NCA Clinical Workforce Development, Team-Based Care 2019 Webinar Series
Webinar broadcast on: May 23, 2019 | 2 p.m. EST
In this webinar experts will share their journey in planning, preparing and launching a population health initiative. With the goals of impacting population health outcomes while ensuring cost effectiveness, our experts designed interventions to eliminate gaps in care, particularly among special populations.
2. Expert Panelists
Margaret Flinter APRN, PhD, FAAN
• Senior Vice President/Clinical Director & Co-PI, NCA
Tierney Giannotti, MPA
• Senior Quality Improvement Manager of Population Health
Mary Blankson, DNP, APRN, FNP-C
• Chief Nursing Officer
Bethany Buckridge, BSN, RN
• Population Health Nurse
Robert Block, CPA
• CHCI Chief Financial Officer
3. Do you have an employee with
population health in their title?
• Yes
• No
• Uncertain
4. Disclosure
• With respect to the following presentation, there has been no relevant
(direct or indirect) financial relationship between the party listed above (or
spouse/partner) and any for-profit company in the past 12 months which
would be considered a conflict of interest.
• The views expressed in this presentation are those of the presenters and
may not reflect official policy of Community Health Center, Inc. and its
Weitzman Institute.
• We are obligated to disclose any products which are off-label, unlabeled,
experimental, and/or under investigation (not FDA approved) and any
limitations on the information hat we present, such as data that are
preliminary or that represent ongoing research, interim analyses, and/or
unsupported opinion.
5. Get the Most Out of Your Zoom Experience
• Use the Q&A Button to submit questions!
• Live tweet us at @CHCworkforceNCA
• Recording and slides are available after the
presentation on our website within one week
• View past webinars at www.chc1.com/nca
7. The Weitzman Institute works to improve primary care
and its delivery to medically underserved and special populations through research, innovation, and
the education and training of health professionals.
Weitzman Institute
7
8. Provides education, information, and training to interested
health centers on:
Transforming Teams
• National Webinars on the team
based care model
• Invited participation in Learning
Collaboratives to launch team
based care at your health center
Training the Next Generation
• National Webinar series on developing nurse
practitioner and clinical psychology residency
programs and successfully hosting health
profession students in health centers
• Invited participation in Learning Collaborative
to implement these programs at health center
National Cooperative Agreement
Clinical Workforce Development
9. Learning Objectives
1. Define population health
2. Assess your health center’s progress in
implementing key components of
population health
3. Identify strategies to integrate initiatives
focused on population health
4. Examine an approach to estimating the
financial return on investment for
population health
10. • Kindig and Stoddart’s definition from 2003 was “the health outcomes of
a group of individuals, including the distribution of such outcomes
within the group.”
• Definition evolved with the recognition of the need to incorporate the
role of healthcare providers in impacting those outcomes.
• Since then, various entities, (e.g., CDC, RWJF), have adopted a more
interdisciplinary approach, that highlights the importance of non-
traditional partnerships among different sectors in achieving positive
health outcomes.
• Focuses on populations “within specific geopolitical area” and goes
beyond their clinical health to include “social, economic, environmental,
and individual behavioral and genetic traits.”
Defining Population Health
Sources:
1. Kindig D, Stoddart G. What is population health? American Journal of Public Health 2003 Mar;93(3):380-3.
2. The National Association of Community Health Centers. “Population Health Management Factsheet.” (2015) Retrieved from;
http://www.nachc.org/wp-content/uploads/2015/12/NACHC_pophealth_factsheet_FINAL.pdf
11. 1. Improve patient
outcomes
Goals of Population Health
2. Increase
purposeful
spending and
reduce wasteful
spending
3. Secure appropriate
reimbursement from
value based work
12. Framework Adaptation
Adaptation of two population health frameworks:
• National Association of Community Health Centers (NACHC), proposed eight
“Action steps toward population health management”.
