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The Health Commons Project

The Health Commons Project. OHA Transformation Center Complex Care Collaborative November 5, 2013 Eugene, Oregon.

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The Health Commons Project

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  1. The Health Commons Project OHA Transformation Center Complex Care Collaborative November 5, 2013 Eugene, Oregon

  2. The Health Commons Grant, an award of $17.3 million over three years from the CMS Innovation Center, is a springboard for Health Share of Oregon to create a regional system to better serve the Medicaid population in the Portland metro area. 3-Year Funding Amount $17,337,093 Estimated 3-Year Savings: $32,542,913 3-Year Population Impact: 19,000 patients At the end of the Grant, all initiatives should be financially sustainable The project is one of 107 nationally in the first round of funding, one of the largest single-state projects Overview

  3. November 2011… “We can do this!” • RFP occurs during early formation of Tri County CCO • Multi system collaborative application for CMS “Innovations Challenge Grant” (Nov-Dec 2011) • Alignment with Tri County Assets and Challenge • History of multi party collaboration • Projects must take cost out of system rapidly • Existing projects that can be taken to scale • Focus on “high utilizer” / complex patients as first step in building CCO system of care?

  4. Defining The “High Utilizer” Target Population 9248 high cost members/12 mos

  5. Clinic View of Target PopulationMultiple High Volume Complex Patient Clinics Multnomah County Health Department-NE Clinic Population 10% mbrs = 51% Total Paid Cost/12 mos

  6. Health Commons GrantInterventions LEVEL ONE STRATEGIES produce small per patient per month savings across a large number of patients. ED GUIDES: Non-clinical staff assist patients to a primary care home and make referrals to other programs. STANDARD HOSPITAL TRANSITIONS TO PRIMARY CARE: All metro-area hospitals will use the same discharge summary template; primary care home will develop standard processes for receiving and responding to discharged patients

  7. Health Commons Grant Interventions LEVEL TWO STRATEGIES produce large per patient per month savings across a smaller number of patients. COMMUNITY OUTREACH WORKERS provide high-touch support to high acuity patients within the community, addressing their social determinants of health and encouraging wellness. TRANSITIONAL CARE NURSES AND PHARMACISTS provide intensive discharge planning and home visiting support post-discharge; facilitate effective connection to primary care home. LICENSED BEHAVIORAL HEALTH SPECIALISTS provide intensive transitional support to patients admitted to the hospital psychiatrically; facilitate effective connection to behavioral health home.

  8. Partner organizations for interventions Interventions were based on existing work by Health Share providers, ready for scale up, with the opportunity for spread across all partner organizations.

  9. Evaluation StrategiesCenter for Outcomes Research and Education (CORE)

  10. Information Systems are Critical! • Community-wide Care Coordination Registry • Managing & Tracking Intervention Cohorts • Event Notifications to relevant care teams • One ‘stop’ source for key evaluation data + Standardized Hospital Discharge Summary – Hospital EHRs

  11. Create listsof individuals (registry cohorts) engaged in a SPECIFIC intervention What can users do? • Track individuals through steps/phases of a SPECIFIC intervention • Collect dataon encounters, assessments, checklists and other intervention-specific activities or ‘touches’ • View member-level health services profile, past 12 mos • Seewhat other intervention teams are or have worked w/ patient • Receive daily notifications of ED and Inpt events for clients • Track mileage and/or patient support funds disbursement • View dashboardsdisplaying progress on key processes/outcomes

  12. Year 1 Roll Out • Grant Oversight (GO) Team formed to monitor and guide work • Grant Metrics Dashboard, Evaluation Plan, Operational Plans for each initiative • Intervention Clinical Leads, Steering Cttes, Project Managers in place • Staff for all 5 interventions hired, trained and fully functional in roles • “Intersections” Group formed to coordinate and synchronize efforts • Project Management Office (PMO) established • Lean Training to support increased efficiency, effectiveness • Learning Collaborative meetings held: All Staff Kickoff; Leadership Outcomes Improvement Collaborative • Communications Strategy with monthly updates, website, Board and stakeholder communications

  13. Year 1: Individuals Served To Date

  14. Year 1: Launch x 5 Hiring / Training / Deploying65 FTE

  15. Year 1 Challenges • How do you engage providers / leaders: in clinics, in hospitals, in EDs, etc? • Intensive work with hospital and clinic leaders • What is the right workforce to address patient/ client needs? • Rnvs Social Worker vs “outreach worker” • Who are the patients / clients? What do they really, really need? • And which are the ones we can really, really help? Archetypes? • What is a reasonable case load for each type of intervention? • What kind of supervision is needed? • What case load is needed for financial sustainability? • How do we coordinate with and learn from each other? • Who needs to meet with whom about what? • How does this fit into other organizational care management work? • How do we create a rapid learning system?

