Paul Grundy MD MPH, Kristi Bohling-DaMetz RN BSN MBA,

David Ehrenberger MD

HealthTeamWorksGolden, Colorado

16 September 2018

Bringing the Medical Neighborhood to Life:Key Drivers of High Performing Delivery Networks

Faculty Disclosure

• Paul Grundy MD MPH has no financial relationships to disclose relating to the subject matter of this presentation.

• Kristi Bohling-DaMetz RN BSN MBA has no financial relationships to disclose relating to the subject matter of this presentation.

• David Ehrenberger MD has no financial relationships to disclose relating to the subject matter of this presentation.

Disclosure

• The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational use(s) of drugs, products, and/or devices (any use not approved by the U.S. Food and Drug Administration).

• Applicable CME staff have no relationships to disclose relating to the subject matter of this activity.

• This activity has been independently reviewed for balance.

Learning Objectives—and key take-aways

1. Describe 3 “network foundation” services that are key to powering 3-Part Aim performance of collaborative and accountable practices.

2. Describe how formal collaboration with community-based, non-medical services (community-integrated model of healthcare) can be particularly effective in assessing and addressing social determinants of health.

3. Name important ways a medical/health neighborhood—with its collaborative of community providers—can address the “pathophysiology” of burnout and help restore purpose and work-life balance (vitality).

Making Advanced Primary Care Tick

Paul Grundy MD MPH:• Beyond the Medical Home--Why Neighborhoods matter• System perspectives from both sides of the Atlantic on “what

works”

Away from Episode of Care to Management of Population with Data

The Network as System Integrator• Creates a partnership across the medical neighborhood• Drives PCMH primary care redesign• Offers a utility for population health and financial management

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System Integrator

Community Health

PopulationHealth

Per CapitaHealth

PatientExperience

PublicHealth

Michigan Patient-Centered Medical Home Program

Program showed statewide transformation of care.

9.9% Decrease in adult ER visits

27.5% Decrease in adult ambulatory care sensitive inpatient stays

11.8% Decrease in adult primary care sensitive ER visits

8.7% Decrease in adult high-tech radiology usage

14.9% Decrease in pediatric ER visits

21.3% Decrease in pediatric primary-care sensitive ER visits

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4,022 primary care doctors at 1,422 practices around the state in its sixth year of operation. These practices care for more than 1.2 million BCBSM members. Currently in year 8; 14 July 2017.

United Kingdom: The PCH Model and Experience

Four core characteristics of a Primary Care HomeThe provision of care to an evidence based, registered population size of 30,000 to 50,000 people

A combined focus on personalization of care with improvements in population health planning, provision and outcomes

An integrated, multi-disciplinary workforce, with a strong focus on partnerships spanning primary, community, secondary, third sector, mental health and social care

Financial drivers aligned with the health needs of the whole population working towards managing a delegated whole population budget

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The 30-50k population of a PCH, through being the right size to scale and right size to care, brings benefits for the future development of Primary Care:

• Improved patient care: Enhancing proactive and person centered care by focusing on the needs of the person rather than the needs of the service. Enriching the experience of an individual in a care system with increased satisfaction, particularly in relation to good access to services

• Increased staff fulfilment: The PCH provides the environment and conditions for workforce development and effective team working, alleviating pressure across the local system and increasing the ability to attract and retain staff.

• Improved utilization of locals resources: care teams that do the work take responsibility for a whole population budget for that registered community, redirecting resources from the acute sector where they can be more appropriately invested in primary care

• Delivers improvements in General Practice: multi-disciplinary teams in primary care will release more time for GPs

• Helps to stabilize Primary Care: make it easier for local providers to engage with each other and disparate units of Primary Care to coalesce into more robust units

The PCH Model Will Deliver Multiple Benefits in Primary Care

Association Between Elements of the PCMH Model & Clinical Quality in the Veterans Health Administration

Nelson K, Sylling PW, Taylor L, Rose D, Mori A, Fihn SD. Clinical Quality and the Patient-Centered Medical Home. JAMA Intern Med. 2017;177(7):1042–1044. doi:10.1001/jamainternmed.2017.0963

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PCMH 2.0 in action

A coordinated Health System

Health IT Framework

Global Information Framework

Evaluation Framework

Operations

Specialists

Public Health Prevention

Public Health Prevention HEALTH WELLNESS

Nurse CoordinatorSocial Workers

DieticiansCommunity

Health WorkersCare Coordinators

PCMH

PCMH

Community Care Team Hospitals

The Medical Home is Not a Car…

…Why it takes a Medical Neighborhood

David Ehrenberger MD

ADVANCED PRIMARY CARE: DRIVERS

• 5-Part Aim• Healthcare Value• Advanced Primary Care• Delivery Network• Foundation• Impact Drivers• Lived-Environment• Community Integrated Primary Care• Medical & Health Neighborhoods