• Partnership (RWFJ Funded) among American Hospital Association/Health
Research & Educational Trust, Institute for Healthcare Improvement,
Network for Regional Healthcare Improvement, Public Health Institute, and
Stakeholder Health, to create “Pathways to Population Health: An Invitation
to Health Care Change Agents”.
The NACHC Population Health Management factsheet can be found at http://www.nachc.org/wp-
content/uploads/2015/12/NACHC_pophealth_factsheet_FINAL.pdf
Stout et al. Pathways to Population Health: An Invitation to Health Care Change Agents. 2018. Retrieved from
http://pathways2pophealth.org/files/Pathways-to-Population-Health-Framework_102218.pdf
13. Framework
Improve Health of the Population
– Data
– Team-Based Care
– Behavioral Health Integration
– Care Management
Improve Social Well Being of the Population
– SDOH Screening and Referrals
– Health/Community System Partnerships and
Communication
Systems Issues to Consider
– Redeploy staff
– Financial Return on Investment
14. Organizing Patient Data
• Consider all data sources
• Assign patients to
panels/Empanelment
• Develop and use patient
registries
• Outreach to patients you
may not have met
Improve Health of the Population
15. Risk Identification
• Risk scores generated from internal and/or
external using different methodologies
• May use patient’s prior history of ER visits,
admissions and/or conditions, health
outcomes, SDOH
How do you decide who within the population to
focus on?
• Dashboards, leveraging the team, etc.
Risk-Stratification
Improve Health of the Population
16. Do you collect and/or use risk
scores?
• Yes
• No
• Uncertain
17. • Provide access to actionable data directed to the
appropriate team members
• Care gaps for patients here for a visit today
• Hospital admissions and discharge lists
• Consider method of dissemination
• Within the EHR
• On dashboards updated daily/monthly
• Via Excel files
Population-Specific Interventions Require
the Use of Data
Improve Health of the Population
18. Do you get notification when
patients are admitted and/or
discharged from the hospital?
• Yes
• No
• Uncertain
20. Elements of Planning for a Population
Health Approach
• Centralized
approach
• Decentralized
approach
21. • Increase pediatric behavioral
health screening
• Implement Medicare Annual
Wellness Visits
• Reduce unnecessary
emergency room visits
Population-Specific
Interventions To:
Improve Health of the Population
22. 22
How Behavioral Health Integration
Supports Population Health
Medical initiated warm hand-off and behavioral health initiated warm hand-off
• Reactive: Initiated by medical provider (e.g. medical screenings)
• Proactive: Initiated by BH provider based on dashboard
• BH diagnosis and no BH visits
• Health related diagnoses that can impact emotional health
• e.g. opioid prescription, chronic pain diagnosis, nicotine use diagnosis)
• High risk patient can be a client with a PHQ score over 15 (moderately severe)
24. How Telehealth Supports
Population Health
Improve Health of the Population
Health centers have increasingly recognized the potential for
telehealth, in its various forms, to address service and access
gaps resulting from provider shortages
• eConsults
• Synchronous
• Asynchronous
25. Nursing Visits/Co-Visit with BH (in-
between provider visit surveillance)
• Routine prescription
monitoring programs (PMP)
Checks (delegate status)
• Medication Reconciliation
• Side Effect Surveillance
• Random/Routine Toxicology
• Controlled Substance
Agreement Review/Signing
Nurse Care Management Supports Population
Health
Improve Health of the Population
26. How Ongoing Training and Education Supports Pop Health
Complex Care Management, which is a telehealth model that
creates a knowledge network for nurses
Includes both didactic
and case-based
learning, where
frontline nurses and
student nurses can
present complex cases
and get feedback and
support from a multi-
disciplinary team of
experts on next steps in
their care planning
Improve Health of the Population
27. Focusing on SDOH Screening and Referrals
Supports Population Health
Improve Social Well Being of Population
Some SDOH to Consider:
• Housing
• Utilities
• Access to Food
• Safety
Social determinants of health (SDOH) are conditions in the
environments in which people live, learn, work, play, worship, and
age that affect a wide range of health, functioning, and quality-of-life
outcomes and risks. SDOH contribute to 40-50% of health outcomes.
