Montefiore Medicine Population Health Management - NJHCQI
Montefiore MedicinePopulation Health ManagementPresentation byJoel PerlmanSenior Advisor to the CEOMontefiore MedicineJune 22, 20161
Children’s Hospital at Montefiore Montefiore Einstein Center for Cancer Care Montefiore Einstein Center for Heart andVascular Care Montefiore Einstein Center for TransplantationNotableCenters ofExcellenceTeaching 1,395 Residents & Fellows 470 Allied Health Students 2,100 Graduate &Undergraduate Nursing 200 Home Health Aides 100 Social WorkersResearchAcademic Clinical Translational HealthServicesMedicalCommunityCommunityHealth 31,000 Employees 2,000 Physicians 4,800 Medical & AlliedHealth Staff 3,860 Integrated ProviderAssociation Providers 3,150 Employed 5,650 RN/LPN 3,600 NYSNA RNs 10,900 SEIU/1199Workforce Health EducationCommunity AdvocacyWellnessDisease Mgmt.NutritionObesity PreventionPhysical ActivityReduce Teen PregnancyLead Poisoning PreventionPrimary &SpecialtyCareHospitals 11 Hospitals 3,092 Acute Beds 150 SkilledNursing Beds 1 FreestandingEDCorporateFunctions Finance Legal StrategicPlanning Purchasing Compliance Marketing Public Affairs Neuroscience Orthopedic Ophthalmology OB/GYN HomeCareAdvanced Primary Care Mental HealthSubstance Abuse Sub-specialty Care DentalSchool Based HealthCenters Mobile HealthInformationTechnology Clinicalsupport NetworkapplicationsHome HealthProgramsPrimary CareHouse CallProgramCMO Care Management( 400K Covered Lives) DiseaseManagement Care Coordination Telemedicine Pharmacy Education2
Montefiore Health System EconomyTotal Operating Revenue, MHS and MMCBy Year, 2012-2016 (in thousands) 5,500 5,000 4,500 4,000MHSMMC 3,500 3,000 2,500 2,00020122013201420152016*Of Note, Montefiore Medicine was created in 2015 and the introduction of the Albert Einstein College ofMedicine adds approximately 350M in operating revenue not reflected on the graphMontefiore: An Introduction – Revised 10/201533
The Bronx1.4 million residents in the pooresturban county in the nationMedian household income 34,00054% Hispanic, 37% African-AmericanHigh burden of chronic diseasePer capita health expenditures 22%higher than national average80% of health care costs paid bygovernment payersMontefiore: An Introduction – Revised 9/20154
Our CommunitiesBronx, Westchester, Rockland, andOrange, NY – 3.1 Million Orange380KEconomic ninsured16%12%11%11%Chronic Disease 67%ChildOverweight/Obese32%29%33%36%Asthma(per 100K)58141213Cancer(per100K)484494507498Source: U.S. Census, New York State Dept. of Health, NYS Dept. of Labor5
Payer Mix : Outsized Gov’t Payer MixMMC Payer Mix, 2015MHS Payer Mix, 20153%3%15%20%37%45%MEDICAREMEDICAID, OTHER GOVERNMENT, AND UNINSURED *COMMERCIAL1199 AND SELF INSURED37%40%MEDICAREMEDICAID, OTHER GOVERNMENT, AND UNINSURED *COMMERCIAL1199 AND SELF INSURED6
Montefiore’s PopulationHealth Model : A Strategic andFinancial ImperativeMontefiore: An Introduction – Revised 9/20157
Strategic goalsStrategic Goals1Advance our partnership with the Albert Einstein College of Medicine2Create notable Centers of Excellence3Build specialty care broadly4Develop a seamless healthcare delivery system with superior access,quality, safety and patient satisfaction : Population Health- Triple Aim5Maximize the impact of our community serviceMontefiore: An Introduction – Revised 9/20158
New Era of Population Health; TransitionFrom Managing Price to Managing CarePremiumPremiumShareholdersInsurance CompanyIntegrated ProviderAssociationInsurance Company Pay Claims And“Coordinate Care”SavingsStakeholders:MD’s/DeliverySystem Care ManagementOrganizationInvest in Health andSocial ServicesSavings9
Montefiore Integrated Provider Association (IPA)The IPA was formed in 1995 and operates as an physician/hospital partnership,contracting with managed care organizations to accept and manage risk underValue Based Arrangements.Membership: 3,871 2,691 physicians 618 PCPsOf those providers: 2,043 employed 1,823 private practiceGovernance Board membership includes 14 physiciansand 5 system executives Requires consensus due to 1/1 vote splitJanuary 2015 NYS approved new regulations IPAs may now contract for all lines ofbusiness and products, supportingestablishment of the Hudson Valley IPA1010
