Pop Health Exam 2

ch. 10 - transitions of care US chronic disease statistics

-125 mil in US have >= 1 chronic condition -50% have multiple chronic conditions -expected 157 mil by 2020 -prevalence of chronic disease increases with age -prevalence: measurement of total number of cases at a point in time -incidence: measurement of the total number of 'new' cases during a period of time -75% HC resources consumed by 5 chronic diseases (heart disease, cancer, trauma, mental disorders, pulmonary disease) -82% medicare beneficiaries >= 1 chronic condition -25% medicare beneficiaries >= 4 chronic conditions -70% of all deaths are attributable to chronic illnesses -medicare beneficiaries with >= 4 chronic conditions are 99% more likely to be hospitalized and receive services from 14 different physicians on avg

ch. 10 - transitions of care Pareto principle applies to HC

-20% of US pop consumes 80% hc resources -5% of US pop consumes 50% of hc resources

ch. 20 workplace pop health impact of job stress on heart disease

-30-40% employees report work as "very or extremely stressful" -high job stress/strain associated with: heart disease, high blood pressure, depression, musculoskeletal disease, increased lifestyle risks (overweight, smoking, heavy alcohol use, low physical activity) -job relates stress contributes to10-30% of heart disease risk in working people

ch. 10 - transitions of care goals of our health system

-better health -better care -lower cost

ch 14 - pop health in action Care coordination

-care coordination is a key element to pop health -risk stratifying + patient engagement + building and tracking relationships

ch. 9 health system navigation goals of health advocacy programs

-consumer engagement in health decisions? -provide consumer education? -change consumer behavior? -improved employee productivity? -or just help people cope and find solutions?

ch. 10 - transitions of care 80/20 rule Pareto principle

-pareto diagrams are based on the principle of separating the vital few from the trivial many -developed by joseph juran, based on the work of italian economist vilfredo pareto (1848-1923) -juran used to pareto principle in his work on quality improvement

ch. 9 health system navigation of those with a health problem, health advocates recognize two types of health consumer

-those who can find their way through the hc maze -those who cannot those who cannot find their way through the hc system are unlikely to reach the best possible outcomes and will drive up costs unnecessarily

ch. 9 health system navigation from health advocacy perspective, there are only 2 populations of people

-those who have a health problem -those at risk of getting a health problem regardless of which group a person is in, help navigating the hc system is useful

ch. 20 workplace pop health workplace health model

1) assessment -individual (demographics, health risks, use of services) -organizational (current practices, work environment, infrastructure) -community (transportation, food and retail, parks and rec) 2)planning and management -leadership support (role models and champions) -management (workplace health coordinator, committee) -workplace health improvement plan (goals and strategies) -dedicated resources (costs, partners/vendors, staffing) -communications (marketing, messages, systems) 3) implementation -programs (education and counseling) -policies (organizational rules) -benefits (insurance, incentives) -environmental support (access points, opportunities, physical/social) 4)Evaluation -worker productivity (absenteeism, presenteeism) -healthcare costs (quality of care, performance standards) -improved health outcomes (reduced disease and disability) -organizational change, "culture of health" (morale, recruitment/retention, alignment of health and business objectives)

ch. 20 workplace pop health Fieldale farms

4,600 employees Heart disease costs $50,000 per heart attack Offers Gym memberships Free health screenings one-on-one nutritional counseling educational sessions at work about heart disease, diabetes and other preventable health problems. Incentives Wal-Mart gift certificates, T-shirts George Foreman grill gym bag impact: through diet, exercise, and medication changes, 26% of employees with elevated blood pressure and cholesterol lowered their risk results:Health costs increased by 2% National average 12% Health insurance plan spends $3000 per employee National average $5,800 60% of employees take part

ch. 20 workplace pop health NHWP training and assistance

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ch. 11 - hc quality and safety across the care continuum Consumer Perspective

A goal of the CMS Quality and Safety Strategy for 2013 and Beyond is to promote person and family engagement as partners in their care. The ACA calls for a focus on the patient experience, self-management, and shared decision making. The consensus is that informed, engaged consumers will select high-quality providers and share in the decision-making process. Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys enable objective data collection and public reporting related to perceptions of health care.

ch. 11 - hc quality and safety across the care continuum National Quality forum (NQF)

