Payment and Delivery System Reform Marshall Chin, MD, MPH, Emmy - - PowerPoint PPT Presentation

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Solving Disparities Through Payment and Delivery System Reform

Marshall Chin, MD, MPH, Emmy Ganos, PhD, Scott Cook, PhD, Peter Milgrom, DDS, Elizabeth Howell, MD, MPP, Len Nichols, PhD, Kathryn Gunter, MPH University of Chicago, Robert Wood Johnson Foundation, University of Washington, Icahn School

• f Medicine, George Mason University

Solving Disparities Through Payment and Delivery System Reform

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Chin Disclosures / Funding

• Support for this research was provided by the Robert Wood Johnson
• Foundation. The views expressed here do not necessarily reflect the

views of the Foundation.

• AHRQ T32 HS00084, K12 HS023007, U18 HS023050
• Merck Foundation
• NIDDK P30 DK092949
• Co-Chair, NQF Disparities Standing Committee
• CMS (NQF collaboration), CMMI (technical assistance)
• Former President, SGIM
• AMA, AHA, Joint Commission, Families USA, VA, America’s

Essential Hospitals, NACHC, Instit Medicaid Innovation, CDC, AAMC, NCQA, NIMHD

Solving Disparities Through Payment and Delivery System Reform

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Learning Objectives

• Understand emerging opportunities and

issues in reducing disparities by integrating payment and delivery system reform.

• Recognize practical implementation issues

and potential solutions in implementing payment reform to reduce disparities.

Solving Disparities Through Payment and Delivery System Reform

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Agenda

• RWJF perspective – Emmy Ganos
• Policy background – Marshall Chin, Scott

Cook

• 3 grantees – lessons learned – Peter

Milgrom, Elizabeth Howell, Len Nichols

• Key stakeholder interviews – Katie Gunter
• Discussion - All

Finding Answers: Solving Health Disparities through Payment and Delivery System Reform

Notes from Robert Wood Johnson Foundation Emmy Ganos, Ph.D. Program Officer

Building a Building a Culture of Hea Culture of Health lth in America in America

County Health Rankings and Roadmaps Model

Payment + Equity Focus + Care Innovations

Lots of Questions + Finding Answers

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Policy Background

Marshall Chin, Scott Cook

Finding Answers University of Chicago

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Background

• Healthcare disparities persist
• Value-based payment

– Shift from fee-for-service (volume) to value- based payment (quality)

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

MACRA (Medicare Access and CHIP Reauthorization Act)

• 2019 – Quality Payment Programs

– Merit-Based Incentive Payment System (MIPS) – Advanced Alternative Payment Model (APM)

• Quality metrics, Health IT, Cost

accountability

Solving Disparities Through Payment and Delivery System Reform

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Where’s Equity?

Solving Disparities Through Payment and Delivery System Reform

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

RWJF Finding Answers

• 2005-2014: Focus on care transformation

to reduce disparities

– Grants – Systematic literature reviews – Technical assistance

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

A Roadmap and Best Practices for Organizations to Reduce Racial and Ethnic Disparities in Health Care

Chin MH, et al. JGIM 2012; 27(8):992-1000 www.solvingdisparities.org

National Academy of Medicine – Systems Practices for Care of Socially At-Risk Populations Centers for Medicare and Medicaid Services – CMS Equity Plan for Improving Quality in Medicare

Solving Disparities Through Payment and Delivery System Reform

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Roadmap for Reducing Racial and Ethnic Disparities in Care

1) Recognize disparities and commit 2) Implement QI infrastructure and process 3) Make equity an integral part of quality 4) Design intervention(s) 5) Implement, evaluate, and adjust intervention(s) 6) Sustain intervention(s)

Chin MH et al. JGIM 2012; 27:992-1000

Solving Disparities Through Payment and Delivery System Reform

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Business Case

Solving Disparities Through Payment and Delivery System Reform

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Solving Disparities Through Payment and Delivery System Reform 2014-2018

• “to develop evidence that payment and

delivery system reform designs that at- tempt to manage extrinsic and intrinsic incentives for overall quality and effi- ciency, while also explicitly attempting to reduce health care disparities, can produce positive results for each goal.”19

DeMeester et al. Health Affairs 2017.

