System Transformation and Care Coordination 2017 Care Coordination Forum Health Care Collaborative of Greater Columbus Vondie M. Woodbury President The Woodbury Group
Things To Consider This Morning and Going Forward.. Health Care is Undergoing Rapid Transformation Cost is Unsustainable Think: Auto Industry 1970’s and ‘80’s Redesign at Multiple Levels Hard wired data and value - ROI Will Human Services Be Next? Three-level Chess National – Policy Change and Payment State – Medicaid as a Laboratory Local – Delivery of Service You Are All In the Business of Health Care What is Your Next Step?
The Patient
Clarke’s Story Personal Situation
Medical Situation
History of Chronic Illness
Homeless
Entered through ED
No Income/No Job
Hospitalized – Including Intensive Care
No Primary Care Physician
Diagnosed with Ventricular Aneurism Stabilize for Surgery Discharged with Physician Orders including daily monitoring of medication – Coumadin Bill at Discharge: $25,000
Substance Use Disorder – long term Uninsured No Family or Other Support System Failed Mental Health Exam No Personal Identification/Paper Trail No Transportation No Ability to Manage Diet
Resource Alignment: Addressing Those With Greatest Need Complex Patients & Multiple Social Determinants Identify and use community assets to stabilize people Homeless High risk pregnancy Parolees Behavioral Health Including Substance Use Multiple Chronic Conditions Dual Eligible – poor and fragile Heavy use of ED Create and hard wire partnerships to coordinate care • Assist hospitals and primary care providers to stabilize patients Use of CHW’s and other nontraditional health workers
The Medical System
Healthcare Pivots to Prevention and Maintaining Health The Value of Upstream Work…AND Community Collaboration “Successful redesign of health care is a community by community task. That’s technically correct and it’s also morally correct, because in the end each local community – and only each local community – actually has the knowledge and the skills to define what is locally right.” --Don Berwick
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Commonwealth Fund Study: – Triple Aim, Value-Based Purchasing and Coverage Expansion Impact Change Triple Aim The goals of improved health, improved care quality, and lower per capita cost of care have become the organizing framework for the U.S. health care system, injecting patients’ social needs into the health care continuum
Move to Value-Based Purchasing Increased Coverage New public and private payment models are holding providers accountable for health care quality and costs; almost two-thirds of providers report they are signing valuebased contracts with commercial payers1
Slide used with permission of Deborah Bachrach Manatt, Phelps & Phillips, LLP Research Funded by: The Commonwealth Fund, the Pershing Square Foundation and the Skoll Foundation.
With Medicaid expansion for adults with incomes up to 133% FPL and the availability of subsidized coverage for individuals and families with incomes up to 400% FPL, more than 32 million individuals could gain coverage under the ACA—the vast majority of whom will have low and modest incomes and unmet social needs
J. Stone, “Survey Results: Percentage of Providers Taking on Risk Doubled Since 2011” (New York: The Advisory Board Company, June 5, 2013), http://www.advisory.com/Research/Health-Care-Advisory-Board/Blogs/Toward-Accountable-Payment/2013/05/Accountable-paymentsurvey 1
Health Care Transformation – Drivers of Change • Delivery Restructuring • Integrated Delivery • PCMH – Team Based Approach • Patient Engagement • Individual Health Assessment • Prevention – Keeping People Well • Personal Compliance is key • Data Driven • Risk Stratification • Measure for Quality/Clinical/Access and Cost Goals • Payment For Value Not Volume • Target (reduce) high frequency use • Improve Outcomes • Community Assets and Public Health Tools • Community Needs Assessment • Environmental and Socioeconomic Factors
Integrated Delivery Networks How will large integrated systems connect with community infrastructure? - Contract with care coordination companies? - Integrate internal resource structures? - Work with community providers? - Health Plans?
The Patient Centered Medical Home •
• • • • • •
Team Based Care – Not Physician Centered – Patient Centered • Physician • Nurse • Medical Assistant • Care Coordinator • CHW • Social Worker Access is Convenient • More online tools • Appointment and Focus is on Wellness & Prevention • Health Coach • Targets behaviors How Patient Experiences Care is Critical • Patient Assessment for SDH • Satisfaction with Service – ties to reimbursement Process Improvement is Continuous Care is Coordinated • Embedded Care Management • Coordination Across Clinical and Community Settings Data
Social Determinants Modern Healthcare – February 3, 2014 The “X”Factor in Disease Management “Healthcare systems in impoverished areas are turning toward tackling the social conditions that lead to ill health, but they may pay a financial penalty since payers still do not reimburse for those activities.” “A recent study in Health Affairs found the risk for hospital admission for hypoglycemia in lowincome patients with diabetes increased by 27% during the last week of the month when food budgets are strapped and food stamps run out – compared with the first week of the month.
