Role of Home Care in Population Health Management

Dr. Noreen Nelson

Clinical Assistant Professor

New York University Rory Meyers College of Nursing

Quality and Technology Solutions for Value Driven Home Care November 16-17, Saratoga Springs, NY

Dr. Noreen Nelson NYU Meyers College of Nursing

Population Health Management (PHM) –Why Now?

Goal: keep a client population as healthy as possible by

• Incorporating Healthy People 2020

• Minimizing the need for expensive interventions such as emergency department visits, hospitalizations, and more…

• Improving collaborative efforts between all settings to maintain financial viability of home care organizations

MACRA- 13 quality measures: Population Management & Care Coordination are two of the 8 subcategories meeting these quality measures. Home Care Agencies-collaboration opportunities

Multiple Chronic Conditions: A Day in the Life

http://www.ahrq.gov/professionals/prevention-chronic-care/decision/mcc/video/index.html

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The Patient Protection and Affordable Care Act(PPACA), commonly called the Affordable Care Act(ACA) or Obamacare, is a United States federal statute enacted by President Barack Obama on March 23, 2010.

Dr. Noreen Nelson NYU Meyers College of Nursing

Population Health Improvement Program

The New York State Department of Health’s Population Health Improvement Program (PHIP) will promote the Triple Aim –

better care,

better population health and

lower health care costs

by selecting regional contractors to provide a neutral forum for identifying, sharing, disseminating and helping implement best practices and strategies to promote population

health and reduce health care disparities in their respective regions.

Source: https://www.health.ny.gov/community/programs/population_health_improvement/

Dr. Noreen Nelson NYU Meyers College of Nursing

New Era of Healthcare: Population Health Management (PHM)

Development of Processes to demonstrate:

• Improving the patient experience of care, including quality and satisfaction;

• Improving the health of populations; and

• Reducing the per capita cost of health care.

• What’s missing?.....

Dr. Noreen Nelson NYU Meyers College of Nursing

New Era of Healthcare: Population Health Management (PHM)

Drivers:

• Medicare Access and CHIP Reauthorization Act of 2015 Quality Payment Program (MACRA)

• Reimbursement-higher for • Accountable Care Organizations • Bundled Payments for Care Improvement (BPCI) • Patient-Centered Medical Home Model• Health Homes

Triple Aim Video: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

Dr. Noreen Nelson NYU Meyers College of Nursing

New Era of Healthcare: Population Health Management (PHM)

PHM focus: high-risk patients who generate the majority of health costs

Resulting in creation of • Health Action Priorities Networks (HAPN) or in New York State, HealthlinkNY

• Delivery System Reform Incentive Payment Program (DSRIP)

• Qualified Entities (nationwide)

Dr. Noreen Nelson NYU Meyers College of Nursing

Population Health Management---Public Health Definition with a Twist

HealthCatalyst proposes this definition• “the science and art of preventing disease, prolonging life, and promoting

health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.” (C.-E.A. Winslow, Yale School of Public Health –early 1900s)

Source: Health Catalyst: https://www.healthcatalyst.com/population-health/

The twist …….accomplished by mutual engagement and supportive accountability as

co-collaborators to develop meaningful system processes by design, delivery, coordination, and payment of high-quality health care to achieve quality health outcomes for all (Nelson, 2016).

Dr. Noreen Nelson NYU Meyers College of Nursing

Population Health Management (PHM)

Programs

• Targeted to a defined population

• Utilize a variety of individual, organizational, and societal interventions

• To improve health outcomes and

• Client satisfaction

Dr. Noreen Nelson NYU Meyers College of Nursing

SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.

SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.

New York State Prevention Agenda Dashboard - State Level

NYS https://apps.health.ny.gov/doh2/applinks/ebi/SASStoredProcess/guest?_program=/EBI/PHIG/apps/dashboard/pa_dashboard

Albanyhttps://apps.health.ny.gov/doh2/applinks/ebi/SASStoredProcess/guest?_program=/EBI/PHIG/apps/dashboard/pa_dashboard&p=ch

Saratogahttps://apps.health.ny.gov/doh2/applinks/ebi/SASStoredProcess/guest?_program=%2FEBI%2FPHIG%2Fapps%2Fdashboard%2Fpa_dashboard&p=ch&cos=41

Dr. Noreen Nelson NYU Meyers College of Nursing

Promoting health is challenged by

• the way health information is shared (cultural relevance),

• the choices people make (behaviors),

• the places where people live (social conditions, environment), and work

• their access to care (health care insurance coverage and quality of care received)

Impact on population health: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

Dr. Noreen Nelson NYU Meyers College of Nursing

Role of Home Care: Population Health Management

Incorporates proactive strategies and interventions to coordinate, engage, and are clinically meaningful, cost effective & safe.