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Payment / Value-Based Purchasing

• Pay for performance
• Infrastructure - Preventive and

primary care

– e.g. community health workers

• Social determinants of health / population

health

Solving Disparities Through Payment and Delivery System Reform

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Motivation

• Intrinsic

– Professionalism – Do the right thing

• Extrinsic

– Financial – Other rewards

Solving Disparities Through Payment and Delivery System Reform

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Policy Context: Payment and Equity

• CMS – Equity Plan
• Social risk factor adjustment in payment

– National Academy of Medicine – HHS Asst. Secretary for Planning and Eval. – National Quality Forum

• Need to use multiple policy and

payment levers to achieve equity, not just social risk factor adjustment

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

CMS and Private Payors Align the Financial Incentives

• Require public reporting of stratified disparities

data

• Pay for reducing disparities

– Include equity accountability measures in payment programs – structure/process/outcome

• Strengthen incentives for prevention

and primary care

– Update MD RVU payment schedule – cognitive – Global payment / shared savings – flow of money –Intersectoral partnerships – Social determinants

Chin MH. Creating the business case for achieving equity. JGIM 2016.

Solving Disparities Through Payment and Delivery System Reform

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Align the Financial Incentives 2

• Align equity measures across public & private

payors

• Take care of safety net providers

– Adequate payment – Calibrate DSH reductions to insurance expansion – Support for quality improvement – Risk adjustment to create level playing field

• Conduct payment and delivery demo projects
• Have explicit equity lens - payment and QI

Solving Disparities Through Payment and Delivery System Reform

PREDICT 14-county Quality Improvement Project with a randomized controlled design with primary outcomes of access to dental care and oral health at 2 years

Peter Milgrom, DDS University of Washington dfrc@uw.edu

Advantage Dental

Dental Care Organization founded in 1994 by dentists concerned with lack of care in rural Oregon. Mission: Provide dental leadership, service and access to care for our communities in a professional, entrepreneurial, and sustainable manner.

Oral Health in Oregon’s CCOs – A Metrics Report, March 2017

Adults Children

Oral Health in Oregon’s CCOs – A Metrics Report, March 2017

Delivery System

Patient seen in community setting Clinical findings and risk assessment entered in Electronic Health Record Electronic notification sent to Primary Care Dentist and Case Management Community based prevention and treatment provided Case Management assists in triaging to care Community teams engaged if necessary

Global Budgeting

Oregon Health Authority 16 CCOs Quality Improve Metrics at CCO Level and CCO Withhold Provider Care PCDs Specialists Community EPDHs DCO Withhold Dental Care Organization Advantage Dental Administration & Profit Case Management Services

Pay for Performance

Withhold

Eligible to all OHP network providers

DHS Dental Assessment within 30 days Sealants on molars of 6-9 & 10-14

PREDICT Incentive

Clinical community team

Incentive based on Intervention county assigned Regional Manager Community Liaison Expanded Practice Permit Dental Hygienist

Centralized administration team

Incentive Based on performance

• f ALL 7 intervention counties

Case Management All other Administrative employees not called out in

• ther two

groups

Dental Home

Incentive based on individual provider performance within the Intervention County Primary Care Dentist Advantage Dental Clinics

PREDICT: Dental Utilization (Calendar 2016)

# with any claims total eligible % with any claims DESCHUTES 7125 15695 45% DOUGLAS 6268 13417 47% JACKSON/JOSEPHINE 5609 17110 33% KLAMATH 2763 6304 44% MORROW 1192 2178 55% WASCO 1703 2783 61% # with any claims total eligible % with any claims DESCHUTES 1004 15695 6% DOUGLAS 2100 13417 16% JACKSON/JOSEPHINE 100 17110 1% KLAMATH 508 6304 8% MORROW 603 2178 28% WASCO 922 2783 33%

