Medical Home: The Interface between Personal Health and Public Health

1. Medical Home: The Interface between Personal Health and Public Health Caring for Individuals Attending to Populations Florida Medical Home Demonstration Project Orlando, Florida Learning Session 2 – April, 28, 2012 W. Carl Cooley Jeanne W. McAllister Center for Medical Home Improvement

2. Disclosure We have no disclosures of conflicts of interest or financial relationships related to this content.

3. Agenda The relationship between individual health and population health – why it’s important Defining Practice-based Population Health (PBPH) Some tools for PBPH Related PBPH to the health of the community

4. Population Health Experience • Have you introduced any population health tools (registries, reports, tracking) during this learning collaborative? • Who has been expected to document/report on the health of a population within the practice? • Patients with asthma • Immunization status or state immunization registry • Did the reporting help to improve care? How? • Was reporting associated with incentives? penalties?

5. Who the heck are Hygeia and Panacea? "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 . . ."

6. Two of the daughters of Asclepius • Hygeia = health, prevention of sickness, sanitation • Public health • Panacea = universal remedy, healing, treatment • Personalhealth

7. Triple Aim – the only path to high quality health care that is affordable

8. Cost of care per patient • Improve (lower) the cost of care • Avoid sacrificing quality • Avoid waste • Muda - using resources without adding value • Measurement

9. Experience of care • Improve the individual patient experience • Six dimensions of IOM report – care that is: • Safe • Effective • Patient-centered • Timely • Efficient • Equitable • Measurement

10. Population health • Improve the health of a population • Define a population • Patients with special health care needs • Patients with asthma • Patients with rising BMI • Patients transitioning to adult health care • Measurement

11. PBPH – Practice-Based Population Health *Practice-based population health: information technology to support transformation to proactive primary care AHRQ publication no. 10-0092-EF, July 2010 The Agency for Health Quality Research (AHRQ) defines practice-based population health (PBPH) “as an approach to care that uses information on a group (“population”) of patients within a primary care practice to improve the care and clinical outcomes of patients within the practice. PBPH changes the focus from reacting to the ad hoc needs of individual patients to proactive management of a practice’s patient panel.”

12. Medical home functions are interrelated • The tools of practice-based population health are also the tools of care coordination • Reports of the results of your care for populations inform: • Your care of individual patients • Your staff regarding the practice’s quality results • The families of your patients who are interested and a good source of feedback about improvement • Data about the populations of patients in your practice can inform public health officials about the health of the community at large – enhancing your community connection

14. Preconditions for practice-based population health • Specify a population of concern – broad or narrow • Keep a registry with sub-populations • CSHCN • with asthma • with diabetes • In the transition age group • Well children • in need of autism screening • in need of immunizations • at risk for obesity • Develop and track measures of population health • Use of controller medications in asthma • HgbA1C • % age 14 to 16 with transition plan • % age 24 months screened for autism

15. Why population health? • Tracking • Untracked lab work is either wasted or didn’t happen • Either way it doesn’t contribute to improved care • Anticipating • Knowing who needs what care produces • Better outcomes, more efficient use of resources • Monitoring • Monitoring is both tracking and measuring • Measuring population health is measuring quality • Reliability • Tracking is only way to be sure of… • The best care for every patient every time

16. Tools of population health Registries Reports Tracking

17. Registries • Database or spreadsheet • Paper or electronic • EHRs and registries • Contains fields • relevant to the population • relevant to measuring quality of care • More dynamic than periodic reports • May form “case load” for care coordinator or “special interest” team • Populate retrospectively or prospectively

18. Children with Special Health Care Needs Registry – example (names removed)

19. Registry to track newborn screening results and follow-up

23. Registry – Brief Team Time – 5 min • Identify a population for a registry • All children/youth with special health care needs • ?Stratify by complexity • Specific condition • Group for screening, e.g. all 18 month olds • Age group • How would you create this? • Who would be responsible for the registry? • Who would see/use it? • How could it improve care?

24. Registry Discussion from Teams5 minutes

25. Reports • More static than registries • Reports are difficult without an electronic information system to generate them • Registries can generate reports • Used to monitor identified QI goal or regulatory/quality requirement • Improved diabetes outcomes • Improved developmental screening rates • Immunization rates • Value of reports • Stimulate further quality improvements • Must be shared with all staff (shared stake in outcomes) • Consider sharing with families (shared stake in outcomes)

26. Reports – Brief Team Time – 5 min Think of 3 reports that would help you improve care for 3 different populations How would you create these reports? How often? What would you do with the data? With whom would you share the data? How could families provide advice about report? Can families see results?

27. Reports Discussion from Teams 5 minutes

28. Tracking • Monitoring follow-up of actions • Lab work referrals • X-ray referrals • Consultation referrals • Transition in care • Medication reconciliation

29. Tracking • What was the action, did it happen, do we have the result, does the patient have result? • Is further action needed? • Tracking improves • Population health outcomes • Patient safety • Waste reduction

30. Tracking tool for specialty consultation referrals

31. Tracking tool for laboratory tests

32. Tracking – Brief Team Time – 5 min Identify a tracking task that you currently do or could do Who monitors the tracking? How is action taken on tracking results? Are reports generated from tracking?

33. Tracking Discussion from Teams5 minutes

34. Medical Home – The Interface between Panacea and Hygeia – between personal health and public health – between your practice and your community

35. General Q and A/Discussion