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

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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

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• Patien

Patient, t, Popul Population

• n, and

, and Comm Community-Centered ered

• Commu

mmunit ity H y Healt alth R Resource urce Linked nked

• Cos

Cost, Qual , Quality, and Popul and Populati tion

• n Hea

Health Outcom th Outcome e Transparency nsparency

• Commu

mmunit ity H y Healt althy L y Livi ving ng Choice

• ices
• Comm

Community Hea Health In th Integr tegrated ed networ tworks ks abl able to to addr addres ess psych s psychosocial, economi , economic and LTC needs and LTC needs

• Righ

Right ca care, at re, at ri right ght time, in ri time, in righ ght setti t setting ng

• Popul

Populati tion

• n-b
• based rei

ed reimbu burs rsemen ement

• Learning O

arning Organization: ganization: Capable o Capable of rapid c pid cycle cle im improvements and provements and deploym ployment o nt of Best Pr st Prac actic tices s

• Commu

mmunit ity H y Healt alth I Integra grated ed

• Commu

mmunit ity H y Healt althy L y Livi ving ng Orient nted ed

• Commu

mmunit ity H y Healt alth C Capaci pacity Builder ilder

• Comm

mmunity b ity based support sed support developer veloper

• Shared c

ared commu mmunit ity y health r th responsibil

• nsibility
• E-hea

E-health and th and tele-hea tele-health ca h capa pabl ble

• Wide use

de use o

• f remote

mote m monitor nitoring ng and te and tele le- hea health th and E-hea and E-health th ma managemen ement

• Health E-

alth E-Learn arning ng resources, urces, social networ tworki king, hea , health th liter literacy tools tools

Efficient, Accountable Care Coordinated Seamless Health Care System 2.0

• 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

Uncoordinated Health Care System 1.0

Innovation-Driven U.S. Health Care System Evolution (CMMI)

Community Integrated Health Care System 3.0 Episodic Non‐Integrated Care

Health Sys Health System T em Transf ansformation

• rmation and Ev

and Evolution

• lution Critical P

Critical Path th

Community Integrated Healthcare

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

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Meet Nancy Jones

Recent ER visit after an asthma episode

• 64 years old
• Married
• Primary caregiver

for her husband who has dementia Diagnoses Diagnoses

• Asthma
• Overweight
• Smoker

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Hospital Family Doctor Specialist Asthma Pharmacy

• Complicated health information;
• No shared, electronic record;
• No one tracking outcomes of care;
• Don’t call? Don’t get care!

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• 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 Crossing the Quality Chasm, 2001

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

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The Michigan Primary Care Transformation (MiPCT) Project

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CMS Multi‐Payer Advanced Primary Care Practice Demonstration Project

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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

• f care improves health outcomes and

contains costs

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Participating Provider and Payer Partners as of April 1, 2013

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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!

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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

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Payment Reform Regular payment for healthcare services

+

Additional per member per month (pmpm) dollars

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Practice T Practice Transf ansformation

• rmation

Care Management Care Management Performance Incentiv

• rmance Incentives

es $1 $1.50 pm .50 pmpm pm $3.00 pm $3.00 pmpm pm $3.00 pm $3.00 pmpm pm __________ __________ $7 $7.50 pm .50 pmpm pm

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Meet Nancy Jones

Recently hospitalized after an asthma attack

• 64 years old
• Married
• Primary caregiver

for her husband who has dementia Diagnoses Diagnoses

• Asthma
• Overweight
• Smoker

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Hospital Family doctor / Care Manager Specialist Pharmacy

Nutritionist

Asthma Educator

• Returned to

better level of functioning

• Working on new

health goals

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OUT OUTCOMES OMES

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• Community service agencies ** in formal

network

• Central HUB with IT connectivity to all

community service agencies including 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 &

• ther 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., wasteful) services
• Ever‐shrinking public funding

Coor Coordi dinated Seamle d Seamless ss Com Community Care Care Syst System 2.0

2.0

Community Integrated Healthcare Uncoor Uncoordi dinat nated Comm d Community unity Care Syst re System em 1.