Patient Screening Tool - Example In the last 12 months did you ever eat less than you felt you should because there wasn’t enough money for food? In the last 12 months, has your utility company shut off your service for not paying your bills? Are you worried that in the next 2 months you may not have stable housing? Do problems getting child care make it difficult for you to work or study? In the last 12 months have you needed to see a doctor, but could not because of cost? In the last 12 months, have you ever had to go without health care because you didn’t have a way to get there? Do you ever need help reading hospital materials? Are you afraid you might be hurt in your apartment building or house? If you checked yes to any of the boxes above, would you like to receive assistance with any of those needs? Are any of your needs urgent? (e.g. I don’t have food tonight; I don’t have a place to sleep tonight
Social Needs Screening Toolkit Health Leads Licensed under a Creative Commons Attribution-ShareAlike 4.0 International License
‌screening for social determinants can detect adverse exposures and conditions that typically require resources well beyond the scope of clinical care. Screening for any condition in isolation without the capacity to ensure referral and linkage to appropriate treatment is ineffective and arguably, unethical‌ Avoiding the Unintended Consequences of Screening for Social Determinants of Health http://jama.jamanetwork.com/ July 21, 2016
Payment Drivers… Enhanced Reimbursement
Shared Savings
Delivery models that incorporate interventions addressing patients’ social needs may be eligible for enhanced reimbursement, such as through: Payment incentives for Patient-Centered Medical Home (PCMH)-recognized providers, that are required to deploy care coordination and self-care supports with linkages to community social service agencies Health home provisions under the Affordable Care Act (ACA), which allow for reimbursement for social interventions targeted towards complex, chronically ill patients New Medicare payment codes for complex care management services that assess and address patients’ psychosocial needs Shared savings programs incentives providers to reduce spending on a defined patient populations. by sharing savings. Providers who are successful in shared savings programs address their patients’ social needs. Examples can be found in: Medicare Shared Savings Program and Pioneer ACO Program Medicaid ACO pilots
Capitated, Global, and Bundled Payments
New capitated payment models require providers and provider systems to take risk for managing covered services within a fixed budget, implicating patients’ social needs. Examples include: Medicare Bundled Payments for Care Improvement Initiative Oregon Coordinated Care Organizations Medicaid managed care organizations, including emerging programs for dual eligibles
Readmission Penalties
Social factors are linked to readmissions risk. Providers are now financially penalized for excess 30-day readmissions under the ACA’s Medicare Hospital Readmission and Reduction Program, incentivizing hospitals to address social needs as part of their efforts to reduce readmissions.
Tracking Data
Quality metrics are used to track whether Medicaid ACO’s Improve patient outcomes;
There is considerable variety but typically include: • Chronic condition management (asthma, diabetes) • Emergency Department use • In patient admission and readmission • Well-child visits • Patient experience • Behavioral Health States beginning to test “non-traditional” quality measures not developed or endorsed by national measurement authority: • Care integration • Care coordination • Social Determinants of health • Long term services and supports
Data Integration
Source: Muskegon Community Health Project – Used with Permission
Evidence on the Effectiveness of Social Interventions The current evidence base is growing Interventions can connect individuals to social support services
Interventions can ameliorate individuals’ unmet social needs Interventions can influence quality and care utilization measures and produce cost savings. Reduced hospitalizations, readmissions, and emergency room visits Increased billable hours by higher level pracitioners Improved health status Fewer missed school days and days of work While recognizing that building the evidence base on social interventions is a priority, many providers have already concluded that investing in these interventions will improve outcomes and reduce costs. They are not waiting for the final pieces of evidence before implementing these interventions.
Finding Community Alignment
“If the not-for-profit hospitals that dominate the healthcare system really want to become health stewards of the populations in their catchment areas—and not just “sick care” institutions—their community benefit priorities need to change.” Modern Healthcare - 2016
Source: Kevin Barnett, Public Health Institute
Intersection: Population Health and Community
• Can we see our CHNA – • What are we Investing In? • Community/Clinical Linkage for Referrals • Who can we refer our patient to? • How Do I get a Community Health Worker?
