Using Smart Data to Risk Stratify Your Communities

Editor's Notes

• #2: The rising rates of chronic disease, our aging populations, changing consumer expectations about how they want to purchase and receive care, along with our increasing access to social media and mobile technologies are transforming the way healthcare is obtained and delivered. To thrive, or even survive in this time of massive change healthcare organizations must become data driven. We must treat data as a strategic asset to inform decision making processes and drive actionable results.
• #3: Our global healthcare industry is under significant pressure to reduce costs and more effectively manage resources while improving patient care. The whirl of activity at the federal level – paralleled by private insurers’ efforts to support medical homes and ACOs –motivation has changed to manage the changing dynamics. Rising rates of chronic disease, aging populations, changing consumer expectations about how they want to purchased and receive care, and increasing access to social media and mobile technologies are transforming the way healthcare is obtained and delivered. Payment models and healthcare systems are evolving from a fee for service approach to an outcomes or value base that requires access to accurate data to document and track results. To thrive, or even survive in this time of massive change, healthcare organizations must become data driven. We must treat data as a strategic asset and put processes and systems in place that allow access to and analysis of the right data to inform decision-making processes and drive actionable results.
• #4: Big Data is the combination of analysis, metrics and indicators that includes the combination of traditional and non-traditional data sources. Big data provides solutions that should be used to develop business strategies, service launches, marketing strategies, and other communication initiatives. There is no better place than healthcare to use big data to help make the world a better place. Healthcare organizations have operated based on incomplete and imprecise cost and care measurements and up until now, didn’t have the comprehensive view of the clinical and operational processes they needed to improve. We are now turning to data and analytics in ways, similar to other industries that rely on digital information to improve service and reduce costs.
• #5: At the core of a data driven healthcare organization is the ability to analyze a wide range data, from within and outside its four walls, to determine what is happening right now with regard to patient, staff and population profiles as well as financial, clinical and operational processes. Healthcare organizations that want to become data driven must commit to valuing data as a strategic asset, a part of their culture and developing an understanding of the flow of information and acting upon data driven insights.
• #6: Gaining access and applying clinical and advanced analytics enables healthcare entities to improve: Pinpoint which patients are the highest consumers of health resources or at greatest risk for adverse outcomes, readmissions, and then putting programs into place to optimize their heath status and measure how they are doing against set targets Take prescriptive action to perform appropriate interventions at appropriate time and assist patients to make better choices What are the main predictors for readmission? The drive now is to understand as much about a patient as possible, as early in their life as possible, picking up warning signs of serious illness at an early enough stage that treatment is far more simple and less expensive than if it had not been found until later.
• #7: The goal of population health management (PHM) is to keep a patient population as healthy as possible, minimizing the need for expensive interventions such as emergency department visits, hospitalizations, imaging tests and procedures. This not only lowers costs, but also redefines healthcare as an activity that encompasses far more than sick care. We are in the healthcare business, not sickcare. While PHM focuses partly on the high risk patients who generate the majority of health costs, is systematically addresses the preventive and chronic care needs of every patient. Because the distribution of health risks changes over time, the objective is to modify the factors that make people sick or that impact their illness.
• #8: If I asked everyone in this room to give me their definition of population health I know we would have a wide variety of definitions. Population health buzzword Population health is a group of patients, similarities, commonalities, disease structured by slicing and dicing your market to break it down to systematically manage the members within .
• #9: We need to become accustomed to thinking in terms of caring for an entire population and not just for the individual patients who are actively walking in our doors, seeking care from us. However, the foundational step of targeting high risk patients is, of course to identify them. How do we systematically improve outcomes for a population of patients, one patient at a time?
• #10: Pop Health means knowing what’s going on with all our patients and taking action automatically to proactively achieve the best outcomes. We need to maintain regular contact and support their efforts to manage their own care, 50% of chronic care is lifestyle driven. Another 20% is genetics, so if we could have patients pick their patients, we’d have that licked! and at the same time manage those high risk patients to prevent them from becoming unhealthier and developing complications. To most effectively do this we must supply proactive preventive and chronic care to all patients both during and between encounters This requires key information to maintain regular contact with patients to engage and support their efforts to manage their own health.
