Population Health Management Strategy & Program …partnershiphp.org/Providers/Policies/Documents/Popul… · Web viewPopulation Health and Population Health Management are relatively

Population Health ManagementStrategy & Program Description

2020MCND9001

(previously MCNP9001, MCCD2027)

Original Date: 11/13/2019

Revision(s) Date: Previously Applied to MCCD2027 11/13/2019 to 04/08/2020 MCND9001 (04/08/2020): N/A

Partnership HealthPlan of California |Population Health Management Strategy & Program Description | page 2

Table of ContentsProgram Purpose.........................................................................................................................................2

Introduction.............................................................................................................................................2

Data Analysis and Strategy......................................................................................................................2

Population Needs Assessment.............................................................................................................2

Community Supports and Social Determinants of Health...................................................................2

Population Segmentation............................................................................................................................2

Population Characteristics and Needs.....................................................................................................2

Data Integration and Population Segmentation..................................................................................2

Integrated Datasets.............................................................................................................................2

Children, Adolescents, and Disabled Adults........................................................................................2

HEDIS Measure Reports.......................................................................................................................2

Predictive Modeling.............................................................................................................................2

Segmentation Process.............................................................................................................................2

Programs and Services................................................................................................................................2

Organizational Support for PHM..........................................................................................................2

Risk Segment.......................................................................................................................................2

NCQA Program/Services......................................................................................................................2

Organizational Support........................................................................................................................2

Other Activities – Intervention that Indirectly Affect Members..............................................................2

Initiative Type......................................................................................................................................2

Definition.............................................................................................................................................2

Informing Members about Available PHM Programs..............................................................................2

Coordination of PHM Programs...............................................................................................................2

Informing Members on Interactive Content............................................................................................2

Program Evaluation.................................................................................................................................2

Clinical Measures.................................................................................................................................2

Utilization Measures............................................................................................................................2

Member Experience............................................................................................................................2

Identifying Opportunities for Improvement........................................................................................2

Delivery-System Supports for Population Health Management..................................................................2

Value-Based Payment Programs..............................................................................................................2


Incentivizing Patient-Centered Medical Home (PCMH) Recognition.......................................................2

Sharing Data............................................................................................................................................2

eReports:.............................................................................................................................................2

Partnership Quality Dashboard (PQD):................................................................................................2

Transformation Technical Assistance..................................................................................................2

Population Health Department Structure....................................................................................................2

Team Roles and Responsibilities..............................................................................................................2

References...................................................................................................................................................2

Population Health Program Approval..........................................................................................................2


Program PurposeTo identify the strategy and organizational structure Partnership HealthPlan of California (PHC) utilizes to assess, segment, and act in order to meet the needs of its member population within the context of the various communities in which PHC’s members live.

Introduction Population Health and Population Health Management are relatively new terms in health care. In theory, population health defines the space between public health and individual health care; however, these terms have different meanings to different audiences. For example, public health professionals consider primary prevention activities, such as community-wide smoking cessation efforts, to be a form of population health management. Risk-bearing entities, such as integrated health systems, focus on controlling global costs and population health management as a means to achieve cost savings. Primary care providers consider management of data and quality improvement interventions that improve clinical quality scores a means of population health management. Both the National Committee of Quality Assurance (NCQA) and California’s Department of Health Care Services (DHCS) have their own definitions for population health management by managed care plans. For the purposes of this program description, PHC follows the NCQA definition: “Population Health Management (PHM) is a model of care that addresses individuals’ health needs at all points along the continuum of care, including in the community setting, through participation, engagement and targeted interventions for a defined population. The goal of PHM is to maintain or improve the physical and psychosocial well-being of individuals and address health disparities through cost-effective and tailored health solutions.” (NCQA, 2018)

PHC has a cohesive plan of action for addressing member needs across the continuum of care through a strategy that engages not only the Population Health department, but also multiple departments within the organization. PHC utilizes its population’s unique characteristics and needs to identify programs and services that will help individual members within PHC’s population. The Population Health Management (PHM) program also highlights PHC-sponsored delivery system supports designed to enhance population health management within our provider network and describes PHC’s process for annually re-assessing the member population needs and the effectiveness of our population health strategy at meeting those needs.

Data Analysis and Strategy PHC has a PHM Steering Committee that meets at least four times per year to review aggregate data to evaluate how PHC’s interventions met population needs over the prior calendar year, to identify gaps in care, and to propose new program offerings to overcome these gaps. Data gathered to perform this quantitative analysis include the datasets described elsewhere in this document, along with Census Data, community data sets shared through provider data exchanges, and data shared by the State of California regarding PHC’s assigned membership. External regional/community efforts are evaluated with data provided through either summary reports or Health Information Exchanges (HIE). PHC uses that data to analyze service utilization patterns, disease burden, and gaps in care for our members taking into account their risk level, geographic location, and age groups. PHC uses these findings to evaluate the programs and services offered by PHC to determine if the benefits offered are adequate to meet our member needs. Community resources are examined to determine if additional service needs


should be integrated in to PHM strategies. In addition, the PHM Steering Committee examines the internal resources needed to achieve the aims of our PHM strategy, including staffing, systems, educational and knowledge base, and funding.

