cco oregon round table health metrics and outcomes
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CCO Oregon Round Table Health Metrics and Outcomes. Amit Shah, MD. Why measure?. Population Health. "Triple Aim". Experience of Care. Cost per Capita. What We All Want . Patient/ Provider View. Payer/ Purchaser View. Access to Care Be there when I need you. Accountability

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Presentation Transcript
what we all want

Population Health

"Triple Aim"

Experience of Care

Cost per Capita

What We All Want

Patient/ Provider View

Payer/ Purchaser View

Access to Care

Be there when I need you.


Take responsibility for making sure I receive the best possible health care.

Comprehensive Whole Person Care

Provide or help me get the health care services I need


Be my partner over time in caring for my health.

Coordination And Integration

Help me navigate the health care system to get the care I need in a safe and timely way.

Person and Family Centered Care

Recognize that I am the most important member of my care team – and that I am ultimately responsible for my overall health and wellness.

why measure1
Why Measure?
  • -Health care transformation will require significant amount of infrastructural and
  • clinical system redesign
  • -We know what we should be doing but why are we not achieving?
  • -We know what we should be doing but often do not know how we are doing?
  • -Allocation of funds to move transformation based on performance
  • -Subjective improvement not always =objective improvement
oha incentive metric
OHA Incentive metric
  • -P4P program part of CMS waiver granted to Oregon for transformation
  • -Outcomes based (important to move towards outcomes with understanding of what is need to build the process)
  • -OHA delegated committee to determine which metrics used and approved by CMS
  • -17 of 33 metrics are incentivized (must reach certain threshold in order to obtain full quality bonus and participate in bonus pool of money)
  • -monies used to fund transformation at clinic system level
list of measures
List of Measures
  • Alcohol or substance (SBIRT)
  • Follow-up after hospitalization for mental illness
  • Screening for clinical depression and follow-up plan
  • Prenatal timeliness of care
  • Elective delivery before 39 weeks
  • Ambulatory Care: Outpatient and ED utilization
  • CRC
  • Patient-Centered Primary Care Home Enrollment
  • Developmental screening in the first 36 months of life
  • Adolescent Well Child Visits
  • HgA1C control
  • EHR adoption
  • Mental and physical health assessment within 60 days for children in DHS custody