• #11: There are not enough providers and care managers to manage every patient continuously. The unsustainable growth of health costs, the growing lack of access to healthcare and increasing disparities in care have forced changing how health care is delivered. Successful health management involves a large number of routine tasks that do not have to be performed by human beings. Bringing modern information technology to bear on these tasks saves time, money, and makes Population Health Management economically feasible. Automation also allows organizations to better define and assess population needs and stratify populations based on geography, health status, resource utilization, and demographics.
• #12: Shifting the Paradigm!!! Population Health Management requires a significant change in the way of thinking and the practice patterns of providers. many physicians don’t understand why the old ways of practicing medicine are no longer adequate. We have to help them shift in the ways of thinking and their practice patterns. The cartoon caption has the doctor telling the patient ‘when we want your opinion, we’ll give it to you.”
• #13: Shifting the paradigm Providers will have to work together, with the patient and family to coordinate care and exchange health information in a culture of shared responsibility. These changes pose significant and potentially daunting challenges. Not only are we embracing new reimbursement models to support population health, but we also must encourage our providers to adopt a new way of doing business.
• #14: Leaders have to take firm control to achieve Population Health Management. Change management includes educating providers and staff members about the need –Including clinicians in the leadership of an initiative helps to alleviate the resistance. Healthcare Leaders needs also to build coalitions with other healthcare providers and community organizations.
• #15: The Triple Aim is that framework for optimizing health system performance. Meaningful healthcare analytics today generally need data from multiple source systems to help address the triple aim – the three concurrent aims for improve the experience of care, improve the health of populations and reduce the per capita costs of healthcare. It’s important to point out this framework is called the Triple Aim, not Triple AIMS. Population Health is only one components, achieving this objective would help attain the other two. All three components must be balanced and addressed simultaneously to reach the overarching goal of optimizing our healthcare system.
• #16: The adoption of health analytics is essential yet it cannot succeed without workflow redesign and change management. Healthcare technology in itself will not drive changes in practice or outcomes. Without workflow, process and relationship change, it will not work. Among the key characteristics that are necessary are an organized system of care, the use of multidisciplinary care teams, coordination across different care settings, enhanced access to primary care, centralized resource planning, continuous care, both in and outside of office visits; patient self management education, a focus on behavior and lifestyle changes and the use of data access and reporting for communication among providers and between providers and patients. Risk stratification has to be updated frequently. Of the patients who generate the highest costs in a given year, less than 30% were in that category the prior year. If we want to improve the quality of care and lower the cost of care special attention needs to be paid to all of the patients and their changing health status. Data makes population health management feasible, scalable and sustainable.
• #17: To manage population health effectively we must be able to define, track and monitor the health of individual patients. We must also stratify our population into subgroups that require particular services at specified intervals. Making population health actionable requires stratification by risk, conditions, and tools that allow the clinical teams to prioritize, distribute, and monitor intervention activity results continuously. Providers must be able to identify those patients who will benefit from additional services– -those needing reminders for preventive care or tests -patients overdue for care or not meeting management goals -patients who have failed to receive follow-up after being sent reminders -patients who must benefit from discussion of risk reduction From a care management viewpoint, patients should be stratified by their risk of getting sick or sicker. Grouping patients into categories by condition has been the traditional approach of disease management programs. In contrast care management stratification focuses on whether patients are ill enough to require ongoing support from a member of the care team, have less serious chronic health conditions that warrant interventions to prevent them from worsening or are fairly healthy and just need preventive care and education Patients are also stratified by demographics, health status, behavioral risk and financial risk.
• #19: Patient Engagement = Successful Population Health Management Patient Engagement is at the cornerstone of the healthcare transformation because it can impact health outcomes, reduce health care cost and be better care than tradition methods.
