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Mar 12, 2023 368 likes •857 views

The presentation will begin shortly. The content provided herein is provided for informational purposes only. The views expressed by any individual presenter are solely their own, and not necessarily the views of HRET. This content is made

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The presentation will begin shortly.

The content provided herein is provided for informational purposes only. The views expressed by any individual presenter are solely their

  • wn, and not necessarily the views of HRET. This content is made available on an “AS IS” basis, and HRET disclaims all warranties

including, but not limited to, warranties of merchantability, fitness for a particular purpose, title and non-infringement. No advice or information provided by any presenter shall create any warranty.

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  • The Why: Population Health Management
  • Carmela Coyle, President & CEO, Maryland Hospital Association
  • The How: Faith Community Health Networks
  • Reverend Bobby Baker, Chip Clay, Memphis Congregational

Health Network

  • Vincent DeMarco, President, Citizens’ Health Initiative
  • Darlene Won, LifeBridge Health

Overview

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Population Health Management

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  • “Managing the health outcomes of a group of

individuals”

  • Primary care
  • Patient activation and involvement
  • Care coordination for disease and chronic care
  • Focus on health and wellness
  • About more than just care – social supports

Population Health Management

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Page 6

Environmental and Social Factors 20% Family History and Genetics 30% Personal Behaviors 40%

Source: Determinants of Health and Their Contribution to Premature Death, JAMA

Health is driven by multiple factors that are intricately linked –

  • f which medical care is one component.

Medical Care

10%

Health is About More Than Clinical Care

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Changes How Hospitals Think

  • Do more to earn more  Rewards for efficiency and quality
  • Care for an individual patient  Care for an entire population
  • Acute care  Ambulatory care  Community care
  • Competition  Collaboration
  • Hospital care  Health care

Population Health Management

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Requires Different Role for Hospitals

  • Supply proactive, preventive and chronic care to all
  • During and between encounters
  • Regular contact with patients
  • Support patient efforts to manage their health
  • Manage high risk patients to prevent from worsening

Requires Partnership

Population Health Management

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Global Budgets and other payment incentives

  • Apply to all Maryland hospitals
  • One, annual $$ amount to care for all patients
  • Spending growth is capped
  • Payment incentives to manage all readmissions
  • Payment incentives to manage 65 complications
  • Focus on removing avoidable utilization
  • Value-based payment: pedal to the metal in MD

The Maryland Experience

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Faith Community Health Networks

  • Need community partners to help coordinate care
  • Faith community often has established interest in health
  • Congregations bring the power of community
  • Often a connection with hospitals’ faith-based missions
  • Many hospitals and faith orgs share a non-profit tradition
  • Provides eyes, ears and support outside the hospital
  • Community benefit opportunity
  • Greater understanding of diversity in our communities
  • Creates patient and consumer engagement

The Why

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Welcome to the Memphis Model

  • Dr. Bobby G. Baker,M.Div.
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The Healthcare System needs the Faith Community

  • Acute Care
  • Episodic Care
  • Personal Care
  • Practicing Medicine
  • Fee for Service

Chronic Care Relational Care Partnering with Patients Population Management Value Based

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CHN=The Trust Factor

Trust is the highest form of human motivation. It brings out the very best in people. Stephen Covey

Respect Trust Reliability Talk Straight Listen for Understanding Make Commitments

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The Congregational Health Network is a Asset Based, Faith Centered, Social Support Intervention that Improves Outcomes and Organizes Community Resources around Healthcare.

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Enhance & Leverage Congregational Strengths

  • Accompaniment
  • Convening
  • Connection
  • Storying
  • Sanctuary
  • Blessing
  • Prayer
  • Endure

Gunderson, Gary. Deeply Woven Roots: Improving the Quality of Life in your Community. Minneapolis: Fortress Press, 1997.

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World Health Organization 1986 Fundamental conditions for Health

  • Peace
  • Shelter
  • Education
  • Food
  • Income
  • Stable Ecosystem
  • Sustainable Resources
  • Social Justice
  • Equity
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Safety Net Partners

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The CHN Covenant Agreement

A signed document spells out partnership.

