Population Health Management, Access to Care and Patient Safety

COLLEEN KRAFT, MD HEALTH NETWORK BY CINCINNATI CHILDREN’S

2

Faculty Disclosure Information:

In the past 12 months, I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) or provider(s) of commercial services discussed

in this CME activity.

I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Learning Objectives

• Discuss the relationship between individual health, population health, and patient safety

• Provide tools and strategies for improving access and patient safety using population health as a framework.

• Share techniques for identifying populations where improved access could improve safety.

8/22/2014

Population Health—not a new concept

"I swear by Apollo the physician, and by Asclepius, and by Hygeia and Panacea, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation ."

Two of the daughters of Asclepius

• Hygeia = health, prevention of sickness, sanitation

• Public health

• Panacea = universal remedy, healing, treatment

• Personal health

http://www.healthpolicyohio.org/wp-content/uploads/2014/11/WhatIsPopHealth_PolicyBrief.pdf

Population Health: Geography

PHM Program Elements Population

Identification Health

Assessment Risk Stratification

Health Promotion and

Wellness Health Risk

Mgmt Care

Coordination & Advocacy

Care Mgmt

Program Outcomes and

Evaluation

Quality improvement reporting and feedback (loop)

Population Identification

• Any inpatient admissions? • Inpatient and Emergency Department? • Primary Care practices who utilize your

hospital? • Specialty Care practices who utilize your

hospital? • Surrounding community

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Population Distribution

% population

1%

35%

64%

Healthy

Chronic

Complex % expense

25%

70%

5%

Patient Safety

population

inpatient

Inpatient/MH community

MH/Community

Healthy

Chronic

Complex

Assess Stratify

Implement Solutions

Measure & Report

Registry

• Database or spreadsheet • Contains fields

– relevant to the population – relevant to measuring quality of care

• More dynamic than periodic reports • Populate retrospectively or prospectively • Running/maintaining registry could be a hospital or

alliance/ACO function for associated primary care practices

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Inpatient and SSEs

• Registries can organize: – Patient diagnosis – Risk for fall – Allergies – Cognitive capacity

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Overview of serious safety events

• Serious reportable event (National Quality Forum)

• Never event (Agency for Healthcare Quality and Research)

• Sentinel event (The Joint Commission)

Incident Reporting

• Majority of events are not reported through hospital incident reporting systems – Estimated 86% not reported – Staff misperception of patient harm – Staff reluctance to report – Nurses most often report events

• OIG estimates 27% of in-patients experienced at least one adverse event or temporary harm

Incident Reporting

TYPE OF SYSTEM # OF HOSPITALS

WITH SYSTEM

General incident reporting system 189

Specialized incident reporting system 132

Infection tracking 98

Pharmacy or medication error tracking 43

Patient complaint tracking 40

Security issues 14

Harm to staff 7

Regulatory compliance 4

Registries

• Allow for the denominator to be the number of patients;

• Serve as a reminder of patient concerns prior to a risk of a SSE;

• Reporting becomes part of the care of the patient and reportable on the registry;

• Leads to questions of “what happened” and “what can be improved”, supports a culture of safety

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Building a Culture of Safety ERROR

ADVERSE EVENT

Huddle, registry review to prevent errors from being made in the first place Detecting and reversing

error before it causes harm

Repairing or minimizing the damage caused by errors that cannot be prevented or reversed

Building a Culture of Safety “The single greatest impediment to

error prevention in the medical industry

is that we punish people for making mistakes.”

Dr. Lucian Leape

Professor, Harvard School of Public Health Testimony before Congress on

Health Care Quality Improvement

Patient Safety

population

inpatient

Inpatient/MH community

MH/Community

Healthy

Chronic

Complex

Care Management, Practice Partnerships, Data Sharing for Quality

ACTIVITIES THAT PROMOTE PATIENT SAFETY

Innovative Care Management

Practice Network Development and

Transformation

Data for Quality and Financial Management

Care Management

• Most effective at the practice level • Face-to-face works best—relationships • Registry guides best practices • Care coordination and transitions most

important – Build in time for inpatient and outpatient care

managers to meet

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• Measures – Patient Experience (Satisfaction) – Access to Care – Patient Function (ADLs, school attendance,

school performance, physical activity) – Quality/Evidence based guidelines – Cost of Care

Population health

• Identify a population needing improvement • Define that population

– Patients with behavioral health disorders – Patients with chronic conditions (Asthma, BMI >95%) – Patients needing preventive care

• Measurement – Experience? – Function? – Evidence-based guidelines?

Population health and Access to Care

• Registries – Preventive Care – Chronic Care Management

• Reports – Quality Metrics – Admissions, ED visits, Re-admissions

• Tracking – Huddle Sheet – Pre-visit planning

Tools of Practice-based population health

Alina

• Third admission for status asthmaticus in 4 weeks

• Asthma is set off by fumes in her family’s apartment

• Family desperately wants safe housing

Alina

• Team Alina – Inpatient Team – Nurse Case

Manager – Social Worker – Family

• Medical Legal Partnership

• Temporary Housing

Population Health Management ACTIVITIES THAT PROMOTE THE PATIENT SAFETY

Practice Network Development and

Transformation

HNCC and Community Physicians

• Health Network Practice Engagement – Practice Network Agreements – Accurate Attribution – Quality Incentives – Patient-Centered Medical Home – CCHMC inpatient/outpatient care manager

collaboration

HNCC PCP Attribution Model Flowchart

No claims for member?

