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Pathways Community HUBDecember 16, 2019
Context of HUBs
Current spending vs. Current outcomes
PMPM and FFS HEDIS Measures Shared Savings Pay for Individually Identifiable Outcomes
Based on volume.
Most prevalent healthcare payment model.
The more you do, the more you earn.
US health outcomes are declining as costs escalate.
Focused on medical factors of risk (no SDOH).
Based on % based accountability method.
Places a very small amount of financial accountability per person/per risk factor on assuring risk is addressed.
Better than having no measure of quality and may serve as a foundation for improvement.
Based on spending less on specific populations over time, with better outcomes.
When patients may change providers every 6 - 12 months, as is common in some Medicaid programs, incentives to generate savings may not focus on improving individual’s health.
No Quality focus
Based on solving actual problems, focusing on outcomes which are:
● Meaningful the the individual served, and
● Resulting in their ability to be healthier and more productive
In the HUB Model - Ties payment to each individually confirmed risk mitigation across medial social and behavioral health domain.
In the HUB model 50% of dollars must be tied to confirmed outcomes (addressed risk factors) in the HUB Model.
Neither connect $ to results. Approach typically tied to 1-3% of the contract value.
This level of percentage incentive is not seen often in business strategies to be enough to create impact.
Has not been proven to be effective in the literature.
Dr. Michael Porter at Harvard Business School: this approach is showing promise for medically focused factors
Emerging data.
Link between spend and outcomes?
Back to Basics
$ Must Be Tied to Meaningful Work Products
▫ What are the measurable work items that produce wellness?
▫ How do we organize, incentivize and get the work done?
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Addressing Risk Factors
Work Item Components
Change the drivers, to produce meaningful work products• Mitigate Risk
• Whole person approach, spanning the interlocking health factors
• Medical• Social • Behavioral Health
• Engaging their relationships as a central force for change.
Opportunity for Transformation
How can we go from here?
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What Can We Do?What makes the difference?
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Imperatives
Prevent justice system involvement
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Avoid unnecessary medical treatment
Fight Against the Pillars of Poverty
Growth and Development Health education, employment, and wellness
Fragmented Approach
Behavioral Health
Services
Day Care
MedicationAccess
Medical Home
Team Work – Your Community, Your HUB
▫ What are preventive IMRF?
▫ How could mitigation of an IMRF be measured?
▫ Compare mitigations of risk measures to HEDIS, FFS, Shared Savings.
▫ Is a risk mitigated a protective factor?
Model Overview The Pathways
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Direct Services = Intervention
Care Coordination = Assuring Connection to
Intervention – Risk Mitigation
Community Care Coordination – care coordination provided confirms connection to health and social services.
A Community Care Coordinator:
• Finds and engages at-risk individuals• Completes comprehensive risk
assessments• Confirms connection to care• Tracks and measures results
• Find those at greatest risk
• Identify their specific risk factors
• Assure the packages of intervention are delivered that address the risk factors!
Community Care Coordination
Small, incremental outcomes build to big outcomes
Care Coordination - Whole Person Care
Behavioral Health
Services
Day Care
MedicationAccess
Safe Sleep Education
Safety Education
Medical Home
Housing
Nutrition Education
SubstanceUse
Parenting Training
Food Employment
Assess and Address Risk
Factors
Physical Behavioral &
Economic Health
CHWs Help Clients Address Risk
Example: Medical Home Pathway
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2020 Standard Pathways
● Adult Education
● Behavioral Health
● Developmental Referral
● Employment
● Family Planning
● Food Security
● Health Coverage
● Housing
● Immunization Referral
● Learning
● Medical Home
● Medical Referral
● Medication Adherence
● Medication Review
● Medication Screening
● Oral Health Postpartum
● Pregnancy
● Social Service Referral
● Substance Use
● Transportation
Where do the Risks Come From - Risk Registry
Medical Domain
▫ Nutrition and food stability▫ Vaccinations▫ Vision▫ Hearing▫ Development▫ ER visits▫ etc.
