The 3 D's How Determinants and Data are Driving Delivery Improvements

1. The 3 D's • How Determinants and Data are • Driving Delivery Improvements Dr. Lisa A. Simpson, MB, BCh, MPH, FAAP President & CEO • February 12, 2019

2. Outline 1 Setting the Stage 2 Determinants 3 Data 4 Delivery Improvements 5 Q & A @DrSimpsonHSR

3. VISION AcademyHealth envisions a future where individuals and communities are made healthier by the use of evidence in decision-making. MISSION Together with its members, AcademyHealth works to improve health and the performance of the health system by supporting the production and use of evidence to inform policy and practice.

4. #EvidenceMatters

5. AcademyHealth works with its members and partners To build a vibrant and diverse community… 1 2 To advance the science of evidence production and use 3 To move knowledge into action…

6. Leveraging ~4,000 Members & Organizations AcademyHealth Interest Groups • Advocacy • Behavioral Health Services Research • Child Health Services Research • Disability Research • Disparities • Global Health and Health Care • Health Economics • Health Information Technology • Health Workforce • Interdisciplinary Research Group on Nursing Issues • Learning Health Systems • Long-Term Services and Supports • Oral Health • Public Health Systems Research • Quality & Value • State Health Research and Policy • Surgical and Perioperative Care • Translation & Communications • Women & Gender Health

7. Includes targeted new program develop and implementation Strategic partnership builds on shared vision for evidence-informed policy and practice improvements Creates synergies between evidence producers and evidence users in real world context Reflects commitment to working with members to amplify impact of the field Supports mutual learning – Brammer as Senior Scholar Lorem Ipsum has two main statistical methodologies are used in data analysis which summarizes data.

8. HSR Definition “Health services research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well-being. Its research domains are individuals, families, organizations, institutions, communities, and populations."

9. The Questions Health Services Research Answers • What works? • For whom? • Under what circumstances? • At what cost? • And once we know what works, • How do we scale and sustain it?

10. National Context: Key Themes at 2019 National Health Policy Conference • Drug prices • Healthcare costs • Innovation in private sector & states • Social determinants of health

11. Outline 1 Setting the Stage 2 Determinants 3 Data 4 Delivery Improvements 5 Q & A @DrSimpsonHSR

12. Social Determinants • Social determinants of health are defined as “the complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities…[including] the social environment, physical environment, health services, and structural and societal factors.” “conditions in the places where people live, learn, work, play, and pray (that) affect a wide range of health risks and outcomes.” Centers for Disease Control and Prevention. NCHHSTP Social Determinants of Health: definitions [Internet]. Atlanta (GA): CDC; [last updated 2014 Mar 21; cited 2018 Mar 2]. Available from: https://www.cdc.gov/nchhstp/socialdeterminants/definitions.html

13. Social Determinants

14. Determinants and Delivery Healthcare Delivery Social Determinants

15. Population Health and Disparities • “Two years after the largest expansion of health insurance in 50 years, inequality remains a fundamental attribute of American health care” • Differences by income greater than race/ethnicity for quality of care, reasons for ED visit • Greater improvements in affordability among low income • Need to focus on upstream, social determinants of health Sommers et al, Milbank Quarterly, January 2017

16. Despite Growing Attention to SDOH… “… the literature has not yet been reviewed comprehensively to generate an integrated, evidence-based summary of how to best address the social determinants to achieve positive health effects without increasing, and perhaps even decreasing, health care spending.” Taylor et al, PLOS One, 2016

17. Determinants Most Commonly Addressed • Housing • Food insecurity • Adverse childhood experiences (ACEs) • Others…

18. Permanent Supportive Housing Learn More Play Video

19. Food Insecurity • Limitations of existing tools to identify food insecurity in clinical settings (e.g. adaptations of Hunger Vital SignTM) • Weak evidence base to date of health system role in addressing • Embedding two-item screener in EHR; referral generated in the EHR. • Various models for addressing, e.g. • On-site SNAP application screening and enrollment (e.g. at Chase Brexton Health in Baltimore). • The Pathways Community HUB Model, which relies on community care coordinators (CCC) to conduct outreach to at-risk individuals through home visits and community-based work. • Recent scoping review of screening in healthcare settings • 25 articles; 17 observational (DeMarchis et al, 2019)

20. Food Intervention Reduces Healthcare Spending Berkowitz et al, Health Affairs, April 2018

21. Those with two or more ACEs varies from15.0% (NY) to 30.6% (AZ). Most children with any one ACE had at least one other, ranging from 54.4% to 95.4%.

