Rural Health Transformation and the Heart of New Ulm - Minnesota ...

Rural Health Transformationand the Heart of New UlmSpeaker: Toby FreierFriday, July 12, 20133:30 – 4:30 p.m.

Toby FreierToby Freier is president of New Ulm Medical Center, part of Allina Health. He is married withthree young children. He is a fellow of the American College of Healthcare Executives and pastfellow of the Healthcare Financial Management Association. He holds a Master’s degree inbusiness administration. Toby has more than 10 years of rural health care executive experiencein Minnesota, Wisconsin, and North Dakota. Within his local community, Toby has contributedas a leader with Rotary International, Chamber of Commerce, Park and RecreationCommission, and his local church.

7/1/2013Transforming Rural HealthMinnesota Hospital AssociationTrustee Conference 2013Toby Freier, PresidentNew Ulm Medical CenterSession Objectives• Identify roles and opportunities for ruralproviders in the new era of health care andpopulation health• Recognize why rural communities can lead theway with achieving the Triple Aim• Review a nationally recognized communityhealth initiative and its strategies, successes,and challenges1

7/1/2013Google Map Satellite Feed from my Hometown in North Dakota2.5 million people2

7/1/2013New Ulm Medical Center• City – 13,500• Primary Service Area – 40,000• Critical Access Hospital• Allina Health• 550 Allina employees• 40 physicians• $70 million budgetMission /Vision/Success3

7/1/2013Rural HealthStrengthsChallenges•Tobacco, Alcohol, &Drug Use•Diet & Exercise•Unsafe Sex•Access to Care•Quality of Care•Coordination of Care•Affordability of CareHealthBehaviorsMedicalCare25%•Workplace Safety•Infectious Diseases•Air / Water Quality•Community SafetyPhysicalEnvironmentSocioeconomicStatus• Health InsuranceCoverage• Education• Employment / Income• Family & SocialSupports• Affordable Housing4

7/1/2013Triple Aim Strategy ApproachBetter Care &ExperienceBetter HealthOutcomesLower Costper CapitaHealthcareIntegrationElectronicHealthInformationCommunityHealthEngagementClinicalServiceLines &SystemIntegrationHard work ahead5

7/1/2013Value of Rural Health ProvidersPhysicians(Clinics)HospiceHome CareClinical Service LinesTertiaryCareHospitalDMEPharmacyClinical Service LinesSeniorCare/ALRuralProviderPhysician IntegrationNew Ulm HospitalNew Ulm Medical Center“One Team”New Ulm Clinic(Physicians Group ofNew Ulm)6

7/1/2013Clinical Access ModelRelationshipsNumber ofpeopleentrusting uswith theirhealthScope of servicesprovided to patientsProvider AccessUrgentcareLocalspecialistsER /HospitalistTeamClinicModelSeniorCarePrimaryCareRegionalclinicTertiarybasedSpecialtyCareOutreach(visiting)EmployerbasedOn-linecareTelehealthCommunitybasedHealthServices7

7/1/2013Creating Stability Key to our Access ModelA Need for Regional Collaborationto Neutralize “Scale” Disadvantage8

7/1/2013System Clinical Service Lines• Aim: Allina Health’s clinical service lines (CSL)provide consistently exceptional and coordinatedcare across the continuum of care and acrosssites of care.- Rural sites included and valued- Oncology, Neurology, Rehabilitation, Mother Baby,Mental Health, Cardiovascular, Integrative Medicine- Quality initiatives- Telehealth- Training & EducationDeveloping a Cancer Care Service Line for NUMCSPACEEXPANSIONVPCIINTEGRATIONPROVIDERSREGIONALIZATION•Co-location oftreatment andclinic•Doubling thesize ofchemotherapyarea•Patient / FamilySupportFunctions•Clinical trials•GeneticCounseling•Care Navigation•Development ofpathways,guidelines, andprotocols•Complimentaryand AncillaryIntegration•IncreaseDr. Piroso tofull-time•Integrate withMinnesotaOncology•Primary careinvolvement•Onboard newOncology Leader•CommunityEngagementacross theContinuum•ProviderNetworkingacross SWMinnesota9

7/1/2013Better Care & Experiences• Core Measures to 99%• Actual Preventable Re-admits’s 40% belowExpected• Diabetes Optimal Care to 45%• Depression Remission up to 28%• Breast Cancer Screening to 87%• Colon Cancer Screening to 75%• Clinic Patients Definitely Recommend – 91%• HCAHPS – 75%Market Share for Inpatient Services50%45%40%35%30%20102011201225%20%Allina Health10

7/1/2013Primary Care Relationships2500021% Increase20000150002010201120122013P10000RelationshipsHospital Cost per Admission$5,800$5,700$5,600$5,500$5,40012%Decrease201020112012$5,300$5,200Cost per Adjusted Admit11

7/1/2013Genuine Efforts to Reduce Cost of Care• Added a Social Worker in Emergency Department– Increased our direct expense by $35,000– 41% Reduction in ER Visits– 49% Reduction in Hospital Admissions– Reduced our revenue by $400,000– Improved patient quality of lifeEntering Total Cost of Care Era12