In addition to the PHM Steering Committee oversight, PHC has a Population Health Management Committee to cultivate inter-departmental collaboration and alignment with other organizational initiatives, along with multi-disciplinary workgroups that convene several times per year to analyze the results of the prior year’s efforts and to develop and refine program offerings. The PHM Committee reviews results from the smaller workgroups and evaluates the impact of each program on overall population wellness. New state/community initiatives are considered in order to maximize program participation and efficacy without duplicating efforts. This forum provides the platform from which new initiatives are proposed and planned, and existing programs and services offered are revised, if needed, to ensure continuous process improvement and program evolution in accordance with the needs of the population.

Population Needs Assessment PHC routinely collects data regarding cultural, ethnic, racial, and linguistic needs of its members, and conducts a quantitative evaluation to determine unmet needs. Data sources may include, but are not limited to, US census and enrollment data, member surveys, member complaints, and other published health statistics, as well as data provided by Plan sponsors or other sources. The data collected is analyzed no less than annually with the goal to ensure that PHC and its providers deliver services to our members that meet the needs of our culturally diverse population.

The Health Education unit prepares an annual Population Needs Assessment (PNA) that documents member and regional detail describing PHC’s demographics, cultural and linguistic needs, health inequities, social and structural barriers to care, and proposes an action plan to address identified disparities. The PNA includes language preferences, reported ethnicity, use of interpreters, traditional health beliefs and beliefs about health and health care utilization. The Sr. Health Educator provides a summary report of PNA findings for discussion with CAC/FAC members during their regular meetings in both Northern and Southern regions. The PNA with proposed actions undergoes review by the PHM Steering Committee, PHC’s Internal Quality Improvement Committee, PHC’s Quality Utilization Advisory Committee, PHC’s Physician Advisory Committee, and by PHC’s Board of Directors before submission to California’s department of Health Care Services (DHCS) per regulatory requirements.

Community Supports and Social Determinants of Health PHC’s Health Analytics department estimates the impact of Social Determinants of Health (SDH) for the region and membership through proxy data sources. One such source of SDH information is the California Healthy Places Index (HPI) data produced by the Public Health Alliance of Southern California (healthyplacesindex.org). This freely available data set ranks California census tracts on a composite score of health disadvantage by incorporating data on 25 individual indicators organized in eight domains, namely economy, education, healthcare access, housing, neighborhoods, clean environment, transportation, and social environment. For each census tract, each indicator is expressed on a standardized scale (Z-scores) of increasing disadvantage, and averaged for each domain. The overall score is calculated as the weighted sum of domain scores. The HPI data set also includes the percentiles of each domain and individual indicator, as well as the overall composite values to rank each census tract.


Using the residential address of members found in the Membership data files received from DHCS, PHC’s Health Analytics team determines the geographic coordinate of the census tract that corresponds to each member’s valid address using SAS software. The calculated census tract is then used to join PHC’s data with a data set downloaded from HPI (https://healthyplacesindex.org/about/). These rankings are used in combination with the rest of the SDH data to estimate the SDH risks of each of PHC’s members.

Member-specific sources for SDH data include transportation claims that demonstrate member need for services, location, and distance from providers; demographic attributes found in membership data; specific social risk factors identified from diagnosis codes; and homelessness data derived from member’s addresses and diagnosis-coding. Members new to the health-plan and having either a Senior or Person with Disability (SPD) aid code, or identified as California Children’s Services (CCS) beneficiaries have a detailed assessment of their social supports, barriers to care, food security, and financial resources, as well as their medical history and current care needs. Members who have serious and persistent mental illness (SPMI) receive care for those conditions through the county-administered Mental Health Managed Care, which is carved out of PHC’s benefit package and assigned to the county in which the member lives (see APL 17-018 Medi-Cal Managed Care Health Plan Responsibilities for Outpatient Mental Health Services). In addition, PHC’s disease registry flags member with several SPMI conditions, such as schizophrenia or major depression. PHC uses prescription data for anti-psychotic and specific anti-manic medications as a means to identify members who may have any SPMI, and leverages these data to ensure members with SPMI receive care for comorbid medical conditions.

Population SegmentationPopulation Characteristics and Needs PHC leverages multiple data sources, surveys, and approaches to assess the regional population, the overall membership, and subpopulations within the communities we serve. These activities are designed to determine how to best meet the needs of the community and membership, how to update existing programs to better target member needs, and to develop programs to address unmet needs of subpopulations.

Data Integration and Population Segmentation PHC segments the population through multiple lenses to ensure that there are programs designed to reach all levels of risk and intensity of care needs within our membership. PHC’s Health Analytics department extracts data from diverse sources in order to assemble an integrated data source that provides detailed information on individual member needs and behavior. The data are sourced from:

Medical claims and encounters from both PHC’s in-house claims system and behavioral claims from PHC’s contracted provider of mental health services.

