Ca Care Transition Summit Ju June 18, 2019 An award winning - - PowerPoint PPT Presentation

Ca Care Transition Summit Ju June 18, 2019

Who ar are e we

An award winning 403(b) non profit complex case management organization specializing in delivering evidenced based medical and behavioral health care in the metropolitan Detroit area. Our mission is to identify gaps in care and social determinants which have a significant effect on the cost and success of medical treatments.

Our ur Mod

• del
• Medication Reconciliation
• Health Education/ Health Coaching
• Clinical Assessment
• Navigation of Community Resources
• Person Centered Planning
• Life Skill Development
• Facilitation of Health Care Partnerships

Com

• mplex

x Case ase Man anagement

• Our Strategy

Integrating patient centered care coordination models across medical, behavioral, and social systems to address social determinants of health.

• Our Foundation

We currently utilize the successful Camden Coalition Model which highlights the focus on social determinants of health and the research of

• Dr. Jeffrey Brenner.

Com

• mplex

x Case ase Man anagement

• Our Approach

We have developed a focused approached to reconnecting patients back to there primary care providers and away for local emergency departments.

• Goal focused

Coordinate all services with the patients, providers and the health care administrators with a focused goal of reducing the overall cost of care and improving patient outcomes

Out utreach App pproach

Partner 4 health has four programs that we provide to Health Plans, PHO’s and Hospitals to address social determinants of health and inpatient post discharge needs.

• Community Outreach
• Emergency Diversion
• Hospital to Home (Transitional Care Program)
• Maternal Support

Com

• mmunit

ity Out utreach Prog

• gram

High risk patients Identified

• Case management assigned
• Initial psychosocial assessment
• Primary care appointment scheduled
• Ongoing community outreach
• Monthly care coordination review

Em Emer ergency Div iversion Prog

• gram

Licensed Social Workers imbedded in ED

• Psychosocial assessment completed at bedside
• Community appointment scheduled
• Post discharge follow up
• Referral to outreach services, pharmacy or

health education

Hos

• spit

ital l to

• Hom
• me

Prog

• gram

Hospital Transitional Care Nurse visit (Inpatient)

• Psychosocial assessment completed at bedside
• Health education prior to discharge
• Medication reconciliation by Pharmacist
• Discharge planning needs coordinated
• Referrals to ongoing community outreach

services

Mater ernal l su support t Prog

• gram

Board Certified Midwife Community Outreach

• Psychosocial assessment completed
• Prenatal and Postpartum visits
• Referrals to ongoing community outreach

services

Staffing tea eam

• Advance Practice Provider
• Nurse Care Manager
• Community Outreach Worker
• Pharmacist
• Mental Health Social Worker
• Physician advisor

P4H is dedicated to implementing an integrated healthcare delivery model for patients with multiple or complex medical conditions, that are most often combined with behavioral health problems and socioeconomic challenges.

Average Cos Cost model Savings

Base Year Costs Insureds in Program Year Over Year Net Cost Reductions* Average Year over Year Cost Reductions/Insured >$100K 8 $ 822,219 74% > $50K < $100K 18 $ 277,002 30% >$25K < $50K 27 $ 189,305 33%

Com

• mpetit

itiv ive adv advantages

Community Roots

• All staff from the local metropolitan Detroit communities.

Patient Experiences

• Our staff have over a 100 years of combined experience in

transitional care management, Hospital discharge planning, and community outreach services. Affiliated Partners

• Partners 4 Health is currently affiliated with Common

Ground, Oakland Family Services, Neighborhood Service Organization and Southwest Solutions. Financial Outcomes

• Currently we are saving our health plan providers an average

cost of $1 million a year.

• 15% Reduction in hospital readmission rates in 2018

Questions DaJuan Smith, MSW, LMSW President/CEO Partners 4 Health 313-686-0202 dsmith2@nso-mi.org

Addressing Social Determinants of Health at ProMedica

Linda Chambers Associate Vice President Rehab Services and SDOH Clinical Integration

THOUGH HEALTH CARE IS ESSENTIAL TO HEALTH IT IS A RELATIVELY WEAK HEALTH DETERMINANT

“ ”

McGinnis/Foege “Actual Cases of Death in the US”

JAMA November 1993

U.S. Healthcare from A GLOBAL PERSPECTIVE

Source: Reverehealth, https://reverehealth.com/vbc/vbc-providers/

More people die of preventable diseases and complications in the U.S. than in any other developed nation.*

*Per 1000,000

The United States spends more money per person on healthcare than any

• ther nation with comparable incomes.