A nonprofit organization dedicated to improving the quality of healthcare in the United States. NQF embodies a three-part mission: To set goals for performance improvement To endorse standards for measuring and reporting on performance To promote educational and outreach programs

ch 14 - pop health in action Keys to Success

A reliable and sustainable population health model relies on execution in two main areas: Access: Is the model feasible and meaningful to its stakeholders (patients, providers, systems)? Outcomes: Does the model improve the critical health outcomes of quality, service, and cost for individual patients and the population served? Models that engage physicians, support staff, patients, and payers in problem solving have a better chance of seeing results.

ch. 20 workplace pop health CDC

A workplace health program has the potential to both keep healthy employees in the "low-risk" category by promoting health maintenance, while also targeting those unhealthy employees in the higher-risk categories, therefore lowering overall health insurance costs. A systematic review of 56 published studies of worksite health programs showed that well-implemented workplace health programs can lead to 25% savings each on absenteeism, health care costs, and workers' compensation and disability management claims costs.

ch 14 - pop health in action Common Principles

Access Right care at the right time Provider's perspective: Sufficient providers to deliver services Sufficient and accessible services for patient needs Patient's perspective: Was I able to get a convenient appointment? Was I cared for while at the appointment? Do I have confidence that I matter to the providers and health delivery system? Access (continued): Acute access: urgent need Maintenance access: recommended well visits and chronic care management, largely ambulatory in nature Personal access: patient requested advice on non-urgent or chronic problems Clinical decision support: Effective use of electronic data to improve decision making for patient care Includes electronic health records, claims data, and practice management systems Monitored by the Office of the National Coordinator under the meaningful use legislation Critical for mining patient panels to identify patient needs Risk stratification: Scans a patient population to prioritize resources for highest cost, highest care need patients Use of clinical decision support to categorize patients: Uses defined definitions to find patients who are in need of extra support or services Allows the provider to prioritize those who are in more immediate need Encourages assimilation of best practices from one population to another Patient engagement: Using techniques to activate patients as partners in their own care: Uses motivational interviewing techniques and self-management goal-setting strategies Often measured by patient satisfaction data or the use of process measures such as "number of patients who have filled a prescription" Patient engagement is about relationship management between the provider and the patient Building and tracking relationships: Managing care and costs between visits: Combination of cohesive, complimentary, and collaborative care for a patient across all entry points Dependent on clinical decision support to allow access to medical records across settings Assumes that primary care serves as the base of care needs and that specialists are engaged as needed Requires transitions between providers to be coordinated to ensure a seamless patient experience Should ensure that patient care is provided without error Measuring and improving outcomes: Implies that delivery systems will track improvement over time Endorses using evidence-based medicine as a basis for care Requires that health delivery systems focus on safety and quality metrics Endorses transparency of metrics Works best when system-level thinking is employed

ch 14 - pop health in action Payment models

Ambulatory episodic-based payment Uses a fee-for-service base pay Allows for shared savings above fee schedule on specific diseases or conditions with set benchmarks Uses a provider of care as the "quarterback" of services across an integrated system Accountable care organizations (Medicare Shared Savings Program) Requires performance in set of quality metrics, including patient experience Allows for shared savings if members of the ACO are successful in hitting benchmarks in quality and satisfaction measures

ch. 11 - hc quality and safety across the care continuum Centers for Medicare and Medicaid Services (CMS)

Beginning in 2000, CMS implemented quality initiatives incrementally, with increasing sophistication to ensure quality health care for all Americans through accountability and public disclosure. CMS standardized quality data collection and reporting processes, initially focusing on the hospital setting. Current initiatives focus on publicly reported quality measures for nursing homes, home health agencies, hospitals, dialysis facilities, and ambulatory care providers. CMS launched Medicare.gov quality comparison websites, where performance by hospitals, physicians, and alternate care facilities is posted.

ch. 20 workplace pop health sample techniques

Biometric Screening - Clinical process Key indicators Health Risk Assessment- survey tool eval health and identify risks Environment and Culture at the Workplace The culture of an organization has the potential to have a larger effect on the health of employees than the health programming offered. Financial incentives promoting "extrinsic motivation" Outside; Gain a reward; Avoid a punishment Games, Competition, and Collaboration - Gamification Use of Technology, Apps and Smartphones

ch. 11 - hc quality and safety across the care continuum Institute for HC Improvement (IHI)

