Practice Transformation Academy Kick-off Meeting

Practice Transformation Academy Kick-off Meeting The Care Transitions Network National Council for Behavioral Health Montefiore Medical Center Northwell Health New York State Office of Mental Health Netsmart Technologies

Value in Value-Based Payments = Quality Cost

Payments Continuum Source: J. Rubin Principle Health Management Asso. 2016

Contracting with a Payer Or $

If a tree falls in the forest and no one collected the data, it didn t make a sound.

Value in Value-Based Payments = Quality Cost

Value-Based Payment Readiness Patient- and Family- Centered Care Design Data-driven Quality Improvement Sustainable Business Operations

Phase of Transformation (Milestone 13) 7/10 organizations in Phase 1 3/10 in Phase 2 PAT Scores and Trends Population Management (Milestone 7) 5/10 have a system for identifying high risk patients, but the identification process for other risk levels is inconsistent or not yet standardized Quality Improvement Milestones (14, 15, 16) 5/10 have not yet identified an organized QI approach 6/10 have a limited number of staff who are trained and participate in QI activities 8/10 produce reports on provider/care team performance, but distribution is limited, they may not be shared in a fully transparent manner, and follow up is inconsistent

Aligning our Terms! Value-based Payments requires Risk Stratification which requires Population Health Management therefore these concepts are not loosely linked but are structurally contingent on one another.

Population Health Management A set of interventions designed to maintain and improve a patient s health across the full continuum of care from low-risk, healthy individuals to high-risk individuals with one or more chronic condition. (Felt-Lisk & Higgins, 2011) Population management requires providers to develop the capacity to utilize data to risk stratify patients into groups and then respond to the needs efficiently and effectively.

The Promise of Population Health Management Promotes a culture of measurement & problem solving Brings together utilization review focus on cost with clinical care focus on outcomes in other words it provides means to see how quality metrics are linked to cost

Principles of Population Health

Components of Population Health Management 1. Knowing what to ask about your population 2. Data registry to describe/risk stratify your populations 3. Proficiency with quality improvement tools to respond to the findings 4. Continuous quality improvement policies/procedures to sustain data specification targets

Common Indicators Used to Stratify Risk Behavioral Health Diagnosis Schizophrenia, Bipolar, Depression & Anxiety, PTSD & Stress, SUD Hospitalization Utilization Rates Re-hospitalization Rates Emergency Department Utilization Rates Medical Co-morbidities Social Determinants of Health

Overview of the Phases of Planning Activity Definition Activity Sequencing Activity Resource Estimating Tool: Network Diagram Activity Duration Activity Schedule: Calendar Tool: Gantt Tool: Work Breakdown Structure

Stretch Project Planning Guiding Questions Throughout the day please consider the following questions: 1. How might your stretch goal change from your original proposal? 2. Who will you include on you transformation team and why? 3. What metrics will you use to measure your effectiveness toward this stretch goal? 4. What are your anticipated barriers to meeting your stretch goal?

Log Frame Process Using a logframe (logic model) is one way to develop a clearer understanding of the goals and objectives of a project, with an emphasis on identifying measurable objectives, both short-term and long-term. Narrative Summary Indicators Data Sources Assumptions Goal Objectives/Outcomes Outputs Activities Project Results Project Deliverables If the horizontal logic is followed AND assumptions hold true; Then the project will likely succeed.

Support my organization to make the paradigm shift to population health management. Determine what metrics are needed to capture new care pathways for our high risk/high cost populations. Increase reliability of financial, clinical and patient experience data. Sample Stretch Project

Exercise: Develop Your Stretch Project Log Frame Narrative Summary Indicators Data Sources Assumptions Goal Make the paradigm shift to population health management to improve patient outcomes Objectives/Outcomes Improved care coordination Reduced re-hospitalization rates Percent of high risk clients receiving care coordination/ care management Medicaid data EHR Coordinated/managed care will improve health outcomes Outputs Established risk stratification approach to investigate client population 1. Percent of clients with established care pathways 2. Percent of high risk clients referred to care management EHR Care pathways will be followed and patients will be referred Activities 1. Identify common indicators used to stratify risk 2. Design and implement data registry 3. Identify operational workflows to support risk stratification processes 1. Indicators selected 2. Data registry protocol in place 3. Staff implementing workflows Organizational protocols Monthly staff meetings Staff are given the tools and resources to effectively implement this approach

Phase 1: Activity Definition In Phase 1 we are: Identifying the key activities that need to happen for your stretch project Breaking down these activities into tasks Once broken down, the tasks can be: Clearly defined Analyzed for dependencies and risks Scheduled

