Achieving Triple Aim Results

Transcription

1 IHI 2014 National Forum D28/E28 These presenters have nothing to disclose Managing Populations George Kerwin, CEO/President, Bellin Health Pete Knox, Executive Vice President, Chief Learning & Innovation Officer Bellin Health December 10, 2014 Achieving Triple Aim Results 2 1. Strategic alignment 2. The framework for managing populations 3. Specification for the new production system 4. Examples of managing populations Bellin employees/family members NWTC employees/family members Pioneer population Disabled populations The Algoma Community 5. What are we learning 6. Questions & Answers 1

2 Objectives: 3 1. Provide a framework for strategic alignment of population management within the organization 2. Provide a set of comprehensive specifications for the new production system required for successfully achieving the Triple Aim within defined populations 3. Demonstrate success with a variety of poplations using new production system framework Bellin Health Overview Serving a market of 600,000 people Bellin Hospital, a 220-bed community hospital with proven excellence in heart and vascular care; orthopedics and sports medicine; family programs and services; cancer care; and minimally invasive procedures including robotic surgery Bellin Health Oconto Hospital, a 10-bed critical-access hospital in Oconto Bellin Medical Group and Bellin Health NorthReach, a 114- member primary care group with 32 clinic sites and proven excellence in disease management and wellness care Employer Clinics, 115 clinics located within employer facilities FastCare Retail Clinics, 4 retail clinics located in grocery and discount retail stores Physician Partners, Ltd, more than 180 independent specialty physicians and mid-level providers Bellin Psychiatric Center, a dominant provider of in- and outpatient behavioral health services, staffed by 7 psychiatrists, 4 psychologists and 21 therapists Unity Hospice, providing hospice and palliative care services 2

3 5 6 MANAGE POPULATIONS TO ACHIEVE THE TRIPLE AIM AIM PRIMARY DRIVERS 100% of cost, health & experience targets are met according to the aligned agreements we enter into with each Partner where Bellin has risk for an attributed population High Functioning Patient Care Knowledge of Population Connected Experience Across Continuum Medical Utilization Management Partner Relationship Management Engaged & Activated Consumer 3

4 7 MANAGE POPULATIONS TO ACHIEVE THE TRIPLE AIM Primary Driver SECONDARY DRIVERS Care Delivery Model Based on Risk (High, Rising, Low) High Functioning Patient Care Customized Team-Based Culture Risk Stratification Infrastructure Convenient Access to Care Team 8 MANAGE POPULATIONS TO ACHIEVE THE TRIPLE AIM Primary Driver SECONDARY DRIVERS Provide the System with Knowledge of the Population at the Executive Level Knowledge of Population Provide the System with Knowledge of the Population at the Mezzanine Level Provide the System with Knowledge of the Patient at the Point-of-Care Level Provide Scorecards for Strategic Partners Based on Aligned Goals 4

5 9 MANAGE POPULATIONS TO ACHIEVE THE TRIPLE AIM Primary Driver SECONDARY DRIVERS Aligned Care Team & Coordinated Network of Partners Connected Experience Across Continuum Shared Patient Information Longitudinal Care Plan Standardized Care Pathways Standardized Communication & Information System Across the System Community Connections 10 MANAGE POPULATIONS TO ACHIEVE THE TRIPLE AIM Primary Driver SECONDARY DRIVERS Identify & Acquire Needed Clinical Data Analyze Clinical Data for Variation & Trends Medical/ Utilization Management Use Data Usage Opportunities for Action to Reduce Cost &/or Improve Care Manage Adherence to Defined Practices & Protocols Report on Clinical Utilization to the Customer/Payer Partner with Operations to Manage the Clinical Aspects of the Onsite Care Team 5

6 11 MANAGE POPULATIONS TO ACHIEVE THE TRIPLE AIM Primary Driver SECONDARY DRIVERS Aligned Payer/Employer Partner Relationship Management Aligned Expectations Quantify & Measure Employer Satisfaction Retention & Expansion 12 MANAGE POPULATIONS TO ACHIEVE THE TRIPLE AIM Primary Driver SECONDARY DRIVERS Personal Activation Engagement Engaged and Activated Consumer Culture of Health Health Literacy/Activation System of Resources & Support 6

