNMCSD 2: Jun 2013 – May 2014, 135 patients NHCP 2.5: Jul 2013 – Jun 2014, 51 patientsNMCSD 3: Nov 2013 – Oct 2014, 74 patients NHCP 4: Nov 2013 – Oct 2014, 61 patientsNMCSD 4: May 2014 – Dec 2014 (4 mo. Projected), 86 patients NHCP 5: May 2014 – Dec 2014 (4 mo. Projected), 16 patients*Projections are through December 2014 because of the M2 data delay
8,676,5137,004,901
$0
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
$7,000,000
$8,000,000
$9,000,000
$10,000,000
Annual Avg. for 2Years Prior
1 Year PostIntervention
Purchased Care Costs
Actuals Projected
$1.2MSavings
26,322,179
15,758,246
$0
$5,000,000
$10,000,000
$15,000,000
$20,000,000
$25,000,000
$30,000,000
Annual Avg. for 2Years Prior
1 Year PostIntervention
Total Cost(Direct and Purchased Care)
Actuals Projected
$9.4MSavings
3° Intervention Impact n = 499 (as of Apr 2015)
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3° Intervention Impact n = 499 (as of Apr 2015)
Valuation Periods: NHCP 1: Dec 2012 – Nov 2013, 10 patientsNMCSD 1: Nov 2012 – Oct 2013, 50 patients NHCP 2: Feb 2013 – Jan 2014, 16 patientsNMCSD 2: Jun 2013 – May 2014, 135 patients NHCP 2.5: Jul 2013 – Jun 2014, 51 patientsNMCSD 3: Nov 2013 – Oct 2014, 74 patients NHCP 4: Nov 2013 – Oct 2014, 61 patientsNMCSD 4: May 2014 – Dec 2014 (4 mo. Projected), 86 patients NHCP 5: May 2014 – Dec 2014 (4 mo. Projected), 16 patients*Projections are through December 2014 because of the M2 data delay
6,213
4,819
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
Annual Avg. for 2Years Prior
1 Year PostIntervention
Total PCM Visits(Direct and Purchased Care)
Actuals Projected
1,066 FewerVisits
12,949
9,686
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Annual Avg. for 2Years Prior
1 Year PostIntervention
Total Specialty Care Visits(Direct and Purchased Care)
Actuals Projected
2,447 FewerVisits
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Demographics & Biometrics for All Cohorts
Age Count Percent0 ‐ 17 53 11%18 ‐ 34 77 15%35 ‐ 64 188 38%65+ 181 36%
Total 499 100%
Gender Count PercentFemale 277 56%Male 222 44%
Total 499 100%
Patient Type Count PercentActive Duty 30 6%Dependent 296 59%
Other 1 0.2%Retired 172 34%
Total 499 100%
Condition Type # In All Cohorts Percent of Total (n= 499)
Asthma 31 6%Chronic Pain 123 25%Diabetes 152 30%
Heart Disease 203 41%Hypertension 223 45%Mental Health 224 45%
Obesity 45 9%
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Outcome MetricsPrimary Secondary Tertiary
Util
izat
ion
Clin
ical
M
easu
res
Beh
avio
r
- ER & Specialist Visits - Inpatient Admissions- Readmissions - Length of Stay
- Referral Rate to H&W / Clinical Pharmacist Staff- Caseload of H&W / Clinical Pharmacist
- Network Care Utilization % (vs. Capture Rate) - Technology Utilization - Cost: DC, PC, & Total (Aggregate and PMPM/PMPY)
- Initial Disease Diagnosis(CVD, COPD, CHF,Hypertension, Diabetes)
- BMI- Tobacco Use
- HEDIS Metrics (HbA1C, LDL, etc.)
- Provider Continuity / PCMH Continuity
- Poly-Pharmacy Patients- Primary Care Visits / Yr. - Missed Visits Proportion - PRT Scores
- Health Assessments
- % Attainment of H&W Goals
- PAM 13 Score
- HbA1C - Incidence of Acute Incidents- Systolic BP (i.e., Myocardial Infarction,- LDL Stroke, etc.)
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• https://public.tableausoftware.com/views/EnrollmentServicesandRisk/TotalPopulation?:embed=y&:display_count=no
Population Health Mapping
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Cultural Health Determinants: Live Well!
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Live Well, San Diego!
• 3 – 4 – 50!– The key to impact upstream determinants
• Drive from Healthcare to Wellness!
• Era of Economic Austerity– The tie of Health to our financial solvency
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Questions/Discussion
22
"The views expressed are solely those of the author(s) and do not reflect the official policy or position of the US Navy, the Department of Defense, or the US Government."
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BACKUP
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Month Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015
Primary / Secondary Prevention
Finalize IT and Legal Requirements
Identify Target Populations
Train-the-Trainer
ESC Pilot
Administrator / Champions Pilot
Relay Health Integration
Beneficiary Pilot
Integration of Technology into H&W
Integration of Technology into MHP
Advanced Analytics & Reporting
Technology Pilot Milestones
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Population Health Determinants
Individual traits
Biology of Disease
Institute of Medicine: Committee on Public Health Strategies to Improve Health – Jan 2011
Community, Social, & Health
Services
Health Care Services
Macro-System Breakdown
Bridge
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Proactive IHC List Scorecard
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Integrated Health Community:ProgramAlignment
IHC Prevention Strategy
National and Local Program Alignment
Primary Prevention
• BUMED Medical Home Port• MHS Quadruple Aim• Navy and Marine Corps Public Health Center• NMCSD/NHCP Health and Wellness• Live Well, San Diego!• National Prevention Strategy
• 21st Century Sailor & Marine• Total Force Fitness• Operation Live Well, Healthy Base Initiative• Health Wellness Assessment• SDHHSA 3-4-50 campaign• California ‘Health in All Policies’• HHS Million Hearts Initiative• CDC Sodium Reduction in Communities• Let’s Move!
