Population Management PCMH 2011 Northwest Medical Partners

1. NW AHEC Practice Transformation Series
Building Medical Homes Together
Population Management in the Medical Home - NCQA PCMH Standard 2

2. Presented by:
Deborah Dirkse, MHA, PCMH-CCE
Quality Improvement Consultant
Wake Forest School of Medicine
NW AHEC
dldirkse@wakehealth.edu

3. Objectives
Introduce the Concept of Preventive Medicine and Population Management
Understand why we need population management and preventive care management
Introduce the Preventive Care Management Model
Introduce the Population Management Model
Understand how the Population Management Model is implemented in a PCMH

4. Preventive Medicine
In the beginning of the twentieth century, the most frequent causes of death were from infectious diseases and the life expectancy in the United States was less than 48 years. Now, more than 100 years later, life expectancy has risen to more than 77 years, and the most frequent causes of death are chronic diseases: heart disease and cancer. Healthy lifestyles and preventive screening can help to minimize patient risk factors for these diseases, identify treatable conditions early, and help to optimize patients' health and well being.
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5. Disease Prevention
Immunization programs aim to prevent the spread of communicable diseases among a population. The immunization of a particular person carries personal and societal benefits. While the individual is able to protect himself or herself from contracting the disease, they are also limiting the spread of disease.
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6. Benefits of Preventive Care
Prevention intervention offers benefits across the spectrum of the population. While there is obvious benefit to an individual who is screened and treated successfully for a condition, there are also health and cost benefits to the community at large from prevention efforts. This training will describe the individual and population benefits of preventive efforts.
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7. Public Health Impact
There is an impact on the public health of a population from patients’ choices regarding preventive services. Costs to the public, in both health and economic terms, can be substantial based on preventive care choices made by individuals.
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8. Disease Prevention
An Example:
According to the Advisory Committee on Immunization Practices, an average of 36,000 deaths annually occurred from 1990-1999, and 226,000 hospitalizations per year from 1979-2001 were associated with influenza.
Studies have shown that influenza vaccine is effective at reducing influenza illness rates and complications.
Influenza is transmitted through large droplet respiratory droplets (through coughing and sneezing).
Estimated vaccination rates among those in groups (including health care workers and close household contacts) for whom influenza vaccine is recommended is less than 50%.
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9. Economic Costs
Many preventable diseases, or diseases that can be more effectively treated if detected early, have a significant economic impact on the population as a whole. Lost productivity, insurance and medical care costs for many chronic conditions such as diabetes, heart disease and cancer are enormous.

10. Economic Costs
An Example:
The American Lung Association reports that direct medical cost of lung cancer treatment is approximately 5 billion dollars per year.
90% of all lung cancers are caused by smoking.
While a single individual’s choice to smoke or not to smoke may not have a significant impact alone, a population’s rate of smoking will have a significant impact on costs. For that reason, successful quit smoking campaigns can have economic as well health benefits.
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11. Disease Prevention
Immunization programs aim to prevent the spread of communicable diseases among a population. The immunization of a particular person carries personal and societal benefits. While the individual is able to protect himself or herself from contracting the disease, they are also limiting the spread of disease.
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12. Workflows for Preventive Care
Improved work flows, and encouraging patients and other office team members to join in the effort to promote preventive care interventions may be a method to improve access for patients to preventive care.
There are two ways to approach the delivery of preventive care: patient specific and population specific. We will review methods and workflows for each approach.

13. PATIENT SPECIFIC PREVENTION

14. Guidelines
Guidelines for preventive care are based on patient demographics and risk factors. Preventive care covers a variety of interventions, from simple tests or evaluations that are easily incorporated into a patient’s visit (e.g. blood tests, blood pressure measurement) to test procedures that requires counseling, scheduling, preparation and time (e.g. colonoscopy or mammography).
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15. How to use Reminders & Guidelines
Create a reminder system for patients due for preventive services. This can take several forms:
Give patients a preventive care sheet that lists the interventions that are appropriate for them, and when they are due. [create one, or use CDC]
Create alerts in EHR for preventive care, to prompt clinicians when patient is being seen.
Use secure patient portal to prompt patient when interventions are due.
Have patient fill out immunization assessment forms prior to office visit.
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16. How to use Reminders & Guidelines
Have a set of standing orders for immunizations or distributions of patient information based on guidelines for care. Appropriate immunizations are administered prior to the clinician portion of the visit. Informational materials may also be distributed to facilitate discussion about needed testing or intervention.

