Population Health

1. Population Health Population Health Management Interventions Lecture c This material (Comp 21 Unit 7) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0005. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Population Health Management InterventionsLearning Objectives — Lecture c • Describe the components of Behavioral Health support. • Articulate successful strategies for human resource recruitment, retention, and training for population health staff. • Describe the necessary health information technology for documentation of population health interventions.

3. Behavioral Health Support • Behavioral support for primary care team through: • Clinic-based services: • Training. • Embedded behavioral health specialists. • Facilitated referral. • Community-based education and behavioral support: • Community health workers. • Community support specialists (volunteers). • Disease-specific peer buddies and mentors. • Technology-enhanced support.

4. Behavioral HealthLevels of Community Intervention • Accelerated referral. • Higher level or more intensive level of care/service. • Sub-specialty psychiatrist, substance use, or behavioral service. • Embedded services. • Onsite health behavior support and engagement with team. • Onsite psychiatric treatment. • Onsite substance abuse treatment. • Referral management for more difficult patients. • Consulting psychiatrist. • Consulting/supervising health behavior psychologist. • Specific health behavior interventions and groups. • Whole culture: caring, personal relationship. • Skilled in behavior change management. • Basic psychiatric illness recognition. • Basic substance use disorder recognition. • Part of team. • Team attitude: “you can do it,” “we can help,” “whatever it takes.”

5. Continuum of Patient Behavioral Needs: From “Low Assessed Behavioral Needs” to “High Assessed Behavioral Needs” • Low assessed behavioral needs • Relatively healthy. • Able to self-initiate. • Self-identify for services. • Able to learn. • Can apply general feedback to their own lives. • Benefit from support, bolstering, coaching, motivational interventions. • High assessed behavioral needs • Meet diagnostic criteria for behavioral disorder (e.g., eating disorder, depression, SMI, substance abuse). • Medically complex, requiring tailored intervention and monitoring. • Exhibit high-risk behaviors, self-harm. • Unable to change behavior without therapeutic intervention. • Difficulty learning, applying general feedback to their own lives.

6. Case Management and Behavioral Assessment Completed in Database • Health status. • Medication adherence. • Life-planning activities. • Cultural and linguistic needs, preferences, and limitations. • ADLs. • Caregiver resources. • Nutrition. • Physical activity. • Pain. • Stress. • Sleep. • Tobacco use. • Alcohol use. • Substance use. • Emotional status and depression. • Domestic violence and neglect. • Cognitive function. • Patient activation.

7. Database Produces Summary of Assessment: Example of a General Health Behaviors Table 7.24 Table. Johns Hopkins HealthCare, LLC, Population Health Research and Development

8. The Interdisciplinary Team Process 7.25 Chart. Johns Hopkins HealthCare, LLC, Population Health Research and Development

9. Care Plan Adapted from Johns Hopkins Medicine (2016).

10. Summary of Population Health Interventionists 7.26 Table.

11. Retention and Recruitment Strategies 7.27 Table.

12. Johns Hopkins Medicine Population Health Conceptual Model — 3 Engage all stakeholders, monitor program implementation, and seek to continuously improve programs to maximize health outcomes 7.28 Figure. Adapted by L. Dunbar, Johns Hopkins HealthCare (2016)

13. Relationship of Data and Analytics to Population Health Interventions • We’re interested in evaluation that leads to population health intervention research. • Surveillance and assessment to determine population needs and patterns, and (over time) to track population-level health changes or trends resulting from interventions. • Identification of population sub-groups in need of particular interventions (e.g., risk stratification). • Monitoring of intervention processes, procedures, and implementation. • Evaluation of intervention effect on designated clinical, behavioral, community, health system, and economic outcomes.

14. Population Health Intervention Research “Research that involves the use of scientific methods to produce knowledge about policy and program interventions that operate within or outside the health sector and have the potential to impact health at the population level.” Population Health Intervention Research Initiative for Canada. (2012). Government of Canada, Canadian Institutes of Health Research, Institutes, Institute of Population and Public Health. Retrieved on March 29, 2016, from http://www.cihr-irsc.gc.ca/e/38731.html.

15. Basic Processes of Population Management and Accompanying IT Requirements 7.29 Chart. Adapted from Kilbridge, P. (2013).

16. IT Requirements for Population Management • Population Identification. • Population Tracking. • Care Delivery. • Cross-continuum Care Management. • Patient Engagement. • Administration, Performance Monitoring, and Reporting. Kilbridge, P. (2013).

17. I. Population Identification • Requirements: • Data acquisition and aggregation. • Analytics-based population definition. • Predictive modeling. • Algorithmic population identification. • Patient-provider attribution. • Systems: • Data aggregation platform: EMR clinical data repository; clinical data warehouse; HIE data warehouse. • Claims data source. • Statistical modeling tools. • Algorithms and analytics for inclusion/exclusion criteria by population. • Processes, algorithms for attribution. Kilbridge, P. (2013).

18. II. Population Tracking • Requirements: • Populations: high-risk/high utilization; chronic disease group; preventive care. • Map against care guidelines. • Map against care over time. • Systems: • Disease and population registries. Kilbridge, P. (2013).