–

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579 11 695 1

Liaisons Congregations Navigators Congregation and Community Director Paid Staff Volunteers

Connection – CHN as an example 250,000+

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What Does a Liaison Do?

 Recruits congregational members into the network  Notifies Navigators of developments/changes  Follows network members into and out of inpatient setting  Coordinates transition from hospital  Marshals community resources  Provides information and referral services  Facilitates wellness activity participation

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Member Registration

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What Does a Navigator Do?

 Develops a network of community resources  Coordinates outpatient care  Helps clients navigate the service systems  Provides avenues for prevention and education  Maintains program documentation and participates in ongoing program evaluation and reporting

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Title of Slide Goes Here

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Navigators

  • Congregation
  • Population
  • Disease specific
  • Community
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CHN Congregations 46 Level 4 229 Level 3 36 Level 2 195 Level 1 695 trained liaisons 21,335 members registered Training Participation:

917 in Care & Visitation 313 in Care for Dying 168 in Mental Health First Aid 125 in Aftercare 95 in Transplant 80 in Disease Live With 52 in Today’s Health Iss 297 in Navigate Health System 166 Cancer, Med, Miracles 71 in Better Brains6/10/15 - 09/09

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Congregation Engagement Levels

  • 1. Signed Covenant
  • 2. Active Liaisons,

Registered Members

  • 3. Building Connections

and Capacity

  • 4. Community Engagaement
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Focus Areas

Elderly and Advanced Disease Mental Health Chronic Disease Infants and Mothers

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Care Pathways

Education Prevention Intervention Access Aftercare

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CHN CLASSES

  • 1. Alliance Aftercare Training
  • 2. Better Brains
  • 3. Caring for the Dying
  • 4. Congregational Care and Visitation
  • 5. Disease Conditions We Live With
  • 6. Healing Homes Family Violence Training - Organized Crime Commission & Victims to Victory
  • 7. Mental Health Issues & Resources for your Congregation
  • 8. Navigating the Health System
  • 9. Avoiding Burnout in Ministry
  • 10. Healthy Hearts: Prevention, Detection, & Treatment of Heart Disease
  • 11. Cancer, Medicine and Miracles
  • 12. Living With Alzheimer’s
  • 13. Living Well at Any Age
  • 14. Food & Faith from the Farm to Lord’s Table - Memphis Food and Faith
  • 15. HIV and STD’s Uncovered
  • 16. Christian PREP – Successful Relationship/Successful Lives
  • 17. Principals of Manhood
  • 18. Faith in the Face of Cancer
  • 19. Law School for the Community
  • 20. Living with Stroke Series
  • 21. Fighting Cancer Together
  • 22. Diabetes Empowerment Education Program
  • 23. Eyes, Vision, and Health: Making the Connection
  • 24. Creating Success Through Right Relationships
  • 25. Power to Forgive is Power to Heal
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CHN Information Database

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CHN INTERVENTION

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  • Focus on residents of ZIP Code 38109
  • Assets
  • Provide community Navigator
  • Trust/Relationships
  • Leverage CHN congregations
  • Assets
  • Restore Parish Concept
  • Congregation/Community
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All CHN Patients Have A Longer Time-to-Readmission

Regardless of diagnosis or conditions, all patients in the Congregational Health Network had significantly longer time- to-readmission than matched patients out of the network (CHN=426 vs. Non-CHN =306 days) from 2008 through 2011, first quartile. 426 306 CHN Non-CHN

Time to Readmission

LONGITUDINAL DATABASE (2005 -2011)

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Hospital Metrics Pre-CHN Post-CHN Total admissions 159 101 Admits/patient 3.2 2 Total readmits 37 17 Readmits/patient 0.74 0.34 Total patient days 1,268 772 Days/admit 8 7.6 Days/patient 25.4 15.4 Total charges $6,396,111 $3,740,973 Average charge/admit $40,277 $37,409 Average charge/patient $127,922 $74,819 ER admissions 84.90% 80.20% SUBSET N=50 Pre-Post Within Subject Cohort Comparison

Summary of Findings

At 25 months into the work of CHN, there were 473 people in the network. We have identified a subset that came through the hospital prior to CHN and looked at hospital utilization for the subset pre and post CHN, excluding trauma, expiration and hip replacement.