Pharmacy claims data from PHC’s Pharmacy Benefit Manager, as well as carve-out drug claims from the state, which include HIV drugs and drugs utilized for treatment of severe mental health diseases and substance use disorders.

Laboratory results. Shared electronic health records, such as hospital discharge reports and Specialty Care

Center consultation notes. PHC Health Services programs, which includes data on referrals to case management

https://healthyplacesindex.org/about/


programs, case management assessments and activities, prior treatment authorizations requests (TARs), and referral authorization requests (RAFs).

Vaccination data from the California Immunization Registry (CAIR), integrated with medical claims, and pharmacy claims.

HPI data set that ranks California census tracts on a composite score of health disadvantage.

Integrated Datasets Using the data from the sources mentioned above, PHC builds member-level subpopulation datasets each month. Age-specific criteria incorporate demographics (age, gender, race/ethnicity, language, address of residence), eligibility data (insurance, aid code category, continuous enrollment), medical and behavioral health services utilization, disease burden, SDH, care management indicators, cost of care and a prospective risk score. Examples of the integrated subpopulation datasets are described below.

Disease registries for 19 common chronic conditions. This data set integrates data from medical/behavioral claims, pharmacy claims, and laboratory results to identify members suffering from up to 19 chronic diseases in the prior year. These diseases identified are: asthma, bipolar disorder, diabetes, chronic kidney disease, congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, chronic liver disease, dementia, schizophrenia, severe depression, post-traumatic stress disorder, hypertension, traumatic brain injury, obesity, cancer, tobacco use, and substance use disorder. In addition to chronic conditions, other data elements that are included in the registries data are:

any emergency visit, hospital admission, and prescription drug services received by those members in the same period, as well as the cost of those services, all from data in medical and pharmacy claims data;

demographics, eligibility aid code category, and Primary Care Physician (PCP) assignment from Member Enrollment data;

homelessness status, derived from address elements in the Member Enrollment data and diagnoses in medical claims and encounters;

enrollment in PHC case management programs from our internal case management data system; and

the member’s PHC Risk Score.

Disease registry data are updated quarterly, and members identified through this are dataset are further segmented according to the stability of their condition. Below is an example of how a member may have his/her needs met across the care continuum based on disease registry data.


Perinatal Care. This data set uses medical claims and laboratory results to obtain newborn delivery data, such as admission and discharge delivery dates; procedures and diagnoses for the delivery event; and flags for cesarean section, prenatal, and postnatal services. It also uses medical/behavioral encounter data and pharmacy claims, along with advanced data sources such as immunization registries, to incorporate flags for flu and TDAP vaccinations, opioid utilization, any emergency visits or hospital admissions occurring during pregnancy, and the organization’s case management system for flagging enrollment in case management programs. Additional data elements in the perinatal data set are demographics, eligibility data, PCP assignment, flags for chronic conditions and homelessness, and risk scores, all using the data sources described in the Disease Registry above. PHC provides support to pregnant and newborn members through services offered through provider offices, as well as via direct outreach to members by PHC staff. Cases requiring more support are escalated to more intensive programs, such as the examples shown in the diagram below.

High-Risk MembersEach month, PHC Analytics runs risk stratification reports for the entire population based on a custom risk score methodology (details described below). A monthly dataset is compiled from medical and pharmacy claims data to obtain member-level data showing emergency visits, hospital admissions, and drug utilization counts and costs, total admission days, most frequent diagnoses for ED and inpatient visits. The dataset also utilizes member enrollment data to integrate demographics as well as the data sources described above to obtain flags for chronic conditions and homelessness. In addition to the factors listed above, the risk score assesses pediatric members for presence of respiratory conditions, ongoing outpatient visits according to their medical conditions, and filled prescriptions. The results are matched with the data from the Care Coordination case management system to identify the members already receiving Care Coordination department services. PHC’s

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Care Coordination department contacts high-risk members not already flagged as enrolled in case management for potential enrollment into Complex Case Management (see policy MCCP2007 Complex Case Management) as well as other interventions.

The criteria for identification of high-risk members are reviewed annually according to the policy review schedule, and updated to capture members with high utilization patterns and may benefit from assistance from Care Coordination department services.

Children, Adolescents, and Disabled AdultsPHC identifies care needs for children and adolescents through multiple methodologies. All newly enrolled children and adolescents are sent a new member assessment in order to identify emerging risks, chronic medical conditions, and available support systems. In addition, monthly reports identify children who have changes in their level of risk. Members with known or escalating risk are referred to Care Coordination for further assessment. In addition to initial assessment, pediatric members identified as CCS beneficiaries are contacted annually for reassessment, review of developmental milestones, and for assistance in transitioning from pediatric to adult care when appropriate.