County Indicators: Building Out Social Determinants of Health
Hospital CB Programming/Investment – Chaotic Sponsored by Board
Sponsored by Board
Sponsored by Physicians
Activity
Activity
Sponsored by Physicians
Activity
Disorganized Chaos
Activity
Activity
Sponsored by
Administration
Activity
Activity
Sponsored By Community Benefit
Activity
Sponsored by Nursing
Sponsored By Mission
Poor Accountability Drives New Requirements Hold non-profit hospitals to a higher standard; Penalize those that don’t deliver; Failure to complete CHNA or CHIP face a potential $50k fine; Penalties can accumulate and might jeopardize tax exemption;
The Needs Assessment and Implementation Plan – 501(r) CONDUCT ASSESSMENT – GATHER AND ANALYZE DATA • Shared Process • In collaboration with others • Hospitals, state, local health departments, community* • Demographic data – qualitative and quantitative
INCLUDE INPUT FROM PERSONS • State, local, or regional governmental health department • Members medically underserved, low-income, minority populations • Written comments on previous assessment and implementation strategy *Joint assessment and implementation strategy permitted if same definition of community used by all participants and each hospital clearly identified.
Define and Validate Priorities Establish criteria to identify priorities - could include - Burden - Scope - Severity or urgency of the need - Estimated feasibility and effectiveness interventions - Health disparities associated with the need - Importance the community places on addressing the need Identify priorities with community input using methods such as ranking, discussion and debate Validate priorities - confirm with community and internal staff
Community Priority Needs – What Has Emerged? Health Care Access (5) Housing (5) Unemployment (4) Food Insecurity (3) Uninsured (3) Transportation (3) Mental Health (3) Care Coordination (3)
• • • • • • •
High Crime (2) Obesity (2) Low Birthweight Babies (2) Lead Poisoning (2) SU Prevention (2) Income/Poverty (2) Teen Pregnancy (1)
Hot SpottingTools: Geo-Mapping Community – Zip Code 83704
Mapped Records: 6,527
Total Records: 6,598
SOCIAL DETERMINANTS OF HEALTH: Individual Health Assessments ECONOMIC STABILITY
NEIGHBORHOOD AND PHYSICAL ENVIRONMENT
EDUCATION
FOOD
COMMUNITY AND SOCIAL CONTEXT
HEALTH CARE SYSTEM
Employment
Housing
Literacy
Hunger
Social Integration
Health Coverage
Income
Transportation
Language
Access to healthy options
Support Systems
Provider Availability
Expenses
Safety
Early Childhood Education
Obesity
Community Engagement
Provider linguistic and cultural competency
Debt
Parks
Vocational Training
SNAP Program
Discrimination
Quality of Care
Medical bills
Playgrounds
Higher Education
Behavioral Health
Appropriate Care
Support
Walkability
Trade School
Pharmaceutical $
Health Outcomes Mortality, Morbidity, Life Expectancy, Health Care Expenditures, Health Status, Functional Limitations Source: Kaiser Family Foundation
Rio Arriba Story – Align SUD Treatment What didn’t work for families – Silos – No Coordination • • • • • • • • •
No same day TB test or medical clearance Stand-alone detox located 90 minutes to 3 hours from nearby residential programs No automatic transition from detox to residential No transportation to services Providers unable to communicate with one another Nobody measuring overall outcomes Providers unable to communicate about shared clients Prescribers not checking PMP Database Narcan largely unavailable
• Integrated use of the HUB and spokes model + Pathways
Community Care Management • Identify the Social Determinants of Health • Patient Assessment • Identify Community Resources – Align with Needs • CHNA – Where are Resources? • Gap Analysis – Where do you need to build Capacity? • Create a Process for Coordinating linkage to Community Resources • Eliminating Silos to Allow for Coordination and Data Sharing • Assist patients with accessing resources • ACO or PCMH Staff? • Use of a HUB? • 211 Linkage • Document – DATA – success and feedback loops to referral source
Community Benefit Population Health Hub & Spoke Model Sample community and CB programs/services
FOOD FOOD
BEHAVIORAL BEHAVIORAL HEALTH HEALTH
TRANSPORTATION TRANSPORTATION
CONTINUING CONTINUING CARE CARE
INPATIENT INPATIENT ACUTE ACUTE CARE CARE
CB HUB
ACO ACO ED ED
EMPLOYED EMPLOYED & & INDEPENDENT INDEPENDENT PHYSICIANS PHYSICIANS PHARMACY PHARMACY ASSISTANCE ASSISTANCE
COMPLEX CARE MANAGEMENT
Community Community Referrals Referrals
ACCESS ACCESS TO TO CARE CARE
HOUSING HOUSING
COMMUNITY HEALTH WORKERS
HOMELESS SHELTER
OTHER CB PROGRAMS EXAMPLES
CB programs listed are examples only
Community Linkage – Design with HUB
Considering the First Target: Housing Example
What Next?