22. Focus on Adverse Childhood Experiences, Sept 2017 • 15 commentaries • 13 research papers • 2 technical appendices • Topics: • National Action Agenda • Frameworks & Measurement • Systems of Care and Clinical Practice • Community and Family Approaches • Policy

23. Priority Areas for Innovation and Improvement Clinical Protocols Outcomes and Costs Specify and test family- and youth-centered methods to assess and discuss ACEs and foster essential self-care, resilience, and relationship skills in clinical and other settings. Evaluate the effects of alternative clinical and self-care interventions, including effects on health outcomes, utilization, and health care costs. Capacity Building and Accountability Provider Self-Care Define and cultivate provider, health care system, and community-based core competencies related to ACEs, and the training, payment, and accountability models that will be effective in establishing these competencies. Promote and examine the effects of provider self-care related to ACEs, resilience, and relationship skills on quality of care and other outcomes.

24. What works to address SDOH? • Decade of studies (2004-2014) • Eligibility: • Inclusion of a social service intervention, or healthcare that targets SDOH • Quantitative measures of health outcomes, healthcare costs or both • Well-documented study design • 123 articles, only 39 fully met inclusion criteria Taylor et al, PLOS One, 2016

25. Interventions to Address SDOH Taylor et al, PLOS One, 2016

26. Cross Sector Partnerships Show Early Promise • Partnership of Baylor Scott and White Health and Dallas Park and Recreation (DPR) Department • Wellness, upstream strategies to address SDOH • Multi-disciplinary team on the campus of DPR • Retrospective, pre-post design Wesson et al, Health Affairs, April 2018

27. Tools to Measure Social Determinants • The Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) • Health Leads Social Need Screening Toolkit • HealthBeginsUpstream Risk Screening Tool • CMS-developed Accountable Health Communities Screening (AHCS) Tool. • WE CARE (Well child care, Evaluation, Community resources, Advocacy, Referrals, Education) • Various other tools (see UCSF’s SIREN) • Cerner’s HealtheIntent and Epic’s Healthy Planet

28. Integration SDOH Data into EHRS “…no single current biomedical standard captures the breadth of information necessary for documenting the determinants in a manner appropriate for clinical care, quality improvement, and research” • Technical Issues • Standards for SDOH tools/measures • Current codes imprecise w highly variable application • Implementation Issues • Community vs individual level data collection • Integration into clinical decision support systems • Workflow issues (e.g. who/where to ask sensitive questions) • Policy issues • Enhanced infrastructure (referrals, tracking, resource lists) • Better evidence of ROI Cantor & Thorpe, Health Affairs, April, 2018

29. Gaps in Research on Interventions to address SDOH • Few studies examining impact of social interventions on healthcare spending • Few studies examined impact of interventions focused on transportation, public safety, education, and income support • Most studies focus on low income only • Methods vary and could be strengthened • Comparisons, larger samples, more robust designs/analytic methods Taylor et al, PLOS One, 2016

30. Outline 1 Setting the Stage 2 Determinants 3 Data 4 Delivery Improvements 5 Q & A @DrSimpsonHSR

31. The 4th Industrial Revolution

32. Key Trends in Data in Healthcare, 2019 Consumer and patient engagement Interoperability, data sharing Continued focus on population health, value, total costs of care Infrastructure & Analytics: the cloud, RWE, AI, ML Continued growth in digital health products (>$25 B) • Virtual care • Clinical grade digital information • Medication adherence • Digiceuticals

33. Digital Health Products • 70% MDs report using mobile/smart devices • 80% US pop used at least one digital health app • >260,000 apps available; $49 B by 2020 • Evidence of impact? • 20 companies -> 156 studies • Only 28% studies on high burden conditions • Few RCTs, some clinical effectiveness, no cost outcomes Safavi et al, Health Affairs, 2019

34. The Dimensions of Big Healthcare Data Tapestry of Potentially High-Value Sources That May be Linked to an Individual for Use in Health Care Weber, JAMA 2014

