Population Health Management David A. Burton, MD

1. Population Health ManagementDavid A. Burton, MD

2. Population Health Management Emphasis on the Continuum of Care Inpatient Clinic Care Hospice Home Outpatient Skilled Nursing Facility Home HealthCare Cemetery

3. Population Health Management Paradigm Shift Inpatient Inpatient Clinic Care Hospice Home Skilled Nursing Facility Home HealthCare Outpatient Cemetery AcuteCare-Centric Management Population-Centric Management

4. Poll question Outpatient Inpatient 1 Outpatient Inpatient Home Health Hospice 2 Outpatient Inpatient Home Health Hospice Clinic Care 3 Outpatient Inpatient Home Health Hospice Clinic Care SNF 4 5 Other combination

5. Population Health Management Anatomy of Healthcare Delivery Symptoms Screening & Preventive Module-Focused Knowledge Assets Management of Preventive, Ambulatory, Acute Medical, Invasive & PAC Modules Health Maintenance and Preventive Guidelines Diagnostic Work-up Diagnostic algorithms Population-Focused Knowledge Assets Diagnostic Algorithms, Triage Criteria, Referral & Intervention Indications Home(Patient Portal) Triage to Treatment Venue Triage Criteria Admission Order Sets Admission Order Sets AmbulatoryNon-recurrent Ambulatory Recurrent Invasive Medical Invasive Surgical Acute Medical IP Med-Surg Acute Medical IP ICU Indications for Intervention Treatment and Monitoring Algorithms Indications for Referral Standardized Follow-up Substance Selection Substance Selection Substance Preparation Pre-Procedure Order Sets Clinical Supply Chain Management Supplementary Order Sets Invasive* Subspecialist Chronic Disease Subspecialist Bedside care Procedure * To Invasive Care Processes Post-procedure Order Sets Treatment and Monitoring Algorithms Post-procedure Care Bedside care practice guidelines, risk assessment and patient injury prevention protocols, bedside care procedures, transfer and discharge protocols Post-acute care order sets IP (SNF, IRF) Home health Hospice Discharge

6. Population Health Management Clinical Integration hierarchy - Care Processes Inpatient SNF Home Health Hospice Home ClinicCare Outpatient Hyperlipidemia Acute Myocardial Infarction(AMI) Cardiac Rehab CoronaryAtherosclerosis Percutaneous Intervention(PCI) Coronary Artery Bypass Graft (CABG) Care Processes

7. Population Health Management Clinical Integration hierarchy - Care Process Families Inpatient SNF Home Health Hospice Home ClinicCare Outpatient Hyperlipidemia Acute Myocardial Infarction(AMI) Cardiac Rehab CoronaryAtherosclerosis Percutaneous Intervention(PCI) Coronary Artery Bypass Graft (CABG) Ischemic Heart Disease Care Process Family

8. Population Health Management Clinical Integration hierarchy - Clinical Programs Inpatient SNF Home Health Hospice Home ClinicCare Outpatient Cardiovascular Clinical Program Ischemic Heart DiseaseCare Process Family Heart FailureCare Process Family Vascular Disorders Care Process Family Heart Rhythm Disorders Care Process Family

9. Clinical Integration hierarchy Clinical Programs – ordering of care CV W&C GI Neuro Sciences Musculo-skeletal General Med Resp-iratory Primary Care Surgery Oncology Peds Spec Mental Health Care Process Families e.g., Diabetes Care Process Families e.g., Heart Failure Care Process Families e.g., Pregnancy Care Process Families e.g., Lower GI Disorders Care Process Families e.g., Obstructive Lung Disorders Care Process Families e.g., Spine Disorders Care Process Families e.g., Joint Replace-ment Care Process Families e.g., Urologic Disorders Care Process Families e.g., Infectious Disease Care Process Families e.g., Breast Cancer Care Process Families e.g., Peds CV Surg Care Process Families e.g., Depression

