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POPULATION HEALTH MANAGEMENT – DEVELOPING A ROADMAP THROUGH COMMUNITY REPORTING
PARTNERSHIPS
RWJBARNABAS HEALTH – JERSEY CITY MEDICAL CENTERMETROPOLITAN FAMILY HEALTH NETWORK
MARCH 9TH 2017
1
Team Members: Candice Pimentel, Louis Alerte & Raushanah Ali
MFHN FQHC• Federally Qualified Health Center – 3 Centers
in Hudson County
• Patient Centered Medical Home (PCMH) designation
• Annual Patient Volume – 19, 000
• Service Provisions: Primary Care Dental Podiatry Behavioral Health Retail Pharmacy Services for Special Population Obstetrics/Gynecology ACA Certified Counselors, etc.
NHCAC FQHC• Federally Qualified Health Center – 11 Sites
in Hudson, Bergen and Passaic Counties.
• Patient Centered Medical Home (PCMH) designation
• Annual Patient Volume – 71, 000
• Service Provisions:
Primary Care
Dental
Mobile Unit Services
Behavioral Health
Pediatric Care
Obstetrics/Gynecology
The Wealth from Health® program is an innovative self-management program which provides the opportunity of rewards to patients of the Hudson County who have been diagnosed with one or more chronic disease that are most sensitive to coordinated outpatient and acute care
Program Objectives: Uncontrolled/poorly managed conditions
Multiple chronic conditions
Non-compliance with medications or medical appointments
Challenging social and economic barriers to health
Stated barriers to care
Frequent inpatient hospitalization/ER visits
High risk/complex needs
Individuals in need of care coordination and caregivers
Program Expansion: Employers Unions Insurers Community health events Supermarkets Barbershops Physician offices Pharmacies Churches/Mosque Partner FQHCs Health departments Schools and program website
HIEAcademic Medical Center
Centers of Excellence
DiagnosticsandLab
Disease Manage-
ment SurgeryAccess
PopulationHealth
Patient Engagement
Post acute care
alignment
Specialty Care
Access
Primary CareAccess
Medical Home
End of life care
SUPERMARKETS
EMPLOYERS
UTILITIESFINANCE
TRANSPORTATION
HOUSING
PAYERS
SCHOOLS
5
Expanding Ambulatory Network
Ambulatory Care Options
Primary Care Office
WorksiteClinic
FQHC1
Freestanding Emergency Department
Retail Clinic
High Acuity Low AcuityEmergency Department
Urgent Care Center
Virtual Visits
Mobile Apps
In-store Kiosk
RemoteMonitoring
DSRIP Program Cycle Development
Define: FQHC Partnership7
Community Resource Inventory
Define: Identify, Educate and Risk Stratify (IES)9
• Make follow-up appointments at patient bed side• Provide follow-up appointments within 72 hours of discharge• Make 2-3 follow-up calls to patients that have missed their follow-up appointments
Identify & Follow- up
• Patient education and PCP/sub-specialist service linkage• Available community resources including health insurance information• Self-management protocols
Education
• Identify high-risk and rising-risk patients in the Emergency Department• Educate patients on patient engagement program and available community
resources• Risk stratifying patients and use of SF12 surveys
Patient Navigation Program
Measure: MFHN ED Navigation10
January February March April May June July August September October November December2014 20 113 73 96 58 352015 42 60 117 110 166 313 352 357 312 109 41 312016 222 257 281 270 270 249 226 256 220 236 284 285
20
113
73
96
58
354260
117 110
166
313
352 357
312
109
4131
222
257
281270 270
249
226
256
220236
284 285
0
50
100
150
200
250
300
350
400
Num
ber o
f pat
ient
s En
coun
tere
d
2014 - 2016 ED Navigation Encounter Statistics
2014 20152016
11
7
Environmental House Assessment
Room Temperature Humidity
Kitchen 75.7 f 43%
Living Room 74.2 f 43%
Bedroom 79.0 f 48%
Bathroom 80.8 f 50%
Mold BathroomSink 9.2Molding 20.5
Tub 15.2Walls 13
Room Temperature Humidity
Kitchen 70.7 f 20%
Living Room 72.3 f 28%
Bedroom 75.6 f 43%
Bathroom 70.4 f 20%
Mold Bathroom Sink 5Molding 0
Tub 5Walls 6
Completed on 05/05/2016 Completed on 02/02/2017
Analysis- Fishbone Diagram
Equipment People
Environment
Methods
EffectInappropriate use of
ED and Inpatient Utilization
Cost
Minimal and inefficient utilization
Health priority
Cultural and spiritual beliefs
Misuse of resources
Lack of awareness
Ineffective support system No Action Plans
Poor referral process
Program Advertisement
Analyze: Social Determinants of Health
55
55
55
61
73
76
116
148
186
544
0 100 200 300 400 500 600
Financial Insecurity
Food Insecurity
Housing Instability
Lack of DM Diagnosis Support
No Health Insurance
Lack of Transportation
Lack of Access to PCP
Poor Weight Management
Lack of Access to Sub-Specialist
Lack of Nutritional Education
Volume
Barr
ier
Top Ten Identified Barriers for Referrals by Patient Navigator (n=2635)
Identifying patients at high risk or with complex health problems
Utilizing nurses and non-clinical navigators to support, advocate for, and motivate chronically ill patients using an innovative points-driven financial rewards system
Deploying a risk stratification tool that incorporates social determinants of health, cultural beliefs and disease burden
Establishing a Community Health Trust of local businesses, local DOH, schools, banks, gyms, and advocacy groups
Risk stratification is conducted upon initial enrollment and every six months thereafter as a basis for navigation, resource prioritization and graduation status
Regular gap analysis performed to identify program weaknesses and opportunities
Comprehensive care redesign programs at reporting partner sites
Created partnerships across clinical practices (100+), schools (120+), community organizations (80+), government (4) and faith-based organizations (40+) to improve communication
Improved patient self-management through the use of EmmiSolutions®(5600 videos monthly)
Comprehensive outreach including community health events and community engagement activities (987+ Events; 34,000)
Population Health Action Items
Strong FQHC Partnerships 15+ Monthly Patient/Family Support
Groups Healthcare Leadership & Innovation
Institute 70+ Local Vendor Discount Pool Social Media/ Co-branding Events Chronic Disease Management 80+ Inpatient/Outpatient Care Redesign
Programs Community Resource Inventory Primary Practices Transformation Monthly Patient Calendar Community Health Trust -150+ Lunch & Learn Sessions
