California Health CareLeaders Network Spring Meeting

Huntington Beach, CA 3/6/15

June Simmons, CEOPartners in Care Foundation

Community Partnership Models

Social Services: An Old Discipline…A New Specialty

Health Happens at Home!Community-Based Organizations (CBOs)

Link the Home to Plans & Providers

to Improve Health and Well-being for Members with Chronic Conditions,

Behavioral Health Challenges and Functional/Cognitive Impairments

CBOs in the Chronic Care Model

Health Care’s Blind SideRWJF Survey of 1,000 PCPs:• 80% “not confident in their capacity to address their

patients’ social needs.” • 86% said “unmet social needs are leading directly to worse

health”.• 76% wish the healthcare system would cover cost of

connecting patients to services to meet health-related social needs.

• 1 of 7 prescriptions would be for social supports, e.g., fitness programs, nutritious food, and transportation assistance.

Health Care’s BLIND SIDE - The Overlooked Connection between Social Needs and Good Health, Robert Wood Johnson Foundation, December 2011, http://www.rwjf.org/content/dam/farm/reports/surveys_and_polls/2011/rwjf71795

Health Care + CBO/Social Services = Better Health, Lower Costs

• Address social determinants of health– Personal choices in everyday life– Isolation, family structure/issues, caregiver needs– Environment – home safety, neighborhood– Economics – affordability, access

• Social service agencies have advantages– Trust, time to probe, different authority– Cultural/linguistic competence– Lower cost staff & infrastructure– High impact evidence-based programs

Role of Agencies like Partners in Care

• “Eyes and ears” in the home

• Comprehensive psychosocial & environmental evaluation

• Gather data and information that is not shared in a medical setting or encounter

• Link medication issues with evidence based intervention

• Cultural competence & trust in local communities

• Attention to caregivers – special services, support, respite

Missing Data = Lost Clinical Opportunities

• Typical in-home assessment includes:– Medications inventory – Rx from all sources, OTC, borrowed, etc.– Patient understanding of meds & adherence issues– Physical & cognitive functioning– Depression screening– Nutrition – special diets, shopping, affordability, ability to prepare– Incidents – like falls, dizziness, confusion– Financial info: ability to afford care– Transportation for access to care– Caregiver information– Housing condition & home safety– Advance directive– Behavioral health: Diet, physical activity, alcohol, tobacco

Targeting: Key to Cost-Effectiveness

• Social determinants often invisible to medicine• Innovations require investment to build better

outcomes and decrease costs• Community partners help identify where these

investments will have greatest impact:– Population health management – prevention– Managing progression of chronic conditions & function– Medications management– Reducing admissions/readmissions & SNF– Late life care – palliative/hospice

Targeted Patient Population Management Services for Progressing Disease/Disability

End ofLife

Complex Chronic Illnesses w/ major

impairment

Chronic Condition(s) with Mild Functional &/or

Cognitive Impairment

Chronic Condition with Mild Symptoms

Well – No Chronic Conditions or Diagnosis without Symptoms

Hot Spotters!

Evidence Based Self-Management,

Home Assessment and HomeMeds

Home Palliative Care

Post Acute and Long Term Supports and Services

Value Proposition: CBOs & Triple Aim

• ED• IP

COST• Pain• Falls

HEALTH

• Needs Met

• Member Retention

QUALITY

Care Transitions Coaching

HomeMedsPlus

Stanford Self-Management Workshops

A Matter of BalanceHealthy MovesHomeMeds

Complex Community Care Management

MealsHome visitTransportation

Services for Diverse PopulationsModerate Risk – Chronic Diseases

w/o disability

Evidence-Based Self-

Management

HomeMeds

Complex – Eyes & Ears in the Home

HomeMeds+ Assessment &

Services

Care Transitions

Frail – Long term services & supports

Ongoing care management

Purchase of services

Who should you REALLY call? CBOs!• LTSS program for duals in California – MSSP

– Keeps nursing-home eligible seniors at home for an average of 5 years!

• Cost? $357/month vs. $3,000+ for SNF

• Care Transitions Coaching & Social Services– On Westside, cut readmissions by more than half!

