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Finding Untapped Value Through Sharing and Use of
Multi-Sector Data Health DataPalooza
May 9, 2016
Mobilizing Community Health with Data
Peter Eckart, Illinois Public Health Institute (@DASH_connect)Alison Rein, AcademyHealth (@alr5)
All In: Data for Community Health
1.
Support a data movement that empowers communities to address social determinants of health
2.
Build an evidence base for the field of multi-
sector data use to improve health
3.
Stimulate and support peer learning and collaboration
DASH and CHP are All In!Community Health Peer Learning Program (CHP)
NPO: AcademyHealth, Washington DC; with National Partnership for Women & Families and NORC as partners
Funded by the Office of the National Coordinator for Health IT
15 communities: 10 Participant and 5 Subject Matter Expert
Data Across Sectors for Health (DASH)
NPO: Illinois Public Health Institute in partnership with the Michigan Public Health Institute
Funded by the Robert Wood Johnson Foundation
10 communities
Core Components of DASH and CHP
Shared data and information
Multi-sector
Collaborative
Outcome:
Capacity Building to Drive Community Health
Improvement
Total Network of 25 Projects10 projects – DASH Cohort15 projects – CHP Cohort
Geographic Scale
Sectors Represented
Data Types / Sources
Connect with Us!Sign up for news at dashconnect.org
Follow us at @DASH_connect and @AcademyHealth #CHPhealthIT
Finding Untapped Value Through Sharing and Use of Multi-Sector Data
Co-Moderators:
Peter Eckart, Illinois Public Health Institute (@ContraPete)
Alison Rein, AcademyHealth (@alr5)
Panelists:
Aaron Truchil, Camden Coalition of Healthcare Providers (@atruchill)
Bren Manaugh, The Center for Health Care Services
Nicole Olson, Providence Center for Outcomes Research and Education
Craig Brammer, The Health Collaborative, with Technology Powered by HealthBridge (@CraigABrammer)
Amy Bassano, Center for Medicare and Medicaid Innovation
Improving Health Care & ReducingCosts withInnovative, Local Data Systems Finding Untapped Value
Through Sharing and Use of Multi‐Sector
Data
total hospital revenue: $132,000,000
total patients with a hospital visit: 42,708
patients visiting 2+ hospitals (same year): 23%patients visiting 2+ hospitals (over 5 years): 41%
Camden Hospital Utilization 2014 Snapshot
theCamden
“Cost”
Curve10% of patients accounted for 74% of receipts
1% of patients = 30%
of charges
10% of patients = 74%
of charges
All Hospital Cha
rges
top diagnosesRespiratory AbnormalityChest PainAbdominal PainSepticemiaAcute Renal FailureUrinary Tract InfectionPneumoniaChronic Systolic Heart Failure
≈1% of population >5 chronic conditions
averages: 57 years old
4.5
ED visits 5.3
inpatient
hospitalized
54
days____$673,000 charges$73,143 receipts
Who uses Camden’s hospitals most?
a data driven process for the timely identification of extreme patterns in a defined region
of the healthcare system
used to guide targeted intervention and follow up to better address patient needs, reshape ineffective
utilization, and reduce cost.
Education &
Employment
Official ID & Vital Records
Food &
Nutrition
Reproductive
Health
MentalHealth
Medication
& Medical
SuppliesProvider
Relationship
s
Health
Maintenance
Substance Use Disorder
Other
Benefits &
Entitlements
Shelter
Legal
Transport
Advocacy
& Activism
Family,
Personal &
Peer
Relationships
Health Data
the observed world
Claims
Health Data
Claims
Other Data
?
Survey Data
ARISEARISECamdenCamden
EMR
Social Service Data
Housing School
Justice Child Services
Public Data
Property
Census
the observed world
18,755 people
with anarrest
93,344 people visiting the hospital12,541
peopleoverlap
5 years, ever having a Camden address
226 people with dual
sector high utilization
Prevalence of socio‐behavioral complications
12,541 dual system patients
*
* visits capped at 100 to avoid outliers. The maximum number of ED encounters was >300 over the 5 year period.
16+ emergency department visits
12,541 dual system patients
arrests
7+ police encounters
226 people with dual sector high utilization
NEXT UP! Bren Manaugh,
The Center for Healthcare Services
Significant
Trauma
History
Comorbid
Chronic
Medical
Conditions
No Support
SystemFractured
relationships
Lack of
Confidence
in or Trust of
System
Poor coping skills;
maladaptive behaviors
They are survivors,
but not self‐sufficient
Lack of
ResourcesHigh
Psychosocial
needs
Poor
engagement
with
appropriate
level of care
WhatWhat’’s the Difference?s the Difference? ModelModel
Community Partners and CollaborationsCommunity Partners and Collaborations*
Hospitals/Health
Systems
CityLeaders
Churches
and FBOs
Police &Sheriff
Schools
Universities
TreatmentAgencies
CountyMentalHealth
Department
SocialServiceAgencies
Utilities
–
Public
and
Private
State
HealthAgencies
Housing
Authority
Insurance
/MCOs
Advocacy
Agencies
CountyCommissioners
Courts
GovernmentJudiciary and
Law
Enforcement
Health
Systems
and
Providers
Education
*85 Member
Organizations
HASA (HIE) Data FlowHASA (HIE) Data Flow
Clinical Analytics Abstract
Client
Providers
Individualpatient view
Data Feeds
Patients &
Consumers
Community
Treatment Plan
Chart ViewFutureClients
LawEnforcement
Homeless
ED
High Utilizer
Program
Alerts
HASAFactsData Analytics Tool
GoAccountNear real‐time
record of medical
encounters
HASAProviderAssistCommunity Health
Record
Labs, Rx’s, & X‐Rays
Community Treatment Plan Community Treatment Plan
in HIEin HIE
•
Access Consultation Report under
Reports tab of ProviderAssist
•
Medication & Diagnosis
Information
•
Brief Case History
•
Future Development: History of
Violence indicator; Partitioned
access to law enforcement
Community Treatment PlanCommunity Treatment PlanPage 2
•
Summary of steps to take
•
CHCS Integrated Care Team Staff
contact information
•
Common Services Used
NEXT UP! Nicole Olson, Providence Center for Outcomes
Research and Education
Community Connections in SW Washington Healthy Living Collaborative &
Providence Center for Outcomes Research and Education
AcademyHealth -
Community Health Peer Learning Program
Our Impact Model for Data-Driven Transformation
Areas of Focus
Providence CORE Overview
Supporting transformation and innovation in community health and
health care.