Brought together thought leaders to devise strategies for improving healthcare quality Developed and launched Triple Aim, which focused on enhancing patients' experience of care, improving the health of populations, and reducing costs Triple Aim became the building block for the National Quality Strategy (NQS)

ch. 19 summary

CER Definition Types of CER Best Practices - PICOT Practical Applications Effects on Population Health

ch 14 - pop health in action Practice Redesign Models

Chronic care model: Chronic care with the focus on medical and community management Patient-centered medical home: Patient-driven care with a focus on prevention, chronic conditions, and utilization Recognition programs: National Committee of Quality Assurance Joint Commission on Accreditation of Healthcare Organizations Utilization Review Accreditation Commission

ch 14 - pop health in action Wagners chronic care model

Chronic condition management: Built from the theory that a patient's relationship with a primary care provider is critical for improved outcomes Requires an interdisciplinary approach to care, including collaboration between specialists and the primary care physician as well as support and ancillary staff Includes community and social support as part of the healthcare equation Uses risk stratifying for priority setting as a key to success

ch. 19 Key components of CER for application to pop health

Compares benefits and harms of healthcare interventions (diagnostics, medical procedures, drugs, etc.) Identifies what works best when, and for whom, for informed decision making Defines results for subgroups that are often excluded or overlooked in standard clinical trials Is conducted in settings that are similar to those in which the intervention will be used in practice Is designed to measure improvement in health outcomes

ch. 19 CER definitions from national authoritative sources

Congressional Budget Office Institute of Medicine Agency for Healthcare and Research Quality American College of Physicians Academy of Managed Care Pharmacy

ch. 9 health system navigation high deductible health plans

Consumer has more "skin in the game" Does having to spend more of your own money make you a "better" health consumer? Data shows people in these plans spend less than non-CDHP Consumers need help understanding provider cost and quality measures Population health outcomes under CDHP as yet unknown

ch. 9 health system navigation can we change consumer behavior?

Consumer-driven health plans assume that the consumer can be "activated" to engage in their own health management. Those who perform well in consumer-driven plans may be "different" from the average individual—inherently more "activated." Advocacy programs can help activate consumers and help others who merely are trying to cope with their situation.

ch. 20 workplace pop health future

During the next 1-3 years, Updating of the popular Health Risk Assessment More "inclusive" HRA, with more health determinants, e.g. Culture During the next 3-5 years, Major transformational change Tactical Programming and Enterprise-wide wellness and performance strategy High Reliability HCO's Value of "Thriving and High Performance" for employeee Sustainability Beyond 5 years, we would expect the pursuit of sophisticated Employer-Employee relationships, with shared values, shared accountability and shared results within enlightened and successful companies and high-performance organizations.

ch. 20 workplace pop health employer objectives

Employee Health - on the job health and safety Employee Wellness - health promotion Employee Productivity - goal is to be on the job and working productively Employee Engagement - Employer of Choice by 'engaging' employees For Healthcare Organizations, Workplace/Workforce is a "model population" for experimentation on best practices in employee wellness and health promotion

ch. 20 workplace pop health employee needs

Employees spend more time in the Workplace than at home Remember, most Health happens outside of the HCO Social Determinants of Health

ch. 9 health system navigation employers perspective

Employer's perspective: -More American adults get benefits through their employers than other sources -91% of employers with >50 employees offer health benefits -Kaiser Family Foundation: 2013 health premium for a family of four = $16,351 -2003-2013 family health insurance premiums grew by 80% -Main focus is on cost of health benefits -Want "value" for their investment -Recognize that good health is good for business -Attempts to constrain costs have resulted in multi-layered, difficult to use, benefit programs

ch. 9 health system navigation health advocacy as an independent service

Engage the individual at their time of need Typically opt-in programs, not data driven Create trusted relationship with user Protect privacy—HIPAA Personal relationship between user and advocate Provide help with any health-related issue facing consumer

ch. 10 - transitions of care Transitions of care across the continuum

Enhanced assessment of post-hospital needs Effective teaching to facilitate learning by the patient and family caregivers Post-hospital care follow-up, including medical and social services Boundary-less transfer of critical information as the patient transitions to the next clinician or healthcare organization or home

ch. 11 - hc quality and safety across the care continuum National Quality strategy (NQS)

