Population Health

1. Population Health Population Health Management Interventions Lecture b This material (Comp 21 Unit 7) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0005. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Population Health Management InterventionsLearning Objectives — Lecture b • List the characteristics of population health interventions. • Delineate interventions and staff who are deployed for high-risk, rising-risk, at-risk, and low-risk populations. • Describe three types of deployment strategies/models for population health management.

3. Traditional Health Care Sources (left to right): James Gathany, 2009, public domain. Jhm1234, 2013, CC BY-SA 3.0. Christianna Care, 2013, CC BY-NC-SA 2.0. David K, 2005, CC BY-SA 2.0. Phalinn Ooi, 2011, CC BY 2.0.

4. Population Health — Continuum of Health Needs and Opportunities • Healthy people. • Goals: stay well, reduce risk for disease. • People with risk factors for disease. • Goals: control risk factors, prevent or delay disease onset. • People with chronic diseases and complex health care needs. • Goals: maximize disease control, provide efficient and effective care, minimize complications.

5. Johns Hopkins Medicine Population Health Conceptual Model — 1 7.20 Figure. Johns Hopkins HealthCare, LLC, Population Health Research and Development (2016)

6. Johns Hopkins Medicine Population Health Conceptual Model — 2 Based on identified population needs, design and implement appropriate interventions for each level of risk 7.21 Figure. Adapted by L. Dunbar, Johns Hopkins HealthCare (2016)

7. Defining Population Health Interventions • Programs, policies, and resource distribution approaches that impact a number of people by changing the underlying conditions of risk and by facilitating health improvement or maintenance for the population as a whole. • Implemented within and outside of the health sector. • Allows a comprehensive and multi-faceted approach to planning and delivering programs and intervention.

8. Characteristics of Population Health Interventions • Well-planned, well-placed, and well-conducted = specificity. • Lead to increased efficiency and effectiveness through appropriate resource allocation to meet varying needs of the population and population sub-group. • Adherence to RE-AIM. • Reach. • Effectiveness. • Adoption. • Implementation. • Maintenance and cost (sustainability). Source: Reach Effectiveness Adoption Implementation Maintenance (RE-AIM).

9. Merger of Public Health and Clinical Intervention Frameworks — Public Health Intervention Wheel 7.22 Chart. Minnesota Department of Health. (2006.)

10. Clinical Intervention Framework — Specificity and Appropriateness • Tertiary prevention: interventions to manage care for people with complicated and chronic health problems such as diabetes, heart disease, cancer, chronic pain; aims to improve disease control, prevent further physical deterioration, and maximize quality of life. • Secondary prevention: interventions to halt or slow the progress of disease at its earliest stages in people with disease. • Primary prevention: interventions to protect healthy people from developing a disease or health condition.

11. Key Elements of Population Health Interventions • Collaborative, team-based care. • Integrated primary care. • Coordinated care (including transition from inpatient to outpatient care). • Inclusion of: • Case management (individual patient assessment and care plan). • Patient self-management support personnel and programs (health educators, coaches, use of assessment, care plan and intervention). • Flexible model of specialist integrated primary care. • Multiple delivery modalities and options. • In-clinic; telephone-based; web-based. • Clinic-community partnerships. • Community-based surveillance, health promotion, and support using lay health agents. • Design and implementation of risk behavior protocols and programs (nutrition, fitness, weight management) that are flexible, adapted to address patients at different risk stratification levels.

12. Care Management Models: Sites and Modalities 7.23 Table. Adapted from McCarthy, Ryan, and Klein.

13. Integrated, Team-BasedPrimary Care • Integrated primary care combines medical and behavioral health services to more fully address the spectrum of problems that patients bring to primary medical care. • Integrate a new discipline — behavioral team — into the primary care team. • Community-based health workers extending services into the patient’s home and neighborhood. • Lift some burden from the primary care team. • Adjust the workflow.

14. Features of Successful Care Coordination • Face-to-face contact with providers/care managers at least once per month. • Care coordinators located near physicians, attended appointments, or saw physicians on rounds. • Care coordinators had “communication hub” with physicians. • Behavioral change education provided. • Care managers contact patient during hospitalization and requested copy of discharge instructions. • Transitions protocols used and monitored for compliance. • Care managers received information on medications from sources other than patients and consulted with pharmacist or physician in the event of a problem. Brown, R. S., Peikes, D., Peterson, G., Schore, J., & Razafindrakoto, C. M. (2012, June).

15. What Do Successful Interventions Have in Common? • Target high-risk patients. • Strong transitional care. • Medication management. • Ongoing assessments and monitoring of patients with chronic conditions. • Focused, streamlined care plans. • Close communication between care managers, patients, primary care doctors, and specialists. • Personal face-to-face contact between care coordinator and patient.

16. Lessons from Medicare’s Demonstration Projects • Demonstrations included: disease management, care coordination, and value-based payments. • Program fees put at risk, and value-based payments (other than bundled payments) did not save money or reduce admission. • Seven percent reduction in admissions for programs in which case managers had significant interaction with physicians. • Seven percent reduction in admissions for programs with significant in-person interaction between case managers and patients. • Programs lacking personal interactions between care managers, doctors, and patients showed no effect. Congressional Budget Office. (2012, January).

17. What Is the Patient Experience, and Who Are the Team Members? • What is the experience of a patient enrolled in a population health program? • Who are the team members interacting with patients?

