Employee Health Plan

The Baptist Health Employee Health Plan (EHP) is BPP’s first value-based contract and continues to be administered by Florida Blue. Our quality ratings in this agreement have continuously satisfied contract requirements, earning us shared savings from 2019 through 2021. BPP leans heavily on the commercial care coordination team, comprising health coaches and a certified diabetes educator. In 2022, the team coached 72 plan members with diabetes and 88% saw an improvement in their A1c value. Although shared savings was achieved in 2021, the amount was significantly lower than in previous years due to 2020 being a benchmark year. In calendar year 2020, utilization was significantly lower than prior years due to the COVID-19 pandemic.

EHP Membership

BPP continues to partner with Aetna under a shared savings only, value-based agreement for their Aetna Whole Health product. It is a lower cost, narrow network, commercial alternative that Aetna offers to employee groups, both fully insured and self-funded. Although the Aetna Whole Health relationship has existed since 2018, enrollment in the product remains consistently low and BPP has yet to achieve shared savings. Achievement of quality targets remains challenging, mainly due to random variability of quality scores driven by low enrollment. However, BPP stabilized per member, per month medical costs.

To increase enrollment and obtain a statistically significant membership base, BPP agreed to allow Aetna to offer the product with an out-of-network option beginning in 2022. BPP and Aetna expect the out-of-network product benefit will attract more members to the product and Aetna/CVS is also offering Aetna Whole Health as a health plan benefit under their employee health plan. BPP anticipates that any increased enrollment due to this change will not be fully experienced until calendar year 2023, since the change occurred after the open enrollment window closed for 2022. BPP remains engaged with Aetna to support the broader Baptist/Aetna business relationship and to gain experience managing a younger, commercial population outside the Baptist Health Employee Health Plan.

Risk Score

.87% Current

.81%

-6.2% Medical Services

-1.4% Medical & Pharmacy Services

Commencing in January 2021 and continuing throughout calendar year 2022, BPP participated in a value-based, shared savings agreement with Florida Blue for their myBlue HMO line of products sold to residents of Clay, Duval, and Nassau counties via the health care exchange. MyBlue products are heavily subsidized commercial HMO health plans, sold to individuals and families on the health care exchange, sometimes referred to as Obamacare.

BPP entered into this value-based agreement to increase the quality of care and improve the total cost for members attributed to Baptist Primary Care physicians. Prior to the existence of this agreement, BPP physicians and community physicians participated in a provider network for myBlue that did not include a value-based component. The BPP value-based agreement did not alter the existing network agreements, and many are still in place today.

After two full contract years, BPP chose not to participate in the myBlue value-based agreement for a third year and terminated the agreement at the end of 2022. MyBlue provided a valuable opportunity for BPP to apply its population health initiatives to a non-Medicare, health care exchangebased population. However, the myBlue population required significantly greater resources to realize quality and total cost targets when compared to BPP’s Medicarebased beneficiaries. Additionally, monthto-month total medical costs were highly variable, which made it extremely difficult to determine which initiatives were successfully impacting shared savings. Despite these circumstances, BPP consistently met peerbased quality targets set by Florida Blue.

HealthPlace on Demand

Baptist Health launched HealthPlace on Demand in March 2020, an online, 24/7 virtual visit service powered by Telescope Health. In addition to offering this service to all Baptist Health patients, members of Baptist Health’s Employee Health Plan are eligible to use the service and qualify for a discounted copayment.

Baptist Health’s partnership with Telescope Health also allows the implementation of pilot programs to address specific needs across the health system. Telescope Health serves as a stop-gap for Original Medical beneficiaries who are discharged from Baptist Medical Center Beaches and included in the BPCI Advanced model; beneficiaries without an assigned Baptist Primary Care physician who experience barriers to follow-up care qualify for a virtual visit.

Virtual visits also benefit qualifying patients in the post-acute setting. Among BPP’s preferred network of home health care agencies and skilled nursing facilities, Telescope Health virtual visits are leveraged to help prevent patients from visiting the emergency department, ultimately preventing avoidable readmissions.

Patients can download the app at baptisthealthplace.com and have access to 24/7 virtual care.

Social Determinants of Health

Social Determinants of Health in Epic

Tobacco Use

Dec. 6, 2022: High Risk

Alcohol Use

Dec. 6, 2022: Heavy Drinker

Financial Resource Strain

Dec. 6, 2022: Low Risk

Housing Stability

Dec. 6, 2022: Unknown

Physical Activity

Dec. 6, 2022: Sufficiently Active

Transportation Needs

Dec. 6, 2022: No

Transportations Needs

Social Connections

Dec. 6, 2022: Moderately Isolated

Intimate Partner Violence

Dec. 6, 2022: Not At Risk

Depression

Nov. 29, 2022: At Risk

Stress

Dec. 6, 2022: Not At Risk

Food Insecurity

Dec. 6, 2022: Unknown

The BPP Social Services team expanded from three members in 2020 to 11 members in 2022 to support the increased number of patients with complex needs. The team offers services in multiple locations, including medical offices, patient’s homes, and facilities. Social workers complete comprehensive biopsychosocial assessments to identify factors impacting a person’s overall health and well-being. They also leverage a person-in-environment perspective, looking at the environmental contexts in which that person lives and acts, to uncover the dynamics affecting a person’s life.