HEALTH SERVICES & SYSTEMSORGANIZATION & DELIVERY OF CARE
SOCIAL DETERMINANTS OF HEALTHPOPULATION HEALTH DRIVERS
CLINICAL STRATEGIESSCREENINGS & TREATMENT
OUTCOMESHEALTHCOST
QUALITY
CONNECTED SYSTEMSSTRUCTURE OF CARE DELIVERY
HEALTH POLICY PAYMENT & FINANCE
PHYSICAL ENVIRONMENTBIOGRAPHIES & LIFE EVENTS
SOCIAL STRUCTURE & CULTURE BUILT ENVIRONMENT
Program
Evaluation
Research
A way to understand what you’re seeing in the data, get at
root causes, and develop smart, locally informed responses.
To inform effective strategies that help communities
collaborate on multi‐sector solutions targeting root causes.DATA
COMMUNITIES
A multi‐sector partnership that can act with systems and policy
changes in support of local solutions.COALITIONS
Community-Based Health ModelHealth Living Collaborative of SW WA
DATA‐DRIVEN
STRATEGY
TO LEARN AND ACT
COLLECTIVELY
KEY TAKEAWAY
HLC Community Connections Initiative
HEALTH CARE
HOUSING
EDUCATION
PUBLIC HEALTH
Managed Care OrganizationsDelivery Systems & ProvidersAging and Disability Services
Housing &Homelessness Orgs
Public School Districts
Local Health Jurisdiction
CRIMINAL JUSTICE
County Sheriff’s Office
Stakeholders: Leadership,
Programs, Analytics, and
Compliance
SECTORS INVOLVED IN SITE VISITS
Our community needs to share actionable
and connected
data in an continuous
cycle of learning around community
efforts to improve health and well‐being.
County Sherriff's Office –
Inmate Reentry Program
Program Purpose: Connect
inmates to resources needed to
prevent future incarceration.
Program Activities:Program provides treatment,
education, and development of an
achievable action plan upon
release.
Corrections officers work with
local service providers to
coordinate services in and out of
jail: housing, employment, mental
health and substance abuse
treatment, and other needs.
How can multi‐sector data support this
multi‐sector program?
For more info see this video from Clark County.
DATA‐DRIVEN
STRATEGY
TO LEARN AND ACT
COLLECTIVELY
Goal: Integrated and Actionable DataDATA TO LEARN AND ACT COLLECTIVELY
Our community needs to share actionable and connected
data to learn, plan and act together
in an continuous cycle of learning around community efforts to improve health and well‐
being.
Make it community‐
based. CHWs add context
to understanding of
community need and
help generate local
solutions.
Cross‐sector coalitions tackle systems &
policy change to support local action.
Prepare your community
to measure the
impact of its
efforts. Prioritize
populations
where multi‐
sector services
are needed
most.
NEXT UP! Craig Brammer, The Health Collaborative, with Technology Powered by HealthBridge
Data -
What We’re Doing Today
Payment ReformRecognizing and rewarding clinical
excellence
AnalyticsUsing information to
understand and improve care across
the region
Transparency Making information
available to consumers so they can make
informed decisions and better partner with their
providers
InteroperabilityIntegrating data systems to
ensure that the right information is at the right
place at the right time
Clinical Data Monthly Stats
15 M Clinical
Messages
15 M Clinical
Messages
450 Practices
450 Practices
50 EHR
Vendors
50 EHR
Vendors
600,000 Patients
600,000 Patients
6,500 Physicians
6,500 Physicians
10,000 Results
to Health Plans
10,000 Results
to Health Plans
Social Services
Use Cases
Health Plans
Public Health Community Leaders Pharmacy
Primary Care Providers•Cardiovascular Health•Colon Cancer Screening Rates•Diabetes Management•Patient Experience
Hospital •Effectiveness•Patient Experience•Emergency Department
Consumers, Employers, & Providers
Risk-Adjusted Quality MeasuresRisk Adjusted Rate
Measure 2013 2014 2015 Q2% Change from 2013
PCR (30-Day Readmits) 1.3 1.5 1.5 15.4%PQI CHF 3.8 3.0 2.9 -23.7%PQI Composite 12.3 10.0 9.3 -24.4%PQI COPD 2.9 2.4 2.1 -27.6%
*Medicare FFS and OH-Medicaid data not included
CPCi Aggregate Risk-Adjusted RatesAll Payers*
2015 Q2 Aggregate Payer Data
NEXT UP! Amy Bassano, Center for Medicare and Medicaid
Innovation
The Fun Part!