19. III. Care Delivery • Requirements: • Clinical data view, e-prescribing; clinical documentation; communication tools. • Patient-centered view of interventions due. • Decision support for interventions. • Systems: • EMR or physician portal. • Registry: patient-centered view. Kilbridge, P. (2013).

20. IV. Cross-Continuum Care Management • Requirements: • Care manager: patient data access; clinical documentation; communication tools. • Care plan mapped against patient data. • Remote data acquisition; vital signs; lab values. • Real-time video interaction at remote locations. • Systems: • Care management systems. • Mobile EMR; registry access. • Home-monitoring data capture. • Telemedicine capabilities. Kilbridge, P. (2013).

21. V. Patient Engagement • Requirements: • Patient contact information: email, mobile phone number. • Multiple communication modalities. • Systems: • Patient portal. • Text-based communication systems. • Call center. Kilbridge, P. (2013).

22. VI. Administration, Performance Monitoring, and Reporting • Requirements: • Contract negotiation and management. • Revenue distribution. • E-measure calculation and reporting. • Performance date vs. care plan; contracts at clinician, physician, and organization-wide level. • Systems: • Dashboards, other display tools. • Linked contract management and financial systems. • Revenue cycle systems. • Financial decision support and cost accounting. Kilbridge, P. (2013).

23. The Greatest Challenges — 1 • Data normalization. • Claims data: essential to population management; are qualitatively poor and insufficient in accuracy and granularity for care delivery decisions. • EMR data: essential; must be reconciled with claims data around a single data model (may be the single hardest task).

24. The Greatest Challenges — 2 • Risk stratification. • Complex. • Factors: • Quantitative clinical and demographic data. • Qualitative data. • Social issues: housing, food availability. • Transportation. • Availability of community resources.

25. The Greatest Challenges — 3 • Determining the most effective way to intervene. • Most effective mode: telephone, text, in person. • Delivery care in the most cost- and clinically effective venue. • IT tools can be used to track interventions, patients’ characteristics, and outcomes.

26. Population Health Management InterventionsSummary — Lecture c • In Lecture c, we: • Described the components of behavioral health support. • Articulated successful strategies for human resource recruitment, retention, and training for population health staff. • Described the necessary health information technology for documentation of population health interventions.

27. Population Health Management InterventionsUnit Summary — 1 • In this unit, we: • Described the population health data necessary for segmenting into risk-cohorts. • Differentiated the key cohorts of a population by degree of risk. • Analyzed the root causes of risk in a population by utilizing socioeconomic data, behavioral data, electronic medical record data, and other demographic data. • Explained the processes and key decision points by which interventions are prioritized for segments of the population.

28. Population Health Management InterventionsUnit Summary — 2 • In this unit, we: • Listed the characteristics of population health interventions. • Delineated interventions and staff who are deployed for high-risk, rising-risk, at-risk, and low-risk populations. • Described three types of deployment strategies/models for population health management. • Described the components of behavioral health support.

29. Population Health Management InterventionsUnit Summary — 3 • In this unit, we: • Articulated successful strategies for human resource recruitment, retention, and training for population health staff. • Described the necessary health information technology for documentation of population health interventions.

30. Population Health Management InterventionsReferences — Lecture c — 1 References Brown, R. S., Peikes, D., Peterson, G., Schore, J., & Razafindrakoto, C. M. (2012, June). Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Aff (Millwood), 31, 6, 1156–1166; AHRQ. (2012). Congressional Budget Office. (2012, January). Lessons from Medicare’s demonstration projects on disease management, care coordination, and value-based payment. Issue brief. Kilbridge, P. (2013). A framework for IT-enabled population management. The Advisory Board Company. Accessed April 26, 2016, from https://www.advisory.com/research/health-care-it-advisor/research-notes/2013/a-framework-for-it-enabled-population-management Reach Effectiveness Adoption Implementation Maintenance (RE-AIM). Virginia Polytechnic Institute and State University. College of Agriculture and Life Sciences. Retrieved March 29, 2016 from http://www.re-aim.hnfe.vt.edu/ Charts, Tables, Figures 7.24 Table: General Health Behaviors Table. Johns Hopkins HealthCare, LLC, Population Health Research and Development. 7.25 Chart: The Interdisciplinary Team Process. (2016). Johns Hopkins HealthCare, LLC, Population Health Research and Development

31. Population Health Management InterventionsReferences — Lecture c — 2 Charts, Tables, Figures 7.26 Table: Summary of Population Health Interventionists. 7.27 Table: Retention and Recruitment Strategies. 7.28 Figure: Population Health Conceptual Model - Adaptation. Dunbar, L. (2016). Adapted from Johns Hopkins HealthCare, LLC, Population Health Research and Development. 7.29 Chart: Adapted from Kilbridge, P. (2013). A framework for IT-enabled population management. The Advisory Board Company. Accessed April 26, 2016, from https://www.advisory.com/research/health-care-it-advisor/research-notes/2013/a-framework-for-it-enabled-population-management Images Slide 4: ABC Approach Pyramid (2016). Slide 9: Care Plan Screen Shot, Modified. (2016). Johns Hopkins Medicine.

32. Population HealthPopulation Health Management InterventionsLecture c This material (Comp 21 Unit 7) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0005.