Established as part of the Affordable Care Act (ACA), the NQS serves as a catalyst and a compass for a nationwide focus on quality improvement efforts and approach to measuring quality The NQS strategy is to concurrently pursue three aims: Better health Better care Lower costs

ch. 19 Practical applications of CER in pop health

Example: value based insurance designs application aspects and potential impact: Provides incentives (e.g., copay reduction, deductibles) that steer health plan enrollees to treatment options identified to have "better" value and positive net health outcomes Example: value based purchasing Application aspects and potential impact: Places responsibility on healthcare provider to demonstrate outcomes. This may include: Measuring and reporting comparative performance Paying providers differently based on performance Designing value-based insurance designs that complement

ch. 19 Types of CER

Experimental studies Randomized controlled trials Cluster randomized trials Pragmatic (noncontrolled clinical trials) Nonexperimental studies Prospective observational studies Systematic reviews Meta-analysis Health technology assessment

ch. 19 CER Effects on pop health

Fills knowledge gap where few robust studies are available to compare different treatment options in different subpopulations. Guides practical healthcare decision making in selecting best options. Supports the improvement of healthcare quality and outcomes. May reduce unnecessary healthcare spending.

ch 14 - pop health in action Closed vs non-closed systems

Fully integrated systems (hospital, ambulatory, payer systems) can build standardized processes to meet the Triple AIM within a network of care. Example: Kaiser Permanente uses a closed system with a payer-provider model to help drive care at lower costs. Non-integrated systems will have to create governance to guide care decisions regarding patient-centered delivery throughout the payer network. hard, but essential

ch. 11 - hc quality and safety across the care continuum Inpatient Hospital Quality Improvement

Groundwork laid by CMS' Premier Hospital Quality Incentive Demonstration project (2003), under which participating hospitals earned incentive payments for achieving performance goals on VBP metrics Financial penalties were implemented under the Deficit Reduction Act (DRA) of 2005: Hospitals no longer received additional payments for care rendered to patients with healthcare-associated conditions Never Events Under a comprehensive CMS VBP initiative (2012), payments to hospitals are based on performance in six domains: Safety Patient- and caregiver-based experience and outcomes - HCAHPS Care coordination Clinical care Population/community health Efficiency and cost reduction

ch. 11 - hc quality and safety across the care continuum Challenged to Measuring Quality and Safety from a Population Health Perspective

Health care is delivered in a fragmented system, which incentivizes volume, and not value, of services. With little interoperability among multiple existing health information systems (HIT), it is difficult to assess the health status of an individual patient or a population. Care for people with chronic conditions is not well coordinated.

ch. 10 - transitions of care Context as a vital sign

Health happens—one person at a time, one day at a time, one decision at a time Within the context of where and how people live: Where they work, learn, play, shop Influenced by their level of education, income, employment Determined by their access to healthy food, safe environments, available transportation, healthcare services Health does not happen primarily within healthcare sector: It happens within the context of each person's life not in their doctor's office Their cultural, social, and economic frameworks are modified by their values and priorities.

ch. 9 health system navigation factors driving health advocacy

Healthcare cost increases Complexity of health benefits programs Consumers being asked to assume greater responsibility for managing their own health Medical care system disorganization and inefficiencies Problems getting access to care Increasing medical technology and super-specialization Information overload Increasing focus on quality of care and patient safety Difficulty of managing a parent's health issues Privacy concerns of employees with health issues No where else to turn for help

ch 14 - pop health in action Value based payment

Healthcare reform is focused on moving from volume-based care to value-based care: Prevention and Wellness + Chronic Disease Management = Reduced Utilization and Cost

ch. 8 behavioral economics conclusion

Humans make inconsistent decisions using certain rules of thumb in particular situations. Healthy behavior requires an entire social ecosystem: family, community, and state. Behavioral economics can have substantial effects on population health with proper legislation and techniques for individual empowerment.

ch. 19 Potential value of CER - impact on pop health

Improved healthcare quality and patient outcomes: Greater precision in selecting options Best chances of positive outcomes (e.g., preventing, diagnosing, treating and monitoring a medical condition) Shifts in healthcare system in the use of proven treatment options Financial and economic aspects: Promotes rigor of evidence to support most cost-effective options Reduces unnecessary financial spending on care that does not improve population health

ch. 10 - transitions of care Pareto principle

In 1941, Juran was introduced to the work of Vilfredo Pareto. He studied the Pareto principle (the 80-20 law), which states that, for many events, roughly 80% of the effects follow from 20% of the causes, and applied the concept to quality issues. Thus, according to Juran, 80% of the problems in an organization are caused by 20% of the causes. This is also known as the rule of the "Vital few and the Trivial Many". Juran, in his later years, preferred "the Vital Few and the Useful Many" suggesting that the remaining 80% of the causes must not be completely ignored.