Disabled adults are identified through the SPD aid code and receive a Health Risk Assessment to determine their need for an individualized care plan (ICP) upon enrollment into the care plan. Each month, the entire adult population is screened for evolving risk through the PHC Risk Score Model to identify members not yet enrolled in Care Coordination programs, and who may benefit from development of an ICP to ensure appropriate access to care and community supports.

Many of the children, adolescents, and disabled adults are also beneficiaries of local county agency programs. PHC performs robust data reviews monthly from a variety of source codes to identify children and adolescents, as well as disabled adults, who are gaining care through Medical Therapy Units (MTUs), Regional Centers, Genetically Handicapped Persons Program (GHPP), and other dedicated programs for these populations. Data reviewed includes monthly membership data files along with medical/behavioral and pharmacy claims history from the state; health appraisal results; internal medical/pharmacy claims data; and data obtained from county and regional providers showing member program enrollment. PHC’s Care Coordination department tracks these members through Essette, PHC’s electronic case management system, to ensure members receive the support necessary for coordination of care between PHC programs and the services available in the community, and to reduce duplication of services.

HEDIS Measure ReportsPHC tracks Healthcare Effectiveness Data and Information Set (HEDIS) performance measures for the health plan to view in aggregate, by region, and by county. Information aggregated for HEDIS measures include medical and pharmacy claims data, laboratory results, assessments performed by providers, chart reviews, immunization registry data, and other sources. The data for these measures is compiled in the HEDIS certified software (Inovalon) for annual review, presented in the Partnership Quality Dashboard (PQD) for monthly status tracking and analysis.

The PHM Steering Committee uses this aggregated information to analyze interventions and opportunities for the plan’s PHM activities and outcomes. PHC tailors interventions to the geography, practice standards, and social determinants of the region. Examples of this include:


Children and adolescents who do not have chronic medical conditions are tracked through HEDIS measures targeting preventative care, including those that promote engagement in well child visits, age-appropriate immunizations, and developmental screenings.

Adult HEDIS measures identify gaps in care or opportunities for improvement in local wellness, and interventions are tailored to the geographic availability of services, practice standards, and the pattern of social determinants of the region.

Predictive Modeling PHC utilizes the data sources mentioned above to produce risk scores for the population with known risk factors and available claims data using two different methodologies: the Pediatric Risk Stratification Protocol (PSRP) and the PHC Risk Score Model for adults.

Pediatric Risk Stratification ProtocolThe PSRP identifies members less than 21-years-old at risk for poor health outcomes without support. This protocol gathers information from PHC’s member demographics, medical and pharmacy claims, and encounters data, as well as cost data when a member has a new onset of utilization. Using these data sources, the algorithm described in (Snyder, Willey, McKenna, Foley, & Coleman, 2005) to calculate the risk score of every pediatric member every month. The assigned risk score correlates with percentiles that allow us to classify members into utilizer risk groups that distinguish between the moderate and high-risk populations.

PHC Risk Score ModelThe PHC risk score model for adult members (ages 21 and over) is constructed from PHC member’s demographics and SDH characteristics, and from medical and pharmacy claims, and encounters data. PHC’s Analytics team uses a longitudinal subject-specific model, also called Generalized Linear Mixed Model (GLMM) to predict the probability that a member will become a high utilizer member. Monthly reports compute the risk score of every adult member as the probability function for high utilization using the odds ratio at individual level. Each probability score correlates to percentiles that allow classifying members into utilizer risk groups distinguishing between the moderate and high-risk populations.

PHC’s Analytics team generates these risk scores monthly, and members identified with threshold risk scores are assigned to risk-tiered programs. As PHC reviews the population through these risk scores, new subpopulations may be identified that warrant either member-specific or broader subpopulation intervention strategies.

Segmentation ProcessNo less than annually, PHC analyzes and segments the entire population for need and appropriate intervention(s) as described in the Population Segmentation Report. Risk scores prove valuable in assigning members to risk-tiered programs for individuals whose health and wellbeing require the support of intensive interventions. In addition, by analyzing HEDIS Measures, census information, HPI, data provided by our providers and community partners, PHC identifies opportunities and interventions for members who have low risk scores or have insufficient data to assign a risk score. PHC works in partnership with local providers and community resources to analyze, develop, and implement interventions that support the health and wellbeing of the entire population (see diagram that follows).


Programs and ServicesPHC’s mission is “to help our members and the communities we serve be healthy.” HEDIS is a national standard for measuring how well a population’s preventative care and chronic conditions are managed; these measures are an important framework by which PHC’s interventions are evaluated for Keeping Member’s Healthy and Identifying Members with Emerging Risk. This data are synthesized with the information obtained in the analyses described above, and an integrated approach is crafted for managing the various levels of member needs, not only within the health plan but also in collaboration with providers, specialists, and community program offerings.