Any Advantage provider By RCEPDH

Dentist treatment after 1B or 2 (2016)

County 0-4 years 5 to < 21 years # seen 60 days # high risk % seen 60 days # seen 60 days # high risk % seen 60 days DESCHUTES 18 35 51% 36 62 58% DOUGLAS 19 47 40% 199 585 34% JACKSON/JOSEPHINE 2 0% 1 20 5% KLAMATH 5 15 33% 28 65 43% MORROW 5 0% 19 48 40% WASCO 5 14 36% 54 127 43% Total 47 118 40% 337 907 37% County 0-4 years 5 to < 21 years # seen by year end # high risk % seen by year end # seen 60 days # high risk % seen 60 days DESCHUTES 22 35 63% 46 62 74% DOUGLAS 26 47 55% 333 585 57% JACKSON/JOSEPHINE 2 0% 7 20 35% KLAMATH 5 15 33% 42 65 65% MORROW 5 0% 20 48 42% WASCO 8 14 57% 72 127 57% Total 61 118 52% 520 907 57%

Within 60 days Until end of year

"high risk" indicates being classified as 1B or 2 at a screening visit (audit file), by day 305 of year (so to have 60 days of follow up) "seen" indicates a claim for a non-preventive service (and not 0191, 0602, or 0603) at some day on or after high-risk indication day

Major Issues

• Delivery System
• Access to sites, community understanding of model
• 16 CCOs
• Competing sealant programs and OHA rules
• For profit company in non profit space
• Parent consents
• Consistency of risk/need assessments
• Compensation System
• IT and accuracy of audit (scorecard) feedback
• Random selection of counties and different baselines, perceived unfairness
• Frustration that progress is out of team’s control

Partnership to Reduce Disparities in Postpartum Care: Lessons Learned

Elizabeth A. Howell, MD, MPP Vice Chair of Research Department of Obstetrics, Gynecology, and Reproductive Science Icahn School of Medicine at Mount Sinai Funded by the Robert Wood Johnson Foundation RWJF I.D. 72257

Opportunity

• Childbirth number one reason for hospital admission
• Postpartum (PP) care offers opportunity to impact

current and future health of underserved women

• Low income women of color have higher:

–Maternal mortality/morbidity; pregnancy complications; chronic illnesses (e.g., hypertension, diabetes) –Less likely to get appropriate medical follow-up post- pregnancy putting long term health at risk (e.g., increased risk of Type 2 DM)

• Significant disparities in receipt of postpartum care;

Medicaid ~ <60% vs. commercially insured ~ >80%

39

Partnership to Reduce Disparities in High Risk Postpartum Care

• Combined delivery system reform with payment reform

to improve quality and reduce disparities in high risk postpartum care

• Primary aim was to increase rates of timely postpartum

visits among high risk obstetrical patients

• Secondary outcomes include glucose monitoring,

maternal depression, ED Visits, hospitalizations, and cost

Payment Redesign

• Cost share to finance social worker & care

coordinator

• Patient incentives – PP visit payments, raffle
• Small physician incentives
• Nonfinancial incentives: clinician education,

performance feedback Delivery System Redesign

• Evidence-based case management intervention
• Prepares/educates women about GDM, HTN,

bolsters support & self management, increases access to community resources

• Occurs during postpartum hospital stay

(education pamphlet, partner summary sheet;

• Additional contacts (calls, emails, mailings) to

connect women with care and resources Targets for Disparity Reduction: Postpartum care glucose, BP monitoring ED visits/ hospitalizations depression screen, costs Population: Postpartum women with gestational diabetes, hypertension, depressive symptoms late registrant high-risk neighborhood