  16. Key Year 1 Learning: Understanding the people we trying to help… “62 year old with multiple hospital admissions” Moving from: “What is wrong with him…” To: “What has happened to him…”

  17. William’s “Problem List” History of Addiction to IV Drugs and Alcohol Chronic Heart Failure COPD Developmental Disorder Schizoaffective Disorder Hepatitis C Admitted to the hospital for almost a month for acute complications of his Chronic Heart Failure. Had a previous 25 day admission 5 months earlier. Intermittent Homelessness Type 2 Diabetes 62 Year Old Caucasian Man

  18. As Often Viewed By Others / Providers… Problems with pain / pan tolerance Irritable Hostile Chronic poor self care Cannot give clear health history Intermittent job history Extremely needy / demanding Stoic, reluctant to admit health problems Chronic relationship problems

  19. What really drives health decline and high-cost utilization in our population? We got to know William, and others like him, we have found: • Poor health literacy • Prevalence of SA and mental health conditions but lack of access to services • Mild to moderate cognitive deficits • Homelessness and food insecurity; chaotic lives burdened with cumbersome eligibility requirements for social programs • Inability to access basic resources such transportation, healthy food, medications, place to exercise, etc • Extensive care coordination needs, particularly between sites of care • Very high prevalence of adverse life events, trauma, and toxic stress: childhood trauma, school failure, job instability, relationship failure, self medication with substance use, high risk behaviors, poor decision making skills…

  20. Impact of Trauma on World View: Chronically Scared Individuals • “Emotional brain” on alert, hyper vigilant • Focus: short-term survival, not long-term strategy • “The world is an unsafe place to live in” • “Thinking brain” less available, poor concentration • Learning difficult; complexity gives way to simplicity • “My own thoughts and feelings are unsafe” • Chronic stress result: “Threat” oriented world view • See threats where none exist • Feel slights where none were intended • React passively or aggressively in order to assess the “threat” • “Other people are unsafe and cannot be trusted” • Do not work as efficiently or effectively • Too busy “staying alive” • Circle the wagons and shoot inward • “I expect crisis, danger and loss”

  21. Obvious conclusion • “Usual medical care” – even really really good usual medical care – will not be enough for the high acuity population. • New forms of “Trauma Informed” care management / case management are needed • Access to mental health and addictions resources is critical • Socially determined risks cannot be ignored or assumed outside of “health care” • New (and less costly) approaches will be required for success

  22. “Health Resilience Program” • Building a Trauma Informed Care System for high needs Medicaid members • Key elements: Safety, Empowerment, Trust, Collaboration, Choice • Comprehends the impact of violence • Provides service in ways that do not re traumatize • Will launch 50 new direct service FTE over 3 years in all high acuity touch points

  23. Health Resilience Specialists are paired with primary health homes and specialty practices to enhance the practices’ ability to provide individualized ‘high touch’ support to patients with exceptional utilization * Staff with engagement skills, compassion, non-judgmental attitude, outreach experience * “Trauma Informed Care” approach * Outreach worker incorporated into the practice team * Clinical Supervision by mental health trained managers; regular huddles; rounds * Transparency: ask permission * Trust :be non judgmental, create safety * Time: slow things down, help process * Tailoring to client: be open, listen

  24. Outreach Worker Interventions • Motivational Interviewing to resolve ambivalence about health-related behavior change • Client advocacy within and among multiple systems • Role modeling advocacy and relational skills • Assistance in navigating health care system • Care coordination • Health literacy education • Self management skill development • Assistance with complex problem solving related to living in poverty with multiple health issues • Providing opportunities to identify as something other than a “patient” • Providing opportunities to experience success and feel confident • Deep listening, acknowledgment and respect for each individual

  25. ICCT Programs • Health Resilience Program: 14 Health Resilience Specialists (HRS) in primary care clinics; 1 in Pulmonary Clinic; 1 in Liver Clinic • Central City Concern Health Improvement Project (CHIP): 5 staff including a Recovery Specialist, RN, Mental Health Specialist • New Directions: 3 social workers in OHSU ED for frequent ED users with Mental Health dx • Tri County 911 Program: 4 social workers for frequent 911 callers, ambulance users.

  26. Health Resilience Program Preliminary Findings Please DO NOT circulate without Permission

  27. Health Resilience Program 222 Clients Engaged AT LEAST 1x on or Before June 30th, 2013

  28. Health Resilience Program 222 Clients Engaged AT LEAST 1x on or Before June 30th, 2013

  29. Year 2: Going to Scale • How do we move from a “portfolio of projects” to a new regional system for high needs members? • How do “Standard Transitions” and “Transitional Care Teams” become a system of seamless transitions between acute and outpatient care? • Spreading to more hospitals, engaging more PCP clinics, then specialty, SNFs; care plans that follow patients from outpatient to ED, to hospital … and back • How do we coordinate all of these efforts at the center of care: PCPH?

  30. Year 2: “Advanced Primary Care” • 2014: APC Collaborative for PCPCH clinics managing large numbers of high needs patients: • Clinic multi professional teams accountable for the overseeing management of defined “high needs” panel segment • Dedicated time and resources • Team formed to meeting needs of patients • Defined outcomes and goals for program and enrollees • Structured relationships with mental health, addictions, key specialty • Development of new payment models • Development of clinic specific models based on resources and needs; collaborative learning • Supported by Transformation Fund, Health Commons Grant, Health Plans

  31. Year 2: Course Corrections Toward Sustainability • Who benefits financially from each intervention and would be a potential funder? • Standard Transitions, C Train, ITT: hospitals and health plans wanting to decrease readmissions • ICCT / HRS: Those at full risk (Health Plans, CCOs, Full risk provider groups) • “Course correction” mini summits for each intervention with potential “funders:” • What would you do if this were “your” program • What results do you need to see to continue this program for our members in your organization? • If a project is not going to be sustainable, shouldn’t we redeploy the resources to meet CCO and CMMI goals?

  32. “Double Loop” Learning Systems Process Improvement Are we doing it right? New Standards Are we doing the right thing? Meeting Stakeholder Goals? REALIGN/ REDEPLOY Unintended Consequences… Better Ideas From Other Initiatives!!! Drift Correction!

  33. Year 2: State Complex Care Collaborative There are mountains beyond mountains... What can we share along the way?

  34. Thank You! david@healthshareoregon.org www.healthshareoregon.org www.healthcommonsgrant.org

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