17. How to use Reminders & Guidelines
Use an up-to-date problem list to keep track of symptoms that are being followed, work ups that are underway but not completed or particularly high- risk areas of patients’ family or medical history:
A 45 year old patient is being followed for rectal bleeding. Patient initially presented after bleeding had resolved, although the clinician had a discussion with the patient to follow up with a colonoscopy if symptoms recurred. Listing this as a problem (rectal bleeding, with a date) can prompt clinician to check in with patient at next visit, even if for a different problem. Similarly, a problem list that notes a strong family history of heart disease or diabetes can prompt clinicians to screen for these when patient presents with unusual complaints, or if patient is in for a routine visit – high priority prevention interventions can be listed on the problem list.
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18. Results / Missed Testing Follow Up
Once the decision is made with the patient to undergo preventive screening, a system to follow up on test results and missed testing can be developed. Strategies to do so include:
When a clinician recommends/orders a test, they identify the urgency of the recommendation (routine screening – low risk, routine screening – high risk, symptomatic), and the practice staff creates a registry of high risk or symptomatic patients. After a predetermined amount of time, office staff reviews the registry to follow up that patients have actually scheduled and completed the screening. The clinician is notified if the patient has not completed the follow up, and the patient is reminded (by phone call, electronic messaging or postal mail) per the clinician. (If the practice is not using their EHR yet, this can be accomplished with a notebook for the office staff to use.)
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19. Results / Missed Testing Follow Up
Tests ordered through an EHR (e.g. blood tests, PAP smears) prompt the office staff or clinician if a result is not entered in a specified period of time.
Patients are told a time frame that they will be notified of results. They are encouraged to contact the office if they have not heard a result in that time frame.
The practice staff can create a registry of results that can take extended periods of time (e.g. PAP smears), and routinely check and update the registry for patients who have not had results come back or have no documentation of follow up (patient notification by letter or secure messaging, follow up appointment.)
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20. POPULATION MANAGEMENT

21. Population Management
At times, offering preventive interventions to a population of patients can be more efficient, and can be accomplished by office staff other than the clinician. It is also an opportunity to reach out to patients who are not in the office frequently. Here, we offer workflows that can be targeted at various populations within a practice.
The basis for managing a population of patients is a registry function of the E H R of your specific practice. The ability to stratify a practice population by demographic data (age, sex) or disease states (from the problem list, medication list or laboratory values) enables specific interventions to be directed at the intended population. This section will describe practice activities that offer interventions to groups of patients within the practice.
Given a certain population in the practice, workflows can be created or redesigned to address concerns or issues of that population. The clinicians and practice leadership need to decide what they would like to improve. That decision may be made based on measurements of preventive care (see next section.)

22. Population Management
A practice panel or population consists of patients that are in the office frequently, and those that are not. A practice-wide initiative on preventive care afford the opportunity to reach out to those patients who are not frequent users of health care but would benefit from preventive screening.
For example, reaching out to all patients who are overdue for a pap smear is one way. Using the registry in your office to identify women under age 25 who have not had a Pap smear in the past 1-3 years (the clinician’s in the office will need to determine the parameters), send the patient a letter asking her to make an appointment to be seen.
An alternate way to manage a population may be to apply an intervention to a specific population (e.g. offer flu vaccines to all patients over the age of 50 years old, or offer pneumococcal vaccines to all patients over 65). How this is done can vary by offering those that are in the office for a routine visit the vaccine prior to the clinician coming into the room, or by sending out a mailing (electronically or by postal mail) announcing a clinic or opportunity for patients to receive the vaccine.