7/1/2013Healthcare Insurance ExchangeNarrow networkCompeting System / PPOACO Comparison toGeneral Contractor Status• Important for providers to the analyze healthservice gaps and minimize our system or networkrisk• $320 million of healthcare for our service area($8,000 per capita x 40,000 people)– $220 million of healthcare for NUMC attributed patients(68%)– $85 million goes to Allina Health, $135M to outsidecontractors13

7/1/2013Community Engagement• Relationships• Moving Upstream• New structures such as CommunityEngagement Council- Schools, Public Health, City, Seniors, Physicians• Educate, Define, EmpowerHow do we engage the community?14

7/1/2013The mortality rate from MIhas dropped considerablyover 40 yearsBut, MI incidence andhospitalization has notdropped during thattimeframeNational Hospital Discharge SurveyOBESITY TRENDS AMONG U.S. ADULTS16

7/1/2013Primary ObjectivesHONU is a demonstration project designed to apply evidence-informed healthimprovement practices, based on the COMMUNITY’s level of risk and preferences(not ours)Long-term is to reduce (age/sex-adjusted) attack rate of acute myocardialinfarctions over 10 years, among 56073 zip code residents age 30-79 years.Moderate-term is to improve the proportion of 56073 zip code residents (age30-79 years; active Allina health record) with controlled modifiable heartdisease risk factors over 5 years. *1. Elevated blood lipids (i.e., total/LDL/HDL cholesterol, triglycerides)2. High blood pressure3. Uncontrolled glucose (i.e., type 2 diabetes, pre-diabetes)4. Obesity5. Tobacco use6. Physical inactivity7. Low fruit/vegetable consumption8. Uncontrolled stress9. Medication (i.e., antithrombotics, antidyslipidemia, antihypertension)underutilization/non-adherence* Primarily informed by the adjusted population attributable risk estimates from the INTERHEART study; Yusuf, et al. Lancet 2004;364:937-52.33• Agricultural area of southcentralMinnesota• “The (statistically) mostGerman town in America”• The “3” “B’s”• 17,199 residents (13,594within New Ulm city limits)• Near perfect gender split• Average age is 40 andadults account for 75% ofthe population• 97% identify as White• 20% report obtaining aBachelors degree or highereducation• 60% of adults are married• Very stable year-over-yearpopulationFun facts about the 560733417

7/1/2013Innovative Features of HONU• Funded and managed primarily by the healthcare system– $9 million by Allina Health• Relatively long-term planned timeframe at 10+ years• Heavy emphasis on branding, promotion, and socialmarketing of intervention plan• Electronic Health Record is the primary population-levelsurveillance toolThe 2009 “Community Diagnosis”• Obesity is very problematic in New Ulm, along withassociated medical risks such as metabolic syndrome.• This is supported by observations of low fruit/vegetableconsumption and significant underutilization ofpreventive medical therapies (e.g., aspirin, statin, bloodpressure medications) among those at high risk.• Intervention efforts should focus on improving the foodenvironment (as it relates to obesity) and medicalmanagement of those at high cardiometabolic risk.3618

7/1/2013Project SectionsThe project includes community education,medical interventions and environmentalchanges, concurrent in the following spheresof influence:Healthcare CommunityWorksiteStratifying the 5607325% are at high or moderate risk* for a CHD event over 10 yearsLow-riskLow-moderate riskModerate riskHigh-risk• 0-4.9% risk•No disease• Few or no risks• 5-9.9% risk•No disease• Some risks• 10-19.9% risk• No disease• Several risks• ≥ 20% risk• Active disease• and/or many risks60% 15% 10% 15%Lifestyle managementEnvironment/policy interventionsAggressive medicalmanagementSome medical management of risk factors* Takes into account age, sex, tobacco use, total cholesterol, HDL cholesterol, systolic blood pressure, personalhistory of diabetes, personal history of CHD, family history of heart attack, and c-reactive protein19

