Patient / Consumer Engagement - Key to Successful ...s3.amazonaws.com/.../public/2015Conference/handouts/CBA5.pdfPatient / Consumer Engagement - Key to Successful Population Health

Patient / Consumer Engagement - Key to Successful Population Health Management

April 12, 2015

Kamahanahokulani Farrar, HHS OCIO Domain Governance

Department of Health and Human Services

Kristina Sheridan, Associate Department Head, Emerging Technologies

The MITRE Corporation DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

© 2015 The MITRE Corporation. All rights reserved. Approved for public release. Distribution unlimited. Case number 15-0947

Conflict of Interest Kamahanahokulani Farrar, MRHM Has no real or apparent conflicts of interest to report. Kristina Sheridan, MS Has no real or apparent conflicts of interest to report.

© HIMSS 2015 © 2015 The MITRE Corporation. All rights reserved. Approved for public release. Distribution unlimited. Case number 15-0947

Learning Objectives

• Identify Clinical and Business Intelligence (C&BI) strategies to support patient outreach.

• Synthesize strategies to manage complex patients that supports multiple providers using shared Electronic Health Record (EHR) resources.

• Evaluate the use of consumer health informatics (CHI) applications in improving self-management, adherence to prescribed treatment regimens and health behavior.

• Identify the benefits and incentives in a Patient Centered Medical Home (PCMH) model in providing continuous and coordinated care.


A Patient’s Story


Patient, Caregiver, Family

Image source: K. Sheridan


Data



Information



Patient Voice



Recovery

Image source: Kate Sheridan


Clinical & Passive Patient-Generated

Health Data

Cultural Shift

Engaged Patient and Active Patient-Generated Health

Data

Patient-Provider Partnership

Current Future

Image source: BigStock


A Patient’s Ecosystem


Impact and Cost of Chronic Conditions

One Chronic Condition

Multiple Chronic Condition

No Chronic Condition

Caregivers

Almost 1/3 people in the US manage at least one chronic condition More than 3/4 of US healthcare dollars are spent on their behalf

Data extrapolated from 1. Wolff JL, Boult C, Boyd C, Anderson G . Newly reported chronic conditions and onset of functional dependency. J Am Geriatr Soc 2005;53:851–855. 2. Bodenheimer, T., Chen E., Bennett, H. Health Affairs 28, no. 1 (2009): 64–74; 10.1377/hlthaff.28.1.64 3. AARP Public Policy Institute. Insight on the Issues, November 2008: Valuing the Invaluable: The Economic Value of Family Caregiving, 2008 Update


Reality for Patients and Caregivers

6 Fe

b 20

12

Engaged Pro-Active

Shared Decision-Makers Partners

Empowered X Images source: K. Sheridan


Value to Patients and Caregivers

PROCESSES Images source: The MITRE Corporation

Track - Manage - Share


Value to Providers

USE FOR CLINICAL DECISIONs

LONGITUDINAL TREND IN SYMPTOM SEVERITY

LONGITUDINAL TREND IN MEDICATION COMPLIANCE

Source: MITRE Corporation/Heinz College Carnegie Mellon University Fall 2014 Capstone Project


A Patient’s Value


Patient Engagement Principles

EASY

EFFECTIVE

PATIENT-CENTRIC

1. IMS Institute for Healthcare Informatics. “Patient Apps for Improved Healthcare: From Novelty to Mainstream.” Parsippany, NJ: October 2013 2. The MITRE Corporation healthAction Patient Toolkit research


Tracking Symptom Severity


Images source: The MITRE Corporation

Tracking Medications

1. Pharmacy Management Strategies for Improving Drug Adherence. William K. Fleming, PharmD S16 Supplement to Journal of Managed Care Pharmacy JMCP July 2008 Vol. 14, No. 6, S-b www.amcp.org 2. Image source: The MITRE Corporation and ONC


Managing Day-to-Day Care

1. Checklist Manifesto How To Get Things Right. Atul Gawande. ISBN 978-1-77544-680-4 2. Image sources MITRE Corporation and BigStock


Informing Care Team Decisions

1. Huba, Nicholas and Yan Zhang. “Designing Patient-Centered Personal Health Records (PHRs): Health Care Professionals’ Perspective on Patient-Generated Data. J Med Syst DOI 10.1007/s10916-012-9861-z https://www.ischool.utexas.edu/~yanz/Huba&Zhang2012.pdf 2. Image sources: The MITRE Corporation

How did they respond to that new

medication?

Are they developing a

new comorbid condition?

Let me find out why their mood is so

low


Integrating Patient-Generated Health Data

Images sources: Microsoft Clip Art and BigStock


Systematized Nomenclature of Medicine--Clinical Terms

(SNOMED-CT)

Symptoms

Problems Procedures

Allergies

Patient/Family History

RxNorm Medications

Vital Signs

Logical Observation

Identifiers Name and Codes

(LOINC)

Measuring Patient Outcomes


1.. Image sources: The MITRE Corporation

Is that medication working?

Should I check-in with my doctor?

Am I really getting better?