Believe You Can Do It: Self Imposed Barriers I don’t think this affects us. This is the way we’ve always done it. We tried something like that and it didn’t work. I don’t have the time. I’m not going to share my data I compete with them.
Be Strategic
The Challenge of Change… Capacity to Engage - Competition Willingness to move out of “comfort zone” Staying “In House” Anxiety about the impact of the ACA Enrollment – Uninsured #’s Increase? Minimum Benefit – SUD/Mental Health? Payment shifts – Back to Financial Assistance? Trust an External Partnership Payment Bigger is Better Getting Past our Differences
Challenges for Community Partners – Trust and Perceptions About Success… ..Once a social programs gets in a government’s budget, it becomes nearly immortal. I develops a constituency and then receives funding year after year, usually without any serious attempt to determine how effective the program is…
•Performance is poorly assessed – no data •Measurement tracks quantity of services not impact •Services are fragmented – silos– limits ability to address complex social problems
Questions To Consider What Providers Require: (1) Quickly Stabilize a Patient to Improve Health Outcomes (2) A Closed Loop (Data) What Happened to this patient? Your Value Statement. Why Should Health Systems Support You? The Local Partnership Question: Who is Interested Now? Are Hospitals Open to Your Partnership? The Elephant Question – Where Do You Start? The Design Question – What is it Going to Look Like? HUB and spokes? Decentralized?
What: Considering Risk/Cost and Opportunity
•Navigation •Housing •Behavioral Health •High Risk Births
Human Resources: Community Health Workers Are indigenous to the community in which they work. Assist clients with navigating a complex healthcare system and accompany clients through treatment, monitoring social service needs, and helping them overcome obstacles to their own health and ability to follow treatment from the medical community. Advocate for vulnerable individuals and communities
How? Organize: Five Conditions of Collective Impact Common Agenda Shared Measurement Mutually Reinforcing Activities Continuous Communication
Backbone Support
• All participants have a shared vision for change including a common understanding of the problem and a joint approach to solving it through agreed upon activities.
• Collecting data and measuring results consistently across all participants ensures efforts remain aligned and participants hold each other accountable.
• Participant activities must be differentiated while still being coordinated through a mutually reinforcing plan of action.
• Consistent and open communication is needed across the many players to build trust, assure mutual objectives and create common motivation.
• Creating and managing collective impact requires a separate organization (s) with staff and a specific set of skills to serve as the backbone for the entire initiative and coordinate participating organizations and agencies.
What is Your Shared Vision? It’s like a Mission or an “Audacious” goal… Emergency Room Utilization Demands a common/shared understanding by partners; Partners willing to give up personal or organizational agenda for the common good; Based on Cross Sector Collaboration: Stakeholder disagreement is common Consider the use of an external facilitator to help guide the process Alignment around a common goal is intended to also align resources; Funding requests evolve to show continuity – reducing fragmentation in the community; A common agenda requires an understanding of root cause;
Sample Housing HUB
CI Shared Vision – A Balanced Portfolio of Interventions – Linking Silos Example: ED Data Indicates Recurring Asthma Episodes
TREATMENT Acute Care Hospital Emergency Room
TREATMENT Primary Care PCMH/FQHC
INTERVENTION Clinical-Community CHW Navigators
PREVENTION Community and Consumer Education
INTERVENTION Human Services SOCIAL DETERMINANTS
ENVIRONMENTAL Smoke-free Zones Air Quality
POLICY & SYSTEM CHANGE Housing Codes Tobacco Tax
Mutually Reinforcing Activities Under CI •The Core Strength of the Model – Everyone has some “skin in the game”; •Diverse Stakeholders from many sectors work together to solve a common problem; •Stakeholders do not do the same thing but focus on individual activities at which they excel; This work is about different stages of a singular continuum Root causes of social problems and their solutions are
Shared Measurement •Success is measured through the use of common metrics; Mining data – Your CHNA; Use of a dashboard •Use of data by each of the partners is one way that the Collective Impact model holds the partners accountable for their part in the continuum of activity; Partners understand the importance and power of shared data Decisions are made based on this data Partner responsibility is tracked •Transparency of data also allows for the ability to spot patterns, identify solutions and respond rapidly to environmental change; Camden Coalition – targeting utilization & cost Jesse Tree Program – Galveston Texas – targeting food insecurity & access
Vondie M. Woodbury vondiew@gmail.com 231-571-3889 Join me on LinkedIN