10. Clinical Integration hierarchy Clinical Support Services – delivery of care ordered 12 Clinical Programs (“Ordering of Care”) CV W&C GI Neuro Sciences Musculo-skeletal General Med Resp-iratory Primary Care Surgery Oncology Peds Spec Mental Health Care Process Families e.g., Diabetes Care Process Families e.g., Heart Failure Care Process Families e.g., Pregnancy Care Process Families e.g., Lower GI Disorders Care Process Families e.g., Obstructive Lung Disorders Care Process Families e.g., Spine Disorders Care Process Families e.g., Joint Replace-ment Care Process Families e.g., Urologic Disorders Care Process Families e.g., Infectious Disease Care Process Families e.g., Breast Cancer Care Process Families e.g., Peds CV Surg Care Process Families e.g., Depression Clinical Support Services (Delivery of Care) Therapeutic Clinical Support Service (work flow models) (e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy) Diagnostic Clinical Support Service (work flow models) (e.g., Pathology and Laboratory Medicine, Diagnostic Radiology) Ambulatory Clinic Clinical Support Service (work flow models) (e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics)) Acute Medical Clinical Support Service (work flow models) (e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg) Invasive Clinical Support Service (work flow models) (Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])

11. Clinical Program CARDIOVASCULAR Care Process Families Heart Rhythm Disorders Ischemic Heart Disease ACS AMI PCI CABG Vascular Disorders Heart Failure Care Processes ICD9 Diagnosis Code Groupings ICD9 Procedure Code Groupings CPT-4 Code Groupings ICD9 Volumes I-II 17,674 Diagnosis Codes 2013 CPT® Code Set 9706 Codes ICD-9 Volume III 3,903 Procedure Codes

12. Population Health Management Medicare 2011 fee-for-service payments by venue Inpatient SNF Home Health Hospice ClinicCare Outpatient $ 18.4 Billion 7.1% $ 29.7 Billion 11.5% $ 31.7 Billion 12.3% 90.6 Billion 35.1% $ 10.1 Billion 3.9% 77.6 Billion 30.1%

16. Poll question • How does your organization prioritize improvement projects • Respond to desires of highest volume physicians with loudest voices • Respond to regulatory and accreditation imperatives • Based on pre-defined strategic criteria (including objective and subjective factors) • Other

17. Our Philosophy: Be Systematic Services Installation Services, Critical Improvement Services Systematically Change Process and Behavior Analytic Applications Key Process Analysis, Dashboards, Advanced Analytics Systematically Apply Evidence and Standardize Late-Binding™ Data Warehouse Platform Data Warehouse, Architecture, Metadata Management, Security, and Auditing Systematically Integrate Data and Measure

18. Catalyst Adaptive Data Warehouse Catalyst’s Adaptive Data Model Metadata: EDW AtlasSecurity and Auditing Common, Linkable Vocabulary Financial Sources (e.g., EPSi, Peoplesoft, Lawson) DepartmentalSources (e.g., Apollo) FinancialSource Marts DepartmentalSource Marts Readmissions Patient Satisfaction Sources (e.g., NRC Picker,Press Ganey) Administrative Sources (e.g., API Time Tracking) AdministrativeSource Marts PatientSource Marts Diabetes Sepsis EMR Source Marts HRSource Mart EMR Source (e.g., Epic, Cerner) Human Resources (e.g., PeopleSoft) More Transformation Less Transformation

19. Catalyst approach Foundational Applications Discovery Applications Advanced Applications 3 Application families 2 Late-Binding™ Data Bus Content-driven applications Late-Binding™ Data Warehouse Platform Data Acquisition Engine and Storage 1 Metadata-driven platform Metadata Engine 19

20. Clinical Integration Leadership Team (CILT) AdministrationVice-Chair CMOChair CNOVice-Chair Chief Information Officer Chief Knowledge Officer Cluster #1 Cluster #2 Cluster #3 Cluster # … Cluster #N ClusterCMO ClusterCMO ClusterCMO ClusterCMO ClusterCMO ClusterCNO ClusterCNO ClusterCNO ClusterCNO ClusterCNO ClusterAdministrator ClusterAdministrator ClusterAdministrator ClusterAdministrator ClusterAdministrator Cluster = Hub Hospital/Region, Medical Group, Health Plan, Section/Division