1.0

Community Care System Evolution in MI

Community Integrated Health Care System 3.0 Confused Consumers; Inefficient Care Delivery

MDCH MDCH DRAFT of a Community Care Sys DRAFT of a Community Care System Critical P em Critical Path

• Pati

tien ent, P t, Popu pulation lation & Co Commu mmunit nity-Cen entered tered

• Co

Commu mmunity Hea nity Health th Reso Resource L Linked nked

• Cost, Qual

Cost, Quality, ity, and and Popu pulation lation Health Health Outc Outcom

• me Transp

e Transparency ency

• Co

Commu mmunity Hea nity Healthy L thy Living Ch ving Choices ces

• Co

Commu mmunity nity Hea Health I th Integrated n grated networks ks capable o pable of addre ddressing ps ssing psychos hosoci cial al, , econom economic and LTC and LTC needs needs

• Right c

Right care, re, at r right t ght time, in me, in right set ght setting ng

• Popul

Populati tion-b

• n-based

ed reim reimburse rsement ent

• Learni

Learning org

• rganization:
• n: cap

capable of e of rap rapid deplo deployment nt of

• f Best

Best Prac Practices

• Co

Commu mmunity Hea nity Health th Integrated grated

• Co

Commu mmunity Hea nity Healthy L thy Living Or ving Orien iented ed

• Co

Commu mmunity Hea nity Health th Ca Capaci pacity B ty Builder ilder

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Commu mmunity ba nity based su sed support developer pport developer

• Sh

Shared com community ty he health respons responsibility

• E-heal

health a th and t d tele le-heal

• health c

h capable pable

Organized, Accountable, Person‐Centered Community Services

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Health Determinants

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

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• Competition for shrinking funds
• Community resources in programmatic silos;

fragmented impact & evaluation

• Little experience collaborating with medical setting
• Inefficiency and duplication

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Hospital PCP Specialist Pharmacy

Transportation

Respite Care

Utility & Rent Assistance

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• Community resources formally organized into

coordinated networks

• Responsibility is shared
• Agencies connected by IT
• Performance based on outcomes

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Purpose f Purpose for T r Transf ansforming t

• rming to Community Care Syst

Community Care System 2.0: em 2.0:

• To ensure that at-risk individuals are served in a timely, coordinated manner;
• To ensure that a person and populations are connected to meaningful health

and social services that produce positive outcomes;

• To avoid duplication and keep individuals from falling through the cracks

Community Health Access Project (CHAP) Connecting Those at Risk to Care, 2010

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Michigan P Michigan Pathw thways t ys to Be Bett tter Health (MPBH) er Health (MPBH) Demonstration Pr Demonstration Project

• ject

Piloting the Pathways Community HUB Model

Project Co‐Directors: Elaine Beane, MPHI Carol Callaghan, MDCH

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CMS Health Care Innovation Award (HCIA)

Michigan Pathways to Better Health (MPBH) Demonstration Project

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Award: MPHI, 3-year cooperative agreement Duration: July 2012 through June 2015; Hubs were functional and serving clients by end of January, 2013 Impetus: If left unaddressed, social determinants of health will prevent people from getting and staying healthy Objective: Demonstrate whether the Pathways Community HUB model improves outcomes and reduces costs

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Michigan P Michigan Pathw thways t ys to Be Bett tter Health er Health (MPBH) Demonstration Pr (MPBH) Demonstration Project

• ject
• Pilot the Pathways Community HUB model in 3

counties: Ingham, Muskegon, and Saginaw

• Target population
• Adults
• Medicaid or Medicare insurance
• 2+ chronic diseases
• Interventions
• Develop a Community Hub with an IT system for

sharing information among community agencies providing care coordination services

• Deploy 75 Community Health Workers + RN/SW

supervisors to use Pathways to link high‐risk individuals to health and human services.

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Pathways Community Hub Model

• Centralized Community Hub assures efficient and

effective service delivery in a community:

• Reduces duplication of efforts
• Coordinates fragmented delivery
• Holds agencies accountable for value rather than volume
• Hubs assign referrals to Community Health Workers

(CHWs) to connect individuals to needed social and healthcare resources

• CHWs use Pathways (protocols) that identify the critical

actions leading to desired outcomes

• Hubs create Incentives based on results (completed

pathways); performance is reported to the community

Pathways Community HUB Model http://www.innovations.ahrq.gov/guide/HUBManualTOC.aspx

MPBH Demonstration MPBH Demonstration

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Pathw thways Model: ys Model: A T A Tool t

• ol to Measure

Measure Outcomes Outcomes

Target Population - Find those at greatest risk Confirm connection to evidence-based care Measure the results

OUTCOMES

1- Find

2 - Treat 3 - Measure

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Pathw athways ys

 Social Service Referral  Smoking Cessation  Medication Assessment  Medication Management  Medical Referral  Medical Home  Health Insurance

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Health Social

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

Do you need a primary medical provider?



Do you need health Insurance?

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Do you smoke cigarettes



Do you need food or clothing?

