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Implementation of a Population Health Model at Mayo Clinic

Michael Bryan, MDAssistant Professor of Family MedicineMayo Clinic Arizona

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Who We Are

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Drivers for Change….

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Starting the Process…

• Office of Population Health formed in 2012, later became the Population Health Committee

• Multidisciplinary

• Regional Leads

• Team Leads

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To Go From This…

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To This…

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Strategy

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Population Health Programs

• Common Themes

• Response to Drivers

• Living in the Moment

• Everyone Wins

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Population Health Programs- Access

• Portal Utilization

• Arizona Primary Care= 85%

• Patient Empanelment

• 100%

• Non Visit Care

• Electronic Consults

0

200

400

600201420152016

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Population Health Programs-Community Engagement

• Community Health Needs Assessment

• 2016-2019

• Access to Care

• Cancer

• Homelessness

• Transplantation Medicine

• Multiple Community Service Events

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Population Health Programs-High Risk Patient Management

• Care Transitions

• Complex Care Coordination

• ED visits from 200 to 88

• Hospitalizations from 85-30

• Total Charges 5.4 million to 2.6 million

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Population Health Programs- Team Based Care

• Role Definition

• New Care Team Members

• Standardized Rooming

• Medication Renewals

• Non Provider Visits

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Population Health Programs-Co-Location

• Building Redesign

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Population Health Programs- Quality

Chronic Conditions

• Diabetes

• Vascular Disease

• Hypertension

• Asthma

• Depression

Preventative Care

• Breast Cancer Screening

• Cervical Cancer Screening

• Colon Cancer Screening

• Immunizations

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Lessons

• Changing Behavior (Provider and Patient)

• Technology is Everything

• Conflicting Evidence

• Uncertainty

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Thank You