Strategy Management in the Military Health System: Achieving the Quadruple Aim

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Strategy Management in the Military Health
System Achieving the Quadruple Aim

• Ms. Paula Evans
• Office of Strategy Management
• Office of the Assistant Secretary of Defense for
  Health Affairs
• paula.evans_at_tma.osd.mil
• 27 July 2010

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Goals for this briefing

• At the conclusion of the session, participants
  will be
• able to
• Understand the MHS Quadruple Aim
• Understand the MHS Strategic Imperatives
• Understand the Pt Centered Medical Home
• Understand the critical importance of MEPRS in
  monitoring strategic performance

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The Quadruple Aim
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MHS Quadruple Aim

• Readiness
• Pre- and post-deployment
• Family health
• Behavioral health
• Professional competency/currency
• Population Health
• Healthy service members, families, and retirees
• Reduced tobacco, ETOH and unhealthy eating
• A Positive Patient Experience
• Quality healthcare outcomes
• Patient and family centered care, access,
  satisfaction
• Cost
• Responsibly managed
• Focused on value

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Achieving Excellence in the Delivery of Care

• Performance is a characteristic of a system
• Every system is perfectly designed to achieve
  exactly the results it gets
• Design leads to performance reliability leads to
  excellence
• So if you want different performance, you need a
  different design
• Process-by-process, change-by-change we can get
  better and improve across all six areas that
  described experience of care (Crossing the Chasm,
  2001)
• Safe
• Effective
• Patient-Centered
• Timely
• Efficient
• Equitable
• But, we need data..

Source Achieving the Quadruple Aim Military
Health Leading the Nation, Don Berwick, MD, MPP,
MHS Conference, January 27, 2010.
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Aligning the Incentives Rewarding Both Outputs
and Outcomes

• Deliver patient centered primary careand
  optimize performance around

• Improve health (HEDIS)
• Enhance access and continuity (reducing no shows,
  ER visits)
• Care is rewarding to patient and provider
  (satisfaction, retention, staff turnover)
• Synchronize direction and incentives for
  TRO/MTF/Regional Commander, including initiatives
  that are
• Facility-specific
• Good for entire region or service
• Good for all military patients
• Beneficial to the MHS as a whole

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MHS Strategic Imperatives
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Strategic Imperatives

• The MHS has developed a set of strategic
  imperatives that we believe will positively
  impact the Quadruple Aim
• Strategic Imperatives are the things that will
  yield the greatest return from the finite
  resources available

Strategic Imperatives are the critical few things
we must do to achieve the Quadruple Aim

• Each measure has specific targets for FY10, FY12,
  FY14
• The difference between our current performance
  and target performance is our performance gap
• Each imperative will have an Executive Sponsoring
  Coalition (i.e. one of the Integration Councils)

Each Strategic Imperative has one or more
performance measures
As an organization, we will align resources and
focus management efforts on our Strategic
Initiatives over the next 1-5 years

• To close our performance gap we will
  concentrate
• efforts on a few strategic initiatives (i.e.
  Patient
• Centered Medical Home)

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MHS Strategic Imperatives Scorecard
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How Do We Support Change in the Right Direction?

• Understand desired end-state
• Balanced approach to Quadruple Aim
• Readiness maximized
• Healthy Outcomes and Patient Experience improved
• Sustainable Costs
• Emergency Department Use
• Retail Pharmacy
• Agree on goals
• One size does not fit all
• Year over year improvement
• Facilitate and incentivize the change

Balance
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Key MHS Initiative for Achievingthe Quadruple
Aim is the Patient Centered Medical Home (PCMH)
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Team-Based Healthcare Delivery

• Creation of Clinical Micropractices
• Appropriate utilization of medical personnel
• Improve communication among team members

Population Health
Access to Care

• Improve phone and electronic appt scheduling
• Open access for acute care
• Emphasis on coordination of care
• Proactive appointing for chronic and preventive
  care

• Emphasis on preventive care
• Form basis of productivity measures
• Evidence-based medicine at the point of care

Patient Centered Medical Home
Advanced IT Systems
Patient-Centered Care

• Secure mode of e-communication
• Creation of education portal
• Reminders for preventive care
• Easy, efficient tracking of population data

• Empower active patient participation
• Seamless communication
• Encourage patient participation in process
  improvement

Refocused Medical Training
Decision Support Tools

• Evidence-Based Training
• Integrated Clinical Guidelines
• Decision Support Tools at the point of care

• Emphasize health team leadership
• Incorporate patient-centered care
• Focus on quality indicators
• Evidence-based practice

Patient Physician Feedback

• Real-time data
• Performance reporting
• Patient feedback
• Partnership between patients and care teams to
  improve care delivery

Model adapted from the NNMC Medical Home
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MHS PCMH Journey
NNMC PCMH Pilot Begins Jun 2008
Services Develop PCMH Policy Guidance Apr Jul
2010
MHS PCMH HA Policy Sep 2009
2nd MHS PCMH Summit Oct 2010
2,634,614 Enrollees in a Level II PCMH End of
FY 2012
Performance Planning Pilots Begin Oct 2010
Edwards Ellsworth FHI Pilots Aug 2008
MHS Conference (Enterprise-Wide
Communications) Jan 2010
Resources Aligned in 2012-17 POM Jun 2010
1st MHS PCMH Summit Sep 2009
Enterprise-Wide Secure Messaging Capability
Available Jan - Mar 2011
Services Present Early Results of PCMH
Performance Aug 2009 (RA)
ASD/HA and SG Congressional Testimony (for
Stakeholders Buy-in) Feb 2010
Framework for Analysis Approved (i.e. Measures
and Standards) Dec 2009
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Business Case to Support PCMH
What should PCMH accomplish within Primary Care?
What do we need to do?

