CSI-RI: Community Health Team Planning Workgroup

10/25/13

Reactions to Community Health Team Learning Collaborative:

Maine

Maine PCMH Pilot Practice “Core Expectations”

1. Demonstrated physician leadership2. Team-based approach3. Population risk-stratification and management4. Practice-integrated care management5. Same-day access6. Behavioral-physical health integration7. Inclusion of patients & families8. Connection to community / local HMP9. Commitment to waste reduction

10. Patient-centered HIT

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PCMH Practice

High-need Individual

Maine PCMH Pilot Community Care Teams

Transportation

Workplace

Environment

Food Systems

Shopping

Income

HeatFaith

Community

Literacy

Coaching

Physical Therapy

Hospital Services

Specialists

Outpatient Services

Med Mgt

HousingCare Mgt

Behav. Health & Sub Abuse

Family

Schools

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CCT Populations ServedCCTs review data from available sources (Medicare RTI reports, MaineCare Utilization reports, other payers, HIN) to identify • Hospital Admissions

o 3 or more admissions in past 6 monthso 5 or more admissions in past 12 months

• Emergency Department Utilizationo 3 or more E.D. visits in past 6 monthso 5 or more E.D. visits in past 12 months

• Payer identification of high-risk or high-cost patients

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Reactions to Community Health Team Learning Collaborative:

Vermont

October 21, 2103 77

Principles of Team-Based Care

Shared GoalsClear RolesMutual TrustEffective CommunicationMeasureable Processes and Outcomes

Mitchell et al, Core Principles & values of effective team-based health care, 2012 (Discussion Paper, Institute of Medicine, Washington, DC. www.iom.edu 777

Department of Vermont Health Access

Community Health Needs Assessments

Slides 9-17 Extracted from Community Health Needs Assessment Summary Reports completed by Holleran

Consulting

Background• Hospital Association of R.I. led the Community Health Needs

assessment in a timeline to comply with requirements set forth in the ACA and to further the hospitals commitment to community health and population health management

• Conducted September 2012 – May 2013• Memorial Hospital (Care New England Health System) and

South County Hospital participated

South County Hospital

Identified Areas of Need Access to Care Alcohol Cancer Incidence Immunizations Mental Health Status Overweight and Obesity

South County Hospital

South County HospitalDIABETES • Goal: To promote healthy lifestyles that reduce obesity,

improves pre-diabetes awareness, and results in better management of diabetes care (including self-management).

• Strategies: 1. Improve awareness of healthy lifestyles and prevention of obesity through Community Education and Health Screening Programs 2. Improve access to medical specialists for diabetes and endocrinology 3. Improve diabetes metrics within the Patient Centered Medical Community (PCMC) initiative 4. Maintain and ensure access to formal Diabetes Self-Management Education Programs

South County HospitalMENTAL HEALTH AND SUBSTANCE ABUSE • Goal: Improve mental health by increasing access to appropriate, quality

mental health services including substance abuse services, and improve care coordination across the continuum of care.

• Strategies: 1. Ensure that the SCHHS collaboratively addresses mental health related needs in the community it serves 2. Enhance access to mental health clinicians in primary care physician offices 3. Improve awareness of warning signs and symptoms of Mental Health and Substance Abuse to help ensure that interventions are managed at the most appropriate level of care

South County HospitalCANCER • Goal: To provide a multidisciplinary, patient-centered cancer program

that ensures a continuum of care that spans prevention, diagnosis, treatment, palliative and hospice care, and survivorship.

• Strategies: 1. Create a community cancer center facility that supports achievement of the stated goal 2. Ensure the availability and local access to cancer specialists and clinicians for cancers that can be appropriately managed in a community setting 3. Provide community outreach and cancer screening efforts to educate residents about the risk factors for cancer and benefits of early diagnosis 4. Increase the proportion of cancer patients referred to the STAR program service offerings

South County HospitalHeart Disease • Goal: Reduce the burden of heart disease through early identification,

and early and appropriate treatment/management. • Strategies:

1. Improve awareness of healthy lifestyles and risk factors for heart disease through Community Education 2. Increase the proportion of adults who have appropriate screening for hypertension and/or high cholesterol 3. Reduce re-hospitalizations rates for adults with heart failure as the principal diagnosis 4. Increase the proportion of heart attack survivors who participate in cardiac rehabilitation program upon discharge

Memorial Hospital

Identified Areas of Need Access to Care Asthma Breast Cancer Cardiovascular Health Diabetes Mental Health Status Overweight & Obesity

Memorial Hospital

Memorial HospitalImplementation Plan• Mental Health and Substance Abuse

– Goal 1: Decrease morbidity from diabetes and heart disease among persons with mental illness, including substance abuse disorders.

– Goal 2: Improve mental health by increasing access to appropriate, quality mental health services including substance abuse services.

• Heart Disease– Goal 1: Increase the number of women who are aware of their risk for heart

disease.– Goal 2: Reduce heart disease through early identification, and early and

appropriate treatment/management.• Diabetes

– Goal 1: Increase the number of people who are aware of the risk factors for diabetes.

– Goal 2: Increase diabetes self-management education for people living with diabetes.

Medicare FFS Top Diagnoses

Extracted from Presentation: “Readmissions in Rhode Island: Deep Dive into the Data.” Butterfield, Kristen

Extracted from Presentation: “Readmissions in Rhode Island: Deep Dive into the Data.” Butterfield, Kristen

Next Steps?