Population Health at Legacy Health
Melinda Muller MD
Amy Chaumeton MD
Objectives
 Educate regarding medical home and population health
initiatives at Legacy Health
 Discuss the role of the EMR and technology in improving the
workflows and outcomes
 Review the clinical outcomes
 Review the initial ROI data available
May 11, 2015
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History of Medical Home at Legacy
 Initial work with payers in 2000-2006
 First site transformation in 2007 with health plan assistance
 Three more sites began transformation in 2008
 Rest of sites began transformation in 2009 – present
> All sites functioning in model since 2012
> All new sites are started using the model
 All Oregon sites are Tier 3 PCPCH per State of Oregon guidelines,
Washington sites are now also certified
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Medical Home at Legacy
> Patient centered
> Empanelment
> Team based
> Advanced access
> Behavioral health integration
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Components of the Model
 Patient Centered Care
> Care focuses on what the patients need and want
 Empanelment
>
>
>
>
Patient is assigned to a PCP and team
Team uses data to provide proactive care
Patients get care they need during visits AND outside of visits
Panel coordinator does targeted outreach
 Team Based Care
>
>
>
>
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Integrated care by the team
Everyone working to top of certification and licensure
Nurses provide “case management “ for the population based on risk
Other team members as needed – social worker, pharmacist,
pharmacy technicians
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Components of the Model
 Advanced Access
> Patients get care when & how they want and need it
 Same day access at the clinic
 Telephone follow up/management
 Email follow up/management
 Behavioral Health Integration
> Real time coaching for patients as needed on self management skills
> Coordination with outside services
> Community Health Workers, Social Workers, Psychiatric Nurse
Practitioners
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Team Based Care
Everyone works to the top of their certification and licensure
 RN Case Manager
> Chronic disease management, more intensive care
 Pharmacist
> Medication instruction, dose changes, chronic disease management
 Pharmacy technician
> Refills, manages pharmacy correspondence
 Panel coordinator
> Population management
 Care management
> Access to behavioral health and social services
 Community Health Worker
> Social support
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Who is in the Legacy Medical Home
 All patients who seek care at our 24 primary care clinics
 Care is guided by patient need
> Young and healthy: reminders about preventive care
> Chronic disease: reminders around prevention as well as care
focused on their chronic disease
> High needs: extra assistance from other team members, could include
health coach, nurse case manager, social worker, coordination with
outside agencies
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Population Health
 Population health is defined as the health outcomes of a group of
individuals, including the distribution of such outcomes within the
group.
 It’s moving from specific clinical work for high risk patients to
managing the whole population including paying attention to the
financial aspects of care
 New skill sets and data are needed
> Integration of claims data with clinical data
> View patients from a macro level vs single patient level
> New workforce or redeployment of existing workforce
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PHSO
Mission
To improve the health of and reduce the costs for at-risk
populations through population health analytics and population
health management using clinical and claims information
A centralized,
dedicated
population
health
analytics team
PHSO = Population Health
Services Organization
Identify
at-risk
populations
Assess risks and
opportunities
Dedicated care
team will engage
with members
“at-risk” and
providers
Why is a PHSO needed?