18. The High-Risk Patient Experience in Population Health Programs The journey for J-CHiP community patients Johns Hopkins Community Health Partnership, 2012

19. Community Health Workers • Low patient engagement in low-resource, urban centers. • CHW programs effectively increase engagement. • CHWs: paraprofessional community-based workers. • Functions: • Locating and engaging patients. • Assessment of barriers to care and existing support. • Mitigation of identified barriers. • Adherence support (reminders, on-going assessment, coordination). • Focused health education. • Social support: support groups; participate in the organization of volunteer-based support. • On-going surveillance/monitoring.

20. Community Support: Navigators • Community support specialists can provide instrumental and social support to patients. • Network of support characterized, supported, and supplemented by CHWs. • Envision a multi-dimensional program consisting of: • Community support specialists: lay health workers. • Disease-specific peers and mentors. • Existing care givers.

21. CHW Initial Visit: Barriers to Care • CHW completes barriers to care survey, documents results in database, and schedules appointment with case manager to complete assessment. Johns Hopkins HealthCare, LLC, Population Health Research and Development (2016)

22. Case Managers Embedded in Primary Care Clinics • Builds on patient-centered medical home and other models with embedded nurse case managers. • Focuses on complex patients. • Works in close collaboration with primary care physician and serves as the clinical supervisor of the care management team.

23. Embedded Case Managers • Functions: • Comprehensive patient assessment including health behaviors, barriers to care, and screening for mental health issues and substance use. • Generation of a multi-dimensional care plan in collaboration with primary care team. • On-going care coordination. • Medication reconciliation. • Patient education, self-management training and support. • Monitoring.

24. Population Health Management InterventionsSummary — Lecture b • In Lecture b, we: • Listed characteristics of population health interventions. • Delineated interventions and staff who are deployed for high-risk, rising-risk, at-risk, and low-risk populations. • Described three types of deployment strategies/models for population health management.

25. Population Health Management InterventionsReferences — Lecture b — 1 References Brown, R. S., Peikes, D., Peterson, G., Schore, J., & Razafindrakoto, C. M. (2012, June). Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Aff (Millwood), 31, 6, 1156–1166; AHRQ. (2012). Congressional Budget Office. (2012, January). Lessons from Medicare’s demonstration projects on disease management, care coordination, and value-based payment. Issue brief. Kilbridge, P. (2013). A framework for IT-enabled population management. The Advisory Board Company. Accessed April 26, 2016, from https://www.advisory.com/research/health-care-it-advisor/research-notes/2013/a-framework-for-it-enabled-population-management Reach Effectiveness Adoption Implementation Maintenance (RE-AIM). Virginia Polytechnic Institute and State University. College of Agriculture and Life Sciences. Retrieved March 29, 2016 from http://www.re-aim.hnfe.vt.edu/ Charts, Tables, Figures 7.20 Figure: Population Health Conceptual Model. (2016). Johns Hopkins HealthCare, LLC, Population Health Research and Development 7.21 Figure: Population Health Conceptual Model - Adaptation. Dunbar, L. (2016). Adapted from Johns Hopkins HealthCare, LLC, Population Health Research and Development.

26. Population Health Management InterventionsReferences — Lecture b — 2 Charts, Tables, Figures 7.22 Figure: Public Health Intervention Wheel (2006). Office of Public Health Practice, Minnesota Department of Health. From Wheel of Public Health Interventions: A Collection of “Getting Behind the Wheel” Stories 2000-2006. (p. 1). Retrieved May 2, 2016 from http://www.health.state.mn.us/divs/opi/cd/phn/docs/0606wheel_stories.pdf 7.23 Table: Care Management Models: Sites and Modalities. (2016). Adapted from McCarthy, Ryan, and Klein. From T. Bodenheimer and R. Berry-Millett. (December, 2009). Care Management of Patients with Complex Health Care Needs. Research Synthesis Report No. 19. Princeton, N.J.: Robert Wood Johnson Foundation.

27. Population Health Management InterventionsReferences — Lecture b — 3 Images Slide 3: ID# 11162 [Man Sneezing] (2009). Gathany, James. Centers for Disease Control and Prevention, Public Health Image Library (PHIL). Retrieved March 29, 2016 from http://phil.cdc.gov/phil/details.asp?pid=11162. Public Domain. Johns Hopkins Hospital New Clinical Building (2008). Jhm1234 (Own work). Wikimedia Commons. Retrieved March 29, 2016 from https://commons.wikimedia.org/wiki/File:Johns_Hopkins_Hospital_New_Clinical_Building.jpg. CC BY-SA 3.0, via Wikimedia Commons Christiana Care President and CEO Robert J. Laskowski, M.D., MBA, with ... [Modified with permission] (2013) Christiana Care. Retrieved March 29, 2016 from https://www.flickr.com/photos/christianacare/13090319524. CC BY-NC-SA 2.0. Pills. (2005). David K. Retrieved March 29, 2016 from https://www.flickr.com/photos/plasticrevolver/56222679/. CC BY-SA 2.0 Ortho Clinic [Modified with permission] (2011). Phalinn Ooi. Retrieved March 29, 2016 from https://www.flickr.com/photos/phalinn/5648940965. CC BY-SA 2.0. Slide 10: Clinical Intervention: Prevention Pyramid (2016). Slide 18: The Journey for J-CHiP Patients. (2012). Johns Hopkins Community Health Partnership (J-CHiP). Slide 21: Needs Assessment Screen Shot. (2016). Johns Hopkins HealthCare, LLC, Population Health Research and Development.

28. Population HealthPopulation Health Management InterventionsLecture b This material (Comp 21 Unit 7) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0005.