• 10.1% readmission rate vs. 27.1% for those who met criteria but did not receive intervention

• HomeMeds-Plus– Home visit, med rec, pharmacist, psychosocial/ functional assessment,

home safety evaluation• In physician group post hospital – 13% lower rate of ED use & 22% lower rate

of readmission w/in 30 days• Discovered medication-related problems in 63% per pharmacist…AFTER

hospital medication reconciliation

Quality/HEDIS Measures

• Fall risk management• Medication reconciliation post-discharge• Potentially harmful drug-disease interactions• Blood pressure control• Antidepressant medication management

•Older Adults Received:– Advance care planning

– Medication review

– Functional status assessment

– Pain assessment

• HomeMedsPlus visit helps meet all measures!

"No risk factor for falls is as

potentially preventable or reversible as

medication use. (Leipzig, 1999)

HCBS Service Lines, Potential Purchasers & Value Proposition

Targeting Tiers of Need for Home Visit or Self-Management Support

Risk Criteria/Needs Tier 1 Tier 2 Tier 3 Tier 4Acute/LTPAC Use

Primary care only

Intense use of primary care and specialty care for chronic condition

1+ ED visit or unplanned IP in past year; Intense use of primary care and specialty care for chronic condition

2+ ED visit or unplanned hospitalizations or SNF stay in past year

Medications <5 prescribed meds

5-8 prescribed meds 5-8 prescribed meds 9+ prescribed meds

Functional Impairment

None known Ambulatory, independent, with assistive devices

Occasional assistance needed with ADL or IADL

Daily hands-on assistance needed

Cognitive Impairment

None known None or mild – able to arrange services or has caregiver who can do so

Mild to Moderate – needs assistance arranging services

Moderate to severe

Social factors Any or none Any or none. Prepare caregiver for decline.

Likely caregiver issues

Literacy/ health literacy

Speaks English; understands healthcare instructions

May need translation services or explanation but able to act on healthcare instructions

Not able to understand or act on instructions

Not able to understand or act on instructions

Self-management

Clinical signs outside of goal

Clinical signs outside of goal; at risk for decline

Clinical signs significantly outside goal

Clinical signs significantly outside goal/deteriorating

HomeMeds-Plus Targeting Criteria

1. Age 65+ and2. ED/hospital use in 6 months, plus 2 or more:

a) Hospital LOS > 6 days; orb) Six or more prescribed meds; orc) Warfarin/antiplatelet or insulin/diabetes meds; ord) Dx CHF, COPD, depression, anxiety, bipolar, psychosis; ore) DX of diabetes, dialysis, hemodialysis, renal failure, CKD, ESRD,

CAD, COPD or CHF; orf) Mild cognitive impairment; org) Recent treatment for fall or confusion; orh) Age 80+; ori) Limited caregiver support

Evidence-Based Self-Management• Who is it for?

– 2+ chronic diseases judged by CMs to be able to benefit• What is it?

– 6-week series of peer-led classes, including:• Stanford suite of Chronic Disease Self-Management Programs • Others: A Matter of Balance, Savvy Caregiver, Pain Management

• Why do it?– Less pain/distress– Improved member satisfaction– Fewer falls --More exercise/activity– Lower utilization of high-cost services– Decreased caregiver burden/depression

What is Self-Management?In order to live a healthy life, people with chronic

conditions must use these strategies:

Problem-Solving

Gain support of family members

Manage Pain

Understand and deal with emotions

Healthy Eating

Physical Activity

Medication Management

Planning

Manage fatigue

Work with Health Professionals

Stanford Healthier Living (CDSMP): Participant Health Outcomes

Sources: Lorig, KR et al. (1999). Med Care, 37:5-14; Lorig, KR et al. (2001). Eff Clin Pract, 4: 256-52; Lorig, KR et al. (2001). Med Care, 39: 1217-23.

Randomized, controlled trial of 1,000 participants

More appropriate use of healthcare services (less

ED/hospital more primary)

Overall Improved health status & quality of life

Greater self-efficacy and empowerment

Enhanced communication with physicians

Increase inExerciseEnergy

Psychological well-being

Decrease inPain and Fatigue

DepressionShortness of Breath

Limitations on Social and Role Activities

HomeMeds℠ - Bridge between Home and Healthcare

• HomeMeds℠ is designed to enable community agencies to keep people at home, out of hospital & nursing home, by addressing medication safety

• Practice change with workforces that already go to the home – more cost effective use of existing effort

• Targets problems for significance, accessibility to in-home staff, and likelihood of positive prescriber response.