Yes No Question

Initiation Step

Action Step Action Step

Completion Step Assign Pathways

Care Coordinator

Medical Home Preg. Social Service

A 5 2 10 B 1 3 4 C 9 15 18

Find the right person Collect information – Initial Checklist Measure Results (Connections to Care)

Work Flow

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HUB HUB Regional organization and tracking of care coordination

• Focus on at-risk
• Eliminate duplication
• Benchmarks – confirmed

connection to care

Community HUB Network29

Care Coordination Agency

(CHWs)

Food Jobs Housing Healthcare Care Coordination Agency

(CHWs)

Food Jobs Housing Healthcare Care Coordination Agency

(CHWs)

Food Jobs Housing Healthcare

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HUB Model: HUB Model: Coordination and Ef Coordination and Efficiency ciency

Align agencies and service funders Facilitate delivery of agency services Pathway results and inform ation Stream lined perform ance reporting to m ultiple funding sources

1- Coordinate

2 - Collect 3 - Invoice 4 - Distribute

Tim ely distribution of funds to m aintain agency services

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MPBH Pilot Sit MPBH Pilot Sites

• Ingham County –

Ingham County – Lead is ead is Ingham County Health Dept. Ingham County Health Dept. (ICHD) (ICHD)

• Hub – Ingham Health Plan
• CHW deployment – ICHD (partnership with 8 different agencies)
• Convener – Power of We Consortium
• Sagina

Saginaw County – w County – Lead is ead is Sagina Saginaw Community Mental Health (CMH) w Community Mental Health (CMH)

• Hub – Saginaw CMH
• CHW deployment – 3 agencies (2 of which are hospitals)
• Convener – Mich. Health Info. Alliance (MiHIA) & ALIGNMENT Saginaw
• Musk

Muskegon County – egon County – Lead is Musk ead is Muskeg egon Community Health Pr

• n Community Health Proj.
• j. (MCHP)

(MCHP)

• Hub – Muskegon County Government
• CHW deployment – MCHP ~ Trinity Health System
• Convener – MCHP

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MPBH Goals MPBH Goals

Long Term Outcomes: the Triple Aim

• Reduce total cost of care
• Save CMS more dollars over 3 years than the project will cost
• Savings will largely come from decreased hospitalizations and ED visits.
• Improve healthcare quality
• Improve health status

…move the needle on healthcare costs by addressing social concerns…

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Respite Care HUB / CHW Utility & Rent Assistance Smoking Cessation

Transportation

Healthcare System

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(Efficient & Accountable Care) Coor Coordi dinated Seamle d Seamless ss HEA HEALTH CARE CARE Syst System 2.0 2.0 Uncoor Uncoordi dinat nated d HEA HEALTH CARE CARE Syst System 1 1.0

Innovation Driven US Health Care System Evolution

Community Integrated Health Care System 3.0 (Episodic Non Integrated Care)

Health Care Sys Health Care System AND

AND Community Care Sys

Community Care System: em: PARALLEL

RALLEL Ev

Evolutions &

• lutions & Critical P

Critical Path th

Uncoordinated COMMUNITY CARE System 1.0 Coordinated Seamless COMMUNITY CARE System 2.0 (Confused Consumers; Inefficient Care Delivery) (Efficient, Accountable, Person‐ Centered Community Services)

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• Builds on the ACO foundation
• Integrates payment mechanisms including public health and community health

resources into a common population-based payment.

• Reaches into the community to address underlying population health issues,

coordinate social services , and encourage healthy community living.

The goal is population-wide im The goal is population-wide impr proved ed health and a bett health and a better v er value/result lue/result for the patient, f r the patient, family mily, and community o , and community over time er time

Institute for Healthcare Improvement. Healthcare Transformation, 2006

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Bridging the Divide between Health and Health Care

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March 2013 JAMA article, Stephen Shortell “health care delivery accounts for only 10% of preventable deaths. . . . . . . . consensus is developing that truly controlling health care costs and improving the overall health of the American people will require a much closer partnership, permeable boundaries, and increased interdependence among the health care deliv health care delivery syst system, the em, the public health public health sect sector

• r, and the

, and the community de community development and social lopment and social ser service sect ice sectors”

• rs”

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Stat State Inno e Innovation Model (SIM) tion Model (SIM) Planning Project Planning Project

NEW award from CMS to develop a plan through consensus-building to transform the Michigan health system and reform the payment system to reward performance and value, not volume.

• Intensive 6-month process to produce the State

Plan, due to CMS on Oct 31st with opportunity to apply for implementation funding

• MANY Michigan leaders are participating

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FUNDERS, P FUNDERS, PAYERS, & POLICYMAKERS YERS, & POLICYMAKERS

Results Reported Results Reported

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Thank You!

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Tom Curtis, MPA curtist2@michigan.gov (517) 241-1287