• Reduce visits/person
• Maintain total touches (visits non-visits)
• Increase enrollment
• Increase market share
• Recapture PSC (savings)
• Increase preventive services

• Right number of providers for enrolled population
• Right number of support staff per provider
• Right space for efficient operations
• Right information systems
• Train our people to more effectively function as
  a team

What should PCMH accomplish outside of Primary
Care?
PMPM
Direct Care

• Reduce ER demand (savings)
• Reduce inpatient demand (savings)
• Reduce specialty demand (savings)

PMPM (Focus on pharmacy)
Purchased Care
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Standards MeasuresWhat They Are Why They Are
Different?

• Standard An established norm or requirement
  usually manifested in a formal document that
  establishes uniform specifications, criteria,
  methods, or practices
• Measure A number or quantity that records an
  observable value or performance

• Example Hybrid Car
• Standards
• Uses two or more distinct power sources to move
  the vehicle
• Low emissions (i.e. SULEV rated
  Super-Ultra-Low-Emission Vehicle)
• Measures
• Fuel economy (mpg city/hwy)
• Acceleration (time from 0-60 mph)

In this example, standards distinguish hybrids
from other cars while measures allow consumers to
compare the performance hybrids against other
cars.
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Why Do We Need Standards and Measures?

• Standards and measures allow us to test a
  hypothesis
• Hypothesis The PCMH is a model of primary care
  that will have a significant positive impact on
  MHS pursuit of the Quadruple aim enhanced
  patient experience, improved population health,
  better managed per capita cost, and increased
  medical readiness.
• Standards allow us to differentiate medical homes
  from traditional models for primary care
• Standards describe the key characteristics
  required for a practice to qualify as a medical
  home
• Standards do not force one-size-fits-all they
  are simply a set of fundamental criteria that
  must be met
• Without standards, the term medical home can be
  used loosely, potentially damaging the
  credibility of the medical home initiative
• While standards can be used to determine what a
  medical home is, measures allow us to determine
  how they are performing
• Performance versus control groups (Are medical
  homes doing better than traditional models for
  primary care?)
• Longitudinal performance (How is a medical home
  doing over a span of time?)
• Best performers (Where are the opportunities for
  best practice transfer?

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Tracking PCMH Implementation
Number and percentage of enrollees getting their
care from a Level 2 Patient Centered Medical Home

• We have standards that define the patient
  centered medical home
• We have measures and targets that describe the
  outcomes we want to achieve
• We should articulate the number of patients that
  will migrate to a patient centered medical home,
  and by when

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PCMH Enrollment ProjectionsTHE TARGET
Notes HCSC Health Care Support Contractors
(X) of enrolled population with Plus
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Estimated Overall Impact of PCMH on the
Quadruple Aim
of Enrollees Getting Care from Level 2 PCMH

• ExpectedPerformance from Level 2 PCMH

Overall Impact on Quadruple Aim
X

R
75
3.75M -
G
54
50
2.5M -
G
Y
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1.25M -
Y
11
R
10
500K -
Y
5
R
250K -
R
(XX) Denotes FY12 target
Projections 2012
Projections 2011
Projections 2010
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Importance of MEPRS in All This
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The MHS Value Equation for Measuring PCMH Success
Readiness
Experience of Care
Population Health


Value
Cost (Over a Span of Time)
Creating a high value Military Health System is
predicated on defining and measuring value.
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MHS Strategic Imperatives Scorecard MEPRS Data
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Magic Linkage
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What PCMH questions do we need answered that
MEPRS would help on?

• How many people are enrolled to a PCMH?
• What are the demographics of those enrolled to a
  team?
• What is the enrollment ratio, i.e. enrollee to
  providers?
• What is the demand rate for those enrolled in
  PCMH?
• How much primary care of those enrolled in PCMH
  is not seen by providers within the PCMH team?
• How much primary care seen by the team is for
  those not enrolled in the team?
• What is the productivity of the team?
• What is the overall cost of the team?
• What is the PMPM of individuals enrolled in PCMH?

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MEPRS Based Data is Essential for Knowledge
Transfer

• Having aggregate measures isnt enoughwe need
  information at the team level to evaluate
  performance and support best practice transfer of
  PCMH
• At a fourth level MEPRS, data can be aggregated
  and analyzed by medical home team within a given
  MTF
• A PCMHs performance can then be compared with
  others.
• We believe that as teams learn from each other,
  their performance will improve over time
• Leadership has asked OSM to propose a single
  approach for measuring all aspects of a PCMH team
  and present to the JHOC on 11 Aug 10

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Our Challenges

• Labor intensive to create individual
  identification of teams
• Lack of standard implementation rules
• Not so simple very complicated
• Inefficient processes for data entry
• Inadequate training of staff to appropriately
  account for time
• IM/IT disconnects

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Pay Off by Measuring Individual PCMH Teams

• Identify top performers
• Report to our investors using hard evidence
  (facts) on the results of the PCMH initiative
• Prove something that no one has proven in the
  country
• Share best practices and eliminate unwarranted
  variation

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What Will It Take?

• Agreement to work together to find an optimal
  solution
• Skill in designing efficient processes and
  procedures to capture data and allocate resources
• Pilot testing to avoid unintended consequences
• Willingness to act quickly and get to yes

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It is not the strongest of the species that
survives, nor the most intelligent, but the one
most responsive to change. - Charles Darwin
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Back-up Slides
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Definitions Strategic Imperatives
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Strategic Imperative Definitions
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Strategic Imperative Definitions (Contd)