Montefiore Care Management Organization (CMO)The CMO was formed in 1996 as a subsidiary of MMC and is the contracted entityby which Montefiore conducts care management and plan administration. Serves administrative functions(e.g. claims payment,credentialing) Performs care management asdelegated by health plans Risk stratification Predictive analytics Social Service partnerships,(e.g. housing at risk) Over 1,200 staff11
es18,000Lives12
Overview of Value-Based PaymentArrangements at MontefioreSource2015 Population2015 Est. RevenueRisk Contracts220,000 1,360mShared Risk165,000 1,022 mMedicaid Health Home (CareCoordination)10,000 18 m395,000 2,400 mTotalsGoal: To reach 1,000,000 covered livesMontefiore: An Introduction – Revised 9/201513
New York State Medicaid RedesignSignificantchallengesRequiring arange ofrecent Stateinitiatives NY State’s Medicaid health care spending significantlygreater than the National Average Prevalence of preventable chronic conditions continues torise NY one of the highest States for avoidable hospital use. Delivery System Reform Incentive Payment (DSRIP) program- 8B over 5 years DSRIP Goals:- Improving access to high quality integrated- “Care Management for all”- Transition from FEE FOR SERVICE to VALUE BASEDPAYMENTS (VBP) – Goal 90% VBP by end of decade- Promote regional provider collaborations across the CareContinuum - PPSSource New York State Health Innovation Plan, Medicaid Redesign Team Final Report14
Regional Approach: 1 Million Lives Strategic partnerships supportpopulation health imperative Delivery System Reform Incentive Payment (DSRIP) Lead the Hudson Valley Performing Provider System,with over 500 partner organizations, including: 19 Hospitals, 4 FQHCs with 29 sites and 59Skilled Nursing/Long Term Care/Hospice Lead participant in the Bronx Partners for HealthierCommunities Performing Provider System Clinical Affiliations Jacobi Medical Center, Bronx, NY Morris Heights Health Center, Bronx, NY St. Barnabas Hospital, Bronx, NY St. John’s Riverside Hospital, Yonkers, NY St. Joseph’s Medical Center, Yonkers, NY Strategic Partnerships Northwell Health, Multiple Locations Maimonides Medical Center, Brooklyn, NY15
DSRIP funding represents a smallpiece of transitioning to VBPPRELIMINARY 7.5B2 2B1Total opportunity includingMedicaid, commercial andMedicareMedicaidopportunityAnnualvalueShift to value-based payments withexisting network 40M3DSRIP fundingShift to value-based paymentswhile expanding networkMaintain current model while expanding Expand to Commercial andto full HVC Medicaid Medicare livesLabelpopulation200 K4330 K1MMedicaid lives1 Based on Medicaid PMPY of 6000 and 330 K lives in HVC;2 Based on Medicare PMPY of 12,000 and 170 K lives in HVC and commercial PMPY of 7,000 and 500 K lives;3 Assume max DSRIPpayment atMontefiore:An 40m/year;Introduction – Revised 9/20154 Performance attributionCommercial and Medicare lives16
DSRIP ProjectsIntegrated delivery system focused on evidencebased medicine and population health2.A.ISystemTransformation2.A.III Health home at-risk intervention program2.A.IV Medical village using existing hospitalinfrastructure2.B.III ED care triage for at-risk populationsClinical improvement3.A.IIntegrated primary care andbehavioral health3.B.IEvidence-based disease managementstrategies- cardiovascular3.A.IIBehavioral health communitycrisis stabilization services3.D.IIIEvidence-based asthmamanagement strategiesPopulation-wideProjects4.B.ITobacco use cessation efforts focused onpopulations with low SES and poor mental health4.B.IIIncreased access to high quality chronicdisease preventive care and management17
Care Managementand Coordination –What do we really mean?18