• Care processes that include

• Consideration of factors impacting a person’s health

• Design/strategies that provide coordination across the continuum

• Engagement of consumers to be involved in their own health

• Matching providers and technology with individual’s needs

• Better connection with established community & social services

Dr. Noreen Nelson NYU Meyers College of Nursing

SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.

SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.

Impact of Social Determinants of Health

“Social and psychological circumstances can cause long-term stress. continuing

anxiety, insecurity, low self-esteem, social isolation and lack of control over

work and home life, have powerful effects on health”

and let’s not forget depression!

(Source: Wilkinson, R & Marmot, M (Editors) (2003). Social determinants of health: The solid facts (2nd Ed.) p. 12 Retrieved January 17, 2016, from http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf)

Dr. Noreen Nelson NYU Meyers College of Nursing

“See” the Social Determinants

• Neighborhood and Built Environment• Access to Healthy Foods• Quality of Housing• Crime and Violence• Environmental Conditions

• Social and Community Context• Social Cohesion• Civic Participation• Perceptions of Discrimination and

Equity• Incarceration/Institutionalization

Source: http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/addressing-determinants

• Economic Stability• Poverty• Employment• Food Security• Housing Stability

• Education• High School Graduation• Enrollment in Higher Education• Language and Literacy• Early Childhood Education and

Development

• Health and Health Care• Access to Health Care• Access to Primary Care• Health Literacy

Dr. Noreen Nelson NYU Meyers College of Nursing

Medication non-adherence costing $300 billion annually

Source: Adherence and health care costsRisk Management & Healthcare Policy. 2014; 7: 35–44.

Published online 2014 Feb 20. doi: 10.2147/RMHP.S19801

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934668/pdf/rmhp-7-035.pdf

Dr. Noreen Nelson NYU Meyers College of Nursing

Reframing Our Thinking to Improve Client (Consumer) Satisfaction

What is Palliative Care? Palliative Care: Patient Centered Care• https://www.youtube.com/watch?v=DKTzESwCUXQ&list=PLI

jsDla1RqFDV_Ma1AHC1p0gvv3rbtGAA

• Get Palliative Care https://getpalliativecare.org/

New York https://getpalliativecare.org/providers/new-york/

• Palliative care focuses on maximizing a person’s quality of life, including treating pain, symptoms and stress associated with a serious illness.

• Whether the goal is life prolongation or cure, palliative care is provided concomitantly, regardless of a patient’s age or disease progression.

• Unlike hospice, palliative care has no prognostic restriction, and is suitable for anyone who has suffered from dealing with a complex illness.

Dr. Noreen Nelson NYU Meyers College of Nursing

Quadruple Aim

From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

http://www.annfammed.org/content/12/6/573.full

Dr. Noreen Nelson NYU Meyers College of Nursing

Perceptions

• “The joy of practicing medicine is gone.”

• “I hate being a doctor…I can’t wait to get out.”

• “I can’t tell you how defeated I feel…The feeling of being punished for delivering good care is nerve-racking.”

• “I am no longer a physician but the data manager, data entry clerk and steno girl… I became a doctor to take care of patients. I have become the typist.”

http://www.annfammed.org/content/12/6/573.full.pdf+html

• A 2013 survey of 30 physician practices found that electronic health record (EHR) technology has worsened professional satisfaction through time-consuming data entry and interference with patient care

• Dissatisfied physicians and nurses are associated with lower patient satisfaction

• Valuable time spent at computer or working with inefficiencies

Dr. Noreen Nelson NYU Meyers College of Nursing

Quadruple Aim: Impact on Health Professional Caregivers

Dr. Noreen Nelson NYU Meyers College of Nursing

Quadruple Aim-Caring for the Caregivers (Health Care Professionals)

• Ensuring solutions strongly consider the impact to the health care providers

• Bringing back the humanizing element into health care

• Initiated by physicians but includes impact to all health care providers

Achievement of quality outcomes, building trust and relationships with client consumers to improve engagement and compliance relies on a workforce that is satisfied, loyal and caring

The secret to caring for clients is to care about our health care providers

Dr. Noreen Nelson NYU Meyers College of Nursing

Dr. Noreen Nelson NYU Meyers College of Nursing

A Day in the Life of a Caregiverhttps://www.youtube.com/watch?v=bs_7jWqSeIM

Dr. Noreen Nelson NYU Meyers College of Nursing

Caring for the Caregivers

Why is this important?