• #20: Population health management in action How many of you are familiar with SMA? Shared medical appointments have been proposed as a way of improving, disease-management outcomes, and patient care, reducing costs, and improving access Cleveland Clinic has been providing SMAs for over 10 years
• #21: Group medical visit Patients with similar health conditions or problems are scheduled together A 90-minute physician appointment held simultaneously with 8 to 10 patients Patients receive medical exam and pertinent health education Medical care from start to finish (not a “class”) An individual appointment in a group setting The need for improved access and stress on our nation’s health care has resulted in creative solutions in tackling these challenges. Shared Medical appointments (or SMA's) are an innovative way of creating appointment access and an opportunity for improving the quality of care for patients. A shared medical appointment is a visit where multiple patients are seen in a group, usually for follow up care. Patients have the benefit of a longer visit with the physician and when appropriate, access to other members of the health care team, such as a nutritionist or health educator. During the shared visits, patients are seen in a private exam room for individualized care and while waiting they have access to a other healthcare professionals.
• #22: SMAs offer an innovative, interactive approach to healthcare that brings patients with common needs together with one or more healthcare providers. While an individual appointment typically lasts 15 minutes, a shared appointment is 90 minutes long, allowing participants to spend more time with the healthcare team. During a typical SMA, patients are seen together in a setting that encourages asking questions, and sharing concerns and experiences. Patients learn from the healthcare team and from each other in this environment. Patients enjoy the opportunity to relate to other people who are dealing with similar health issues, share stories and ideas, and truly create a bond. SMAs are particularly valuable to people dealing with chronic conditions like asthma, diabetes and hypertension— Every patient has the opportunity to be a role model to someone else.
• #23: Well Child visits for pediatricians is an excellent group for a SMA Sleep Apnea/Pulmonology example
• #24: How many times do patients walk away from the traditional appointment saying things like this? Noncompliant patients are great candidates for a SMA
• #26: I’d like to introduce you to Donald -- a 58 year old white male who is a HONDA – a Hypertensive, overweight, noncompliant diabetic adult. Donald also has a history of COPD While well, he is enjoying life, working, relaxing, playing golf, taking walks with his dogs.
• #27: Donald is well
• #28: Donald is well
• #29: Donald Lives here with his family– he moved here outside Tucson to take advantage of the weather because of his health issues
• #30: The Hospital builds a COPD analysis read the slide LifeMode Groups are characterized by lifestyle and share an experience such as being born in the same time period or a trait such as affluence Tapestry Profiles divide and group the hospitals consumer markets to more precisely target their best customers and prospects. This targeting method is superior to using “scattershot” methods that might attract these preferred groups. Segmentation explains customer diversity, simplifies marketing campaigns, describes lifestyle and lifestage, and incorporates a wide range of data. Segmentation systems operate on the theory that people with similar tastes, lifestyles, and behaviors seek others with the same tastes—“like seeks like.”
• #31: Hospital launches the campaign using YCU platform, reaching the targeted population via focused means via social media, advertising , etc
• #32: Donald Has a history of asthma and COPD and Is at Risk. Currently the monsoon season in AZ is still in effect. Higher humidity means a higher risk for Donald.
• #33: Air quality issue as the monsoon season is still in effect in mid September in Tucson Air pollution. Outdoor and indoor air pollution in your lungs can trigger shortness of breath or lead to an infection.  Avoid traffic jams, smoke, strong chemicals, aerosol sprays, and the outdoors during air pollution alerts.
• #34: Donald receives timely, appropriate referral
• #36: Pertinent Health Information Goes to Donald People with COPD often lack good nutrition. Patients with chronic bronchitis tend to be obese. Patients with emphysema tend to be underweight. Loss of weight and muscle mass is associated with a poor outcome in COPD. Good nutrition improves the ability to exercise, which in turn builds muscle strength and lung function. Obese patients with COPD who lose weight sleep better
• #37: YourCareUniverse -- Cutting edge technology based applications for actionable, patient engagement, education and quality improvement is now available to continuously identify and impact our patients.