Stretch Project Example Establish population health management approach Identify metrics Establish risk stratification approach Establish QI approach Design and implement data registry Train staff Identify current data points/processes Identify tools Implement approach Map all data points Finalize all materials and protocols Identify gaps Establish team workflows Develop or adapt registry tool Contingency plan for training and lost productivity Crosswork and determine potential data collection approaches Train staff Select final metrics

Stretch Project Example Establish QI Approach Establish QI team Develop monitoring and evaluation plan Data collection Develop policies and procedures Workflow revisions Staff training Develop data collection tools and protocol Materials for distribution Monthly data collection Cultural reinforcement Quarterly data collection Accommodate loss in productivity

Exercise: Identify Your Stretch Project Activities Identify the key activities for your stretch project and break them down into detailed level of tasks Key question: What is everything that needs to happen in order for this activity to be completed? Use one color of sticky note and one activity/task per sticky note

Phase 2: Activity Sequencing Mapping out the identified activities based on sequencing and dependencies Develop M&E plan Revise workflows Establish QI Approach Establish QI team Review current workflows Develop data collection tools and processes Revise policies and procedures Staff training Review current policies/procedu res Training logistics

Exercise: Sequence the Activities for Your Stretch Project Key questions: What can happen concurrently? Where are the dependencies? Make sure you are including all activities Use the sticky notes you just developed and rearrange them into a network diagram

Phase 3: Activity Resource Estimating What staff are available? What additional resources do I need? What skills do I need? Does any of this cost money? What buy in do I need? What constraints do I have?

Exercise: Identifying Your Stretch Project Resources Key questions Who needs to be involved in this activity? What resources do I need to complete this activity? Are there any budget implications for these activities? Compare this to what and who you have available to you for this project you make come away from this activity with some asks you will need to be making Using another color sticky note write down the resources for certain tasks in your network diagram and attach them to that task

Phase 4: Activity Duration Establish QI Approach 1 day Establish QI team 10 days Develop M&E plan Review current workflows Review current policies/procedu res 5 days 5 days 10 days Develop data collection tools and processes Revise workflows Revise policies and procedures 5 days Training logistics 3 days 2 days Staff training 1 day

Exercise: Estimate Duration of Activities for Your Stretch Project For each activity, make realistic assumptions around the duration needed to complete it You can use another sticky note or write on the current ones

Phase 5: Activity Scheduling Using the results of your other planning phases, you are able to build out your activity schedule/workplan to monitor and track on progress Establish QI team Identify metrics Develop M&E plan Establish risk stratification approach Establish QI approach Develop data registry Train staff Roll out intervention Monthly data review Activity Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8

Exercise: Create Your Project GANTT/Workplan Activity Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8

Rapid Cycle Change Four Steps: Leverage your Transformation Plan Develop and execute the Practice Transformation Plan Rapid-cycle change: Use PDSA to drive population health management Sustain improvement through Continuous Quality Improvement (CQI)

Rapid cycle change is a systematic problem-solving approach to understand client needs, restructure processes, and make the most efficient use of available resources. Rapid Cycle Change

CQI Roles

Leadership s Role in Practice Transformation Communicate how the organization will transform in the next 1-3 years Define new terms (e.g., Population Health Management) Set organizational goals with targets and key performance indicators (objectives/tasks are developed by sub-committee staff) Support and empower the Practice Transformation Lead, who will drive change efforts Set timelines & authorize any timeline modifications Provide resources and the means for acquisition, risk identification/contingencies, procedures for conflict resolution

Root Cause Analysis Root cause analysis (RCA) is a structured method used to analyze problems and learn from adverse events. RCA identifies underlying problems that increase the likelihood of errors, while avoiding the trap of focusing on mistakes by individuals. Example: Fishbone diagram template

Stretch Goal Presentations and Peer Feedback 1. Who will you include on you transformation team and why? 2. What is your stretch goal? 3. What metrics will you use to measure your effectiveness toward this stretch goal? 4. What are your anticipated barriers to meeting your stretch goal? Please email your slides to: JuliaS@thenationalcouncil.org

Next Steps Webinar Dates Communicating the why Wednesday, May 3, 2017 12-1pm Workflow Mapping Wednesday, June 21, 2017 12-1pm Identify staff/team members using the RACI Tuesday, July 25, 2017 12-1pm Cultivating a Culture of Quality Improvement Wednesday, October 18, 2017 12-1pm Incorporating Patients and Families in Transformation Wednesday, November 15, 2017 12-1pm Wrap-up Webinar Tuesday, January 23, 2018 11:30-1:30pm Coaching calls CEO calls Mid-year meeting Thursday September 21 st 9am-5pm

Evaluation https://www.surveymonkey.com/r/7phmzyp

Thank you! www.caretransitionsnetwork.org CareTransitions@TheNationalCouncil.org The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.