Select the MCO assigned PCP

Attribute member to this provider

Most recent 12-24 months of historical claims1 analyzed for specialties of Family

Practice, FQHC, Internal Medicine, OB/GYN, Pediatrician and RHC

With which provider has the member

had the most visits?²

1. Visits defined on the following page. 2. If there is a tie in number of visits the provider with the most recent visit is chosen.

Attribution Flow Diagram

Year 1 – Payout Timeline

Tasks 2015 2016

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Generate Membership/Physician/TIN data

Q1 Data Q2 Data Q3 Data Q4 Data

Format Incentive Reports for distribution

Q1 Data Q2 Data Q3 Data Q4 Data

Audit Incentive Reports for distribution

Q1 Data Q2 Data Q3 Data Q4 Data

Submit Audited Incentive Report Documents to AP

Q1 Data Q2 Data Q3 Data Q4 Data

AP sends checks to the Practices

Q1 Data Q2 Data Q3 Data Q4 Data

Network Team deliver each Practice’s Report

Q1 Data Q2 Data Q3 Data Q4 Data

2015-06

ourn

Patient Centered Medical Home • PCMH Improvement Team

established by CCHMC. • PCMH Coaches provide

consultant and coaching resources.

• Engaging “Early Adopters” to enhance our own learning.

Patient Safety

population

inpatient

Inpatient/MH community

MH/Community

Healthy

Chronic

Complex

http://www.healthpolicyohio.org/wpcontent/uploads/2014/11/WhatIsPopHealth_PolicyBrief.pdf

Beyond medical care

Avondale

Nationwide

Beck (2013)

CCHMC has 90+% of all asthma admissions in county

Quintile 1: • 18 admits among 29,000 kids • 0.6 per 1000 • 17% of pop’n with 2% of admissions Quintile 5: • 299 admits among 17,900 kids • 16.7 per 1000 • 11% of pop’n with 35% of admissions

Children in highest rate neighborhoods more likely to be exposed to bad housing, have a depressed parent, lack transportation, and live in poverty, compared to lowest rate neighborhoods

Who are the critical partners?

• Home health care • Pharmacies

• Legal Aid Society • Public Schools

• Health Department • Community health workers

Cincinnati Asthma Admissions and Neighborhood Asthma Hotspots

Legal Aid Housing Cases Mapped Against Neighborhood Asthma Hotspots

Addressing Housing with Legal Help

CCHMC – CPS Partnership Journey

Foundation built on trusted partnership

Strategic Plan to Increase QI Capability

FY ‘13 • 5%

CPS School RN Trained in QI

• METHOD: 2 Teams in Rapid Cycle Improvement Class (120 days)

FY ‘14 • 40%

CPS School RNs Trained

• METHOD: 1 Team in RCIC Class 13

• CCHMC-CPS Pilot mini learning collaborative

FY ’15 • 100%

CPS School RNs Trained (n=50)

• METHOD: Summer School RN Boot Camp

• Increase Learning in how to promote a “Asthma Friendly School”

• Co-Led Community- CCHMC Team working

FY ‘12 • <1%

CPS School RNs • METHOD:

One-off project with 1-2 RNs

Avondale

Beck (2014)

Avondale

Beck & D. Jones (2014)

“Heat map” of building

code violations

Avondale

CHOICE Buildings to be refurbished by The Community Builders

Beck (2014)

Network of care

Figure. Collaborations between agencies serving children with complex chronic conditions. Acad Ped 2012

schools pharmacy

community health worker

Health Dept home remediation

Legal Aid

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Injury rate per 1000 children aged 1-4 years, 3 year average

Additional conditions Prematurity Grade 3 reading proficiency Mental health

Toward an integrated health and wellness approach

Primary Care and ‘toxic stress’ interventions

• Move from Patient Centered Medical Home to notion of a Community Centered Health Home

• Community system of partnerships

Social Determinants a Clinic Will Detect Maslow’s Hierarchy of Needs

Hunger; homelessness; denial or delay of benefits;

utility shut offs

Domestic violence; mental health issues; inadequate education

services

Overwhelmed new parents; lack of

parenting role models

Unemployment; lack of high school degree;

ex-offender reentry issues

Potential Collaborations

Achieving potential

Esteem & Respect

Belonging

Safety

Basic Human Needs

A. Henize (2013)

EHR social history screening

Benefits

Housing

Depression

Domestic Violence

All others

Lessons

• Vision – change the outcome AND close the gap • Population denominator approach

– Otherwise great silos, lousy outcomes – Measurement and analytic capacity

• Effective network of partnerships – Span missions, but also operations, data

• Building improvement capacity – health care culture, capacity to bridge – community capacity for QI, EHR/measurement

Thank you!

• Questions

8/22/2014