Asthma Initiative of Michigan Partnership Forum June 3, 2013 - PowerPoint PPT Presentation

Asthma Initiative of Michigan Partnership Forum June 3, 2013 Lansing Community College West Campus, Lansing, MI Tom Curtis, MPA Community Linkages Project Coordinator MI Department of Community Health 1

Innovation-Driven U.S. Health Care System Evolution (CMMI) Health System T Health Sys em Transf ansformation ormation and Ev and Evolution olution Critical P Critical Path th Community Integrated Health Care System 3.0 Coordinated Seamless Health Care System 2.0 Uncoordinated Health Community Care System 1.0 Integrated Efficient, Accountable Care Healthcare Episodic Non ‐ Integrated Care • Patien Patient, t, Popul Population on, and , and Comm Community-Centered ered o Commu mmunit ity H y Healt alth R Resource urce Linked nked o Cos Cost, Qual , Quality, and Popul and Populati tion on Hea Health Outcom th Outcome e • Patient/Person Centered Transparency nsparency • Transparent Cost and Quality Performance o Commu mmunit ity H y Healt althy L y Livi ving ng Choice oices o Results ‐ oriented • Episodic Health Care • Comm Community Hea Health In th Integr tegrated ed networ tworks ks abl able to to o Assures Access to Care o Sick care focus addr addres ess psych s psychosocial, economi , economic and LTC needs and LTC needs o Improves Patient Experience o Uncoordinated care • Righ Right ca care, at re, at ri right ght time, in ri time, in righ ght setti t setting ng • o High use of Emergency Care • Accountable provider networks designed Popul Populati tion on-b -based rei ed reimbu burs rsemen ement • Learning O arning Organization: ganization: Capable o Capable of rapid c pid cycle cle o Multiple clinical records around the patient, including LTC needs im improvements and provements and deploym ployment o nt of Best Pr st Prac actic tices s o Fragmentation of care • Shared Financial Risk • Commu mmunit ity H y Healt alth I Integra grated ed • Lack integrated care networks • HIT integrated o Commu mmunit ity H y Healt althy L y Livi ving ng Orient nted ed • Lack of integration between acute and o Commu mmunit ity H y Healt alth C Capaci pacity Builder ilder • Focus on care management and preventive o Comm mmunity b ity based support sed support developer veloper long ‐ term care settings care o Shared c ared commu mmunit ity y health r th responsibil onsibility o Primary Care Medical Homes • Lack quality and cost performance • o Care management/prevention focused E-health and E-hea th and tele-hea tele-health ca h capa pabl ble o Shared Decision ‐ Making and Patient transparency o Wide use de use o of remote mote m monitor nitoring ng and te and tele le- Self ‐ Management hea health th and E-hea and E-health th ma managemen ement • Poorly coordinated Chronic Care 2 o Health E- alth E-Learn arning ng resources, urces, social Management networ tworki king, hea , health th liter literacy tools tools

• Sick Care Focus • Uncoordinated transitions from setting to setting • Payments based on volume rather than value • Poorly suited to manage chronic conditions 3

Meet Nancy Jones Recent ER visit after an asthma episode • 64 years old Diagnoses Diagnoses • Asthma • Married • Overweight • Smoker • Primary caregiver for her husband who has dementia 4

Family Hospital Doctor Specialist Pharmacy Asthma Complicated health information; • No shared, electronic record; • No one tracking outcomes of care; • Don’t call? Don’t get care! • 5

• Person-centered care models • Quality improvement • Accountable for outcomes • Focus on chronic care management “to continually reduce the burden of illness, injury and disability, to improve the health and functioning of the people of the United States and to control costs.” Institute of Medicine 6 Crossing the Quality Chasm, 2001

Success = Improved Population Health, Improved Patient & Provider Experience of Care, and Reduced Cost 7

The Michigan Primary Care Transformation (MiPCT) Project 8

CMS Multi ‐ Payer Advanced Primary Care Practice Demonstration Project Michigan: 1 of 8 states participating in the CMS Demo Duration: 3 years - 2012 through 2014 Impetus: Escalating, unsustainable health care costs and mediocre performance on indicators of health Objective: Demonstrate whether the PCMH model of care improves health outcomes and contains costs 9

Participating Provider and Payer Partners as of April 1, 2013 Practices PO/PHO Physicians Payers 386 35 1700+ 5 Medicaid Managed Care, Medicare FFS, BCBSM, BCN, and Priority Health Serving around 1 million children and adults! 10