Organizational Support for PHMAs an organization, PHC is engaged in promoting the health and wellbeing of members. Various departments address particular segments of the population. For example, Member Services, Health Education, Quality Improvement, Population Health, and Care Coordination provide outreach to members with no identified risk to promote Keeping Members Healthy. Population Health, Quality Improvement, and Health Education collaborate to identify and support Members with Emerging Risk. Care Coordination collaborates with Provider Relations and Member Services to assist members with


their Outcomes Across Settings and to bolster provider communication along the continuum of care. Care Coordination’s clinical and social work team provide highly skilled support to assist members who are Managing Multiple Chronic Conditions.

Members may move along the acuity continuum as their needs change, and services will be matched to the member’s level of need. In other words, while a member may have few identified risks, (they may have difficulty navigating the healthcare system and require an intensive level of intervention. Conversely, a member with multiple chronic conditions may have well-established support systems and not require the assistance of the Care Coordination team in order to access care. The information in the following table outlines PHC’s approach to population health management. The PHM Work Plan and supporting desktop procedures provide details about each service and associated goals for member segments.


Risk Segment NCQA Program/Services

Organizational Support

No Risk:Members with no known risk of disease or for whom we have no claims data; focus on supporting wellness.

Keeping Members Healthy

Member Needs: To understand benefits and how to access them; identify and access providers for primary care; help with prescriptions or DME; access to non-PHC services (Denti-Cal, In Home Support Services, etc.).

Population Health Interventions:Engage members and communities through key-informant interviews, focus groups, and collaboration with community groups in order to understand better member care needs and to promote member benefit utilization.

Health Education Interventions:Develop and distribute member newsletters and benefit information.

Member Services Interventions:Explain benefits and how they may be accessed; connect members to providers.

Quality Interventions:Outreach campaigns to members aimed at improving preventive care (based on gaps identified through HEDIS measurement process).

Care Coordination Interventions: Coordination of Services (appointments, equipment, prescriptions, etc.); education for resources available in their area/community (housing, transportation, support groups, etc.); establish care with new providers.




Low Risk:Members that have risk of disease/ disease exacerbation, a newly diagnosed chronic illness, or a routine pregnancy.

Emerging Risk Member Needs: Access to specialty care and/or behavioral health providers to manage emerging or stable chronic conditions; resources/education supporting lifestyle management to maximize health and wellness, and to mitigate effects of chronic disease; learn ways to manage new diagnoses.

Population Health Interventions:Engage members in order to understand barriers to care and provide member coaching on how to manage chronic illnesses.

Member Services Interventions:Explain benefits and how they may be accessed; connect members to providers.

Health Education Interventions:Develop and disseminate member-appropriate materials (for age, sex, education, culture, and reading-level) to educate members on common conditions and how to manage them.

Pharmacy Interventions:Collaborate with local pharmacies to provide point-of-sale messages to share with members on how to take medications appropriately.

Quality Interventions:Outreach campaigns to members identified through HEDIS measures to encourage members to follow through on chronic condition monitoring tests; support providers in building capacity for seeing and tracking members with these needs.

Care Coordination Interventions: Provide referrals to community support groups/disease prevention programs/Healthy Living courses; coordination of services; and active listening/emotional support.




Moderate Risk:Members going through transitions in their care.

Outcomes Across Settings

Member Needs: Assistance with transitions between settings or across the age continuum.

Member Services Interventions:Support members post-discharge who may need to establish care with a PCP following a hospitalization.

Provider Relations Interventions:Post current information on PHC providers’ members hospitalized or having ED visits via the Provider Portal. Supply tools and supports to improve provider communication across the care continuum.

Care Coordination Interventions: Review and implementation of hospital discharge plan; coordination of services; assess member’s need for ongoing case management; assistance scheduling follow-up appointments; ensuring transportation is available to attend appointments; collaboration with PCP office to ensure a full transition of care.

High Risk:Members with multiple chronic conditions, medically fragile, frequent visits to emergency department and/or inpatient admissions; may also have poor social supports or other psychosocial issues.

Managing Members with Multiple Chronic Conditions

Member Needs: Coordination of medically complex care needs; an individualized care plan to optimize member’s wellness and function. Member may have multiple chronic conditions or may be complex due to other factors such as disorganized care delivery, cognitive or developmental impairment, behavioral health challenges, or lack a wellness support structure.

Care Coordination Interventions: Complex case management support; personalized assessments; individualized care plans; motivational interviewing; medication reconciliation; education/support for disease(s); coordination of services; assistance accessing social and community supports; interagency coordination to reduce duplication of efforts; may include face-to-face interactions.


Other Activities – Intervention that Indirectly Affect MembersPHC operates in 14 counties in California and there are several opportunities to collaborate with providers, county initiatives, and local care management programs to meet needs of individual members through joint action. The following table describes the strategies invoked to promote population wellness through partnerships with community resources and organizations.

Initiative Type Definition PHC Provider Population Reports

Automated list of members with missing services supplied to providers for specific HEDIS measures for direct outreach in order to close gaps in preventative care.

Outreach/ Scheduling Calls

Based on list of care gaps provided by PHC, provider offices call members to remind them about scheduling needed services.