7/1/2013Figure: Matrix of interventions by target audience and sphere of influence over the first 3 years of the HONU ProjectSphere ofInfluenceHealthcareTarget AudienceEnvironment/Policies Key Leaders IndividualsElectronic Health RecordProviders- Enhanced flow sheet and clinical decisionmaking aid (i.e., cardiometabolic riskassessment/treatment (dashboard)- Population dashboard to monitor populationhealth- Ability to use an identification tool forprogram eligibility- Project programs/data closely integrated withprimary care to improvecommunication/collaborationWorksite - Environment/policy assessment- Follow-up consulting (i.e., tobacco controlpolicies; physical activity infrastructure;healthier cafeteria and vending options)- Campaigns (e.g., stairwell prompts)- Incentive benefits design consulting options- Quarterly provider continuing medicaleducation seminars- Cardiometabolic risk managementfeedback reportsEmployers- Wellness committee planning- Employer newsletter- Ongoing employer group meetingsand annual employer summit- Access to online tool to plan employeewellness strategy and programs- Aggregate reports of employee hearthealth screening resultsPatients- Heart risk screenings pluscoronary artery calcium scoring- High (cardiometabolic) riskfollow-up program- Educationalmaterials/resourcesEmployees- Heart health screenings- Lunch-n-Learn presentations- Health behavior changeprograms (individual andgroup)- Educationalmaterials/resourcesCommunity Restaurants/Grocery & Convenience Stores- HONU membership programCity Ordinances- Advocacy for strengthened outdoor tobaccocontrol policies (in partnership with SHIPBoard)Neighborhood /Organization Leaders- Peer mentoring and sustainabilityefforts- GIS-based feedback on health risks- Neighborhood level plannedinterventionsResidents- Heart health screenings- Social marketing campaignspromoting health behaviors- Programs (e.g., cooking classes,walking clubs, physical activityprograms/events)- Tobacco cessation programs- Educational materials- Annual community summitHealthcareHeartBeat Connections ProgramHigh risk patients identified proactivelyfrom the medical recordIncludes welcome packet, educationalmaterials, and 1:1 telephonic coachingwith a health professional whichincludes medication therapymanagementFocuses on optimizing major risk factorssuch as high cholesterol, bloodpressure, nutrition, exercise, and stress20

7/1/2013Initial Outcomes: HBC program(HBC participants with 2 appointments completed by May 2011)Baseline Most Recentn Frequency % Frequency % p-valueAspirin Use* 174Daily 67 38.5 122 70.1 < 0.001Less than daily 107 61.5 52 29.9Cholesterol Medication Use** 150Prescribed 100% adherent 37 24.7 62 41.3 < 0.001Prescribed < 100% adherent 12 8.0 8 5.3Not Prescribed 101 67.3 80 53.3High Blood PressureMedication*** 64Prescribed 100% adherent 30 46.9 41 64.1 < 0.001Prescribed < 100% adherent 3 4.7 5 7.8Not Prescribed 31 48.4 18 28.1*excludes missing and people with a contraindication**excludes missing, people with a contraindication and those not dyslipidemic***excludes people who are not hypertensive and missingInitial Outcomes: HBC program(HBC participants with 2 appointments completed by May 2011)BaselineMost Recentn Frequency % Frequency % p-valueDaily fruit and vegetable 2055+ 49 24.3 119 59.2 < 0.001< 5 153 75.7 82 40.8Missing 3At least 150 mins moderateexercise /wkYes 49 24.3 71 35 < 0.001No 205 153 75.7 132 65Missing/DK 3 221

7/1/2013Initial Outcomes: HBC program(HBC participants with 2 appointments completed by May 2011)BaselineMost Recentn Frequency % Frequency % p-valueLDL 132< 100 23 17.7 42 32.6

7/1/2013Community ProgramsCommunity Health Challenge Programs and Events23

7/1/2013Community Interventions:Food Environment• Project works with local restaurants, groceryand convenience stores to develop morehealthy, affordable items:– NEMS assessment – baseline in all foodestablishments– Convenience Stores “Snack SWAP”Campaign– Work with restaurants to improve andpromote healthy options– Regular grocery store tours– Cooking show– Cooking classes24

7/1/2013WorkSites• Environment/Culture audits,e-newsletter• Quarterly employeechallenge programs• Annual Employer Summit &Hot Topics Breakfast SpeakersBureau• Employee Health ScreeningsEHR as a Primary Data SourceTransition from traditional community datasources….National Health and Nutrition Examination SurveyBehavioral Risk Factor Surveillance SystemCounty Health Tables….to the EHR as a the center of surveillanceHeart of New Ulm25

7/1/2013Add data tableHeart of New Ulm• Residents in New Ulm that use NUMC (6,200)– From 2006 to 2008 there was a weight gain of 6,099pounds (>1 pound per person)– From 2008 to 2012 there was a weight loss of 758pounds– 20% of the community has lost 10 pounds or moreover the past 4 years– Another 31% of the community has had 0 to 10 poundweight loss27

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7/1/2013Children's Health and theFun TheoryProject Successes• Health Screenings• EHR use and dashboard• Community engagement & goodwill• Public policy / key stakeholder interest• Implementation of programs in clinic,worksites, community• Patient activation• Decline in community rate of heart attacks• Behavioral and health outcomes areimproving29

7/1/2013Challenges Ahead• Funding and project governance• Payer collaboration• Maintaining project momentum and interestwithin the community• Replicating in other communities• EHR – integration of HONU programs and clinicaldecision support tools• Further engagement of primary care teams• Integration of new mobile technology• Engagement of at risk populationsTransforming Rural HealthBetter Care &ExperienceBetter HealthOutcomesLower Costper CapitaHealthcareIntegrationElectronicHealthInformationCommunityHealthEngagementClinicalServiceLines &SystemIntegration30

7/1/2013Thank you!Toby.freier@allina.comhttp://www.heartsbeatback.org31