Elements of Delivery and Payment Redesign

Assessments: baseline, 2 weeks, 3 weeks, and 6 months postpartum; claims data

Enrolled Healthfirst Postpartum Mothers (N=510)

n % Mean age -- 28.5 years Latina/Hispanic 357 70% Black/African American 124 24% 1° Spanish -speaking 150 29% Born outside of US 238 47%

• Educ. ≤ high school

283 55%

42

Primary Outcome: Timely Postpartum Visit (HEDIS 21-56 day visit)

Timely Visit/ Patients within HEDIS Window % Timely Postpartum Visit (HEDIS 21-56 day visit) 371/510 73%* Mothers w/ HTN 89/114 78% Mothers w/ GDM 42/52 81% Any Postpartum Visit 406/510 80% Patient Satisfaction with intervention >90% *pre intervention PP visit rate ~ 58%

43

Lessons Learned

• Importance of Aligned Incentives
• Medicaid Managed Care Organization
• Use of quality indicators (HEDIS measures) by New York

State to determine star ratings

• Recognition that postpartum women are especially

vulnerable population

• Large Health System
• Focus on population health management (18,000 annual

deliveries in our health system)

• Interest in innovative new models
• C suite champion

44

Lessons Learned

• Competing Demands for a Large Health System
• Recent merger (7 hospitals and a medical school)
• Regulatory requirements, billing challenges, electronic

medical record, culture, standardization

• Delivery System Reform Incentive Payment (DSRIP)

Program from New York State

• Mechanism for Medicaid Redesign Team Waiver

Amendment

• Aims to restructure the health care delivery system by

reinvesting in Medicaid – reduce avoidable hospital use by 25%

• Nearly $6 billion allocated to this program

45

Lessons Learned

• Attention to Financial Infrastructure
• Medicaid Managed Care Organization
• Implementation of bonus payment to clinicians for timely

postpartum care

• Including obstetricians in bonus structure
• Health System (Billing and Reimbursement)
• Consideration of billing structure (facility and/or provider

bills)

• Changes required in billing system (Eagle) and EPIC
• Clinician training for appropriate billing codes
• Strong partnership required with EPIC staff, and hospital

finance in order to implement

• Channeling of dollars from lump sum payments

46

Lessons Learned

• Cost Share to Support Team-based care
• Outreach/ buy in from clinicians and staff
• Translated into multiple cosponsored efforts by health

system and payer to support care (e.g. management of blood pressure; depression)

• Advancing an Equity Agenda in Large Health System
• Focus on population health management
• Business case
• New revenue streams
• Improve care for highest risk patients may result in cost

savings

• Disparities Dashboard

47

48

• Icahn School of Medicine at Mount Sinai

– Elizabeth Howell, MD, MPP, Amy Balbierz, MPH, Vincent Dobrev, Kezhen Fei, MS, Population Health Science & Policy – Joanne Stone, MD, Jennifer Amorosa, MD, E. Howell, MD – Ob/Gyn – Virginia Walther, MSW, Judy Mason, MSW – Social Work – Social Worker (Brett Barash, LMSW), Care Coordinator (Mabel Del Orbe)

• Healthfirst

– Susan Beane, MD, Medical Director – Rashi Kumar, MUP, Senior Program Manager, Clinical Partnerships – Tola Ilegbusi*, Program Analyst, Clinical Partnerships

• The New York Academy of Medicine (NYAM)

– José A. Pagán, PhD, Norma A. Padrón, PhD – Health Economists

48

Reducing Ethnic Disparities in Health Outcomes Among Uninsured Patients Through Payment Reform

Le Len M. . Nichols, s, Ph. Ph.D. Academy He Health Annual Res esearch Con Conference Ju June 26, 26, 201 2017

www.chpre.org

49

Overview

• Partners, Goals and Background on CHCN System
• Research Question and Implementation Design
• Challenges and Performance So Far
• Next Steps and Questions

www.chpre.org

50

www.chpre.org

Partners and Long Term Goals

• October 2014 Robert Wood Johnson Foundation awarded 3 year

grant to George Mason University, with Fairfax County and Molina Healthcare partners, to test if clinician payment incentives might be used to reduce ethnic disparities in health outcomes