Sources: US Department of Health and Human Services. (2013). Healthy People 2020
topics and objectives. Washington, DC.
Artiga, S., & Hinton, E. (2018). Beyond health care: the role of social determinants in
promoting health and health equity. Health, 20, 10.
28. Engage with community based
agencies
• 211
• Food pantries
• Community Action Teams
• Community Collaboration
Meetings (CCTs-Hospitals)
• School-Based Health
Centers
Health/Community System
Partnerships and
Communication
29. Review the roles of
existing staff:
• Changes to job
descriptions
• Break up tasks
among different
roles when
implementing
new processes
Redeploy Staff
Systems Issues to Consider
30. In a study published in 20171, a risk-stratified primary care
delivery model that used population health strategies and
predictive modeling to match clinical resources to patient needs
reduced inpatient and total spending, at a ratio of $4 saved for
every $1 spent on the program.
In the study period, payers saved $15.8 million (1.7% of risk
adjusted expected cost) during a 26-month implementation
period with a cost of $3.9 million.
Financial ROI
Sources:
1. Johnson T, Heijde M, et al. Population Health in Primary Care: Cost, Quality, and Experience Impact. The American Journal of Accountable Care
2017 Sept;5(3):10-20.
31. Additional Reimbursement
Return on Investment (%) = ------------------------------------ - 1
Additional Annual Expense
Financial ROI
For example, annual cost of Population Health program is $500,000, and
additional reimbursement is $700,000, then ROI is 40%:
$700,000
ROI = ------------ - 1 = 1.4 – 1 = 40%
$500,000
32. Financial ROI
Additional Potential Reimbursement:
1. Monthly PMPM for attributed patients
2. Shared Savings payments
3. Quality Improvement payments (including HRSA)
4. Value Based Payments from Private Payors for
Achieving Targets
33. Financial ROI
Additional Expenses:
o Salaries/Fringe of Enhanced Care Team
o IT Hardware
o IT Software
o Risk stratification, clinical decision support
o Annual IT Maintenance/Support
o Salaries/Fringe of Evaluation personnel
o HIMs, informaticists, data scientists, data analysts
36. Visit our National Learning Library
Contact us at nca@chc1.com
www.chc1.com/nca
37. Resource Highlights
National Learning Library
www.chc1.com/nca
February 15 | Taking Team-Based Care to the Next Level Video Slides
February 22 | Advancing the Practice of RNs and Behavioral Health Providers
Video Slides
February 27| The Vital Role of Behavioral Health: Effective Integration in a
Model of Team Based Care Slides
Editor's Notes
Tierney---
Pop health was focused on health outcomes and measures– left out providers– easily interchangeable with public health
Pop health and public health are related but not interchangeable
Public health department now includes health care providers, private sector, multi-stakeholder approach
Transition--- Tierney gives context to her story/work as the pop health manager
Triple aim*** addition to this slide?
Margaret rewording***
Investment (purposeful spending)
Lead and drive the movement towards VBC fair payment and reimbursement for our efforts for vbc--- lead innovations---***
PCMH Plus content– % of patients into a value based payment arrangement
Tierney
Copy and paste the beautiful portion here***
In 2018 five partner organizations: American Hospital Association/Health Research & Educational Trust, Institute for Healthcare Improvement, Network for Regional Healthcare Improvement, PuPooled resources to create “Pathways to Population Health: An Invitation to Health Care Change Agents”. A framework to support health care professionals to make practical, meaningful, and sustainable advancements in improving the health and well-being of the patients and communities blic Health Institute, and Stakeholder Health. they serve.
Pathways to Population Health is committed to providing a clearer and more coherent understanding of what it means for health care organizations to be on the journey toward population health. This collaboration is facilitated by 100 Million Healthier Lives, a movement of change agents working to transform the way we think and act to create health, well-being, and equity.