Population Health Management (PHM)FrameworkOur holistic methodology for developing and enablingPopulation Health Management. StrategicPHMFrameworkBusiness Case / ROINetwork DevelopmentLegal Structure Operational Organizational GovernanceCare Management ModelProcess ArchitectureEMR Strategic AlignmentInformation Care Management PlatformTechnology Workflow / Rules EnablementMontefiore: An Introduction – Revised 10/20151919
Care Management ProcessLifecycleIdentify &PrioritizeLink individualMonitor &to services and Update Careorganizations to Plans untilprovide careDischargecoordinationPatientIdentify members requiringcare coordination servicesEnrollEnroll highest riskindividuals andeducate about carecoordinationPrimary CareProvider,PCMHDevelop personalizedcare plan based onintensity of servicesneededDevelopPersonalizedCare PlansStratify intoProgramsMontefiore: An Introduction – Revised 9/2015Assess Needs(Baselineand Ongoing)Understandmember’s medical,behavioral, andsocial needs20
Personalized Care PlansAttributed PopulationIdentify &PrioritizeMonitor &Update CarePlans untilDischargePatient EnrollPrimary CareProvider,PCMHDevelopPersonalizedCare PlansStratify intoProgramsData MiningProvider ReferralSentinel Events (e.g., PostDischarge)Self-IdentificationVirtual Healthcare :Telehealth, TelemedicinePrecision MedicineAssess Needs(Baselineand Ongoing) PreliminaryScreening LogicCare Management IntensityFrail ill / HighUtilizersFunctionalChronically illWell andWorried WellHigh Intensive, complex casemanagement Palliative CareMedium Targeted health education andinterventions Self-management /empowermentLow Members accessinformation, as needed
Care Management Process Lifecycle:High-Level WorkflowIdentify &PrioritizeEnrollPreliminaryidentification of cohorts Conductanalytics tosegmentattributedpopulations Segmentbased onutilization,cost, andavailableclinicalinformationHigh utilizers/High riskInitialengagement Make contact Opt-in to caremanagement No contact Opt outFunctionallyillb Selfmanagement CustomizedassessmentsHealthy/worried well Access toinformation asneeded (e.g.,PHR, generalhealth info)AssessNeedsComprehensiveneeds assessmentDevelopPersonalizedCare PlansMonitor &Update CarePlansCare PlanningCare Guidance Telephonicinterview todeterminemedical andpsycho- socialneeds Care plandeveloped(based onproblem list) “Problem list”developed Stratification ofservice levels Inter-disciplinaryteam assignedCare team Accountable Care Mgr(RN, LPN, SW) Behavioral Care MgrSupport resources Accountablecare managerassignedOngoing component Clinical SMEso MDo Pharmacisto Disease-specificSMEs Programso SNFo Palliative Care /Hospiceo House CallsCommunity Services22Specialists
Care Management Process Lifecycle: Resources requiringvarying skill sets – Patient Centered Medical HomeIdentify &PrioritizePreliminary identificationof cohorts Analyst,utilizing thefollowingenablers:– Patient list––from StateClaims,administrative,clinical nitialengagement Coordinator Non-clinical staffwith minimumhigh schooleducation Knowledge ofcommunitymembers,sensitive to localneeds BilingualpreferredAssessNeedsComprehensiveneeds assessment Interviewer Trained andexperienced inmotivationalinterviewing Clinicalbackground(RN, LPN, SW)DevelopPersonalizedCare PlansCare Planning AccountableCare Manager Clinicalunderstandingand knowledgeof localcommunityresources Clinicalbackground (RN,SW)Monitor &Update CarePlansCare GuidanceCare Team Accountable CareMgr (RN, LPN, SW) Behavioral Care MgrSupport resources Clinical SMEso MDo Pharmacisto Disease-specificSMEs Programso SNFo Palliative Care /Hospiceo House CallsCommunity ServicesSpecialists23
Identify &PrioritizeEnrollMonitor &Update CarePlans untilDischargePatientPrimary CareProvider,PCMHDevelopPersonalizedCare PlansStratify intoProgramsAssess NeedsEnrollment and OutreachPatient Engagement(Baselineand Ongoing)Montefiore: An Introduction – Revised 9/201524
