Population M anagement

1. Population Management November 2017

2. Take home points • Quadruple Aim is the goal • Primary care is vital to achieving these aims • Empanelment, Panel Management, Health Coaching and High Risk Care Management are effective strategies for practice-based population management

3. Objectives • Outline the concept of population management.  • Understand the fundamentals of empanelment and risk stratification.  • Describe methods to initiate and sustain practice based population management. • Walk away with one idea to try out in your clinic.

5. Population Health Contributors From: RWJ

6. Population management 101 • What is it?

7. Population management 101 • What is it? • “The science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.” • CEA Winslow – an original definition of public health

8. What is the population management trying to achieve? The Big Picture

9. System designs that simultaneously improve three dimensions: • Improving the health of the populations • Improving the patient experience of care (including quality and satisfaction) • Reducing per capita cost of health care

10. System designs that simultaneously improve three four dimensions: • Improving the health of the populations • Improving the patient experience of care (including quality and satisfaction) • Reducing per capita cost of health care • Care team well-being

11. Population management • So where does population management fit into primary care?

12. Bodenheimer, et al. Annals of Family Medicine. 2014

13. Population management • Practice-based strategies: • Empanelment • Panel management • High risk care management • Health coaching (for another time) Bodenheimer, et al. Annals of Family Medicine. 2014

14. Empanelment Who are our patients?

15. Empanelment • A process of linking each patient to a care team and a primary care clinician • A deliberate attempt to identify the group of patients for whom a clinician or team is responsible

16. Importance of Empanelment • Establishing which patients are assigned to which physicians is important • It makes patients happier • It defines the workload • Helps predict patient demand • Necessary to measure provider performance • Improves outcomes

17. Defining Clinic Populations • Two Approaches: • Community-wide population: Working in a defined geographic area to accomplish the Triple Aim for a community • Defined population: A population that makes business sense around the Triple Aim

18. Tools to help Patient panel size worksheet can be found here: www.aafp.org/fpm/2007/0400/p44.html More on our Resource Hub: resourcehub.practiceinnovationco.org/search/empanelment

19. *Not All Panels Are Equal • Sex, age, illness burden, and socioeconomic status all can affect the “demand” of a panel on providers, teams, and clinics • With even basic data (sex, age, visit numbers) a clinic can adjust panels more accurately • More sophisticated systems can utilize more complicated factors like multi-morbidity, mental health, social determinants

20. Practice Reflections

21. Questions on Empanelment?

22. Panel Management Once you have a list of patients, what do you do with it?

23. Registries Gaps In Care +Team Based Workflows Panel Management

24. Registries • Can focus on particular subpopulations • Disease specific (ie DM, HTN) • Prevention (ieimmunizations, cancer screenings) • Utilization (ie Frequent ER users, recent discharges)

25. Registries • Can focus on particular subpopulations • Disease specific (ie DM, HTN) • Prevention (ie immunizations, cancer screenings) • Utilization (ie Frequent ER users, recent discharges) • Or panel-wide • Key indicators and needed services for all empaneled patients

26. Registries • Lumping patients with similar needs to streamline work and evaluate outcomes • Start with the basics, advance to predictive risk stratification • Subpopulation vs. Intervention – which comes first?

27. Gaps In Care • Goal is to perform all recommended services for a patient regardless of their reason for visit • Can be carried out at the point of care or through asynchronous communications

28. Registries alone don’t improve care. Teams do!

29. Practice Reflections

30. Questions on Panel Management?

31. High Risk Care Management

32. Why Target Complex Patients

33. Top 5% of patients account for 50% of Costs

34. Haas, et al.American Journal of Managed Care. Sep2013, Vol. 19 Issue 9, p725-a735. 11p.

35. Who are the 5% ? Most Intense - Homeless, Schizophrenia, etc • Intense • Multiple unstable chronic illnesses • Depression + anything else • High Utilization • - Other issues (frail, social, financial, etc.) • Moderate • Well compensated multiple diseases • Single diseases • Bio-psycho-socially stable

36. Identification Methods • Thresholds – Certain number of visits or medications or biomarkers • Algorithms – combinations of diagnoses or assessment results • Provider identification – just ask the clinicians

37. Developing a complex care management system Summary: • Define the business case • Determine outcomes for success • Identify and stratify patients • Develop model of care delivery • Structure care management services • Enroll patients • Learn, adapt, grow More on our website at: http://resourcehub.practiceinnovationco.org/search/risk+stratification

38. Practice Reflections

39. Questions on high risk care management?

40. Wrap up

41. Practice Reflections

42. Take home points • Quadruple Aim is the goal • Primary care is vital to achieving these aims • Empanelment, Panel Management, Health Coaching and High Risk Care Management are effective strategies for practice-based population management

43. Resourcehub.PracticeInnovationCO.org