Community Linkages in Michigan

1. Community Linkages in Michigan Carol Callaghan June 11, 2012

2. Origin of Community LinkagesEfforts in Michigan • Michigan is one of eight states implementing the Multi-payer Patient-Centered Medical Home (PCMH) Demo • 410 primary care practices participating, serving >1 million Michigan residents • Built on 5 years of powerful PCMH investment by Blue Cross Blue Shield of Michigan • BUT… minimal attention to the social determinants of health that may have greater impact on the individual’s health status than does medical care

3. Community Integrated Healthcare Community Integrated Healthcare • Patient, Population, and Community-Centered • Community Health Resource Linked • Cost, Quality, and Population Health Outcome Transparency • Community Healthy Living Choices • Community Health Integrated networks capable of addressing psychosocial, economic and LTC needs • Right care, at right time, in right setting • Population-based reimbursement • Learning Organization: Capable of rapid • deployment of Best Practices • Community Health Integrated • Community Healthy Living Oriented • Community Health Capacity Builder • Community based support developer • Shared community health responsibility • E-health and tele-health capable • Wide use of remote monitoring and tele-health and e-health management • Health E-Learning resources, social networking, health literacy tools • Patient, Population, and Community-Centered • Community Health Resource Linked • Cost, Quality, and Population Health Outcome Transparency • Community Healthy Living Choices • Community Health Integrated networks capable of addressing psychosocial, economic and LTC needs • Right care, at right time, in right setting • Population-based reimbursement • Learning Organization: Capable of rapid • deployment of Best Practices • Community Health Integrated • Community Healthy Living Oriented • Community Health Capacity Builder • Community based support developer • Shared community health responsibility • E-health and tele-health capable • Wide use of remote monitoring and tele-health and e-health management • Health E-Learning resources, social networking, health literacy tools Innovation Driven US Health Care System Evolution Anthony Rodgers, CMMI Health System Transformation and Evolution Critical Path Community Integrated Health Care System 3.0 Coordinated Seamless Health Care System 2.0 Uncoordinated Health Care System 1.0 Efficient & Accountable Care Episodic Non Integrated Care • Patient/Person Centered • Transparent Cost and Quality Performance • Results-oriented • Assures Access to Care • Improves Patient Experience • Accountable provider networks designed around the patient, including LTC needs • Shared Financial Risk • HIT integrated • Focus on care management and preventive care • Primary Care Medical Homes • Care management/ prevention focused • Shared Decision-Making and Patient Self-Management • Episodic Health Care • Sick care focus • Uncoordinated care • High use of Emergency Care • Multiple clinical records • Fragmentation of care • Lack integrated care networks • Lack of integration between acute and long-term care settings • Lack quality and cost performance • transparency • Poorly coordinated Chronic Care Management

4. Innovation Driven US Health Care System Evolution Health Care System AND Community Care System: PARALLEL Evolutions & Critical Path Coordinated Seamless HEALTH CARE System 2.0 Uncoordinated HEALTH CARE System 1.0 (Episodic Non Integrated Care) (Efficient & Accountable Care) Community Integrated Health Care System 3.0 Uncoordinated COMMUNITY CARE System 1.0 Coordinated Seamless COMMUNITY CARE System 2.0 (Confused Consumers; Inefficient Care Delivery) (Efficient, Accountable, Person-Centered Community Services)

5. Community Integrated Healthcare Community Care System Evolution in MI MDCH DRAFT of a Community Care System Critical Path Community Integrated Health Care System 3.0 Coordinated Seamless Community Care System 2.0 Uncoordinated Community Care System 1.0 Organized, Accountable, Person-Centered Community Services Confused Consumers; Inefficient Care Delivery • Patient, Population, and Community-Centered • Community Health Resource Linked • Cost, Quality, and Population Health Outcome Transparency • Community Healthy Living Choices • Community Health Integrated networks capable of addressing psychosocial, economic and LTC needs • Right care, at right time, in right setting • Population-based reimbursement • Learning organization: capable of rapid • deployment of Best Practices • Community Health Integrated • Community Healthy Living Oriented • Community Health Capacity Builder • Community based support developer • Shared community health responsibility • E-health and tele-health capable • Community service agencies ** in formal network • HUB with IT connectivity to all community service agencies and medical practices • Referral of high-risk clients to approp System • Coordinated care for moderate /low risk clients via screening, referral to appropriate agency/ service or assignment to CHW • Efficient, accountable care • Transparent cost / quality performance • Results-oriented, accountable agencies • Assured access to care • Improved consumer experience • Public reporting • ** Agencies with services related to social & other determinants of health • Community agencies, each in own silo • Each with care managers • Each producing client care plans • Each producing client / family records • Fragmented care for individuals, families with multiple needs • Uncoordinated cross-agency care for individuals, families • Little or no cross-agency communication or data sharing • Little or no agency communication with medical care providers • No transparent quality/cost performance data • Inefficient, redundant (i.e., costly) services • Ever-shrinking public funding

6. The Pathways/Community HUBModel in Mansfield, OH • Focused efforts on high-risk, hard to reach pregnant teenagers to reduce very high rate of low birth weight infants • Created evidence-based Pathways: homelessness, domestic violence, school drop-out, unhealthy eating, undependable transportation, no health provider, depression, unemployment • Trained and incentivized Community Health Workers (CHW) to locate those in need and help resolve the many challenges faced by these adolescents

7. Results • In three years, low birth weight rates in target areas dropped from 16 per year to 1 per year – and rate was sustained • Millions of dollars saved by avoiding NICUs, Children’s Special Healthcare Services, Special Education services • Other examples of success with Pathways/ Community Care Coordination (https://www.rockvilleinstitute.org/CPCCC/local-champions.asp)

8. 22+ Pathways Defined • Behavioral Health • Child Care • Chronic Disease • Dental • Depression • Domestic Violence • Education/GED • Employment • Food Security • Heat/Utilities • Homelessness Prevention • Housing • Income Support • Legal Services • Medical Debt • Pharmacy/Medications • Pregnancy • Medical Care • Social Isolation • Substance Use/Abuse • Transportation • Vision & Hearing

9. Strategies to address Social & Other Determinants of Health • Organize community service agencies into a formal resource network, including data sharing agreements • Promote use of evidence-based ‘Pathways’ • Assure a trained workforce (‘lay’ CHWs plus health professionals) for efficient, accountable community-based care • Establish central data system with interconnectivity to all agencies (including medical practices) • Encourage positive outcomes with innovative payment systems for CHW’s (e.g., incentives) and community recognition for agencies

10. Roles of the Community HUB • Outreach: Searches out those at risk • Screens or briefly assesses client • Do you have any questions or concerns you would like to tell me about? • Do you need help with transportation? (to health care? job? school?) • Do you have problems with housing? (if yes, foreclosure? homeless?) • Do you have problems getting food? clothing? paying utilities? • Are you looking for a job? (if yes, need help searching? help with resume? need training? felony record?) • Enters data into Interconnected Central Data System • Identifies Evidence-Based ‘Pathway’ for each need

11. HUB Roles (continued) • Refers high-risk to appropriate System (MH, SA, LTC, AAA, HV, SEd) • Sends ‘Pathway’ along with referral to agency • Refers Low/Moderate Risk: • To appropriate service or • To CHW to implement Pathway(s) with client until resolution (including 3 mos. follow-up contact for assurance) • Reports sent back to referring provider or agency • Monitors/Evaluates (by client, provider, agency, community) • Reports to community and to policymakers • Accomplishments, Gaps, Costs – and Costs Averted