23. Creating An Alert Based On Quality Measures And Clinical Guidelines:
1.Check to see what options are already built into your EHR
2.Identify a clinical guideline that clinicians agree with and will follow.
3.Using your EHR to review your practice population to identify areas of care that are lacking (e.g., ACEI are not used in enough patients with heart failure). Create an alert to remind clinicians when caring for those specific patients.
4.Determine where in the record the alert will go, and how it will be managed.
1.a. An alert pops up in the medication list, the note section or when the patient’s EHR is accessed.
2.b. An alert that populates an alert section of the EHR.
3.c. An alert is highlighted by color or graphics.

24. 4. Decide how the alert is acted on.
a. Can the alert be ignored and removed from the screen?
b. Does it have to be acknowledged or acted on before it is removed?
c. Is the clinician prevented from continuing the work until the alert is addressed?
5. Create a system for feedback from users.
6. Review data to see if the alert is working—improvement in outcome and process measures.

25. SCREENINGS

26. U.S. Preventive Services Task Force
Preventive care is an intervention that anticipates the probability of an individual developing a disease based on their individual risk factors. The intervention that a patient and clinician will agree to implement may include screening for specific diseases (e.g. cancer, diabetes), addressing health behaviors that may increase the risk of developing a disease (smoking, inactivity) or active treatment to prevent development of a disease (immunizations). This section will describe the most common and effective preventive measures, based on A and B recommendations of the United States Preventive Services Task Force.

27. Screening
Screening is by definition, "The examination of a group of usually asymptomatic individuals to detect those with a high probability of having or developing a given disease."
•The United States Preventive Services Task Force was initially convened in 1984 and since 1998 has been sponsored by the Agency for Healthcare Research and Quality (AHRQ). It is an independent panel of experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services.
•The website for the Task Force includes the current preventive recommendations, archived recommendations from previous years, and electronic tools to download the current recommendations into hand held electronic devices. We have not listed all of the recommendations here, but you can access the most up-to-date recommendations from the USPSTF.

28. Cancer Screening
Cancer is the second leading cause of death in the United States, second only to heart disease. Some cancers can be detected in early stages by routine screening; treatment is more likely to be effective if initiated in the early stages of the disease. Staging of cancer is dependent on the size of the tumor and its spread, patients will more likely do well if the cancer if found before the tumor is large or has metastasized. This section will review cancers most commonly screened for, as they have screening tests that have been shown to be effective.
Another resource for cancer screening guidelines is found on the website for the National Cancer Institute within the U. S. National Institutes of Health.
The leading cause of cancer related deaths is lung cancer, with a death rate of 53.8 in 2004. There is no screening test for lung cancer, although there are preventive measures that can (and should) be taken (e.g. tobacco cessation counseling).
In the patient self-management section of this module, a review of patient education materials and healthy lifestyle choices patients can make will be reviewed.
This section on cancer will review recommended screening measures that have been shown to be effective.

29. Breast Cancer Screening
Breast cancer is the second leading cause of cancer related deaths among women in the United States. Recently, there have been trends that noted declining incidence of breast cancer, although the reasons for that are not clear. There is some speculation that decreasing use of hormone replacement therapy may have played a role, although there is also concern that lower screening rates is also playing a role.
Methods for screening:
Mammography is considered the standard screening tool for breast cancer.
Clinical breast examination, and patient self-examinations are also screening measures that may or may not offer any benefit.

30. Colorectal Cancer Screening
Colorectal cancer deaths have consistently declined for many years, but recently that decline has accelerated. This is attributed to earlier diagnosis through screening and better treatment options. There is also some evidence that colorectal cancer can be prevented through screening by removal of polyps during colonoscopy.
Methods for screening:
Fecal occult blood test (FOBT)
Sigmoidoscopy
Colonoscopy

31. Cervical Cancer Screening
At one time, cervical cancer was the leading cause of death for women, but the incidence and mortality have declined significantly in the past 40 years. This is primarily due to prevention and screening efforts, particularly the Papanicolaou test (Pap test) to identify cervical abnormalities. While rates of cervical cancer have been declining, the mortality of cervical cancer for black women remains twice that of white women.
Methods for screening:
Papanicolaou Test (a sample from the cervix evaluated for cellular changes)
Human Papillomavirus test - Some types of the human papillomavirus are the cause of cervical cancer.