Identify &PrioritizeMonitor &Update CarePlans untilDischargePatientAssessmentEnrollPrimary CareProvider,PCMHDevelopPersonalizedCare PlansStratify intoProgramsMedical/“Big Data” Is Not EnoughAssessNeeds8% Generate 55%of Medical ExpenseAnalytics alone will not be able toidentify underlying drivers influencingdiabetic condition Unstable Housing Substance Abuse Mental Health Financial Distress23Montefiore: An Introduction – Revised 9/20152525
Social Determinants of HealthcareCostsBased on results of over 4,000 assessments of high-riskpatients conducted at Montefiore CMOMontefiore: An Introduction – Revised 9/201526
Care Coordination Bridges the lConditionsCare CoordinationBiopyschosocial Assessment Care Transitions Intensive Care Mgmt ChronicCare Mgmt Palliative and Hospice Care Behavioral Health Mgmt TelemonitoringMedical ConditionsLiteracy · TransportationFinances · Housing · FoodThe Provider ViewThe Patient View27
Care Coordination:Similarities to the Airline IndustryAir Traffic Control 1,140 planes in this snapshot 87,000 flights daily in the US Managing activitiesacross multipleresources Numerous variablesimpacting process Constant monitoring& adjustment28
Care Coordination Is Equivalent to Air TrafficControl Requires precision for safety and efficiencyCareful, detailed planning that rarely follows initial designSignificant number of variables can impact care Patient condition: Subjective and objective data Flow and demand of patient population System / Technology Resource Availability (physician, hospital, pharmacy)Effective care coordination needs to be dynamic, subject tocontinuous reassessment and adjustmentsUse of accurate, real-time data to support workflowMontefiore: An Introduction – Revised 9/201529
PHM Across the Care Continuum –Leveraging IT to Enable Care asedOrganizations / Social WorkPatientCare CoordinationPatientPortalsPrimary EDMontefiore: An Introduction – Revised rs30
Benefits Realized for the Value of Health ITSATISFACTIONPatient, Provider, Staff, OtherValueofHealthITTREATMENT/CLINICALSafety, Quality of Care, EfficiencyELECTRONIC INFORMATION/DATAEvidence-Based Medicine, Data Sharing and ReportingPREVENTION & PATIENT EDUCATIONSAVINGSFinancial/Business, Efficiency Savings, Operational Savingshttp://www.himss.org/ValueSuiteMontefiore: An Introduction – Revised 9/201531
Care Management Organization – PastCare Management Organization - PastPioneer ACOCaseID Redundantprocesses “Siloed” acrossprogramsCaseEnrollmentCare outingCaseEnrollmentCare PlanMonitoringCare PlanSetup ManualworkflowmanagementDisease ManagementProgramsRisk ProgramsAssessCare RCreationoutingData AnalyticsTaskMonitoringCaseIDCaseEnrollmentCare PlanMonitoringAssessCare PlanSetupTaskFollowUpData ingTaskFollowUpData AnalyticsAutomation LayerCareCoord Disparate systems Multiple access pointsEMRMontefiore: An Introduction – Revised hDocumentImagingPharmacy32
Care Management Organization - VisionCaseID Standardized processesacross programs Focused aroundpatient, not disease orconditionCare PlanMonitoringCaseEnrollmentAssessCare PlanSetupPioneer ACORisk ProgramsDisease ManagementProgramsAutomation Layer Centralized technologyplatform Robust data model(problem / interventiondata sets)Population Health Management AutomationWorkflow-driven Care Management FunctionalityPatient and Provider EngagementHealth Information ExchangeBusiness Process and Rules ManagementAdvanced Health Analytics Access to real-time data Interoperability withdisparate systems acrosscare continuumCareCoordCareCoordEMRMontefiore: An Introduction – Revised 9/2015ClaimsLabCaseMgmtTeleHealthRadLab33
Practice Transformation and EHRProviderGap Providereducation/Evidence basedguidelinesDashboards/Public nSupport ToolsAnalyticsReferrals lanned VisitsMontefiore: An Introduction – Revised 9/201534