The United States has a significantly lower life expectancy than other countries that spend less on healthcare.

1 Japan 2 Switzerland 3 Singapore 4 Spain 5 Australia . . . . 31 U.S.

U.S. Healthcare from a GLOBAL PERSPECTIVE

Exhibit ES-1. Overall Ranking

Domains of SDOH RIS RISK

ARE RE WE E ASKI KING TH THE E RIG RIGHT QUESTIONS?

We do …

Ask about and encourage exercise Ask about and encourage people to lose weight Check vital signs Check a child’s growth Provide physical examinations Provide education to patients Criticize patients who fail to show up for appointments

But we don’t …

Ask about safety in neighborhoods Ask about diet and ability to secure healthy food Screen for mental health Look for signs of toxic stress Ask about insurance information Ask if they can’t read Ask if they have transportation

Social Determinants

• f HEALTH SCREENING
• Food Insecurity Screens: 970,572
• SDOH Screens: 118,030
• Screening employees through EAP

55% HAD POSITIVE NEEDS IDENTIFIED

• 39% of those screened had needs in

four domains or more

• 87% of those screened had a high

motivation score TOP NEEDS:

• Financial Strain
• Behavioral Health
• Food

Impact of HUNGER ON HEALTH

• Hungry people are 2.9 times more likely to be in poor

health and have a higher likelihood of chronic conditions.

• They are also 2.45 times more likely to be obese as

a result of poor nutrition.

• Newborns are 1.81 times more likely to be underweight, often

leading to lifelong development and chronic conditions.

• Experiences with hunger had a negative impact on the health
• f children 10 – 15 years later.
• Children who are hungry are 4 times more likely to need

professional counseling.

• Hungry teens are 5 times more likely to commit suicide.

HUNGER in the U.S./Toledo

• 13% of U.S. households are food insecure
• 19.5% of U.S. households with children

are food insecure

• 30.3% of U.S. households – single moms

with children

• 31% of seniors cut or skip meals due to lack
• f resources
• 24% undocumented workers
• 91% people returning from prison
• Almost 75% of SNAP recipients are seniors, disabled
• r working parents
• SNAP benefits are often exhausted before

the end of the month

More than 1 IN 5 FAMILIES with children EXPERIENCE FOOD HARDSHIP in Toledo

HUNGER IS A MAJOR HEALTH CRISIS!

Food is MEDICINE

AMBULATORY: PCP writes a referral for patients that are identified as food insecure. Patients receive 2-3 days’ worth of healthy food for their household ACUTE CARE: Referral upon discharge. Patients receive box of food upon leaving hospital FOOD RECLAMATION: Food normally thrown away is reclaimed and provided to community hot feeding site URBAN FARM: Three-acre farm growing 20 fresh fruits and vegetables HCR PILOT: Food at discharge for SNF patients in Detroit and Flint markets

OF 4,000 MEDICAL PATIENTS COMPLETING SCREEN AND FOOD PHARMACY REFERRAL:

• Reduced ED usage (3%)
• Reduced readmission

rates (53%)

• Increased primary care

visit rates (4%)

• Reduced pmpm (15%)

Connecting Clinical Outcomes AND SDOH DATA

Moms who deliver Low-birth weight babies are …

• More than twice as likely to have domestic violence (24%)

compared to all referred patients (12%)

• Almost twice as likely to report transportation needs (41%)

compared to all referred patients (27%)

• More likely to cite house instability (40%) compared to all

referred patients (27%)

• More likely to report using substances (24%) compared to

all referred patients (14%)

Correlating Demographics to Needs

PLA LACE MATTERS to Health

• Catalytic, $50-million, 10-year

commitment to neighborhood revitalization

• National neighborhood revitalization

model focused on health

• CDFI Investment: Additional $45M loan

pool for housing development, schools, business support

• Social infrastructure and capital

development

THE EBEID

NEIGHBORHOOD PROMISE

PLA LACE-BASED, HE HEALTH FOCU CUSED

Financial Opportunity Center

THANK YOU!

Michigan State Innovation Model (SIM)

TRIPLE AIM

Better Care

Backbone Organizations in Community Health Innovation Regions (CHIRs) serve as Chief Health Strategist to build community capacity to drive improvements in population health

NM NMCHIR

SIM funds are dedicated to five pilot sites in Michigan. The Northern Michigan Community Health Innovation Region (NMCHIR) is our rural pilot.