32. Prostate Cancer Screening
Prostate Cancer is the second most common cancer among men, although the death rate from prostate cancer has been declining. Prostate cancer usually affects older men, and is very slow growing. It is the most common cancer among men, but its death rate is relatively low. There is some controversy about screening for prostate cancer, as it is routinely accepted among patients, but not necessarily supported by research.
Methods for screening:
Digital rectal examination, to determine size and irregular areas of the prostate
PSA test – A blood test that measures levels of prostate-specific antigen
Although screening for prostate cancer has now become commonplace, it is still not clear if there is a benefit to screening, and research continues. Screening guidelines can be consulted, and then a decision made with the clinician and patient.

33. Why work on Population Management?
Safety & quality
Practice Revenue Management
Improved health for patients
Efficiency – more care/less visits

34. Are any of these common in your practice?
Patients don’t keep follow-up appointments
Patients put off important screenings
Patients are not aware of benefits they are eligible for
Screenings
Annual visits
Medicare Preventive Services
A patient comes in with a sore throat and you identify a gap in care but it doesn’t get scheduled
Your office has a slow period where physicals could bring in additional revenue
Patients have had needed services but you haven’t received documentation for their chart

35. WHAT TO DO….

36. How? Key Changes
Identify 3 Chronic and 3 Preventive Services
Stratify Lists to identify priorities
Determine outreach method and frequency of working list
Reach out to patients to close gaps in care
Update information in EHR

37. #1 Identify 3 Chronic and 3 Preventive Services
Decide as a primary care clinic to improve population management.
Choose 3 chronic and 3 preventive services
Run lists of patients needing services in registry or EHR

38. #2 Stratify Lists to identify priorities
Prioritize lists based on goals
Determine outreach method and frequency of working lists, possibly rotating weekly
Identify practice team member(s) who will reach out to patients. Build in accountability
Determine method of contact. (Remember HIPAA):
Individual patient letters
Phone contact with script
Email, Portal

39. Team Responsibilities
In addition to population management activities, build in individual care management
Pre-visit planning and care needs identification
Set up reminders in EHR
Schedule follow-up appointments and referrals
Managing e-referral system
Report on results to practice management

40. #3 Reach out to patients to close gaps in care
Contact patients keeping track of efforts
If patients have received care elsewhere, follow-up to obtain reports or test results
If patients decline intervention, document choice
Notify providers with concerns that are uncovered through patient contact. For example: “Mr. Jones, age 74, declined coming in for his cholesterol test because he indicated he was just too fatigued and hadn’t been feeling well.”

41. Where might you start? Your System?
•Collect email addresses for patients.
•Review your system documentation on how to run patient lists. Contact your vendor for more information if necessary. Capability to expand in 2014. Export lists/reports to Excel if possible?
•Determine frequency of running lists/reports (monthly or quarterly)
•Think about rotating work on lists – possibly weekly
•If lists can include patient demographic and/or contact information, include on report.
•Export to Excel where columns can be added to indicate contact method, initial contact date, notes
•Learn to sort and filter lists – AHEC can help with this!

42. #4 Update Information in EHR
Follow-up on reports from outside sources and specialists
Enter information or scan reports into patient charts

43. HOW DOES THIS RELATE TO PCMH?

44. PCMH Standard 2 MUST PASS ELEMENT
Factor 1 : Factor 1: The practice generates lists of patients and uses the lists to remind patients of at least three preventive care services needed appropriate to the patients’ age or gender (e.g., well- child visits, pediatric screenings, immunizations, mammograms, fasting blood sugar, stress test).

45. Factor 2: The practice generates lists of patients who need chronic care management services and uses the lists to remind patients of at least three chronic care services needed. Examples include diabetes care, coronary artery disease care, lab values outside normal range and post-hospitalization follow-up appointments. Examples for children include services related to chronic conditions such as asthma, ADHD, ADD, obesity and depression.

46. Factor 3: The practice generates lists of patients who may have been overlooked and who have not been seen recently. The practice may use its own criteria, such as a care management follow-up visit or an overdue periodic physical exam.

47. QUESTIONS?