Social Determinants of Health (SDoH) barriers contribute to a portion of our patient’s identified needs. Since transitioning to Epic, the Social Services team utilizes the SDoH Wheel to track these factors over time. This allows all care team members to easily view and provide a more holistic perspective when developing a care plan. The graphic in the left column is an example of how SDoH needs are represented in Epic.

In addition to collaborating with Baptist Health’s Social Responsibility team, the Social Services team utilizes FindHelp to identify and refer resources to patients. This tool is a closed-loop community-based organization (CBO) referral platform embedded in Epic. It identifies CBOs that provide services specific to a patient’s need. Referrals can be tracked and analyzed to determine specific needs for different areas in our community and highlight opportunities for partnerships.

The Social Services team continues to receive referrals for patients or caregivers needing assistance navigating the complex process of receiving long-term home and community-based services. To help meet this need, BPP has a strategic partnership with Aging True. Over the course of the past three years, this partnership has evolved to become an invaluable resource for patients and caregivers. Aging True provides in-home, nonskilled support services while patients wait for activation of long-term care services. BPP’s partnership with Aging True allows patients and families to age at home. This tailored program, along with other communitybased resources, is critical in supporting patients and caregivers through their health care journey.

Patient Experience

Ever since her husband of more than 50 years died a few years ago, Geraldine Jones has had trouble paying for her monthly prescriptions.

After a BPP nurse care coordinator referred the 81-year-old widow to Yessica Marshall, LCSW, a BPP social worker, Geraldine was connected to patient assistance programs that helped defer the cost of her brand-name medications.

But Geraldine’s problems didn’t stop there. She confided to her social worker that she was experiencing depression due to limited family support and had become fearful of leaving her home, following numerous fainting spells.

In addition, Geraldine had stopped preparing her own meals because she could no longer stand for extended periods of time and was fearful of falling in her bathroom and shower, as it was not equipped with any safety assistance devices.

Yessica immediately referred Geraldine to a local non-profit, Aging True, which has helped thousands of seniors in the Jacksonville community with the assistance they need to live independently.

Aging True completed a safety evaluation of Geraldine’s home. They added special grab bars and other modifications to her bathroom and provided an in-home aide twice a week. The aide accompanies Geraldine on short walks to encourage mobilization and increase her opportunities for socialization. Aging True also coordinated the delivery of hot meals through Meals on Wheels.

Geraldine also receives telehealth counseling services from Aging True to help her navigate changes in her mental health.

SNF at Home

The Skilled Nursing Facility (SNF) at Home model is a pilot initiative in partnership with River Garden Senior Services and Baptist Home Health Care by BAYADA. Both are members of Baptist Health’s postacute preferred provider network. This interdisciplinary, collaborative model of care aims to reduce the SNF length of stay by transitioning patients home with home health care services as soon as the patient is ready.

This model leans heavily on rehabilitative services and the patient’s level of function throughout the recovery process. Welldefined inclusion criteria helps foster positive outcomes by focusing on the patient’s prior history, safety protocols, and communication of expectations with the patient and primary care provider. The pilot went live in December 2021 and has cared for 20 patients through December 2022. This model’s readmission rate is 10% and fosters a halo effect for our Medicare value-based agreements.

Reasons to Heal at Home

• Decreased infections

• Decreased falls

• Decreased confusion

Nationally, Medicare-eligible lives are growing at a rate of 10,000/day. Over the next four years, forecasts predict an estimated 20% increase in our local senior demographic. Baptist Health’s Senior Strategy serves this population, supports providers caring for this generational shift, and maintains competitiveness in the health care marketplace.

As a clinical strategy, it is a coordinated system-spanning infrastructure to support senior wellness, maximize senior function, augment provider resources, and mitigate risk. Patients often share common physical, emotional, and psychosocial concerns that can be magnified by the loss of independence and the unknowns of chronic disease. These factors often lead to decisionmaking in times of medical crisis. The Senior Strategy builds upon multi-faceted resources including discussions of preparedness planning and goals to optimize care and more thoughtfully engage appropriate clinical transitions.

As a contract strategy, it stands at the intersection of our population health clinical strategy. Our goal is to maximize quality and reduce redundancy to lower health care costs and our mission to remain viable as a health care leader in the community.

Geripsychiatry

Integration with Baptist Behavioral Health

Rehabilitation

Standardized assessment models for cognitive testing, teaching, and function

Serious Illness Management and Advocacy (SIMA)

Chronic disease management model

Pharmacy

Support for complex medication management and harm reduction

Home-Based Models of Care

Enhanced home support models, SNF at Home, and HouseCalls

AgeWell

Clinic-based, longitudinal care for chronic, critically ill patients