Tierney
Weave PCMH recognition throughout these themes
Tierney
Title revision– ‘Every patient belong to someone’ ‘Organizing the Data: The Who’ ‘Organizing Patients/Patient Data’
Empanelment punch on that content- every patient belong to some bodies** Share provider or share the condition or share the risk factor
Not everyone calls them patient registries– not always notes in the literature--- other places population based dashboard– electronic tool– track the populations--- modules– names, understanding the bucket may be called different things--- full range of ways to present
Patient registry (E.g., PCP panel)
Know the population- look at the sub populations
Using panels- look at different conditions (opioids, diabetes)
HCs can choose a variety of conditions to focus
Managing the care of that population
*Transition note: Accountable care requires identifying who is held responsible for orchestrating care—tests—if not within the org—then who beyond the HC (specialists) are needed
Tierney
Risk- Stratification– only way we have risk scoring may be because Medicaid managed care sends it to us or your eCW autocalculate– if you have the opportunity to risk score– or getting it from a partner– Medicaid authority
Example– risk score and now look at that data– identifying how we can do different--- or digging deeper and noting who you will focus on more specifically
People may ask– how do you risk stratify? Off in the verbal component--- payers will provide risk attribution--- more of the org responsible is on how do you use that data once you have stratified? How do you decide within the population who is making those decisions?
Tierney
Example: Care of the individual– means we have the dashboard when they arrive for the visit– colonscopy gets ordered– came in and it was ordered– dashboard was the care of the individual– individual dashboard back to pop health
Data is overarching concept– what is the type of data? Improvements, patient health outcomes, experience, ROI
Tierney
Managing transitions in care--- ping shows whether they’ve been admitted– getting the care team into action--
Centralized vs Decentralized examples:
-Triage calls
-Diabetes – patients here today and patients
-Homeless patients
Data– from playbooks– screenshots
Medicare- Bethany
Margaret- 2
Mary- 3
Double check with Tierney on bullets****
3 people
Adding urgent care/24 hour advice line
Beth
Combining---
Mary
WHOs
-Reduce no shows for initial appointment
-Brief
-Issues can be resolved in the single visit
Chelsea-
Intent--- Quick recap of the way that patients get from medical to BH
Mary
Planned Care in Behavioral Health
Delivery of Integrated Services
D: we’ve created this collaborative care dashboard that allows BH to ensure that all care that is needed is delivered
Transition: in addition, we are using a data-driven approach to enusring patients in medical who need BH services are proactively made know.approached…
Mary--- revise the slides**
Mary
The role of the nurse in our agency is to assist both medical and behavioral health. One of the most common ways I support BH is through nursing visits. Nurses have their own independent schedule where following protocols, standing orders and directed orders, we can assist our patients and providers outside of their other appointments.
Every patient on a controlled substance agrees to a controlled substance contract or agreement which entails routine substance monitoring and drug testing for patient safety. This is a common visit for nurses where they collect a drug screen from the patient, provided education on medication safety and check in on their status, potential side effects, potential substance abuse, and more, and report back concerns to the provider.
Often nurses help BH providers through medication reconciliation visits, side effect surveillance and education when starting new medication, routine medication prepours, EKGs prior to medication initiation, medication counts, and much more.
Mary
Sent to April Joy-
Beth
Definition– April Joy--- where people work, play live and learn– provide statistics** SDOH--- Give less that are controversial– Revisie these bullets– Destinction between further upstream factors—
Beth– noting that they are well familiar on this– using a formal tool CMS.. What do you do?
Take home– webinar onto it’s self– SDOH screenings– very important that people are looking at it– think about coding– codes have direct ties to risk scores– reimbursement
Beth/Mary
Tierney
Make it more general on the strategy***
Chaning the JD--- changing what’s on their plate– scope of practice to leverage to do this work--- creating a place for the framework for this thinking– Ratios/staffing--- are those the right things on their plates? Staff and time.
Intent is that this is the conclusion– Need to determine bullets for this
Health catalyst--- moving to pop. Health increase in efficiency--***