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MLH Decreases Charity Care Costs from 2011-2012

10,000,000 20,000,000 30,000,000 40,000,000 50,000,000 60,000,000 70,000,000 80,000,000 90,000,000 100,000,000 2010 2011 2012 38109 Residents All Patients

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Maryland Faith Community Health Network

Replicating the Congregational Health Network Model Vincent DeMarco, Maryland Citizens’ Health Initiative Education Fund February 2016

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Overview

 Maryland’s Health System Transformation  Regional Public Forums  Development of pilot of the Maryland Faith Community

Health Network at LifeBridge Health

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Maryland’s Health System Transformation

 New incentives for hospitals to develop/deepen partnerships

to keep patient’s healthy—both within and beyond the medical field

 New charge for our coalition to engage in health system

transformation

 Searching for models with strong evidence of impact both

  • n health outcomes and spending
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Number

  • f

forums 11 Number

  • f

participants 800+ Presenters

· HSCRC · Local

Health Improvement Coalitions

· Hospitals

and health systems

· Community

health providers

· Health

Departments

· Faith

communities

· MCHI · Foundations

Attendees

· Consumers · Government

agencies

· Community

groups

· Providers/provider

groups

· Hospitals/health

systems

· Faith-based · Civic

  • rganizations

· Union

Members Constituents

  • f

Attendees · Diverse populations/minorities · Seniors · Low-income populations · Immigrants · Chronically Ill · Children · Families · Caregivers · Parishioners

  • · Healthcare

providers and workers

  • Regional Public Forums
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Maryland Faith Community Health Network

 Pilot based on successful intervention developed at

Methodist LeBonheur Hospital in Memphis, TN in 2006

 Aligns efforts and resources in the health and faith

communities to better care for members of the community who are sick

 LifeBridge Health will pilot the model at Carroll Hospital

Center, Northwest Hospital and Sinai Hospital

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Maryland Faith Community Health Network

 2-year pilot funded by four local foundations along with in-

kind support from LifeBridge Health

 Adapting the model to our unique health care system  More religious diversity  Robust public health department infrastructures  Medicaid expansion/full implementation of the ACA  Strong existing partnerships with faith leaders within our

Health Care for All! Coalition

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Covenant Agreement

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Maryland Faith Community Health Network

Baltimore City

Baltimore County

Carroll County

Ark Church Empowerment Temple First Mount Calvary Baptist Church Gospel Tabernacle Baptist Church Gwynn Oak United Methodist Church Kingdom Life Church Koinonia Baptist Church Light of the World Outreach Center Muslim Community Cultural Center of Baltimore New Good Samaritan Baptist Church Open Bible Baptist Church Perkins Square Baptist Church Prince of Peace Baptist Church Promiseland Community Fellowship Shepherd’s Heart Missionary Baptist Church The Lord’s Church of Baltimore, Inc. Winston Ave. Baptist Church Zion Hill Baptist Church Beth Israel Congregation Collective Christian Ministries Journey of Faith Church Liganore United Methodist Church Sandymount United Methodist Church

  • St. John’s Catholic Church

Goal: 100 congregations participating in the network in year 1, 200 congregations by year two

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Next Steps

 Designing rigorous independent evaluation with PATIENTS

program at University of Maryland School of Pharmacy

 Preparing training for congregational liaisons/official

program launch

 Sharing what we learn

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Please click the link below to take our webinar evaluation. The evaluation will

  • pen in a new tab in your default browser.

https://www.surveymonkey.com/r/hpoe-webinar-02-11-16

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@HRETtweets

#hpoe

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Upcoming HPOE Live! Webinars

  • February 23, 2016

– Going Beyond REaL Data Collection: Collecting Social Determinants of Health For more information go to www.hpoe.org