7 Goals and Results 7

8 Service Delivery

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10 Road Map 10

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12 23 Aim Statement 2014: Build the "perfect" pilot that is scalable throughout the medical group by December 31, 2014 Vision: A Healthier Patient Who is Empowered to Better Manage his/her own Health with support of the Bellin Health Medical Team 2015: Spread process for prototype of Team Based Care to 50% of BMG Accomplishments in the Last 120 days Pilot Patient Care Redesign in BMG Continue using the tool to progress through the steps of the redesign o Measure o Analyze o Design o Verify Gain approval to implement redesign plan pilot (Additional Roles) Advisory Board Consultants 1 st Work Primary Care Cultural Transformation Added: Combine Status Report from NWTC And HFPC Added: Advisory Board Focus on Care Management Across the System High Functioning Patient Care Sponsor: Lois Van Abel Date: Nov 2014 Feb 2015 Measurements Outcome Measures NWTC Goal: $ (med & RX ONLY) HRA avg:79.7 Process Measures NWTC Goal: 50% of Wellness Certificates submitted Balancing Measures Guiding Principles -3 Wins Win for Patient Quality Measures Patient Satisfaction Access Win for Care Team Care Team Satisfaction Patient Panel Health Win for System Value Based Purchasing Received ROI Team Members Executive Sponsor Pete Knox Sr. Operational Lead Lois Van Abel Project Manager Rob MacNeil Driver Owner - Dr. Jerzak, Dr. C. Laseki, Dr. Bongiorno, Dr. B Wozney Team Members: Bart Miller Kathy Kerscher Marcus Oksa Green Lessons Learned Communication is key to change management and to obtain buy-in It s difficult to get all the necessary input that is needed to create new processes. Next 120 Day Commitment -Implement Pilot Protoype -Monitor and Optimize Pilot Design Prior to Spread -Spread to Dr. Jerzak s Pod -Spread to Providers on Redesign Team -Train new NWTC CMA on health coaching -Virtual Component of Disease Management -Phase 1 Disease management -Phase 2 health coaching & disease management. -Comprehensive brand plan to connect to employer -Analyze and Implement Care Management Recommendations from Advisory -Complete the Brand / Employer Matrix 12

13 High Functioning Patient Care Sponsor: Lois Van Abel Date: Nov 2014 Feb 2015 What do we need from Brand and Support Areas for success in the next 120 Days IT Support to assist in development of the templates needed for documentation and ordering Decision Support to create reports and baseline/ongoing measurements Physician Division to support time and expense for the prototype to be implemented O.D support for training Brands to support Care Management Recommendations Brand matrix completion Competency Grid Building the New Production System (120 Day Plan) 26 Patient Care Redesign Employers NWTC Develop Roles and Responsibilitie s for all Care Team Members West De Pere Partners Kryptiq Knowledge of the Population Training on Vitreos, CareManager, and CWM Connected Activated and Experience Engaged Consumer Train on all Creating a Workflow Establish 3 CarePathways for High Risk Patients year goal with Non-BMG Providers. Train Wellness Consultant, Train E-Visits. Modify Culture Survey for Marinette. Roll out Telemed in Marinette Partner Medical Employer Utilization Relationship Management Share Provider Adherence to Evidence Based Pathways 13

14 27 Specifications for the New Production System 28 14

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19 37 Spread based upon the Managing Populations platform 38 Communities Distinct Populations ex: Disabled Population Collaboration of Employers Other Employees Bellin Employees Driver Diagram Framework & Infrastructure 19

20 Case Example: Bellin Health 39 Triple Aim Measures Case Example: Bellin Health 40 Average HRA Score for Employees and Spouses 20

21 Case Example: Bellin Health 41 Percent of Employees and Spouses with a Low (0-50) HRA Score Case Example: Bellin Health 42 Percent Wellness Certificates Completed 21

22 Case Example: Bellin Health 43 Percent Increase in Cost per Employee Plan per Year NWTC POPULATION DATA Total Patients Attributed 1117 No Data 42 Remaining Claims EHR HRA Durations Claims data duration EHR Data HRA Data 2011 April 2014 March 2005 to up to 2014 June 2011 January to 2014 April Total Counts Total claims 64,773 Total admissions

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26 PIONEER RNCC DATA 51 Rate Compliance w/pioneer 33 Metrics Average Cost of Care (Before= Calendar Year After = Jan- June) ED Claims (Jan- June Comparison) Bellin Before RNCC Bellin After RNCC Bellin Before RNCC Bellin After RNCC 53.39% 71.75% 60% 74.46% $1, $ $2, $1, Vision 52 Algoma School District and Bellin Health create a strategic partnership to help Algoma become the healthiest community in Wisconsin. 26

27 Achievement 53 Achieving the vision: Focus on the determinants of health Community activation Coordinated/integrated services Community health/wellness navigation Algoma School District as Integrator Overview 54 Agencies Employers Restaurants Titletown Wellness Healthy Algoma Partnership between Algoma School District and Bellin Health Government Individuals & Families Local Retail Schools Coordination & Integration 27

28 Healthy Algoma 55 $ Fee Schedule $ Withhold WPS Providers GOALS Independent Specialist s Bellin Community 2015 Distribution Achieving the Triple Aim for a Disabled Population 56 Aspiro NEW Curative CP Center STATE Medicaid Resources Data Integrator 5,000 Clients Triple Aim Results Managing Population Driver Diagram Bellin Health 28

29 A Population Health Partnership 57 AIM To improve health, reduce costs and improve the experience (Triple Aim) for the following populations. Clients of Aspiro, N.E.W. Curative, and The CP Center Family members of clients Employer and family members of Aspiro, N.E.W. Curative, and The CP Center What are we leaning? As we build more of the production system it allows us to get more innovative. 2. The essence of the work is based in our learning about Triple Aim. 3. We can control the pace. 4. Payers are willing but nervous. 29

30 59 Specifications for the New Production System 30