Strategy Management in the Military Health System: Achieving the Quadruple Aim

1. Strategy Management in the Military Health System: Achieving the Quadruple Aim Ms. Paula Evans Office of Strategy Management Office of the Assistant Secretary of Defense for Health Affairs paula.evans@tma.osd.mil 27 July 2010

2. Goals for this briefing At the conclusion of the session, participants will be able to: • Understand the MHS Quadruple Aim • Understand the MHS Strategic Imperatives • Understand the Pt Centered Medical Home • Understand the critical importance of MEPRS in monitoring strategic performance

3. The Quadruple Aim

4. MHS Quadruple Aim Readiness Pre- and post-deployment Family health Behavioral health Professional competency/currency Population Health Healthy service members, families, and retirees Reduced tobacco, ETOH and unhealthy eating A Positive Patient Experience Quality healthcare outcomes Patient and family centered care, access, satisfaction Cost Responsibly managed Focused on value 4

5. Achieving Excellence in the Delivery of Care • Performance is a characteristic of a system • Every system is perfectly designed to achieve exactly the results it gets • Design leads to performance; reliability leads to excellence • So if you want different performance, you need a different design • Process-by-process, change-by-change we can get better and improve across all six areas that described experience of care (Crossing the Chasm, 2001): • Safe • Effective • Patient-Centered • Timely • Efficient • Equitable • But, we need data….. Source: “Achieving the Quadruple Aim – Military Health Leading the Nation”, Don Berwick, MD, MPP, MHS Conference, January 27, 2010.

6. Deliver patient centered primary careand optimize performance around: PMPM Direct Care Enrollment Continuity ER Utilization PatientSatisfaction Prevention PMPM (Focus on pharmacy) Purchased Care Aligning the Incentives: Rewarding Both Outputs and Outcomes • Improve health (HEDIS) • Enhance access and continuity (reducing no shows, ER visits) • Care is rewarding to patient and provider (satisfaction, retention, staff turnover) • Synchronize direction and incentives for TRO/MTF/Regional Commander, including initiatives that are: • Facility-specific • Good for entire region or service • Good for all military patients • Beneficial to the MHS as a whole

7. MHS Strategic Imperatives

8. Strategic Imperatives Strategic Imperatives are thecritical few thingswe must do to achieve the Quadruple Aim • Each measure has specific targets for FY10, FY12, FY14 • The difference between our current performance and target performance is our performance gap • Each imperative will have an Executive Sponsoring Coalition (i.e. one of the Integration Councils) Each Strategic Imperative has one or more performance measures As an organization, we will align resources and focus management efforts on our Strategic Initiativesover the next 1-5 years • To close our performance gap – we will concentrate • efforts on a few strategic initiatives(i.e. Patient • Centered Medical Home) • The MHS has developed a set of strategic imperatives that we believe will positively impact the Quadruple Aim • Strategic Imperatives are the things that will yield the greatest return from the finite resources available

9. MHS Strategic Imperatives Scorecard Design Phase Approved Funded Current Performance Known and FY10 Target Approved Measure Algorithm Developed Out-Year Targets Approved Concept Only

10. How Do We Support Change in the Right Direction? • Understand desired end-state • Balanced approach to Quadruple Aim • Readiness maximized • Healthy Outcomes and Patient Experience improved • Sustainable Costs • Emergency Department Use • Retail Pharmacy • Agree on goals • One size does not fit all • Year over year improvement • Facilitate and incentivize the change Balance