ch. 11 - hc quality and safety across the care continuum Evolution of hc quality improvement

Institute of Medicine (IOM)—To Err Is Human (1999) - Defined quality as: "The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" Systems, rather than people, are the issue What is not measured cannot be improved

ch. 20 workplace pop health challenges of workplace wellness

Insurance Affordability Disability and Coercion Privacy and Confidentiality Cultivating Intrinsic Motivation Decision Making- Think Fast, Think Slow Experiencing-Self and Remembering-Self- Kahneman, D, "We don't choose between experiences, we choose between memories of experiences" New Methods, Measures and Metrics- employers need better analysis

ch. 20 workplace pop health Johnson & Johnson

Live for Life Started in 1979 HRA $500 incentive Focuses on: smoking/tobacco use, blood pressure, cholesterol and inactivity. 90% participation $9-10 million a year in savings $400 per employee Strategy -Programs/Activities: Tobacco-free workplaces Health Risk Assessment (HRA) Biometric screening EAP Physical activity challenges Health centers Fitness classes Health education campaigns and classes Healthy coaching Work/life balance programs -Environmental supports: Two on-site health clinics On-site pharmacy On-site fitness centers Healthy food offerings at dining facilities and in vending machines. -Incentive design: While incentives are offered, they are somewhat deemphasized; the program tries to tap into employees' intrinsic motivations to improve their health. Employees can earn up to a $500 credit on their health insurance premiums.

ch. 9 health system navigation middle market employers perspective (100-1500 employees)

Mix of insured (smaller) to "self-insured" programs Self-insured companies hire an administrator—could be a health plan or a third party administrator (TPA) Start to see some customization of benefits—e.g., carve-out pharmacy benefits to a pharmacy benefit manager (PBM) Consultants as well as brokers sell and support clients

ch 14 - pop health in action Community care models

Moves care from within a healthcare setting to the community setting Targets medically and socially complex cases Identifies patients through trends in healthcare utilization (e.g., frequent emergency room care) Ties patient's utilization to community or socio-economic needs as a predictor of utilization over time Example: Camden Coalition of Healthcare Providers

ch. 11 - hc quality and safety across the care continuum National Committee for Quality Assurance (NCQA)

NCQA developed the Healthcare Effectiveness Data and Information Set (HEDIS), which is the most widely reported set of measures for evaluation of health plan and provider performance. HEDIS measures address a broad range of quality and safety concerns (e.g., appropriate management of chronic conditions, access to prenatal services). NCQA, and other measure developers, submit quality measures to the National Quality Forum (NQF) for endorsement.

ch. 9 health system navigation large employers perspective (>1500 employees)

Nearly all are "self-insured" Plan administrator likely to be a health plan Customized benefits—"best of breed" approach Examples of carve-out programs: Pharmacy benefit manager (PBM) Mental health manager Disease management Case management Employee assistance program (EAP) Nurse triage service Dental plan Wellness program

ch 14 - pop health in action conclusions

Patient-centered care is at the heart of population health. Care delivery systems must be integrated and/or highly collaborative to manage populations effectively. Population health management relies heavily on clinical decision support to allow for patient prioritization based on need. Payer models are being tested nationally to support an infrastructure that will enable patient identification and population health needs.

ch 14 - pop health in action Incentives for Pop health

Pay for performance: (P4P) Payer-driven incentives to meet certain metrics Payer, employer, or government incentives to participate in PCMH activities Meaningful use: Federal incentives to upgrade technology and prove meaningful use and understanding of electronic health records Shared savings models: Provider network benefits from shared savings on specified metrics

ch. 9 health system navigation sonsumers perspective - consumer driven health care