21. CV Clinical Program Guidance Team CV PhysicianChair* Nurse DirectorVice-Chair Cluster #1 Cluster #2 Cluster #3 Cluster #4 CVMD Lead CVMD Lead CVMD Lead CVMD Lead CVNurse Lead CVNurse Lead CVNurse Lead CVNurse Lead CVAdministrator CVAdministrator CVAdministrator CVAdministrator Ischemic*MD Chair Heart FailureMD Chair Rhythm DisordersMD Chair Vascular DisordersMD Chair * One of the Clinical Implementation Team chairs also serves as the Guidance Team chair (Ischemic MD Chair in this example)

22. Clinical Implementation Team (CIT)Heart Failure Care Process Family Heart FailureMD ChairCardiologist CV RN DirectorVice-Chair Facility #1 Facility#2 Facility#3 Facility #4 Heart FailureMD Lead Heart FailureMD Chair Heart FailureMD Chair Heart FailureMD Chair CVNurse Lead CVNurse Lead CVNurse Lead CVNurse Lead

23. CIT Work Group Subject MatterExpert Clinical OperationsDirector Data CaptureWorkflow Analysis Data Provisioning CIT Chair (MD)Scientific SME Provider/PatientEducation Team Data Analysis Front Line Clinical OpsWorkflow SME AdministrativeApplicationSteward ClinicalApplicationSteward Data Architect KnowledgeManager * CMIO, CQO, Chief Patient Safety Officer, or Chief Analytics Officer provided individual has requisite qualifications and skills

24. Workgroup Roles DATA CAPTURE Subject MatterExpert Application Administrators (e.g., EMR Administrators, Financial System Administrators) Knowledge Managers • Acquire key data elements • Assure data quality • Integrate data capture into operational workflow Data CaptureWorkflow Analysis Data Provisioning Data Analysis DATA ANALYSIS DATA PROVISIONING • Interpret data • Discover new information in the data (data mining) • Evaluate data quality • Move data from transactional systems into the EDW • Build visualization for use by clinicians Data Architects(Analysis) Knowledge Managers Data Architects(infrastructure) Data Architects(Visualization)

25. Poll question • Which clinical organizational teams do you have • Executive team responsible for prioritization and governance of clinical improvement initiatives • Domain governance teams (e.g., CV Clinical Service Line teams) • Clinical implementation teams (e.g., Heart Failure improvement team) • Infrastructure personnel/work groups to support clinical improvement teams

26. Implementation flow diagram

27. Standard “organizational” work Results Review Implementation Design Launch Approval Kickoff AIM Statement Monthly Tasks and Checkpoints • Mission • Cohort Discover • Data Analysis and Review • BMJ Best Practices • Building Multiple Potential AIM statements • Supplement BMJ content • Refine Cohort • Refine Metrics • Develop Draft Visualizations • Develop Recommended AIM statement #1 • Cluster Reps Obtain Front Line Input • Finalize Cohort • Develop Additional metrics based on feedback • Develop Additional Visualizations to support • PDSA cycle • Cluster Reps Obtain Front Line Input • Improvement Plan • Implementation Plan • Develop cluster rep assignments, and deliverables • Collect cluster rep feedback • Prepare Initial Results from AIM statement #1 • Summarized report for historical review • Refine, recommend AIM statement #2 7 Steps (Work Streams) 1 Gather Knowledge Assets 2 Define Cohort 3 Select AIM Statement Select, Build, Refine Metrics Select Initial Metric Build and Refine Build and Refine Build and Refine 4 Develop Implementation Plan for Process Improvement 5 6 Implementation 7 Measure Progress

28. Pregnancy

29. Surgical Services

30. Discharge from hospital to post-hospital service

31. Pressure injury prevention

32. Standard organizational work Slide Decks Meeting Agendas MD Contract Templates Team Charters Handbooks Job Descriptions Job Family Grids Compensation Grids Project Status Reports Deployment Process Outlines

33. Poll question • How prepared do you feel to implement population health management and shared accountability (e.g., ACO) strategies?

34. Thank you