11. Key MHS Initiative for Achievingthe Quadruple Aim is the “Patient Centered Medical Home (PCMH)”

12. Team-Based Healthcare Delivery • Creation of Clinical Micropractices • Appropriate utilization of medical personnel • Improve communication among team members Population Health Access to Care • Improve phone and electronic appt scheduling • Open access for acute care • Emphasis on coordination of care • Proactive appointing for chronic and preventive care • Emphasis on preventive care • Form basis of productivity measures • Evidence-based medicine at the point of care Advanced IT Systems Patient Centered Medical Home Patient-Centered Care • Secure mode of e-communication • Creation of education portal • Reminders for preventive care • Easy, efficient tracking of population data • Empower active patient participation • Seamless communication • Encourage patient participation in process improvement Refocused Medical Training Decision Support Tools • Evidence-Based Training • Integrated Clinical Guidelines • Decision Support Tools at the point of care • Emphasize health team leadership • Incorporate patient-centered care • Focus on quality indicators • Evidence-based practice Patient & Physician Feedback • Real-time data • Performance reporting • Patient feedback • Partnership between patients and care teams to improve care delivery Model adapted from the NNMC Medical Home

13. MHS PCMH Journey NNMC PCMH Pilot Begins Jun 2008 Services Develop PCMH Policy & Guidance Apr– Jul 2010 MHS PCMH HA Policy Sep 2009 2nd MHS PCMH Summit Oct 2010 2,634,614 Enrollees in a Level II PCMH End of FY 2012 Performance Planning Pilots Begin Oct 2010 Edwards & Ellsworth FHI Pilots Aug 2008 MHS Conference (Enterprise-Wide Communications) Jan 2010 Resources Aligned in 2012-17 POM Jun 2010 1st MHS PCMH Summit Sep 2009 Enterprise-Wide Secure Messaging Capability Available Jan - Mar 2011 Services Present Early Results of PCMH Performance Aug 2009 (R&A) “Framework for Analysis” Approved (i.e. Measures and Standards) Dec 2009 ASD/HA and SG Congressional Testimony (for Stakeholders Buy-in) Feb 2010

14. Enrollment Continuity ER Utilization PatientSatisfaction Prevention Business Case to Support PCMH What should PCMH accomplish within Primary Care? What do we need to do? • Reduce visits/person • Maintain total “touches” (visits + non-visits) • Increase enrollment • Increase market share • Recapture PSC (savings) • Increase preventive services • Right number of providers for enrolled population • Right number of support staff per provider • Right space for efficient operations • Right information systems • Train our people to more effectively function as a team What should PCMH accomplish outside ofPrimary Care? PMPM Direct Care • Reduce ER demand (savings) • Reduce inpatient demand (savings) • Reduce specialty demand (savings) PMPM (Focus on pharmacy) Purchased Care

15. Standards & MeasuresWhat They Are & Why They Are Different? • Example: Hybrid Car • Standards • Uses two or more distinct power sources to move the vehicle • Low emissions (i.e. SULEV rated [Super-Ultra-Low-Emission Vehicle]) • Measures • Fuel economy (mpg city/hwy) • Acceleration (time from 0-60 mph) In this example, standards distinguish hybrids from other cars while measures allow consumers to compare the performance hybrids against other cars. Standard: An established norm or requirement; usually manifested in a formal document that establishes uniform specifications, criteria, methods, or practices Measure: A number or quantity that records an observable value or performance

16. Why Do We Need Standards and Measures? • Standards and measures allow us to test a hypothesis: • Hypothesis: “The PCMH is a model of primary care that will have a significant positive impact on MHS’ pursuit of the Quadruple aim: enhanced patient experience, improved population health, better managed per capita cost, and increased medical readiness.” • Standards allow us to differentiate medical homes from traditional models for primary care • Standards describe the key characteristics required for a practice to qualify as a medical home • Standards do not force “one-size-fits-all”; they are simply a set of fundamental criteria that must be met • Without standards, the term medical home can be used loosely, potentially damaging the credibility of the medical home initiative • While standards can be used to determine what a medical home is, measures allow us to determine how they are performing • Performance versus control groups (Are medical homes doing better than traditional models for primary care?) • Longitudinal performance (How is a medical home doing over a span of time?) • Best performers (Where are the opportunities for best practice transfer?