Preferred provider organization plans (PPO) dominate the benefits landscape In- and out-of-network benefits introduce complexity—reasonable and customary (R&C) reimbursement and balance billing High-deductible, "consumer-driven" health plans (CDHP)

ch 14 - pop health in action Preventive care models

Preventive care management: Focuses on wellness and disease prevention using evidence-based guidelines Represents a relatively cost-effective approach Requires electronic systems to identify and outreach to patients who are due for appointments Recognizes primary care as the core of healthcare management Prioritizes preventive interventions as equal to chronic care visits in terms of importance to a patient Benefits from risk-stratification techniques to prioritize patient needs

ch. 11 - hc quality and safety across the care continuum Quality Measurement

Quality measures are developed by stakeholders based on four criteria: Is there sufficient evidence to indicate that the measure can affect quality? Is the measure scientifically acceptable to produce valid and reliable results? Is the measure usable in quality improvement and decision making? Is it feasible to collect data on the measure?

ch. 11 - hc quality and safety across the care continuum Quality and Patient Safety in Alternate Care Settings

Retail clinics Walk-in medical facilities located inside pharmacies and retail chain stores Care is delivered by nurse practitioners, often without a physician on the premises A growing segment of the U.S. population (an estimated 4.1 million in 2010) visits pharmacy-based, nurse practitioner-staffed clinics for preventive and non-emergent care The Convenient Care Association publishes quality standards and conducts quality certification reviews of member clinics Urgent care centers: More than 9,000 facilities operating in 2014 The American Academy of Urgent Care Medicine offers an accreditation program and a process by which organizations can measure their performance against national benchmarks Long-term care (LTC): Concept has evolved to encompass multiple settings and forms based on the patient's needs and wishes More than 15,000 Medicare and Medicaid certified nursing homes in the United States Current nursing home quality measures are endorsed by the NQF and publicly reported on the CMS Nursing Home Compare website Under the ACA, LTC hospitals must submit data to CMS on an increasing number of quality measures (e.g., catheter-associated urinary tract infections, pressure ulcers, and influenza vaccination rates of healthcare personnel) Home health care: CMS requires more than 10,800 Medicare-certified home healthcare agencies to collect and report performance data on the Outcome and Assessment Information Set (OASIS) tool A subset of these quality-based metrics is posted on Medicare.gov Home Health Compare website Currently reported quality measures are related to: Managing pain and treating symptoms Treating wounds and preventing pressure ulcers Preventing harm Preventing unplanned hospitalizations

ch 14 - pop health in action System level thinking

Setting and measuring goals: Macro level: Broad goals that summarize an improvement concept (e.g., number of 30-day readmissions per 1,000 patient days) Meso level: Goals that look for trends in best practice or need (e.g., list of providers who have the lowest readmission rates) Micro level: Goals that are relevant to hands-on care team (e.g., number of CHF patients who have a 30-day readmission)

ch. 10 - transitions of care summary

Shift from Acute Care to Chronic Care Management Pareto Principle 80/20 How "Context and Circumstances" influence health outcomes and costs Health Starts at Home SODH Emerging models Chronic Care Mgt and Primary Care

ch. 9 health system navigation health plan and administrators perspective

Some health plans have enhanced member service functions or their own advocacy programs. Consumers in general do not trust their health plan. 2/3 of consumers worry that health plan cares more about making money than doing the right thing for members. Almost 50% of consumers report having had a problem with their health plan in the last year. Health plans may include advocacy support as a "differentiator" in the marketplace.

ch. 9 health system navigation physicians perspective

Some physicians will try to help patients deal with administrative issues—to a point Don't have the time or the skills—prefer to focus on clinical issues Don't get paid for helping patients deal with their health benefits Support health advocacy programs that reinforce their treatment plan and support their doctor-patient relationship

ch. 11 - hc quality and safety across the care continuum Role of Health Information Technology (HIT)

The American Recovery and Reinvestment Act (ARRA) of 2009 established financial incentives for hospitals and other providers to invest in and utilize HIT (e.g., electronic health records) under the Meaningful Use (MU) Program. The goal of the MU Program is to build a national HIT infrastructure that might be leveraged to improve population health. HIT has potential for enhancing clinical care processes and improving health outcomes by: Providing clinicians access to current treatment guidelines and decision-support tools Alerting clinicians to patient allergies and potential drug-drug interactions via electronic prescribing systems Helping clinicians identify and manage select patient populations (e.g., patients with diabetes) Helping clinicians track their performance on quality measures based on comparisons to national benchmarks

ch. 11 - hc quality and safety across the care continuum Ambulatory Care Quality Improvement