10 Cou

• unty Reg

egio ion – Nor

• rthwest

t MI

• 303,996

people

4,722

square miles

70%

rural

63.7

people per square mile

Wha hat In Influences Hea ealt lth?

Com

• mmunit

ity Hea ealt lth In Innovatio ion Reg egio ion

Business Community Services & Supports Health Advocacy/ Promotion Health Care Payers/ Insurers Public Health

2017

Business Community Services & Supports Education Funder Health Advocacy/ Promotion Health Care Payers/ Insurers Public Health

2018

Evolu lution of f CH CHIR IR Co Communit ity Partners

• Our partners initiate the process with clients by doing the following:

Member and Partner Roles

Administer our web-enabled SDoH screening tool (36 PCMH sites) Make and receive referrals to our clinical community linkages model Collect input from constituents Participate in our Communication Plan Roll Out Implement strategies to increase equity and population health Conduct Organizational Assessments to assess how embedded systems change is in their own

• rganization.

Affordable Accessible Healthy Food Affordable Healthy Housing Creative Accessible Transit Options Opportunities for Active Living

In partnership…

Cli linical-Community Lin Linkages Mod

• del

Com

• mmunit

ity Con

• nnectio

ions HUB pr process

Referral

• Client Referral to HUB
• HUB central intake registers client into the database
• HUB coordinator assigns client to CHW (RN , SW or CHW)

CHW services

• CHW connects with client 1) Collects information and assesses

needs, 2) Implements Core Pathways 3) links to community resources 4) confirms successful connection to resources

Outcomes

• Measures and documents results
• Reports feedback on referral to referral source

2018 2018 – May 2019 PCMH Scr cree eenin ings

27,961 Screenings Completed in PCMH and CBO offices 14,135 Completed Screenings with Needs (50%) 2,932 Number of completed screenings who identified needs, wanted assistance and provided consent (21%)

Pathways Co Comp mplete and and In n Prog

• gress –

10 Co Coun unties 2018

20 40 60 80 100 120 140

Adult Education Behavioral Health Education; Health Employment Family Planning Health Insurance Housing Medical Home Medical Referral Post Partum Pathway Pregnancy Pathway Smoking ssChild Care Assistance ssChild/Family Assistance ssClothing ssFinancial Assistance ssFood Assistance ssLegal Assistance ssMedical Debt Assistance ssTranslation Assistance ssTransportation ssUtilities Assistance

Total

Total

Pathways In Incomple lete – No

• Res

esource ce or

• r In

Ineli ligible le 10 10 Co Countie ies 20 2018

1 2 3 4 5 6 7 8 9 10 Housing Food Assist Health Insurance Child Care Assist Transportation Utility Assist Medical Debt Clothing Behavioral Health Resource Not Available Ineligible Total

GOAL 1:

Transform Counties

Improve community conditions promoting health within 10 regional counties

GOAL 2:

Transform the System

Improve within and cross- sector system alignment and responsiveness

Im Improvin ing Hea ealt lth In In Nor

• rthern Mich

ichigan

HEALTHY THRIVING RESIDENTS

HUB/County Work

System is Responsive to Resident Voice System is Coordinated and Aligned System Policies and Practices Promote Health Equity

MDHHS MHPs Grants

CHIR Sustainability Post-SIM Period

• Backbone Organization
• Other funders unlikely to support BBO
• Screening integrated into MiBridges
• Clinical Community Linkages
• Medicaid funding alone is not sufficient

Funding

• Medicaid Health Plans
• Continued PCMH requirement to screen for social needs
• Contract Reimbursement for HUB navigation services
• State Plan Amendment for CHW services reimbursement
• Medicaid Bulletin for Children’s Health Access Program

Influence MDHHS/MHPs

• Regional funding strategy includes local health

departments, hospitals, and others

Community Health Assessment and Planning

• Aligned regional “Funders’ Circle” to support local

implementation of CHIPs

• State initiative funding to CHIRs (Housing, Heart, etc)
• Aggressive pursuit of grants to meet local needs

Community Health Improvement

Federal, State, Local Funding

Expansion

• f CHIR

activities into new regions

Strategic Sustainability Planning

Community Health Assessment alignment from local funders Backbone Organization funding Community Health Worker Reimbursement Contracts with Medicaid Health Plans Federal and state grants Partnerships: Northern Health Plan, community foundations and others Statewide scale up of electronic screening tool - integrated in MiBridges