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Expectations of MiPCT PO’s/Practices • Population management – Electronic registry functionality by end of year 1 – Proactive patient outreach – Point ‐ of ‐ care alerts for services due • Access improvement – 24/7 access to clinician – 30% same ‐ day access – Extended hours • Coordination of Care through team ‐ based care – Embed care managers within practices to provide case management and self management support 13

Payment Reform R egular payment for healthcare services + Additional per member per month (pmpm) dollars Practice T Practice Transf ansformation ormation $1 $1.50 pm .50 pmpm pm Care Management Care Management $3.00 pmpm $3.00 pm pm Performance Incentiv ormance Incentives es $3.00 pm $3.00 pmpm pm __________ __________ $7 $7.50 pm .50 pmpm pm 13

Meet Nancy Jones Recently hospitalized after an asthma attack • 64 years old Diagnoses Diagnoses • Asthma • Married • Overweight • Smoker • Primary caregiver for her husband who has dementia 14

Hospital Specialist Nutritionist Pharmacy OUTCOMES OUT OMES Family Returned to • doctor / better level of Care functioning Manager Working on new • Asthma health goals Educator 15

Community Care System Evolution in MI MDCH DRAFT of a Community Care Sys MDCH DRAFT of a Community Care System Critical P em Critical Path Community Integrated Health Care System 3.0 Coor Coordi dinated Seamle d Seamless ss Community 2.0 2.0 Community Care Com Care Syst System Uncoordi Uncoor dinat nated Comm d Community unity Integrated Healthcare em 1. 1.0 Care Syst re System Organized, Accountable, Person ‐ Centered Confused Consumers; Community Services Inefficient Care • Pati tien ent, P t, Popu pulation lation & Co Commu mmunit nity-Cen entered tered o Co Commu mmunity Hea nity Health th Reso Resource L Linked nked Delivery • Community service agencies ** in formal o Cost, Qual Cost, Quality, ity, and and Popu pulation lation Health Health Outc Outcom ome Transp e Transparency ency network • o Co Commu mmunity Hea nity Healthy L thy Living Ch ving Choices ces Community agencies, each in own silo • Central HUB with IT connectivity to all o Each with care managers community service agencies including medical • Co Commu mmunity nity Hea Health I th Integrated n grated networks ks o Each producing client care plans practices capable o pable of addre ddressing ps ssing psychos hosoci cial al, , o Each producing client / family records econom economic and LTC and LTC needs needs • Referral of high ‐ risk clients to approp System • Fragmented care for individuals, families with multiple needs • Right c Right care, re, at r right t ght time, in me, in right set ght setting ng • Coordinated care for moderate /low risk clients • Uncoordinated cross ‐ agency care for via screening, referral to appropriate agency/ • Popul Populati tion-b on-based ed reim reimburse rsement ent individuals, families service or assignment to CHW • Learni Learning org organization: on: cap capable of e of rap rapid • Little or no cross ‐ agency communication or • Efficient, accountable care deplo deployment nt of of Best Best Prac Practices data sharing • Transparent cost / quality performance • Little or no agency communication with • Co Commu mmunity Hea nity Health th Integrated grated o Results ‐ oriented, accountable agencies medical care providers o Co Commu mmunity Hea nity Healthy L thy Living Or ving Orien iented ed o Assured access to care o Co Commu mmunity Hea nity Health th Ca Capaci pacity B ty Builder ilder • o Improved consumer experience No transparent quality/cost performance data o Co Commu mmunity ba nity based su sed support developer pport developer • Public reporting • Inefficient, redundant (i.e., wasteful) services o Sh Shared com community ty he health 16 respons responsibility ** Agencies with services related to social & • Ever ‐ shrinking public funding • E-heal health a th and t d tele le-heal -health c h capable pable other determinants of health

Health Determinants 17 University of Wisconsin Population Health Institute http://whatworksforhealth.wisc.edu/

• Competition for shrinking funds • Community resources in programmatic silos; fragmented impact & evaluation • Little experience collaborating with medical setting • Inefficiency and duplication 18

PCP Hospital Respite Transportation Care Pharmacy Specialist Utility & Rent 19 Assistance

• Community resources formally organized into coordinated networks • Responsibility is shared • Agencies connected by IT • Performance based on outcomes 20