The NQF has endorsed ambulatory measures for assessing the quality of care in a variety of clinical settings -- report on almost 300 unique quality measures ranging from laboratory values to smoking cessation counseling. CMS' Physician Quality Reporting System (PQRS) is a voluntary pay-for-reporting program for Medicare providers. Providers who do not participate in quality improvement programs are faced with financial penalties.

ch. 11 - hc quality and safety across the care continuum Patient Safety Organizations (PSO)

The Patient Safety and Quality Improvement Act of 2005 led to the creation of PSOs and a new framework for collecting, aggregating, analyzing, and more effectively addressing medical errors and adverse events. (New Jersey Hospital Association in NJ) A PSO is defined as a group, institution, or association that improves medical care by reducing medical errors. Information reported to a PSO is protected from legal liability and professional sanctions.

ch. 9 health system navigation conclusions

The U.S. healthcare system will continue to struggle until we find some means to reduce costs. Employers will continue to respond to the increased cost of health benefits by increasing the amount individuals must pay for their health care. Individuals will have to assume a larger role in managing their own health and making healthcare decisions. Health advocacy programs aim to help consumers make more informed and better health decisions, which can lower costs and improve outcomes.

ch 14 - pop health in action Success = Better Care, Lower Cost, Better Patient Experience

The pursuit of the Triple Aim can only be achieved through a population health platform. This implies that health is a confluence of traditional medicine with an understanding of the effect social determinants have on health care. Likewise, the combination of medicine as both an art and a science is essential if population health is to be realized.

ch. 20 workplace pop health workplace health strategies

The strategies and interventions available fall into 4 major categories: • Health-related programs—opportunities available to employees at the workplace or through outside organizations to begin, change, or maintain health behaviors. • Health-related policies—formal or informal written statements that are designed to protect or promote employee health. They affect large groups of employees simultaneously. • Health benefits—part of an overall compensation package including health insurance coverage and other services or discounts regarding health. • Environmental supports— refer to the physical factors at and nearby the workplace that help protect and enhance employee health.

ch. 9 health system navigation small employers perspective (<100 employees)

Usually "insured"—pays premium to health plan that bears financial risk Offers relatively standard insurance programs Few staff at employer to help resolve employee issues Benefit brokers play a big role in selling and after-sale support

ch. 9 health system navigation what help do consumers needs?

Utilization of advocacy services—6% to 10% in large companies, 10% to 15% in small companies Use often mirrors what is going on in employer's benefits program—change of carrier, plan design, etc. Over half of all initial calls related to an administrative issue—bills, benefits, appeals, denials, grievances Cross relationship between types of issues—clinical issues often lead to administrative concerns and vice versa The people who call needed some type of care for some medical issue and have a question or problem Access to care issues: Finding physicians for common needs Identifying specialists Second opinions "Best" doctors, hospitals Network participation status Personal desires and preferences Scheduling appointments Getting medical records transferred Single point of contact through the advocacy program Making connections to other benefit programs: Right time, right place approach to get patient to the right program to meet their needs Referrals to disease management, case management, PBM, EAP, nurse triage service May involve disability carrier, Family and Medical Leave Act (FMLA) approval Provides coordination across a fragmented system

ch. 11 - hc quality and safety across the care continuum Patient Protection and Affordable Care Act (ACA)

Value-based purchasing: Programs vary in design, but share common goal of decreasing costs and improving quality Program components include: Defined performance goals for select quality metrics Financial incentives for hospitals and individual providers Reported results of pay-for-performance initiatives are mixed CMS Hospital Readmission Reduction Program Hospitals are subject to rate reductions for high rates of readmissions due to conditions deemed "preventable" (e.g., heart failure, pneumonia) Patient-centered medical home (PCMH) model: Enhanced, multidisciplinary team care with a primary care physician coordinating care among different specialty providers and practice sites Improved access to care (e.g., extended hours, improved patient-provider communication) Focus on preventing illness and engaging patients in their own health Accountable care organizations (ACO): Affiliations of healthcare providers (hospitals, physicians, and others) that collectively agree to be accountable for the health, and associated costs, of a defined population ACOs are held accountable for multiple quality metrics (e.g., preventive screenings, blood pressure control) The Medicare Shared Savings Program (MSSP) is an ACO model that enables providers to share in the cost savings realized from providing more appropriate, better quality care

ch. 19 Best practices - critical appraisal of CER

Why critical appraisal of CER is important before applying in practice PICOT technique to assess CER: P = Patient population or Problem I = Intervention C = Comparison O = Outcome T = Time frame

ch 14 - pop health in action The Case for chronic care management

Why focus on chronic disease? Majority of healthcare costs are consumed by chronic conditions. Chronic conditions often require more access points to the care delivery system. Maintenance and long-term management of chronic conditions are essential to reduce utilization costs over time. Chronic conditions often bring multiple co-morbidities further compromising care.

