Objectives

2. Using a Registry to Support Population ManagementDavid Van Winkle, MDExecutive Medical DirectorJen Bailey, MSN RNExecutive Director

3. Objectives • Review Clinical Integration Models • Understand system need for a registry • Registry Journey to Support Population Management • Understand and Address Drivers for Change

4. A PHO is a legal organization that enables its physician and hospital membership to work cooperatively toward accomplishing clinical integration. PHO’s who are clinically integrated also provide contracting services on their members behalf. PHO’s are formed and owned by one or more hospitals or physician groups. Lakeshore Health Network is wholly owned by Mercy Health Physician Hospital Organization

5. The History of LHN • Incorporated in 1994 • Over 520 physicians & advance practice providers, 3 hospitals, Ancillary Providers • Servicing Muskegon, Northern Ottawa, Oceana and Mason Counties • Support community collaborations to keep health care local. • History of Strategic Planning focused on the needs of the community with broad physician input and leadership • State and National recognition through • BCBSM • 2009 IHI National Forum Presentation • Trinity National Innovations Award • MSMS/MOA Conference Presentations • Professional Journal Articles

6. The process in which physicians who traditionally compete for business or contracts must work together to develop processes that result in improved outcomes for their patients or bring benefit to their community. These benefits can be in cost savings or in improvement in clinical outcomes. Clinical Integration

7. Chronic Care Model Patient Centered Medical Home-Network or Neighborhood Accountable Care Organization/Organized System of Care Models of Clinical Integration

9. Patient Centered Medical Highlights Joint Principles of the Medical Home • Personal Physician • Physician Directed Medical Practice • Whole Person Orientation • Care is Coordinated and/or Integrated • Quality and Safety are Hallmarks • Enhanced Access • Must be Supported by Payment Reform

10. Capabilities of a Patient Centered Medical Home • Patient Provider Partnership • Patient Registry with Performance Reporting Capabilities • Individual Care Management • Extended Access • Test Tracking and Follow-Up • Preventative Services • Linkage to Community Services • Self-Management Support • Patient Web Portal* • Coordination of Care • Specialist Referral Process

11. Capabilities of a Patient Centered Medical Home • Patient Provider Partnership • Patient Registry with Performance Reporting Capabilities • Individual Care Management • Extended Access • Test Tracking and Follow-Up • Preventative Services • Linkage to Community Services • Self-Management Support • Patient Web Portal* • Coordination of Care • Specialist Referral Process

12. Improves the patient experience of care (including quality, access, and reliability)   Improves the health of populations Reduces the per capita cost of health care Enhance the Triple Aim – Experience, Quality and Cost

13. BCBSM 2013-14 Interpretive Guidelines 2.1 Registry is used to manage all patients with DM 2.2 Registry incorporates services received at most other sites for chronic care and preventative services 2.3 Registry incorporates evidence based guidelines 2.4 Registry information is in use at the point of care 2.5 Registry contains information for every patient in the practice 2.6 Registry is being used to generate communication to patients regarding gaps in care PGIP PCMH & PCMH-Neighbor

14. BCBSM 2013-14 Interpretive Guidelines (cont.) 2.7 Registry is being used to flag gaps in care for all patients 2.8 Registry incorporates demographic information 2.9 Registry is fully electronic 2.10 Registry is used to manage: Persistent Asthma 2.11 Registry is used to manage: CAD 2.12 Registry is used to manage: CHF 2.13Registry is used to manage 2 other additional conditions PGIP PCMH & PCMH-Neighbor

15. BCBSM 2013-14 Interpretive Guidelines (cont.) 2.14 Registry incorporates preventative guidelines & is used to send communication to pts re: needed services 2.15 Registry includes pts assigned by Payers but not yet established 2.16 Registry is used to manage: CKD 2.17 Registry is used to manage: Pediatric Obesity 2.18 Registry is used to manage: Pediatric ADD/ADHD 2.19 Registry identifies individual care manager for every patient who has an assigned care manager PGIP PCMH & PCMH-Neighbor

16. Network Success in Model Deployment Interdisciplinary practice team led by the PCP with improved patient engagement and education about their health care and options. Improving primary and specialty care interaction IT capabilities to record and track care and communicate to the patient Placing emphasis on patient self-care Expanding linkages to community health resources

17. The coordination of care delivery across a population to improve clinical and financial outcomes, through disease management, case management and demand management Population management also emphasizes effective patient self-management through member education and care support. Opportunity? Check out the Robert Wood Johnson County Health Rankings http://www.countyhealthrankings.org/app/#/michigan/2013/muskegon/county/outcomes/overall/snapshot/by-rank Population Management