35. AcademyHealth Data Initiatives Health Data Science Linkages & Networks New Types of Data Open Data

36. Outline 1 Setting the Stage 2 Determinants 3 Data 4 Delivery Improvements 5 Q & A @DrSimpsonHSR

37. Today’s Health System IOM, Best Care at Lower Cost, 2012

38. Background • Consistent evidence of failure to translate research findings into clinical practice • 30-40% patients do not get treatments of proven effectiveness • 20–25% patients get care that is not needed or potentially harmful • Suggests that implementation of research findings is fundamental challenge for healthcare systems to optimize care, outcomes and costs Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly Grol R (2001). Med Care @DrSimpsonHSR

39. Intervention Methods to Change Physician Behavior Mostofian et al, AJMC, 2015 @DrSimpsonHSR

40. Changing Physician Behavior: What Works? A Review of 14 Reviews 58% Passive Dissemination of PEMs is not effective 70% Mostofian et al, AJMC, 2015 @DrSimpsonHSR

41. Care Management Approaches • “…limited impact on quality of care and healthcare utilization for many complex patients” (AHRQ, 2013) • 2018 systematic review: • 15 unique RCTs w complex/high need patients/high utilization • Only 2 on pts w multimorbidity • “To date, rigorously conducted RCTs have not yet demonstrated a clear and clinically meaningful benefit of care management for complex patients.” Baker et al, BMC Health Services, 2018

42. Payment & Delivery Innovation • Rapid growth of new models • 120 ACOs in 2012; 520 in 2017 • 40 initiatives launched by CMMI involving providers in every state & >18 million patients • Clinicians participating in payment reform initiatives “represent every state, many medical specialties, and diverse healthcare facilities such as home health agencies, acute care hospitals, and skilled nursing facilities.” • 2018 MedPAC report: • “we conclude that ACOs may have saved Medicare from 1 percent to 2 percent more than indicated by their performance relative to benchmarks and that two-sided ACO models appear to save more than one-sided ACO models.” Pham et al, Health Affairs, 2017 & June 2018 MedPAC

43. Impact of Financial Incentives on Quality/Value • Recent systematic review: • “generally effective at improving targeted process of care, little evidence for improved patient outcomes” (Cochrane) • Positive impacts of pay for performance programs (PFP) hard to separate from other improvement initiatives • Economic impact even less clear, PFP an inefficient means of improving quality • Shared savings between provider and patient may be stronger than either alone • Explanations? • Crowd-out intrinsic motivation; diminish creativity; encourage cheating and shortcuts; lead to selfish and uncooperative behavior; can be highly addictive (leading to net deteriorations in quality following their withdrawal) Doran et al, Ann Rev Pub Health 2017 @DrSimpsonHSR

44. Most Recent Focus: HRRP Ody et al, Health Affairs, 2019 @DrSimpsonHSR

45. Promoting EBP by Stopping • De-implementation: “[S]topping practices that are not evidence-based.” - Prasad and Ioannidis (2014) • De-intensification: “[S]topping or scaling back the intensity or frequency of medical interventions that are currently part of a patient’s ongoing management.” - Kerr and Hofer (2016) • Exnovation: “Removal of innovations which are not effective in improving organizational performance […]” – Rodriguez et al (2016) @DrSimpsonHSR

46. Review of De-Adoption of Low Value Clinical Practices • 109 Citations (of 26,608 identified) • 39 original research assessing impact • Majority (59%) published since 2010 • 43 different terms used • Areas of study of impact • Cardiovascular • Musculoskeletal • Menopause • 88% reported reductions in target practice • More complex than simply stopping Niven et al, 2015, Implementation Science @DrSimpsonHSR

47. Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review • Clinical decision supports—e.g. point-of care decision supports • Multicomponent interventions—e.g. those that combined clinician education with decision support or provider feedback • Clinician education—e.g. lectureson appropriate use criteria, pocket cards • Patient education—e.g. educationdirectly targeted to patients, shared decision-making Colla et al. Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review. Medical Care Research and Review. 2017, Vol. 74(5) 507–550.

48. One Size Does Not Fit All • Growing availability of data allows for mass customization: • Personalized implementation of EBP • Attention to differential needs in the design of implementation • Avoid worsening disparities

49. Deep Learning in Healthcare Norgeot, Glicksberg, Butte, Nature Medicine, 2019

50. The Work Never Stops: Sustaining & Scaling • Sustainment: • Benchmarking, data feedback • Recognition systems • Incentives • Scaling: • Training • Implementation toolkits • Technical assistance, facilitation • Learning collaboratives • Policy change