Scheduling Block Clinic days at provider sites/ health centers where blocks of appointment time are set for PHC members to receive missing services.

Poster Campaign, School Engagement

Educational events where students create art projects that amplify a health topic such as immunizations; engagements with screening sessions at school clinics.

Provider Newsletters

Monthly Medical Director Newsletter to Primary Clinician Leaders, as well as a quarterly publication by the Provider Relations department (Provider Newsletter) with dedicated space for Quality Improvement and Member Engagement articles for providers to consider applying to their patients.

Provider Education

Coaching, consultation, measure review, and in-depth guidance for providers on HEDIS/ QIP measures, improving communication between providers, and promoting appropriate specialty referrals.

Provider Blast (email or fax)

Communication to all network providers for important information updates. E.g., a fax blast on new standards of use of combined long acting beta agonist/corticosteroid combinations in asthma.

PHC Website Changing banners to communicate health information to providers, community-based organizations, as well as to members.

Point of Service Interaction

Inform pharmacies of important clinical issues (such as drug class duplication) through point of service notices.

Media Campaign Social media campaign(s) focused on improving member education and influencing member decision-making in preventive services/screenings.


Informing Members about Available PHM Programs PHC shares information on programs and services available within the communities served in multiple ways, including PHC’s website, (www.partnershiphp.org), the PHC Member Portal, member newsletters, program introductory letters, as well as telephonically through PHC’s Care Coordination and Member Services department staff. When a member requires a referral into a wellness or Care Coordination program, the member is directed to the Care Coordination staff for assistance with enrollment to the program that best matches the member’s level of need.

Coordination of PHM Programs As an organization, PHC has many different member programs/initiatives concurrently planned and executed. In order to prevent duplication of effort, any department who may plan or execute programs affecting our members has read-only access to the case-management software system, Essette. There is a bi-monthly Member Engagement meeting including multiple departments (Communications, Health Education, Care Coordination, Quality Improvement, Pharmacy, and Member Services) to provide updates on new initiatives and outreach campaigns. In addition, members of the Health Services senior leadership convene monthly to review programs and initiatives to leverage activities to maximum effect and ensure teams are collaborating. PHC Population Health department staff work collaboratively with providers, multidisciplinary health agencies, community resources, and community-based organizations and workgroups. The goal of PHC’s collaboration is to assist in the identification, planning and support of healthy initiatives in the community and to identify community programs and resources that can improve member health and wellness.

PHC’s Population Health team actively participates in both internal and external workgroups to promote sharing of information and reduce duplication of effort. Through collaborative meetings, the Population Health team identifies community resources that may be of benefit to PHC’s members and shares these resources with the organization to promote integration into program offerings and to meet member needs. There are many programs within the community or offered through providers may include:

Whole Person Care Intensive Outpatient Care Management Regional Center participation Public Hospital Redesign and Incentives in Medi-Cal (PRIME) Grants to district hospitals Beacon mental health services (mild to moderate mental health

diagnoses/interventions) County-based SPMI Case Management and other support activities Substance Use Disorder treatment and Eating Disorder treatment Targeted Case Management (TCM) Outpatient palliative care Other community programs such as WIC, Healthy Families, support groups, community

collaboratives, etc.

PHC members enrolled in the programs described above are annotated in the case management system as “External Programs”. This allows members of the Care Coordination team to collaborate with community partners without duplicating services. In addition, PHC has appropriate agreements in place

http://www.partnershiphp.org/


with each county to ensure HIPAA mandates are followed and member data is not shared inappropriately between parties.

Informing Members on Interactive Content Many of PHC’s programs and services are designed to be interactive, allowing members to select the extent to which they wish to engage in these opportunities. In all instances, members have the ability to opt out of the program. Should the member express this wish – in writing, in a telephonic conversation, or through a face-to-face interaction – this preference is documented for each campaign. The PHM Work Plan specifies the interactive services that are offered, member notification, and how to opt out of programs.

Program Evaluation PHC analyzes the impact of PHM programs annually through clinical, utilization, and member experience measures in accordance with the PHM efforts of the year. PHC’s Health Analytics department takes the lead in performing quantitative analyses to monitor cost of services and programs, utilization results in aggregate and by subpopulation, and data supporting the tracking measures identified in specific initiatives. Data gathered to perform this analysis includes advanced data sets described previously, as well as annual medical/behavioral and pharmacy claims data, transportation claims data, health appraisal results, HEDIS data, and data specific to internal programs such as case management, pilot programs, and/or provider performance improvement activities. The PHM Steering Committee receives quarterly reports regarding PHM activities to review for potential areas of concern, opportunities for improvement, and to evaluate the impact of existing programs. This allows PHC’s leadership to review and update activities to meet the needs of the members, as well as identify necessary staffing, education, system, and infrastructure changes/requirements to support the delivery of these services. PHC’s Quality Improvement and Performance Improvement programs use HEDIS monthly and annual reporting and analysis to monitor impact of the programs and to select opportunities for future interventions. The PHM Work Plan tracks the progress of each intervention according to the measures identified at the beginning of the year.