18. Muskegon Health Status

19. Muskegon Health Status http://www.countyhealthrankings.org/app/michigan/2014/rankings/muskegon/county/outcomes/overall/snapshot

20. All Patient Population Management is the cornerstone of clinical integration models including: Chronic Care Model Patient Centered Medical Home Patient Centered Medical Network (ACO) Promote use of Health Information Technology across the health system and community Promote integration of information technology tools Health Information Technology Supports Population Management

21. WellCentive was developed in 2005 by Dr. Paul Taylor and J. Mason Beard WellCentive is based in Atlanta, GA with national and international clients LHN was the alpha and beta test site for WellCentive LHN does not own any portion of WellCentive LHN staff do not work for WellCentive WellCentive is a registry vendor that LHN purchases licenses for our providers LHN has been able to demonstrate a solid business case for this investment year after year LHN Registry Vendor

22. Individual payer registries Chasing Paper by individual provider No efficient way to compare or benchmark Waiting for quarterly and year-end reports Chronic Disease Electronic Management System (CDEMS) FREE Access Data Base Requires Individual Office Servers Maintenance and Manual Process became resource prohibitive Registry Development Network provider collaborative WellCentive Alpha and Beta Site PCP Expansion Select SCP practices LHN Registry Journey

23. A computer system comprised of an application and its database that: Collects data manually or electronically Analyzes the data in various ways Reports the results of the data analyses Registries vary widely in their purpose, scope, functionality, technology, and cost A registry is not an electronic medical record An EMR is not a registry but may contain registry functionality What is a Registry?

24. Population Reporting Outreach- Gaps in Care must move to proactive approach Alerting/Reminding at Point of Care Intuitive- Point and click Internet Based – server based is resource intensive Supports Clinical Integration of Network Supports Pay for Performance Key Functionality of a Registry

25. Identify and Attribute the Population Individual provider Office Practice PHO Health System or Community Demonstrates the illness burden of the population Disease Category Utilization of Services Promote Wellness and Prevention Immunizations (MCIR) Screenings and Diagnostic Tests Registries Support Population Management

26. Supports Specific Population Program Management Initiatives, Grants, and Government Programs Risk Stratification Illness Burden Predictive Modeling Geo-mapping Financial Analysis Total cost of care Utilization Tracking by service type and location Actuarial and Contracting Support Advanced Registry Functionality

27. PHO Use to Demonstrate and Support CI Programs Full Practice Integration from Check In to Check Out Fully integrated into clinical and operational practices Day to Day Clinical Operations Focus Care Summary and Report Card Features Routine (daily, weekly, monthly, quarterly) Operations Point person runs reports to identify gaps in care or patient reminders Passive Use in Conjunction With EMR or Other Analytic Tools Review reports No Integration of Registry in Clinical or Operational Practice Diverse Use of Registries

28. Where are you at in your registry journey? Evaluation of Needs based on population served and Clinical Integration drivers: incentives and PCMH Selection – “Best in KLAS” and References Solid Implementation Strategy to incorporate the tool within your clinical, operational and IT strategy Culture of continuous process improvement to assist moving to the highest level of integration Incorporating a Registry Into Your Organization and Practice

29. Number of licenses Number of Fully Implemented Office Sites IT Staff Support 3.0 FTE’s IS Manager, 2 Data Analysts Provide End User Training in multiple forums Meet routinely with vendor, payers, providers Provide End User Alerts, Reports and Assistance LHN Registry Adoption

30. LHN primary and specialty care physicians use WellCentive Advance solutions including: Internal Medicine, Family Practice, Pediatrics, General Practice, OB/GYN, Cardiology, Neurology, Nephrology, Podiatry, Allergy, and Ophthalmology 90% physician adoption rate after three months Mature data management strategy with multiple Interfaces (labs, PMS, e‐Rx, EMR, and payers) Used for Clinical Integration including: Pay for Performance, PGIP PCMH, NCQA PCMH, PQRS, and Meaningful Use Significant year‐over‐year improvements in clinical and financial outcomes Registry Results

31. Patient Report Card

32. Sample Dashboard

33. Care Summary

35. Assess Organizational Needs and Registry Functionality Link with Clinical Integration Strategies Interface with Current Information Technology Define Population Management Strategy Define Contract Parameters Address Organizational Readiness Elicit Support at all levels: Leadership, Physician, Office Manager, Direct Patient Care and Support Staff Ensure Implementation and Ongoing Support from Vendor LHN Registry Pre-Implementation