• Focuses on adverse effects (falls, confusion, dizziness, vitals) … then determines if medications may be part of the cause.

• Cost-effective use of geriatric pharmacist for complex problems

Health Net© 2013 For general educational purposes only, not for legal or professional advice23

CBOs Strength: Supporting Healthy Lifestyles & Maintaining Independence

CBO CBO

CBO CBO

Majority of costliest 5% have functional limitations

Keeping Frail Elders Out of Nursing Homes

Purchased Services• Safety devices, e.g., grab

bars, w/c ramps, alarms• Home handyman• Emergency response system• In-home psychotherapy• Emergency support (housing,

meals, care)• Assisted transportation• Homemaker (personal

care /chore)• Respite care• Replace furniture or

appliances for safety/sanitary reasons• Heavy cleaning• Home-delivered meals• Medication management

(HomeMeds, dispensers…)

Referred Services• Personal Attendant• Adult Day Health• Home Health• In-Home Palliative Care• Hospice• DME• Evidence-based Caregiver

Support• Home-delivered meals• Housing Options• Communication Services• Legal Services• Insurance Counseling• Benefits Enrollment

(Medicaid, food stamps, etc.) • Money management• Transportation• Utilities• Volunteer services

Community Care

Coordination

Social WorkerRN

Client & Family

12

False Economy = Building Your Own when there Is Already an

Integrated Community Delivery System through CBO Networks

Winning Contracts Isn’t Enough

Referrals

Acceptance

Completion

Behavior change Healthcare• IT supports

targeting/referral• Programming to

support data exchange

• Workflow changes• Champions at all levels• Patient/member

motivation• Share outcomes data• Respect CBO expertise

CBO Changes:• Better IT security• Better IT systems• More insurance• Accreditation• Provider #• Workflow• Understand health

plan regulations• Motivate patients &

participants• Address barriers for

patients

Volume is a prerequisite for sustainability

CBOs Evolving New Infrastructure & Business Tools

• Flexible product lines for specific populations and payers

• Accreditation• CPT codes for billing• Supporting health plan’s Medical Loss Ratio• Integrated Information Technology (IT)• Working through an MSO/TPA• Networks for comprehensive service offerings and

geographic coverage

Partners at Home Network for an Integrated Community Care System

One Call Does It All!

Service Coordination

Evidence-based Self-

Management

LTSS: Meals, home mods,

transport., etc.

HomeMeds/Med Reconciliation

Behavioral Health Specialists

Comprehensive Assessments

Network Office/MSO

One call does it all!

Care Transitions: Buy vs. Build Decision

Members discharged to disparate parts of Southern California

L.A. County

Ventura County

Orange County

Considerations: Driving distances to patient home Knowledge of local services Training and experience Language / Culture Data collection / patient monitoring

Regional Network Model: Centralized, cost- effective, efficient

and experienced!

Individual Hospital Approach: Each hospital must hire, train, manage

and pay transitions directors and health coaches

Health Net© 2013 For general educational purposes only, not for legal or professional advice33

Time for Bold New Partnerships Between Health Plans and CBOs

Affordable excellence– New Models – New Specialty

Depth of experience, with deep local knowledge and connections

Full regional coverage with consistent tools, IT and results Evidence-based programs for chronic conditions and post

acute Careful targeting powerful value proposition Reduce ER, hospitalization, rehab, readmissions and SNF

placement

New Environment=Opportunities & Risks for CBOs and for Medicine

Opportunities:ACA focus on Triple Aim: Social services

address Cost, Quality, Satisfaction & Member Retention

Contracts with Plans & Providers give us Greater Reach, More impact, Sustainability

RisksHealth Plans Try to Build

what We Already DoLoss of government funding w/o new

$ sourcesDemise of CBO Sector

Contact Us

June Simmons, CEOPartners in Care Foundation732 Mott St., Suite 150, San Fernando, CA 91340Main #: 818.837.3775jsimmons@picf.orgwww.picf.org www.HomeMeds.org