Patient EngagementProgram Goals and ObjectivesImprove quality performance Improve adherence to clinical guidelines and qualitymeasures i.e. HEDIS/ACO Convert ‘non-users’ to ‘users’. Chronic fallout (at risk members previously identifiedas having a chronic, catastrophic, or malignantcondition that are no longer flagged with this healthstatus for a subsequent reporting year).Improve patient access to services, experience, andpromotion of healthcare educationUse claims, clinical and appointment sources to identifypatients with gaps in care in need of outreachMontefiore: An Introduction – Revised 9/201535
Patient Engagement via EMMIRecent/Upcoming Campaigns Patients missingservices areidentified viaclaims andclinical dataCampaignsfocused onpreventive careservices andchronicconditionsmanagementpatient educationMailing /Notification/Reminder of overdue servicesIVR/Telephonic Automated campaignsLive Follow-up calls to non-engagedEducational Multimedia and post discharge seriesMonthEmmiPrevent CampaignFebruaryAsthmaTransfer?(Y/N)NoMarchDental HealthEmmiEngage ilDiabetesNoDiabetes High blood PressureDiabetes Nutrition & HealthyEatingDiabetes Overdue A1cDiabetes SmokingMayWellness Visit – Adult (English/Spanish) - MMGYes-JuneWellness Visit – Adult (English/Spanish) - CMOYesJuneHeart FailureNoJuneJuly(early)CADNoHeart FailureHeart Failure next apt with DocCoronary Artery DiseaseChildhood VaccinationsNoJune 7th(tentative)June 14thJune 28thJune 28thJuly 19th
Streamlined Referral Management Workflow:Improve Access, Reduce LeakageReferral OrderPlaced byProviderDirected toExternalProvider?NoReferral and ClinicalInformation DeliveredElectronically ToReceiving PracticeNo Change ToExisting EHRWorkflowYesReferral Sent ToCrimson MedicalReferralsReceiving PracticeOpens & UpdatesReferral WithAppointment InfoWhen ScheduledReason ForSending Out OfNetworkDocument ForReportingPurposesNoCrimson Used ToIdentify Provider WithAppropriateSubspecialty,InsurancePatient Locator bannerMontefiore: An Introduction – Revised 9/2015ProviderWithinPreferredNetwork?YesReferring PracticeEasily IDs, FollowsUp On UnresponsiveReceiving PracticeUpon Completion ofAppointment,Clinical InformationReturnedElectronically37
Sample Practice/Group ReportMontefiore ACO Provider ProfileCalendar Year 2016Product Name [Medicare, Medicaid, Commercial]Provider NameFacilityAllPractice NameSpecialtyAllTotal Population758Pioneer ACO(Medicare) and Emblem(Medicaid, Medicare, Commercial)1.1Attributed PopulationRisk Score (Avg)OverallScore1) MedianAggregateAge/Sex Performance and 2) by Line ofBusiness,3) 90th/75th Percentiles benchmark and# Attribution patients [Product name]4) recommended improvement targetFinancialOverall Domain PerformancePreventive HealthCostPMPMAdult Quality MetricsAdults' Access to Preventive/Ambulatory HealthAdult BMI AssessmentBreast Cancer ScreeningChlamydia Screening in WomenColorectal Cancer ScreeningComprehensive Diabetes CareHBA1C TestingDilated Eye ExamNephropathy Monitoring91%Line of Business, Risk Score andAdditional demographicsOverall 70.27%SS0.00%1.03%1.07%Overall rcialPerformance78.80%48.13%14.29%62.86%Overall Performance80.45%49.24%12.32%66.40%Last QuarterPerformanceLast QuarterPerformance% Target5)Last QuarterPeer AvgImprovement3.00%Performance and6) Peer comparison75th Percentile90.0%90.0%90.0%90.0%91.0%66.0%86.0%% 0%9.00%9.00%Overall Domain PerformancePreventive HealthPediatric Quality MetricsChildren and Adolescents' Access to Primary CareAdolescent Well CareWell Child Visits 0 - 15 Months (5 Visits)Well Child Visits 3 -6 YearsLast QuarterPerformance75th Percentile67.5%87.5%87.5%% TargetImprovement3.00%8.00%5.00%9.00%Overall Domain PerformanceProgram EngagementProject Metrics% Patients engaged in EMMI outreach up to date?% in Referred to Heal pros program % Screened% Response to HCC care alertsMontefiore: An Introduction – Revised 9/2015Overall Domain Performance% TargetImprovement3.00%8.00%5.00%38
Keys to Success inValue-Based Care Overarching vision, clear governance structure, andaligned operations Must define and understand the population 20% of the population drive the costs, 100%determine the quality of care Developing an ongoing care and populationmanagement organizational strategy Ensure IT strategy incorporates full breadth ofpopulation health and care coordination operationalneeds Need for Continuous Quality and PerformanceImprovement and Innovation:Montefiore: An Introduction – Revised 9/201539