• Stress, exhaustion, frustration, burnout is growing on the frontlines –both with professional and lay person caregivers

• Real time shortage in physicians and nurses predicted

• Growing geriatric population

Dr. Noreen Nelson NYU Meyers College of Nursing

Respite Care

Dr. Noreen Nelson NYU Meyers College of Nursing

Let’s keep in mind that millions of individuals’ lives are impacted as lay person caregivers

Dr. Noreen Nelson NYU Meyers College of Nursing

Opportunities for Improvement

• Disparities between quality home nursing care delivery and workload, lack of knowledge and/or billable time to achieve a better client centered engagement balanced with expected accountability.

• Insurance companies need to improve collaborative processes with home care delivery and support resolution of system barriers to achieve quality outcomes –stronger leadership by home care agencies.

• Gap analysis should be completed for specific populations served with the development of a collaborative quality improvement plan across the continuum for a specific population (one size does not fit all).

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Creating a Population Health Management Program

• Visionary leaders, building consensus and • Effectively communicating evolving priorities.

• Prioritize High-Value Interventions

• Strong regional partnerships and affiliations with community groups, payers, and other providers.

• Population Health Workforce – Quadruple Aim

• Better engage patients and impact their behavior

• Improvement in operational capabilities

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Health Care Providers as Caregivers in Alignment with Consumers & their Caregivers

Holistic Population Health Management includes system support to deliver care based on

• Shared decision making delivered in the context of health literacy standards, teach back methods and evidence based practice

• A focus on rising risk clients to prevent high cost future needs

• Quality transitional care inclusive of quality system processes built on root cause analysis

• Home care agency integration of the palliative care trajectory in the management of chronic illness

• Higher accountability of insurers

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Recommendations

• Identification of high risk clients and improving engagement

• Assist in navigating access to care

• Health literacy

• Individualized care within population health based on flexible best evidence

• Expand telehealth beyond cardiovascular

• Improving information sharing between all caregivers

• Inclusion of environmental partnerships/housing interventions

Dr. Noreen Nelson NYU Meyers College of Nursing

Recommendations

• Creative approaches to diabetes care management

• Better support for coordination of care

• Healthy Life Style initiative• Collaborations with primary care alternatives to the ED, chronic disease prevention and

management, behavioral health and public/community engagement

• Break down barriers impacting effectiveness with vulnerable populations

• Advocacy • for access to healthier food options and improvements in the environment

Dr. Noreen Nelson NYU Meyers College of Nursing

Practical Tips for Managing Care Long Term

Agency for Healthcare Research and Quality (AHRQ) Practice-Based Population Health: Subpopulations

• Domain 1: Identify Subpopulations of Patients. Practices can target patients who require preventive care or tests.

• Domain 2: Examine Detailed Characteristics of Identified Subpopulations. Information management systems can allow practices to run queries to narrow down the subpopulation of patients or to access patient records or additional patient information.

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Practical Tips (cont’d)

Agency for Healthcare Research and Quality (AHRQ) Practice-Based Population Health: Subpopulations • Domain 3: Create Reminders for Patients and Providers. Information on

patients can be made actionable through notifications for patients and members of the practice.

• Domain 4: Track Performance Measures. Practices can gain an understanding of how they are providing care relative to national guidelines or peer comparison groups.

• Domain 5: Make Data Available in Multiple Forms. Information may be most useful to practices if it can be printed, saved, or exported and if it can be displayed graphically.

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Challenges to Change

Goal: Improve the quality and effectiveness of care while controlling costs for a defined group of people.

Challenges

• Financial: healthier population will require fewer hospitalizations and procedures.

• Shift in focus toward a team-based, collaborative community model

• Impacted by a complex array of factors –Determinants of health

• Engagement and culture shift of Health Care Providers

Population Health Management https://www.youtube.com/watch?v=ha3i7Pb15wM

Dr. Noreen Nelson NYU Meyers College of Nursing

Dr. Noreen Nelson NYU Meyers College of Nursing

Take-Aways

Resources

Dr. Noreen Nelson NYU Meyers College of Nursing

Population Care Coordinator Program

Barbara Turner, PhD, RN, FAANElizabeth P Hanes Professor

Director, Population Care Coordinator ProgramOnline Program Available

http://pccp.nursing.duke.edu/contact/

Content

• Data driven process

• Multilevel approach (individual, subpopulation, population) to health coordination

• Interdisciplinary & patient centered focus

• Addresses the Care Coordinator Competencies outlined by the American Academy of Ambulatory Nurses

• Consideration of multiple determinants of health not just biomedical

• Focus on needs of patients and populations across the continuum (transitions, chronic, prevention)

Content

• Behavioral health coaching

• Risk reduction

• Transitions in care

• Community resources

• PCMH and ACO

• Practice: Standardized patients

What Are Health Literacy Universal Precautions?

• Health literacy universal precautions are the steps that practicestake when they assume that all patients may have difficulty comprehending health information and accessing health services. Health literacy universal precautions are aimed at—

• Simplifying communication with and confirming comprehension for all patients, so that the risk of miscommunication is minimized.