Claims &
Clinical
Data
Analytics
Platform
CIN
Member
Engagement
PHSO
Care
Team
PHSO
Analytics
Team
Population
PHSO
A draft page
We can spend
time making this
look better if the
concept is
acceptable
Low High
at- atrisk risk
Healthy
Sick
Today
PHSO short-term
PHSO long-term
Limited resources targeted
mostly at the “sick”
(via medical homes
with limited data)
Focus on care transitions,
chronic-complex patients,
disease-specific programs;
some prevention
Improve the health of the
population
Healthy Low High
atatrisk risk
Healthy Low High
atatrisk risk
Healthy
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Sick
Sick
Represents a care team (physicians, nurses, care managers, educators, etc. )
Atrisk
Sick
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Objectives
 Educate regarding medical home and population health initiatives
at Legacy Health
 Discuss the role of the EMR and technology in improving the
workflows and outcomes
 Review the clinical outcomes
 Review the initial ROI data available
May 11, 2015
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Role of Epic
 Shared patient record across the continuum
> ED to inpatient to PCP to specialty and ancillary services
> Labs, diagnostic imaging
> CareEverywhere to view other Epic organizations
 Patient attribution / empanelment
> PCP clearly identified
> Care Team members
 Identify care gaps
> Encounter based in Health Maintenance Activity
> Population based through registries, reporting tools
 Patient engagement through MyHealth portal
> Message provider, request refills, make appointments
> Online scheduling
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Epic: Shared patient record
 All contacts or encounters the patient has with our health system are
recorded in the patient’s chart
>
>
>
>
>
>
ED
Inpatient
Primary Care
Specialty visits
Ancillary services: physical therapy, infusion, nutrition services, etc
Phone calls / MyHealth messages / Refill requests
 If the patient is seen in another Epic facility we are able to see their
records through Care Everywhere
Creates a unified record unique to the patient, not the doctor
Epic: Coordination of Care
 ED Information Exchange (EDIE)
> Alerts PCP of multiple visits to ED in previous 3 months
> Received as an inbasket message
> Helps to coordinate care between ED and PCP offices and care teams
Epic: Empanelment
 The primary care physician is clearly designated and highly visible
 All other care providers are listed in the Care Team
> Facilitates communication
> Improves Reporting
Epic: Identify care gaps
 Health Maintenance Activity alerts the provider when the patient is
due for preventive screenings and care related to chronic illness
Epic: Identify care gaps
 Reporting tools identify patients with care gaps at the population level
 Clinical staff outreach to the patients to remind them of services due
 MyHealth automated reminders for some care gaps
Epic: Patient Engagement
 MyHealth is Legacy’s secure online patient portal
> View test results
> Message provider
> Appointment
scheduling
> Refill Rx
> View (and edit) health
summary
> Billing integration
> Health information
Epic: Registries
 Identifies a cohort of patients
> Usually chronic disease based
> Usually attributed to primary care physician but can be attributed by
specialist or care team/clinic
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Epic: Registries
 Each registry has metrics that are monitored
 Once the patients are identified (registry) the important topics
(metrics) are monitored routinely and care is coordinated
 Clinical staff help monitor these reports and recall patients at
appropriate intervals
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Epic: Registries
 Each of the registry reports are actionable
> Order follow up labs
> Contact the patient
 Satisfies Meaningful Use
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Epic: Population Management, Risk
 Healthy Planet is Epic’s new population management tool
 In the early stages of deployment
 Helps to identify target populations, provide follow up and
coordinate care
 Risk stratification is disease based or for the complexity of the
population
> Legacy Health created a complexity score to stratify populations and
identify those who might be in need of care team support
 Score is a combination of utilization, chronic disease states, high risk
medications and social factors
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Epic: Population Management, Risk
 Complexity score calculated using CER rules to assign point
values to each topic, then a final rule to calculate the score
> Mapping of data from entry by end user in Hyperspace
 Flowsheet, smart data element, demographics, calculations (BMI)
> CER rule assigns a point for the value
 ‘if the patient is a smoker, then assign 1 point’
> Final rule tallies the points resulting in the complexity score
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Epic: Population Management, Risk
 Complexity score calculation – innovative approach
> How do you account for utilization data from a payor without a data
warehouse?