Final Thoughts – Know Where You’re HeadedUnderstand your organization’s long-term vision andnear-term strategy for value-based care delivery.Who are your payer partners (commercial, CMS)?What other provider organizations are you aligning with?What strategic imperatives are impacting your timeline?Which services have the highest market demand?How much of your “infrastructure” (organizational & IT) are you goingto build vs. buy?Montefiore: An Introduction – Revised 9/201540
Final Thoughts – Invest WiselyDevelop your IT strategy for Population Health / CareCoordination around your organizational strategy & operationalmodel Who will you be sharing and exchanging data with? What are the key processes and workflows that IT needs tosupport? What systems (EMR, HIE) can you leverage for population health /care coordination? How will your current BI/Analytics strategy and solutions enablecare coordination? Push the vendor marketplace to develop innovative, agile,interoperable solutions and flexible platforms– Do not force fit workflow to accommodate inflexible solutionfunctionalityThink process first!!!Montefiore: An Introduction – Revised 9/201541
Montefiore Care Management Organization (CMO) Serves administrative functions (e.g. claims payment, credentialing) Performs care management as . by which Montefiore conducts care management and plan administration. 12 420,000 Lives 2016 2018 2014 2012-2013 2000-2011 1997-1999 1996 300,000 Lives 195,000 Lives 150,000 Lives 55,000
CMO Quality & Network Management at 914-377-4477. A downloadable copy of the provider manual is available on Montefiore's website www.cmocares.org. II. THE MONTEFIORE CARE MANAGEMENT COMPANY (CMO) CMO, The Montefiore Care Management Company of Montefiore Medical Center (CMO), is a
IPA and Montefiore Care Management Formed in 1995 MD/ Hospital Partnership Contracts with managed care organizations to accept risk . CMO and UBA . Montefiore Care Management . Source 2012 . Population . 2012 Est. Revenue : 2013 . Population . 2013 Est. Revenue : Risk Contracts . 140,000 : 850 m .
CMO, Montefiore Care Management 200 Corporate Boulevard South Yonkers, NY 10701 . Table of Contents Specialty Page Number Acupuncture 66 Addiction Medicine 66 . Primary Care Montefiore Medical Center 111 East 210th Street Bronx, NY 10467-2401 (718) 920-7441 Gervits, Maria , MD MMC Family Health Center
6 100 years in the bronx montefiore 2012 annual report Academic Medical Center In the heart of one of the nation’s most economically and health-challenged communities, Montefiore is transforming the way healthcare is delivered, providing science-driven, patient-centered care. As the University Hospital for Albert Einstein College of Medicine,
equine medicine b. Food animal or large animal medicine c. Exotic animal medicine d. Marine animal medicine (mammal and fish) e. Poultry medicine f. Wildlife medicine and aquaculture medicine 2. Discuss with your counselor the roles a veterinarian plays in the following: a. Public health medicine and zoonotic disease surveillance and control b .
DEPARTMENT DIVISION NAME Family Medicine Palliative Medicine Algu,Kavita Palliative Medicine Arvanitis,Jennifer Palliative Medicine Berman,Hershl (Hal) Palliative Medicine Buchman,Stephen (Sandy) Palliative Medicine Cellarius,Victor Palliative Medicine Goldman,Russell Palliative Medicine Hashemi,Narges Palliative Medicine Howe,Marnie
Dec 30, 2019 · and assesses the health needs for the Bronx, County, New York. The participating hospital is Montefiore Medical Center, a part of the Montefiore Health System, and encompasses the five Bronx campuses (Moses, Wakefield, Einstein and Westchester Square, and the Hutch Metro Center) and the ambulatory sites in Bronx County.
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