Social Domain▫ Housing▫ Clothing ▫ Transportation▫ Childcare▫ Education▫ Financial and supportive resources▫ etc.
Behavioral Health Domain
▫ Parenting and family interaction
▫ Child abuse and neglect▫ Intimate partner violence▫ Substance abuse▫ Sleep routine▫ etc.
Safety Domain
▫ Safe sleep▫ Automobile restraints▫ Falls, drowning, choking▫ Fire and burns▫ Guns, equipment, and furniture▫ Environment, toxins, exposures▫ etc.
Risk Registry by Domain Partial List - Medical,Social, Behavioral Health and Safety
1/3 of Risks have Behavior Change Learning Modules
▫ 62 evidence-based risk learning modules
▫ Medical, Social, Safety, Behavioral domains
▫ Motivational interviewing approach
▫ CHWs follow up to confirm impact – i.e. using safe sleep, car seat utilized effectively, breast feeding etc.
(Range from parenting, compliance with medical home, financial literacy, healthy eating, reading to children, effective landlord communication, safe sleeping baby…)
The impact of mitigating risks
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The HUB
Care Coordination Today
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Current state: Uncoordinated Coordination
HUB: Community Convener
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HUB: Community Convener
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HUB: Community ConvenerFunding Funding
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HUB: Community Convener
Funding Funding
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HUB: Community Convener
Funding Funding
CHWs help clients connect to all available local direct service providers (the Intervention) including medical, social and behavioral health. Some CCAs are also direct service providers.
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Billing approach
▫ Most of the invoicing is for completed Pathways. Some of these invoice items are also tied to completed assessments.
▫ All Pathways have nationally defined Outcome based units (OBU) similar to relative value units (RVUs)
▫ OBUs are determined based on CHW time and value to patient▫ Learning module < 1 OBU▫ Housing Pathway - 9 OBUs
▫ Negotiate with Payor on:▫ $ per OBU ($/OBU)▫ Accelerates the ability to develop new contracts
Billing approach
State ExampleOhio’ network of networks
▫ 6 certified HUBs
▫ 5 HUBs in development
▫ Provides ready access to CBOs throughout the state
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HUBs work with any population
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Evidence of ROI
For every dollar spent on Community Hub activities, there was a savings of $2.36.
ROI: 236%
Newborns born to mothers at risk for low birth weight delivery
+ High risk: PMPM cost savings of $403+ Medium risk: PMPM cost savings of $252+ Low risk: PMPM cost savings of $171
94%High risk have highest cost savings through inpatient services
$379High risk: inpatient PMPM cost savings
Benchmarking Samples
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Building a HUBHow do you get there
Project Approach and Core Team Activities
▫ Certification ▫ Needs assessment▫ Convening▫ Governance▫ Sustainable Funding and Billing▫ Communications and operations▫ IT, and data model▫ Evaluation and Research▫ Business planning
HUB Strategic Design – Getting Started▫ Form a Core Team Planning Group
▫ Solidify the “Change Agent” leader for the initiative
▫ Create a new umbrella organization or designate a lead agency to be the HUB
▫ Reach out for technical support ASAP including starting the HUB Certification step one process to assure fidelity and sustainability of your approach.
▫ Identify the care coordination agencies who will hire and support the CHWs and get them involved early in the development.
▫ Conduct a community needs assessment or utilize existing data. This data in addition to the priorities of available funding should be used to determine your initial areas of outcome focus.
▫ Continue with outlined Strategic Design
Why Certification
▫ Required to claim evidence-based status with fidelity to the model
▫ Brings substantial resource for the latest Pathways, Learning Modules, Data Model, Benchmarking and Networking with Others Nationally.
▫ Required by some managed care and state funders.
▫ Brings your HUB together with the team of HUBs working together nationally to further improve the model
Certified HUBs
Resources
Pchi-hub.com
Accountability for Results and Strong Relationships Building Stronger Communities
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