Janet Stoeckl, RN, CCM, was recently appointed Interim Director of the Enhanced Patient Services Team, Millennium Population Health Services, reporting to Michele Mercer, Chief Clinical Integration Officer. These expanded duties are in addition to her ongoing role as Clinical Director, including serving as leader of Millennium’s COPD/Asthma initiative best practices and as liaison to the Physician Steering Committee. millenniumcc.org recently sat down with Janet to gain an update on the key initiatives she is involved with.
Q. What do you bring to your expanded duties?
Janet: As Director of the Enhanced Patient Services Team, I can leverage my skills set of building a solid infrastructure for the Enhanced Patient Services program using the guiding principles of National Committee for Quality Assurance (NCQA) Standards for case management.
My nursing career expands over 25 years including working in Hospital Neonatal Intensive Care Unit (NICU) and managed care, and serving as a Certified Case Manager for over 20 years. In addition, my experience with Patient Centered Medical Home (PCMH), clinical integration, project management and utilization management, as well collaborating with physicians, are good compliments to the clinical expertise of Dr. Kenyani Davis, Millennium Assistant Medical Director/Team Leader.
Graphic Courtesy Cerner
Q. What are the elements of Millennium’s Population Health Services Program?
Janet: Millennium’s Population Health Services program has three components: Enhanced Patient Services; Practice Transformation with Asthma and COPD; and Data and Analytics.
Enhanced Patient Services is focused on coordinating care across the continuum for patients. The Millennium Enhanced Patient Services team is an extension of the primary care practice and strives to achieve the following objectives:
- Address gaps in care.
- Assist with meeting quality and performance metrics.
- Help physicians to work with their patients in attaining disease state goals (e.g. A1c, BP).
- Improve medication adherence and patient education.
- Improve the medication reconciliation process within primary care practices.
- Decrease discrepancies found in patient medication lists.
- Identify and address gaps in care for Social Determinants of Health-related concerns.
- Strengthen partnerships with Community-Based Service providers.
- Help patients connect to needed community resources.
- Provide partners with the tools and support for their patients to become advocates for their own health.
Practice Transformation with Asthma and COPD is an approach to identifying a cohort of patients, in this case, disease specific (Asthma and COPD) and segmenting them into risk groups. The goal of this program – supported by Dr. Anthony J. Billittier, Millennium’s Chief Medical Officer — is to align effective intervention within the Primary Care offices that will activate the patient in their own health management and improve quality for the patient and reduce cost. By implementing evidence-based medicine into a practice — the national guidelines of patient care for asthma are The GINA Guidelines and GOLD Guidelines for COPD — we can promote consistency of treatment and optimal outcomes.
Millennium’s Data Warehouse & Analytics Services plays a major role in enabling and supporting both Enhanced Patient Services and the Asthma/COPD initiative by striving to achieve the following:
- Provide a Population Health Technology platform with statistical and qualitative analytics.
- Use predictive modeling and risk stratification that delivers actionable insights for care coordination services and disease management.
- Perform ongoing evaluation of VBP performance in areas of cost and quality.
- Identify registries of high risk/high cost patients for clinical intervention.
Q. Care Coordination is an expertise of yours; what is involved in this?
Janet: Care coordination involves knowingly organizing patient care activities and sharing information among all the clinical and non-clinical partners involved in the patient plan of care. (community- based organizations). This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care for the patient.
Millennium’s Population Health Services Team: (from left) Esra Mustafa, Population Health Services, Clinical Pharmacy Specialist; LaTonya Diggs, LMSW, Population Health Services, Manager of Social Work; Tera McIlwain, Population Health Services, Clinical Pharmacy Specialist; Dr. Kenyani Davis, Millennium Assistant Medical Director/Team Leader; Michele Mercer, Chief Clinical Integration Officer; Sandy McDougal, Population Health Services, Manager, Nurse Coach
Q. Why is Population Health a priority for Millennium?
Janet: There are several reasons why Population Health should matter to all of us.