• Making the office environment and health care system easier to navigate.

• Supporting patients' efforts to improve their health.

Source: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html

Dr. Noreen Nelson NYU Meyers College of Nursing

Dr. Noreen Nelson NYU Meyers College of Nursing

Managing Caregiver Stress https://www.youtube.com/watch?v=_hi7fUUao_Y

Agency for Healthcare Research & Quality

SHARE APPROACH FACT SHEET; link to toolkit -6-8 hour traininghttp://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/shareddecisionmaking/tools/sharefactsheet/share-approach_factsheet.pdf

American Nurses Association: 2016 Culture of Safetyhttp://www.nursingworld.org/cultureofsafety

Social Determinants of Health: Claire Pomeroy https://www.youtube.com/watch?v=qykD-2AXKIU

Certified Qualified Entities (November 3, 2016)

Name of Lead EntityRegion(s) in which QE will publicly report provider

performanceDate of QE Certification

Health Care Cost Institute All 50 states and the District of Columbia June 17, 2014

Amino All 50 states and the District of Columbia December 4, 2014

OptumLabs All 50 states and the District of Columbia November 30, 2015

FAIR Health All 50 states and the District of Columbia May 18, 2016

Dr. Noreen Nelson NYU Meyers College of Nursing

Chronic Conditions Data Warehouse

• The Chronic Conditions Data Warehouse (CCW) is a research database designed to make Medicare, Medicaid, Assessments, and Part D Prescription Drug Event data more readily available to support research designed to improve the quality of care and reduce costs and utilization.

For additional information • https://www.ccwdata.org/web/guest/home

Dr. Noreen Nelson NYU Meyers College of Nursing

Centers for Medicare & Medicaid Services: Home Health Agency (HHA) Centerhttps://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

• Certifying Patients for the Medicare Home Health Benefithttps://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-12-16-Home-Health-Benefit.html?DLPage=1&DLSort=0&DLSortDir=descending

Quality Payment Program • Qpp.cms.gov: https://qpp.cms.gov/

Certified Health Information Technology https://www.healthit.gov/policy-researchers-implementers/about-onc-health-it-certification-program

• The Certified Health IT Product List (CHPL) is a comprehensive and authoritative listing of all certified Health Information Technology which has been successfully tested and certified by the ONC Health IT Certification program.• certified electronic health record technology (CEHRT)

Dr. Noreen Nelson NYU Meyers College of Nursing

Source: Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic

disease in the 21st century: elimination of the leading preventable causes of

premature death and disability in the USA. Lancet. 2014;384(9937):45-52.

PubMed abstract.

National Center for Chronic Disease Prevention and Health Promotion

Office of the Director

The Four Domains of Chronic

Disease Prevention

4. Community Programs

Linked to Clinical Services

• Proven community programs offer considerable savings

over clinician-delivered models.

– National Diabetes Prevention Program.

– Chronic Disease Self-Management Program.

• They address key health problems (e.g., heart disease,

diabetes, arthritis, falls in older people).

• They provide tools and skill-building to help people manage

their chronic conditions.

– Weeks to months of structured lifestyle interventions.

– Standard protocols customized to particular communities.

Projects That Link Health Care

and Community Approaches

Project Description

Million Heartsa Million Hearts is a large national effort that aims to

prevent 1 million heart attacks and strokes from

2012 to 2017 by making heart-healthy lifestyle

choices easier and by improving care for people

needing treatment.

The National Diabetes

Prevention Programb

The National Diabetes Prevention Program links

people at high risk of developing diabetes to

community-delivered, evidence-based lifestyle

interventions that can greatly reduce their risk of

developing diabetes and, because it is delivered by

lay people in community settings, can be more

convenient and cost-effective than similar

interventions delivered in health care settings.

Projects That Link Health Care

and Community Approaches (cont.)

Project Description

Partnership for a Healthy

Durhama

The Partnership for a Healthy Durham has pulled

together many stakeholders to improve health

among the most vulnerable residents of Durham

County, North Carolina. The project has expanded

over time from interventions to improve access to

high-quality health care to include environmental

approaches to promoting physical activity and efforts

to improve primary education.

Truman Medical Centers

Healthy Harvest Produce

Marketb

Truman Medical Centers, an acute care hospital

system located in an urban food desert, has

established a farmers market to enhance access to

fresh and healthy fruits and vegetables for its

patients and staff.

Healthier

People

Lower

Health

Care

Costs

Vision for the CDC

Chronic Disease Prevention System

Improving community conditions to support healthful behaviors and promote effective management of chronic conditions will deliver:

• Healthier

students to

schools

• Healthier workers

to businesses

and employers

• A healthier

population to the

health care

system