Secondary Prevention
• BUMED Medical Home Port• MHS Quadruple Aim• Navy and Marine Corps Public Health Center• NMCSD/NHCP Health and Wellness• Right Care Initiative• National Prevention Strategy
• Operation Live Well, Healthy Base Initiative• Health Wellness Assessment• IBHC Practice Manual• HHS Million Hearts Initiative• CDC National Heart Disease and Stroke
Prevention
Tertiary Prevention
• BUMED Medical Home Port• MHS Quadruple Aim• HHS Million Hearts Initiative
• Health Wellness Assessment• IBHC Practice Manual
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3° Population Identification
“Actionability” Flags: – Recent ER Use ( > 2 visits in last 6 months)– Recent Inpatient Admission ( > 1 admission in last 6 months)– Recent Cost Spike ( > $3000 / month in last 6 months)– Multiple Specialists ( > 2 types of specialist visits in the last 6 months)– Missed Visits ( > 1 missed visit in the last 6 months)
Active and Enrolled
Patients to NMCSD or NHCP
1“Actionability”
Flag
Johns Hopkins ACG or United Impact ProProjection
Tool:
High Utilization/
Cost
At least 1 Chronic
Condition: HypertensionHeart Disease
DiabetesAsthmaObesity
Chronic PainMental Health
Rank Remaining Patients on Average Cost over the Past
2 Years
(# of Patients Is Decided by Capacity of
Case Management)
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MANAGE• Evidence-Based Management:
- Clinical Services- Ancillary Services- Community / Social Services
NAVIGATE• Patient obtains appropriate,
health and health care services when needed
• Patient utilizes optimized, efficient health and health care services
COORDINATE• Organize and synchronize
various health and health care services
• Ensure appropriate communication among service decision makers
MANiC Intervention StrategyACTIVATE
• Patient has the knowledge and confidence to take action
• Patient takes action to maintain and improve health
• Patient “stays the course” under stress
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Current Enterprise Plan
NHJacksonville
Intervention Strategy
InitiationPoint Status
Tertiary TBDSecondary TBDPrimary TBD
Intervention Strategy
InitiationPoint Status
Tertiary 2012
Secondary 2015
Primary 2015
BUMEDNMCPHC NH
Pensacola
NMC Portsmouth
NH Camp Pendleton
NMCSan Diego
NHCamp Lejeune
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Strategic Task Area Fall 2014 Winter 2015 Spring 2015 Summer 2015
BUMED Contract BPR Support *
Program Strategy Development
Operational Implementation Guidance
Data Analytics Development
BUMED Population Health Program Funding (Local Contracts)
Communications Implementation
Community Outreach Support (Web Portal, etc.)
Health Promotion Support
Data Analytic Support
Wearable Technology / Health Portal
IHC Contract Deliverables
*Provided by Deloitte LLC until Jan 2015. New BUMED BPR Contract scheduled to initiate Feb 2015.
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Top Hospitals and Health Care Systems Using PAM Johns Hopkins Coventry Health Care
United Health Group MEDICA
Blue Cross of California Oregon Health AuthorityWellPoint Washington State Health Care Authority
South Carolina Healthy Connections Ohio Department of Medicaid
PAM: The Premiere Measure • Hospitals and health care systems in 30+ states administer PAM
• Used in health care systems that serve over a 130 million members
• The PAM is used in over 21 countries
• PAM is required in the ACA section 3026 (Community Care Transition Program)
• 6 VA hospitals currently use PAM
• 135 peer‐reviewed published studies, using the PAM, have demonstrated improved
patient outcomes and controlled costs
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Naval Medical Center San Diego May 7, 2013
Patient Activation Measure
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Organization Intervention (Based on PAM Level)
SampleSize
Outcomes
PeaceHealth Medical Group
All Medical Home Clinic
Staff Members
Tailored Patient
Interaction
1500 47% ↓ ER and Urgent Care Visits
21% ↑ Control Blood Pressure14% ↑ Patient Appointment
Access
StayWell Health Management
Telephonic‐Health Coaches
TailoredCondition‐
Management Coaching and
Care
1874 22% ↓ ER Visits
33% ↓ Inpatient Admission
Washington StateMedicaid
RNs Tailored Care Coordination Processes
182 80% ↓ Cost for ER / Inpatient Admissions
PAM: A Measure That Improves Outcomes
The normal distribution of a patient population is spread across all 4 activation levels
↑PAM Level ↓Cost
Who What
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AICU / 3°PopulationPopulation Size
(153k Total Enrollees to NMCSD and NHCP)Average Annual Cost (FY12‐13)
(Annual Health Care Costs of $300M)
*152,860NMCSD and
NHCPEnrollees
(*non‐opforces, as of 3/1/14)
397$300MCosts for Other
Enrollees$20.7 M
0.3% 6.9%of patients = of costs
15 times the average per member per year costs (PMPY)PMPY: $52,245 Per Member Per Month Cost (PMPM): $3,400