To begin, at the heart of Population Health is the fact that it is people-focused. The more we can do to improve the health of our fellow humans, the more we lift all aspects of our community, including not having to spend as much money on therapeutic interventions. This assumes that the advances in public health are resulting from improvements in preventative care, diet and exercise.
A focus on Population Health also promotes better patient engagement. You can expect to see patients feeling empowered so that they can better manage their own health.
Q. Why is Millennium Population Health focused on Primary Care?
Janet: By bring Population Health strategies and programs to our Primary Care practices, we are:
• Preparing Primary Care practices for Value Based Care (From Fee for Service to Value Based Payment).
• Coaching Primary Care physicians to become “care team” leaders using evidence-based guidelines to manage cohorts utilizing data in risk relationships.
• Working to match clinical and social determinant of health resources to patient needs, thereby reducing inpatient and total spending, while maintaining or improving quality and patient experience.
Millennium’s investment in Data Analytics is bringing a 360 degree view of patient care to the WNY Region.
Q. How do Data Analytics support Millennium’s Population Health Efforts?
Janet: Data Analytics identifies the patients we should concentrate our efforts on in the Primary Care offices. The inclusion criteria are Medicaid patients; 18 years or older; who have had three or more Emergency Department visits or Inpatient Admissions; and have one or more of the following diagnosis: Diabetes, Hypertension, Asthma, COPD and/or Depression.
Q. How does Enhanced Patient Services tie in?
Janet: The Enhanced Patient Services (EPS) team is an extension of the Primary Care team and offers focused support to our high-risk Medicaid patients. We work closely with each of practice to identify and enroll the patient into the program and coordinate efforts on managing the patient needs. The Community-based program spans two to three months and include providing approximately eight visits working directly with the patients who engage with members of the EPS team including Clinical Pharmacist, Social Worker, Nurse Health Coach, and Community Health Worker.
Q. Why is Millennium also focusing on Asthma/COPD?
Janet: Asthma and COPD are one of the top drivers of Emergency Department and Inpatient utilization. Primary Care practices are collaborating with Millennium on implementing best practices for Asthma and COPD including:
• Evidence based guidelines GINA guideline for Asthma and GOLD for COPD.
• Offering validated assessment tools and education tools for patients.
Overall, implementing a COPD/Asthma program also begins to prepare a practice for Value Based Payment where the physicians serve as Care Team Leaders. At the same time, the practices are realizing results in the “Triple Aim” of improved patient satisfaction; a decrease in unnecessary Emergency Department utilization; and ultimately; knowing the practice is providing the right care at the right time at the right cost.
Q. What progress has been made to date?
Janet: The Millennium Population Health team has reached out to 12 Primary Care team sites to begin communicating the Population Health program objectives and goals, to gauge practice interest, and to begin assessing their strengths and opportunities.
To date, we are actively engaged with the following practices:
• Erie County Medical Center (ECMC)
Grider Family Practice
ECMC Family Practice
• Niagara Falls Memorial Medical Center (NFMMC)
Summit Family Health Center
Golisano Primary Care
• The Chautauqua Center
• Omega Family Medicine Olean/Salamanca
• Foothills Medical Group
• Neighborhood Health Center
• Community Health Center of Buffalo (Benwood)
• Kaleida Health
Buffalo General Primary Care
Hertel Elmwood Internal Medicine – North Buffalo Medical Park
Together, we are building a plan to go live with each practice site for Enhanced Patient Services, and or Best Practice for Asthma and COPD. Along the way, we’re working to improve the patient experience of care (including quality and satisfaction); improve the health of populations; reduce the per capita cost of health care (Potentially Preventable Emergency Admissions (PPA); Prevention Quality Indicators (PQI) for Adult Discharges; Potentially. Preventable Readmission (PPR); Potentially Preventable Emergency Visit (PPV); and improve physician satisfaction.