17. Tracking PCMH Implementation Number and percentage of enrollees getting their care from a Level 2 Patient Centered Medical Home • We have standards that define the patient centered medical home • We have measures and targets that describe the outcomes we want to achieve • We should articulate the number of patients that will migrate to a patient centered medical home, and by when 17

18. PCMH Enrollment Projections“THE TARGET” Notes: HCSC = Health Care Support Contractors (X) = % of enrolled population with Plus

19. Estimated Overall Impact of PCMH on the Quadruple Aim Beneficiary Satisfaction: 59%  64% (62%) Getting Timely Care: 74%  81% (78%) PCM Continuity: 45%  53% (60%) ER Utilization: 72/100  60/100 (60) G G Y G Beneficiary Satisfaction: 59%  62% (62%) Getting Timely Care: 74%  78% (78%) PCM Continuity: 45%  49% (60%) ER Utilization: 72/100  66/100 (60) Y G Y Y Beneficiary Satisfaction: 59%  60% (62%) Getting Timely Care: 74%  76% (78%) PCM Continuity: 45%  47% (60%) ER Utilization: 72/100  69/100 (60) Y Y Y R Beneficiary Satisfaction: 59%  59% (62%) Getting Timely Care: 74%  75% (78%) PCM Continuity: 45%  46% (60%) ER Utilization: 72/100  70/100 (60) Y R Y R % of Enrollees Getting Care from Level 2 PCMH Overall Impact on Quadruple Aim = X R 75% 3.75M - G 54% 50% 2.5M - G Y 31% 25% 1.25M - Y 11% R 10% 500K - Y 5% R 250K - R ExpectedPerformance from Level 2 PCMH Projections 2010 Projections 2011 Projections 2012 (XX) Denotes FY12 target

20. Importance of MEPRS in All This

21. The MHS Value Equation for Measuring PCMH Success Readiness Experience of Care Population Health + + Value = Cost (Over a Span of Time) Creating a high value Military Health System is predicated on defining and measuring value. 21

22. MHS Strategic Imperatives Scorecard & MEPRS Data Design Phase Approved Funded Current Performance Known and FY10 Target Approved Measure Algorithm Developed Out-Year Targets Approved Concept Only

23. MEPRS Code Work Center Input Output Outcome • CHCS • SIDR • SADR • Surveys • M2 • Pop Health Portal • DMHRSi • DMLSS • Local Financial • Systems Magic Linkage

24. What PCMH questions do we need answered that MEPRS would help on? • How many people are enrolled to a PCMH? • What are the demographics of those enrolled to a team? • What is the enrollment ratio, i.e. enrollee to providers? • What is the demand rate for those enrolled in PCMH? • How much primary care of those enrolled in PCMH is not seen by providers within the PCMH team? • How much primary care seen by the team is for those not enrolled in the team? • What is the productivity of the team? • What is the overall cost of the team? • What is the PMPM of individuals enrolled in PCMH?

25. MEPRS Based Data is Essential for Knowledge Transfer Having aggregate measures isn’t enough—we need information at the team level to evaluate performance and support best practice transfer of PCMH At a fourth level MEPRS, data can be aggregated and analyzed by medical home team within a given MTF A PCMH’s performance can then be compared with others. We believe that as teams learn from each other, their performance will improve over time Leadership has asked OSM to propose a single approach for measuring all aspects of a PCMH team and present to the JHOC on 11 Aug 10

26. Our Challenges • Labor intensive to create individual identification of teams • Lack of standard implementation rules • Not so simple; very complicated • Inefficient processes for data entry • Inadequate training of staff to appropriately account for time • IM/IT disconnects

27. Pay Off by Measuring Individual PCMH Teams • Identify top performers • Report to our investors using hard evidence (facts) on the results of the PCMH initiative • Prove something that no one has proven in the country • Share best practices and eliminate unwarranted variation

28. What Will It Take? • Agreement to work together to find an optimal solution • Skill in designing efficient processes and procedures to capture data and allocate resources • Pilot testing to avoid unintended consequences • Willingness to act quickly and get to yes

29. “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” - Charles Darwin 29

30. Back-up Slides

31. Definitions – Strategic Imperatives 31

32. Strategic Imperative Definitions

33. Strategic Imperative Definitions (Cont’d)