9/15/14. Ø Discuss the concepts of population health and panel management. Ø Describe the recent (ongoing) transformation of healthcare

Transcription

1 Health Promotion & Disease Prevention Program VA New York Harbor Healthcare System Department of Medicine & Division Educational Quality and Analytics New York University School of Medicine Ø Describe the recent (ongoing) transformation of healthcare Ø Discuss the concepts of population health and panel management Ø Showcase tools available for population health and panel management (i.e. VA) 1

2 Ø Ø Ø Previous Model My patients are those who make appointments to see me Care is determined by today s problem and time available today Patients chief complaints or reasons for visit determines care Current Model Ø Our patients are those who are registered in our panel Ø Care is determined by a proactive plan to meet patient needs (+/- visit) Ø We systematically assess all our patients health needs to plan care Previous Model Current Model Ø I know I deliver high quality care because I m well trained Ø Care varies by scheduled time and memory or skill of the doctor Ø We measure our quality and make changes to improve it Ø Care is provided according to evidence-based guidelines 2

3 Other Team Members Pharmacist Social Worker Nutritionist Case Managers Trainees Psychologist Other Team Members Teamlet: assigned to 1 panel (±1200 pa2ents) Provider RN Care Mgr Clinical Associate (LPN, MA, or Health Tech) Clerk For each parent facility HPDP Program Manager Health Behavior Coordinator Pa<ent 3

4 A True Multidisciplinary Team that: Ø Works Together Ø Works at the top of their licenses to serve a panel of patients Ø Coordinates a panel of patients care Ø Tracks test results and proactively follows up with patients Physician Based Appointment Based Team Based Panel Based Previous Practice New Practice Roles Roles (where members of the (Silos) team work together) 4

5 Ø Transform the locus of measurement from episodic patient visit to overall panel management Ø From Individual Health to Population Health Ø The ability to measure the care provided to a panel of patients, and to identify patients for key interventions, is essential Panel management can be defined as a set of tools and processes for population care that are applied systematically at the level of a primary care panel, with providers directing proactive care for their empaneled patients Godfrey MM, et. al.,

6 Ø Need tools & processes to identify and address unmet care needs Ø Need tools & processes for outreach and follow-up Ø Importance of non-traditional visits Ø Importance of a team approach Ø Robust EMR since 1995 Ø 30 million unique records Ø 3.2 billion clinical orders Ø 1.8 billion prescriptions Ø 2 billion clinical notes 6

7 Ø Local Database for NYHHS Approx. 30K active uniques Ø VISN3 Database 9 Hospitals in VISN 3 Approx. 150K active uniques Ø Region 4 Database Ø National Database Approx. 4.5 million active uniques Ø Panel based reports Ø Provider based reports Ø Facility based reports Ø Region based reports Ø System based reports 7

8 Ø Importance of cohort definitions Ø Importance of proper coding Ø Importance of documentation (and how) Ø Data outside facility database Ø Importance of data validation and CLINICIAN leaders (and buy-in) Implications on education, clinical roles etc. 8

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11 Patient Name and SSN Ø Tool to identify individual patients in need of help Ø Highlights outliers for provider Improve healthcare delivery Ø Highlights outliers for panel manager to improve coordination of care MH patients DM / Optho 11

12 The CAN score is generated using a multinomial logistic regression model that utilizes demographic and clinical data from VHA national database (4.5 million uniques) Wang, Li et. al.,

13 Ø Six predictor categories (150 data elements) Socio-demographics Medical conditions Vital signs Prior year use of health services Medications Lab tests Ø Outcome variable: hospitalization or death during subsequent 90 days and 1 year } Reflects estimated probability of admission or death within a specified time period (either 90 days or 1 year) } Expressed as a percentile, ranging from 0 (lowest risk) to 99 (highest risk) } Indicates how a given patient compared to other VA patients in terms of likelihood of hospitalization or death 13

14 High Score (e.g., 99) Low Score (e.g., 5) Risk of admission or death that approaches 72% at one year Risk only 3% at one year CAN scores represent probabilities -- although accurate for large groups of patients, may be inaccurate for an individual. 14

15 Patient Name and SSN Wang, L, et. al

16 Scan your list of patients each week to identify those who may be at high risk Call your high risk patients to check in: are medical questions answered? are medications taken as prescribed? Confirm that high risk patients have visits coming up soon Ensure that high risk patients are on appropriate medical therapy Review resources already in use, such as telehealth or specialty care 16

17 Panel management has changed my practice by giving me hope that some of my more difficult patients might actually turn around their health status. It has made me more optimistic in approaching these patients; now I work to maximize the number of outreach efforts that occur from our staff. 17

18 Microsoft Communicator Patient Portals My HealtheVet My Chart at NYU Langone } Secure Messaging Ø ing Patients Ø ing other healthcare providers within facility Ø ing other healthcare providers outside facility 18

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20 Significant change occurring in healthcare Population health and panel management is a shift in our way of thinking about healthcare More proactive Team based Use of predictive analytics Importance of tools and processes for population health and panel management Importance of clinician buy-in and understanding 20