Patient-Provider Partnership

1. Electronic Health Records in the Physician Office. McKesson Corporation, 2007. http://highered.mcgraw-hill.com/sites/dl/free/0073401978/585867/SampleChapter03.pdf 2. Patt MR, Houston TK, Jenckes MW, Sands DZ, Ford DE. “Doctors Who Are Using E-mail With Their Patients: a Qualitative Exploration.” J Med Internet Res 2003;5(2):e9 http://www.jmir.org/2003/2/e9/ 3. Cleveland Clinic © 1995-2013. All Rights Reserved. 9500 Euclid Avenue, Cleveland, Ohio 44195 http://my.clevelandclinic.org/patients-visitors/prepare-appointment/appointment-checklist.aspx 4. Image source: The MITRE Corporation


A Patient’s Care Model


Patient Centered Medical Home (PCMH) Scenario: John and Mary

• John, 75 year old diabetic with comorbidities • Mary, 45, daughter and caregiver • Dr. Jones, General Practitioner • Dr. Smith, Psychiatrist • Dr. Brown, Physical Therapist • Nurse Practitioner Davis

26

Mary Psychiatrist John NP GP

NP

PT


Mary

Patient-Centered Access 27

Patient-Facing Tools

Empowering Patients

Online Access Download Record Secure Messaging

Two-Way Communication Schedule Appointments

Empowering Caregivers

John GP

Extrapolated from “PCMH 2011-PCMH 2014 Crosswalk”, http://www.ncqa.org


Team-Based Care 28

Mary

Psychiatrist

John

NP

GP

PT

Patient and Caregiver

Engagement Team

Meetings

Language Support

Behavioral Health

Self Management Support

Continuity of Care



NP

Population Health Management 29

Proactive Population Management

Clinical Data

Complete Patient Information

Comprehensive Health

Assessment

Evidence-based Decision Support

John Psychiatrist

GP

PT

Mary



Mary

Mary

Care Management and Support 30


John

Medication Management

Self Care Support

NP Psychiatrist

PT

GP

Care Planning

John

Identify Patients for Care Management


Care Coordination and Care Transitions 31

Coordinating Care

Transitions

NP GP

NP Psychiatrist

Mary John

Tracking Data and

Follow-Up


Referrals


Performance Measurement and Quality Improvement

32

Extrapolated from “PCMH 2011-PCMH 2014 Crosswalk”, http://www.ncqa.org Image sources: The MITRE Corporation and Microsoft Clip Art

Reduced Hospitalizations

Patient-Generated Health

Measures

Improved Outcomes

Patient & Caregiver

Engagement

911

Mary John


Patient Engagement Strategy


Patient Centered Medical Home Strategies

• Demonstrate active engagement of patients and families in patient care and quality Improvement activities

• Use payment strategies to support the active engagement of patients as partners in their own care and in practice-level quality improvement

• Support practices with technical assistance, tools, and shared resources to engage patients

• Require health information technology standards to recognize and promote patient engagement

• Require meaningful patient input in the design, implementation, and evaluation of medical home programs

• Support additional research on the feasibility and impact of patient-engagement strategies.

Source: The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care, Feb 2011, AHRQ {publication No. AHRQ 11-0029


Patient Engagement Policy/Standards


Meaningful Use Stage 3

• 25 percent of a provider's patients must access their records through View/Download/Transmit or an ONC-certified app

• 35 percent of patients must receive a clinically relevant secure message

• Providers must incorporate information from patients on "non-clinical" settings from 15 percent of their patients.

Source: John D. Halamka, March 25, 2015, http://www.healthcareitnews.com/ :


IMPACT Act

• The Improving Medicare Post-Acute Care Transformation Act of 2014 “IMPACT Act of 2014”

• Standardized Patient Assessment Data to enable – Assessment and quality measure uniformity – Quality care and improved outcomes – Comparison of quality across PAC settings – Improve discharge planning – Interoperability – Facilitate care coordination

Extrapolated from: CMS.gov: http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.html :


Care Coordination Services Reimbursement

• Supports Chronic Care Coordination • Reimbursement of $42 for the service which applies to

"chronic care management services furnished to patients with multiple chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline."

Extrapolated from: CMS.gov:https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-P.html :


Summary

• Including Patient-Generated Health Data in Clinical and Business Intelligence (C&BI) strategies improves outcomes

• Providing patient-facing tools to manage complex conditions and integrating Patient-Generated Health Data (PGHD) into Electronic Health Record (EHR) resources enhances coordination between multiple providers

• Designing tools and processes to support Patient and Caregiver needs can significantly improve self-management, adherence to prescribed treatment regimens and health behavior

• Patient Centered Medical Homes (PCMH) provide continuous and coordinated care and benefit from including patients and caregivers as valued partners

• The combination of patient-centric strategy, policy, tools and processes will enable patient engagement and lead to successful population health management


Questions Thank You If you have questions please contact: Kamahanahokulani Farrar [email protected] Kristina Sheridan [email protected] @k_sheridan1 @MITREHealth


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Documents

Patient / Consumer Engagement - Key to Successful ...s3.amazonaws.com/.../public/2015Conference/handouts/CBA5.pdfPatient / Consumer Engagement - Key to Successful Population Health