ch. 19 Best Practices - synthesizing body of evidence for CER

Why synthesizing a body of evidence for CER is important Applying the Institute for Clinical Economic Review (ICER)

ch. 20 workplace pop health workplace/workforce population health definition

Workplace health programs are a coordinated and comprehensive set of health promotion and protection strategies implemented at the worksite that includes programs, policies, benefits, environmental supports, and links to the surrounding community designed to encourage the health and safety of all employees.

ch. 10 - transitions of care care management has shifted

acute care episodes (infections, trauma and injury) -> chronic care over time (diabetes, heart disease, cancer, mental disorders, functional disabilities)

ch. 8 behavioral economics physician behaviors

anchoring: decisions are made based on a reference point, with usually inappropriate adjustments; prescribing same treatments in like circumstances without much change status quo: failure to proactively change a default stance; prescribing the same medication at initial consult bandwagon effect: conforming to social norms; carrying out certain actions because others do

ch. 9 health system navigation characteristic of the us hc system

disorganized - both benefits and medical delivery expensive - we spend more per capita than any other developed country technologically sophisticated and often designed for provider convenience, not consumers complexity frustrates consumers

ch. 8 behavioral economics behavioral interventions

employee wellness programs: companies can save $3 for every $1 invested in employees; carrot versus stick medication adherence: non adherence cost = $100 billion i the US; express scripts uses opt in option for mail order delivery substance abuse: emotional trigger cues; ask people to recommit to an action

ch. 9 health system navigation taking a populations approach can help target interventions

every person can be places in one r more groups according to health elated factors: -conditions (asthma, heart disease) -level of health spending -medications -employer -type of health insurance coverage -provider

ch. 10 - transitions of care Barrier and challenges

financial - FFS legal - scope of practice political - repeal and replace; S. of p historical - risk averse; evidence based

ch. 8 behavioral economics future challenges

hard to predict future decisions: physicians attitude depends on the heuristics (rule son thumbs) they use in each meeting success of incentives depends on: size, frequency, trigger, duration, and execution scalability depends on: framing, timing, incentives, distribution, customization, and measurement confounding variables: education, socioeconomic status, social relationships, intrinsic motivation ethics: right to nudge others; extent of legislation

ch. 20 workplace pop health Impact of employee health

health care (direct/visible costs): medical, pharmacy lost productivity (indirect/non visible costs): presenteeism, short term disability, long term disability, absenteeism, workers compensation indirect costs represent 2-3 times direct health care costs

ch. 8 behavioral economics patient behaviors

hyperbolic discounting: prefers the choice that presents sooner to the one that comes later, discounting the value of the later choice present bais: pays greater attention to immediate costs and benefits than to those anticipated in the future law of small numbers: over interpretation of information that is based on an insufficiently small number of observable events relativity and choice: making decisions based on what is currently present versus other available alternatives message framing: the way information is communicated

ch. 8 behavioral economics other health related decisions

mental accounting: when someone has difficulty compartmentalizing complex decisions choice architecture: context in which a choice is presented loss aversion: prefers loss avoidance to acquiring gains

ch. 9 health system navigation private health advocacy programs

recent development - last 15 years fee based - paid either by employer or consumer directly employer benefit model has gained significant traction work in concert with patients physicians

ch. 10 - transitions of care New models of care

structure: -health/medical homes -community based care -from hospital to home function -team based -ancillary staff (community health workers) financial -accountable care organizations -bundled payment models -value based purchasing -risk based accountability

ch. 20 workplace pop health worksite contributions to heart disease risk

work -> -psychological stressors (high demands, low job control, social isolation, effort/reward, imbalance, danger potential) -schedules (shift work, long work hours) -physical job demands (sedentary work, static load, heavy physical exertion) -toxic chemicals (tobacco smoke, carbon monoxide, nitroglycerin, lead) -environment (noise, heat, cold, lack of access to healthy foods) -> cardiovascular disease