Clinical Measures A leading indicator of overall population wellness is how many of the population engage in preventative care activities. Each year, PHC selects significant HEDIS measures for action and sets targets of what percentile of our membership will meet the standard. The PHM Work Plan and the QI Work Plan monitor progress toward reaching member engagement goals. .Utilization Measures PHC tracks member utilization through measures at both an aggregate level for the entire population, as well as for cohorts enrolled into a PHM program:

Hospital Admissions All-Cause Readmission Total Days Hospitalized Emergency Department Visits

While these measures reflect high-cost use of health care services, they also reflect undesirable clinical outcomes. Specific targets for each year are described in the PHM Work Plan.


Member Experience Member experience and satisfaction is measured through several means. Care Coordination performs member satisfaction surveys on closed Complex Case Management to ensure members are receiving quality care and benefiting from the program interventions. Care Coordination also surveys members who participate in the Transitions of Care program for their satisfaction with the services provided. Both member experience surveys gather feedback about:

Overall program information Program staff Usefulness of the information provided through the program Member’s ability to adhere to the recommendations Whether the program helped the member achieve health goals

The data are reviewed individually and on aggregate through quarterly reports. In addition, PHC hosts quarterly committees to encourage members to engage directly with PHC. One such committee is a Consumer Advisory Committee, made up of member representatives from each of the four regions in which PHC conducts business. This committee meets to review PHC’s programs and provide feedback on how PHC is meeting the needs of the community. A separate Family Advisory Committee is comprised of members whose children have special needs. The Family Advisory Committee also provides feedback and recommendations on member experience for this vulnerable population. The Pediatric Quality Committee consists of physicians and county public health physicians who care for PHC members; the committee provides insight into challenges members may have in getting the care they need from a provider perspective.

The Grievances and Appeals department gathers and analyzes trends in member-reported complaints to identify areas for program improvement for the coming year. PHC also has a process for identifying and intervening where there may be Potential Quality Issues (PQIs) related to a provider or provider organization. Finally, PHC participates in annual NCQA-approved Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys; one assesses factors under Health Plan influence, the other focuses on factors under the control of Primary Care sites.

Identifying Opportunities for Improvement No less than annually, the PHM Steering Committee evaluates the impact of the PHM programs to identify opportunities for improvement and select at least one improvement opportunity to address in the coming year.

Delivery-System Supports for Population Health ManagementPHC works intentionally and collaboratively with the provider community to support providers via PHM. The Quality Improvement department outlines strategies for the coming year on how providers will be made aware of population needs in an annual Quality Improvement Program Description (See Policy MPQD1001) and Work Plan, as well as the means by which addressing population needs will be supported.


Value-Based Payment Programs PHC has a number of value based payment programs through which contracted provider organizations can qualify for a financial bonus for quality-related performance. We have separate programs for primary care providers, hospitals, pharmacies, long-term care facilities, and palliative care providers.

Incentivizing Patient-Centered Medical Home (PCMH) Recognition Through our primary care provider value-based payment Quality Improvement Program (QIP), PHC incentivizes contracted primary care practices to achieve and maintain Patient-Centered Medical Home recognition. This program is designed as an annual incentive, intended to encourage and recognize those provider practices that achieve excellent levels of service, care integration and panel management, as recognized by established quality organizations.

Sharing Data PHC shares a variety of member-level data with our provider network in an effort to facilitate coordination of care and population health management. The two main systems for data sharing are eReports and PQD.

Supporting Provider Network

Population Health

Management

Aligned Incentives

(Value Based Payment

Programs)

Sharing DataTransformation

Technial Assistance


eReports: eReports is a web-based platform that supports measurement and reporting for the clinical measures in PHC’s Primary Care Provider Quality Improvement Program (PCP-QIP, PHC’s value based payment program for primary care providers). These are preventive and chronic disease measures derived from HEDIS; the exact measures and therefore data shared via eReports varies and is dependent on the Quality Improvement Committee approved measurement set for the program year. eReports allows providers to monitor their measure-specific performance relative to performance targets, drill down to their denominator and numerator lists by measure, and upload supplemental data (for hybrid HEDIS measures where PHC does not have the data administratively) for integration into their quality score calculation, based on weekly updates of data.

Partnership Quality Dashboard (PQD): Available since 2018, this secure, online platform makes available provider-site-level quality data across quality improvement programs to help inform, prioritize, and evaluate quality improvement efforts. Specifically, PQD functionality includes:

Measure-Specific Data

PQD tracks provider performance on all Primary Care Provider Quality Improvement Program and HEDIS measures relevant to targets.

Trended Data Providers can track their performance on the measures throughout the measurement periods (i.e. monthly rates) as well as from one measurement period to the next (i.e. trended annual rates).