• Molina Virginia and Fairfax County CNCN were perfect partners for

this work

• Inova assumed operational responsibility for CHCN July 1, 2016, and

agreed to continue and prioritize this research project and implement an identical or similar incentive structure

• In addition to research findings, we hope to help establish techniques

that will serve the County, Inova, and the patient population of the CHCN well in the future

Merrifield South County North County

18,000 Enrolled 30-50k visits per year 10-15k undup. Patients County spends $7-9m

www.chpre.org

Logic Diagram of Intervention

Team Payment Incentive Reminders during huddles + meetings

Better CQM performance => Lower Disparities

Disparities DATA!

County staff

Incentive Formula Recap

• Current Salary + (Bonus*productivity*quality)
• 4.0 or more RVU/hr will be entered as “1” in the above equation
• 1.0 or more “target” RVU/hr will entered as “1” in the above

equation

• So the incentive formula would be: current salary + (3% x 1 x 1)
• Target RVUs come from CCS, diabetic or BP education

(7) (8) (9) VARIABLES score_ccs score_hgba1c score_hypt schc

• 8.709**

16.66* 1.043 (3.953) (9.872) (4.738) nchc

• 18.63***

5.697 3.231 (3.515) (7.698) (3.624) bhc

• 5.633*

7.058 7.569* (3.359) (13.06) (4.502) post_schc 3.893

• 11.89
• 12.34***

(4.966) (8.857) (4.081) post_nchc 6.770

• 10.83
• 18.35***

(5.000) (9.695) (5.011) post_bhc

• 0.290

1.385

• 17.95***

(5.743) (6.970) (5.035) time 0.814* 0.996 1.433** (0.488) (1.253) (0.582) time_sq

• 0.00879
• 0.0277
• 0.0303***

(0.00869) (0.0230) (0.0114) Observations 120 120 120 R-squared 0.481 0.476 0.472 Robust standard errors in parentheses *** p<0.01, ** p<0.05, * p<0.1

Score = Hispanic Performance MINUS Non-Hispanic Performance

(1) (2) (3) (4) (5) (6)

VARIABLES ccs_h_perf ccs_nh_perf hgba1c_h_perf hgba1c_nh_per f hypt_h_perf hypt_nh_perf schc 60.19*** 66.38*** 76.42*** 51.82*** 96.21*** 86.46*** (1.872) (3.021) (1.481) (5.416) (2.313) (2.105) nchc 61.90*** 78.01*** 78.19*** 64.55*** 92.40*** 80.46*** (2.753) (3.633) (1.564) (3.184) (2.071) (1.956) bhc 57.73*** 60.84*** 76.69*** 61.69*** 91.93*** 75.65*** (2.282) (3.036) (1.099) (7.449) (2.073) (2.835) post_schc

• 2.921
• 9.217*

3.280 7.604 8.681** 12.73*** (4.603) (5.337) (2.470) (5.242) (3.338) (3.405) post_nchc

• 12.18**
• 21.36***
• 4.533
• 1.272
• 5.722

4.331 (4.737) (5.933) (3.026) (5.190) (3.695) (3.643) post_bhc

• 1.504
• 3.616

7.358***

• 1.594
• 0.605

9.052** (5.377) (5.083) (1.995) (6.557) (3.535) (3.963) time

• 0.865***
• 1.239***
• 0.250***

0.138

• 1.430***
• 1.346***

(0.162) (0.170) (0.0837) (0.146) (0.113) (0.125) Observations 120 120 120 120 120 120 R-squared 0.919 0.917 0.993 0.963 0.985 0.981 Robust standard errors in parentheses *** p<0.01, ** p<0.05, * p<0.1

www.chpre.org

Statistical Model Results

• Controlling for center-specific differences and time

trends…, the payment incentive changes are (so far) associated with:

• REDUCTION in

in Dis isparities in in blo lood pressure control in in all ll 3 centers, mostl tly due to non-Hispanic performance im improvement

• Le

Less statistically relia liable im impact on HgbA1c and CCS

Constructing the Fishbone Diagram for CHCN Merrifield HgbA1c control Patient behavior Language barriers Patients fear D, don’ want to talk or think about it Insulin seen only at end stage In birth country, assoc. with death Switch from oral to injection is BIG deal Refill is a new idea for many Patient behavior Asymptomatic, why treat? D education classes too long Patients penalized for missing class, Yet hard to get to for 2-3 hours; many Not aware of co-pay waiver for completion Education about D essential

www.chpre.org

Challenges

• County moved largest Center 4 miles west in Nov 2015
• Inova took over as operator of CHCN in July 2016
• EHR management and staffing transition considerable
• Bonus system, calculations, and delivery all changed*

www.chpre.org

Next Steps

• Short-term:
• Results of patient focus groups now shared with County and Inova
• Inova doing patient survey now
• Long-term:
• Project will end in October of 2017
• Final recommendations will draw on statistical, focus group, RCA, and

patient survey results

• GMU, Inova, County, local FQs are in talks about CHCN future and role
• f equity goals in perpetuity
• “One Fairfax”

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Key stakeholder interviews

Katie Gunter

Finding Answers University of Chicago

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Study Design

• 38, 60-minute semi-structured telephone

interviews

– Clinical and non-clinical roles: healthcare and dental leadership, administrators, providers, and staff; payer leadership and administrators; principal investigators; and community partners

• 14-19 months into 36-month projects

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Organizational Motivation

• Generate evidence for what works
• Make the business case
• Deliver more efficient care
• Reduce disparities

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Organizational Motivation

Part of the motivation of the company is to use this evidence-based approach to make the care more

• efficient. Every dollar that you spend on a child that

doesn’t need any care, is a dollar you’re taking away from someplace else….so if they can be more economical about the way they care for children, then they will have more money to spend on the adults because the adults are by far more expensive. (Site A, Project Leadership)

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Individual Non-Financial Motivation

• Aligns with personal, professional identity
• Improve care processes
• Improve patient outcomes

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Individual Non-Financial Motivation

Many of my family and close friends still live in the communities and actually experience the kinds of barriers that we are trying to address….a project like this speaks to my own personal commitment to population health and my belief that small projects can actually add evidence to the opportunities that we have as payers and like-minded

• rganizations to address disparities….when we have an
• pportunity to test something like this and discover if there

are advances we can make for our most vulnerable members, it’s worthwhile and it’s feasible. (Site B, Payer, Senior Management)

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Individual and Team-Based Financial Incentives

• Incentives may initiate new care delivery

processes

• Unclear which types of incentives are most

effective for disparity reduction efforts

• Well-resourced infrastructure (e.g., funding

for staff roles) may play a greater role in reducing disparities

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Individual and Team-Based Financial Incentives

A lot of clinicians do things because it’s the right thing to do especially if people make it easy for them to do it. So it’s not about the financial incentive, it’s about the non-financial incentive…. the struggle in clinical medicine is that we often don’t have the resources we need to take the best care of our patients. And so I thought the primary part of this study that was going to be most impactful was this extra [staff] resource and making it easier for clinicians to do the right thing. (Site B, Project Leadership) I think when incentives came in and they identified certain key points that we need to look at and give that holistic care, then it became a standard. And so everybody is doing the same thing, not just this provider over here. All three sites are doing the exact same thing. So it’s now standardized. (Site C, Nurse Clinic Manager)

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Implementation Challenges

• Linking incentives back to individuals in

health care organization

• Addressing concerns from community

stakeholders

• Unexpected organizational changes impact

intervention continuity and sustainability

• Information technology (IT) support for

accurate data tracking and reporting

Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation at the University of Chicago

Discussion