• Secure email of
utilization data
from payor in
Excel
spreadsheet
Payor data
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Clarity
• EMPI mapped
• Clarity table
created
• Data sent from
Clarity to
Hyperspace as
smart data
element
Datalink
Hyperspace
• CER rules to
identify smart
data element and
assign a risk
point for scoring
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Epic: Population Management, Risk
 Score value are identical for inpatient and outpatient
> ‘red’ / ‘yellow’ / ‘green’ thresholds vary
 Scores are near-real time
> Updated when any of the following occur







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

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orders change
lab value change
problem list change
encounter dx change
flowsheet value change
immunizations change
health maintenance due status changed
close encounter
discharge
undo discharge
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Epic: Population Management, Risk
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Epic: Population Management, Risk
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Objectives
 Educate regarding medical home and population health initiatives
at Legacy Health
 Discuss the role of the EMR and technology in improving the
workflows and outcomes
 Review the clinical outcomes
 Review the initial ROI data available
May 11, 2015
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Clinical Outcomes - Diabetes
A1c in last 12 months
90th HEDIS
96%
100%
75th HEDIS
97%
97%
91%
90%
80%
69%
70%
68%
70%
60%
50%
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Clinical Outcomes – Pap Smear
Pap
90th HEDIS
75th HEDIS
100%
90%
85%
80%
85%
86%
75%
70%
57%
60%
59%
59%
54%
50%
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Clinical Outcomes - Mammogram
Mamm
90th HEDIS
75th HEDIS
100%
90%
80%
77%
75%
77%
78%
68%
70%
60%
56%
53%
52%
50%
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Clinical Outcomes – Colon Cancer
Colon Cancer Screen
90th HEDIS
75th HEDIS
100%
90%
80%
70%
62%
63%
64%
66%
69%
69%
70%
60%
50%
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Process Outcomes – follow up calls
Percent of people called within 48 hours of
leaving the hospital or ED, n=2,500 +
100%
97%
96%
95%
95%
96%
96%
96%
96%
95%
94%
94%
94%
75%
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Objectives
 Educate regarding medical home and population health initiatives
at Legacy Health
 Discuss the role of the EMR and technology in improving the
workflows and outcomes
 Review the clinical outcomes
 Review the initial ROI data available
May 11, 2015
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Utilization Outcomes – % ED visits to panel
size
25%
24.8%
24.7%
24.6%
23.9%
23.5%
23.8%
20%
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Utilization Outcomes - % IP visits to panel size
10%
5.7%
5%
5.5%
5.2%
4.9%
4.8%
5.1%
5.3%
0%
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Healthshare ED Utilization
ED Utilization - lower better rate/1000
94.0
89.0
84.0
79.0
74.0
69.0
64.0
59.0
54.0
49.0
52.0
44.6
44.0
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Financial Outcomes
 HVPCC Pilot – 3 year pilot
> Payer sponsored funding of Nurse Case Manager
 Worked with defined cohort of patients
> Upfront PMPM to fund the RN
> Shared Savings on the back end
 Total savings for 2 clinics: $2.2 Million
 Shared savings: $900,000
> Mostly reduction in ED & hospitalization charges
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Financial Outcomes
 Clarity report in Epic to review ED utilization
> ED visits by clinic, diagnosis, volume/frequency
> Drilled down to identify “frequent flyers” – those with more than 7 ED
visits in prior 6 months – total of 63 patients
 Focused Care Management outreach
> Over following 6 months, reduced ED visits by 50%, reduced ED cost
by 50%, Cost/visit increased slightly
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Limitations to model expansion
 Current healthcare financing system still built on FFS
 Tools and workflows that move utilization upstream are not
currently always desirable or sustainable financially
> From IP to OP
> From ED to Urgent Care
> From provider to care team
 New roles and workflows need to be funded in new ways to be
sustainable
> Modified capitation
> Care mgmt fees (ie similar to the CCM from Medicare)
> Easy to administer and implement
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Summary
 Medical Home transformation of primary care clinics key first step
in moving into the population health space
 Population Health expands and advances the work done at the
patient and clinic level to a more macro level including
incorporating the financial component more directly
 Technology is a key component to maximizing the workflows of
the staff by feeding information in a useful way
 Clinical and financial outcomes can be improved utilizing
population health tools and workflows
 New healthcare financing systems are needed to sustain and
expand the model
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Thank you!