Comparable Data PQD allows providers to compare their performance to blinded data of peer providers, including local averages and national benchmarks

Note: While some data on QIP Clinical measures are available on eReports, PQD as a visualization tool serves very different functions. PQD does not allow for any data entry. Instead, all Clinical rates are calculated in eReports, and PQD takes the output of eReports and presents the data longitudinally and comparatively. While eReports displays performance at a given point, PQD shows the trending of historical data. Also different from eReports that compares performance against thresholds, PQD has multiple means of comparison including averages at regional, sub-regional, and county levels.

Transformation Technical Assistance In addition to aligned incentives and data sharing, PHC supports quality improvement and care delivery transformation in our network via the Partnership Improvement Academy and its component offerings. These opportunities are designed to prepare providers to optimize population health, enhance their patients' experiences of care, promote provider and care team satisfaction, and foster a culture of continuous quality improvement. The Academy offerings include the ABCs of QI (QI basic methodology for the model for improvement) and improvement advisors working directly with provider sites to provide support, guidance, and tailored recommendations to support practice transformation and the development of subject matter expertise in quality improvement.


Population Health Department StructurePopulation Health operations are supported by a leadership team and administrative support. PHC’s Population Health department is intended to identify the wellness needs of Partnership’s members and align organizational and community efforts to meet these needs, in accordance with DHCS and NCQA requirements. The method for accomplishing these objectives is to leverage the Population Health departmental resources to engage both internal stakeholders, external stakeholders, and members to align existing projects and efforts toward a common objective. Population Health department staff are allocated to engage with the community to educate community partners on PHC care coordination services, to learn about resources available within the community, and to promote collaboration of effort/reduce duplication of services. In addition, the Population Health department is responsible to develop, maintain, and oversee implementation of PHC’s overall PHM strategy.

Team Roles and Responsibilities Senior Director of Health Services: At the senior level, provides overall direction to the Heath Services (HS) Care Coordination/Population Health/Utilization Management Leadership Team. This position has the ultimate responsibility to ensure that departmental programs and services are consistent and meet all regulatory requirements in every office location.

Director of Population HealthProvides oversight of Population Health strategy, programs and services to improve the health of PHC members. Works with the Chief Medical Officer, Senior Director of Health Services, and Associate/Regional Directors to meet organization and department goals and objectives while developing and tracking measurable outcomes of department services.

ManagerAssists the Director of Population Health in the development, implementation and evaluation of PHC’s population health interventions and oversight. The Manager has day-to-day direction and management responsibility for the implementation of the population health department; reviews and submits issues, updates, recommendations, and information to the HS Leadership when appropriate. Ensures ongoing audit readiness for Population Health deliverables.

SupervisorProvides supervisory oversight during daily department operations for assigned team members through sustained leadership and support. Using best expertise and sound judgment (and in consultation with clinical leaders, providers and staff), provides daily oversight, leadership, support, training and direction of population health staff. Supports and assists the Manager Supervisors in developing and maintaining a cohesive team with a high level of productivity and accuracy to achieve the department's overall performance metrics.

Healthy Living CoachEngages PHC members to identify barriers to care, member concerns, and resources needed. Leads member wellness courses and supports members using PHC’s Healthy Living Tools. Participates in health fairs, community advisory groups, and other activities where PHC members congregate and shares learning with other PHC departments who promote member engagement and wellness.


Education SpecialistIdentifies and participates in provider and member educational opportunities for internal departments, external agencies, training, and materials to support PHC providers, community partners, and members. Provides hands-on support to internal team as well as to PHC providers, community partners, and members.

Project Coordinator Oversees timelines and deliverables for department projects. Provides routine and ad hoc reporting for key Population Health activities and initiatives. Works closely with designated department staff and leadership to gather, compile, and distribute reports and facilitates structured file and record management. Supports ongoing audit readiness activities maintaining structure for audit deliverables, meeting minutes, and file retrieval system.

CoordinatorProvides coordination and administrative support to department manager. Performs a variety of general clerical duties, including data entry, report generation, and develops forms and presentations.

Administrative AssistantProvides direct administrative assistance and support to the department leadership. Manages calendar, organizes meetings, and prepares documentation and written correspondences. Interfaces with other PHC Department Administrative Assistants to organize meetings and activities, responds to requests, and maintains department policies and files.

Note: Staffing is subject to change based upon program need and organizational growth.

ReferencesNCQA. (2018). Population Health Management / Resource Guide. www.ncqa.org. Retrieved from

NCQA.org.

Snyder, A. M., Willey, C., McKenna, M., Foley, P., & Coleman, R. (2005). Development of a Risk Assessment Tool for Predicting Pediatric Health Services Utilization. Journal of Clinical Outcomes Management, 451-458.


Population Health Management Strategy & Program Description Approval

Robert Moore, MD, MPH, MBA 03/18/2020

Quality/Utilization Advisory Committee Chairperson Date Approved

Jeffrey Gaborko, MD 04/08/2020

Physician Advisory Committee Chairperson Date Approved

Nancy Starck 04/22/2020

Board of Commissioners Chairperson Date Approved