36. Develop Implementation Plan Determine Budget Define Staff Roles/Functions Define Process at all levels: PHO and Provider Offices (need to support change from current vs. future state) Provide Training at all Levels Define and Gather Data Sources EPM/EMR, Payer Claims, Manual/FTP/Interface Define Alerting and Reporting needs Assess Data Analysis Capabilities LHN Registry Pre-Implementation Continued

37. Key User Engagement and Readiness Theme – Make it Fun Clear Contacts and Communications Routine Forums for Information and Education Include all Staff in Process Mapping and Design Train and Retrain Alerts and Reporting Feedback and Support LHN Registry Implementation

38. Establish Accountability Measures Produce and Distribute Routine Validated Reports Hold User and Best Practice Workgroup Meetings Establish Routine Office Site Visits and Support Establish Mechanism for Issue Resolution Offer Ongoing Training and Education Drive Accountability to Outcomes Ongoing and Continuous Updates with the Vendor LHN Registry Post-Implementation

39. Kubler-Ross: 5 distinct stages of grief, a process in which people deal with loss (i.e. transforming the health care delivery system) PCMN: Denial – we can do this with our current process & resources Anger – meetings, conference calls, new programs, changing roles, new staff, time commitments…we can’t do this Bargaining – this really isn’t a change, we can do this the old way Depression – project implementation, resource consumption, feeling overwhelmed Acceptance – process solutions, evaluate data, produce reports, improve outcomes, build team, build culture Emotional Response to Clinical Integration

40. Webster: Optimism is "an inclination to put the most favorable construction upon actions and events or to anticipate the best possible outcome". System Wide Change: Realistic Optimism - Structured Clinical Integration Implementation Plans, Dedicated Staff Resources optimizing training and roles, Acceptance of continuous process improvement, a journey not a destination. Emotional Response to Clinical Integration

41. This is change…big significant change impacting business operations and clinical practice How will you measure success? How do you know you are improving? What is your organizational or practice adaptive capacity? Effective Population Management and Registry Adoption Requires…CHANGE

42. Often the reason that we find change so difficult is because we want to change something, that we have never given enough disciplined and focused attention to, to understand why we have thought and behaved as we do. Why is Change Hard?

43. Change management is an approach to shifting/transitioning individuals, teams, and organizations from a current state to a desired future state. It is an organizational process aimed at helping change stakeholders to accept and embrace changes in their business environment. Change Management

44. Dilt’s Idea Of Logical Levels The Environment around us, shapes and is shaped by our Behavior. Behavior is determined by our Capabilities, which are set by our Beliefs and Values, which are defined by our Identity. Everything we do, the circumstances that we gravitate to, in our lives are a reflection of who and what we are. Lasting and meaningful change only happens when something changes in the way that we see and think of ourselves. The Science Behind Change

45. The bigger problem of change comes when we decide other people need to change and try to persuade them to see the error of their ways or manipulate them to change to what we think they should be. For Lasting Change, A Person’s Sense Of Identity Has To Change If you are seeking to change other people, or corporate cultures, then you need to first look at the underlying beliefs of the people you are seeking to change.   Understand and respect how they see themselves and how they want to see themselves.   The Science Behind Change

46. Adaptive Leadership Definition: The practice of mobilizing people to tackle tough challenges and thrive It is not necessary to change. Survival is not mandatory. -W. Edwards Deming (1900 - 1993)

47. Adaptive Leadership • Specifically deals with change that enables the capacity to thrive • Builds on the past, rather that jettison it. • Organizational adaptation occurs through experimentation • Adaptation relies on diversity • New adaptation generates loss • Adaptation takes time

48. Adaptive Leadership “Leadership is the process of bringing a new and generally unwelcome reality to an individual, organization or setting, and helping them successfully adapt to it. -Ronald Heifetz

49. Adaptive Leadership Distinguishing Technical problems from adaptive challenges Technical problems may be very complex, but they have known solutions, that can be implemented by current know-how. Responds to traditional leadership approach. Adaptive challenges can only be addressed through changed in people’s priorities, beliefs, habits, and loyalties. Requires adaptive leadership approach.

50. Adaptive Leadership The Illusion of the Broken System. Any social system (including an organization, country, or family) is the way it is because the people in that system want it that way. No one who tries to name or address the dysfunction in an organization will be popular.