Neighborhood Vocabulary & Definitions

Why Do Neighborhoods Matter?Shifting the perspective from primary care as foundation to…The Delivery Network as foundation

Neighborhood:• It’s where patients live

• The most important center of patient-centered care• It’s what purchasers of high-value healthcare purchase

• Not episodic, fragmented care, CT scans, volume-centric “systems” of care• It takes a community:

• Medical & non-medical drivers of health• Essential building blocks of Advanced Primary Care as shared resources

(“community/neighborhood utilities”) and economies of scale• Meaningful integration: provider team engagement, collaboration,

accountability (5-part aim)

Why Do Neighborhoods Matter? (p.2)Critical look at Advanced Primary Care: Form, Function and Capabilities We know what works: Bodenheimer Building Blocks, NCQA, CPC+

• Attributes of high-value primary care (Simon et al, AFM 2017) We know what it costs: high performing medical homes add ~$105k/provider/year to

expenses• Incremental cost of maintaining a medical home (Magill et al, AFM 2015)

We know where medical homes struggle:• Time allocation study: 27% in direct patient care (Sinsky et al, Annals of IM 2016)• Social Determinants of Health (SDOH)• Health Information Technology (HIT)• Clinical Analytics—owning their own data• Market-relevant value• Workplace “vitality” (vs. burnout)• Primary Care “Pile-On syndrome”

“It takes a neighborhood…”

Integrated Delivery Network:

Drivers of High Performance

Network Transformation Performance Drivers: https://healthteamworks.org/Network-Performance-Improvement/

Essential Neighborhood INFRASTRUCTURE:Making the Medical Home sing• Physician Executive and Governance leadership (dyad)• Business Model to support market-relevant value & reduce TCOC: funds flow• Performance Improvement--coaching, methodology; culture change agents• HIT utility model and support• Advanced Teamwork: structure (teamlets) and function• Workforce Development: health navigators, community health workers, care managers• Community-Clinical Linkages—addressing social determinants of health• Data tools (clinical and payer)—human-centered design to power teams, PI, & identify risk• Creating Community & venue for shared playbook: PCP, Specialty Care Providers, tertiary

care• Business-of-practice optimization• Prioritization of provider and provider team vitality

Neighborhood Design: the Clinically Integrated NetworkSolving for Complexity

1. Physician Leadership and Governance• Accountability for value; marketplace parity (the modern physician paradox)

2. The Turnkey HIT Solution• One platform--multiple practice TINs• EMR, EPM, HIE, Pt Portal • Training and Support

3. Primary Source Data, Analytics, Actionable Reports• End-user validation• Real time, meaningful, actionable• Gold in, Gold out…made easy

4. Performance Improvement • Essential toolkit—Care Planner, Registries• Practice Transformation Coaching• Model for Improvement/Quality Work Plan

5. Payer Contracting• Single Signature, shared savings, risk contracting

Pre-Visit Planning Tool:• Real-Time• HCC Scoring• Gaps ID to power top-of-

license care• SMS, Advanced

Directives• Prospective Rx refills• Future appointments• Pending referrals

Powering Advanced Teamwork

Empanelment and Universal Registry

2-Steps (3-factor) Risk Stratification:• Clinical Data• Utilization• Team Gestalt

Population Management: The Power of Primary Source Clinical Data

Population Management: The Power of Primary Source Clinical Data

Population Management: The Power of Primary Source Clinical Data

The Total Cost of Care: Advanced Primary Care Impact

Blue Cross Blue Shield of Michigan: IMPACT*

• Total Cost of Care: reduced by $26.37 PMPM

• Improved breast, cervical & colon cancer screening

• Hospital utilization decreased by 13.9%• ED utilization decreased by 11.2%• Hospital PMPM cost reduced by 17.2%

*Impact of Primary Care Practice Transformation on Cost, Quality and Utilization PCPCC 2017

Community Integrated Primary Care: Care Management 2020--Kristi Bohling-DaMetz RN BSN MBA

• Accountability and Services focused on the Network’s patient population

• 2-Step Risk Stratification• Community-Clinical Linkages

• Formal, effective and efficient partnerships of medical and non-medical providers of health services

• Resource allocation across a community• Secret to SDOH impact: meeting patients and their families

where they are at

Patient needs define the PCMN

Patient Needs

PCMN

Integrated Teams

Community Linkages

Building the Evidence…

Outcomes (5-Part Aim)

Drivers

Change Concepts

Evidence-BasedPatient Care

+Value-Based

Business Case

The Expanded Care Team – Redefining the Workforce!Traditional Practice-Based Team

PCMN

Physician Physician/NP/PA

MA Clinical Care Managers (RNs)

Non-Clinical Staff Care Coordinators

Social Work

Behavioral Health Consultants

MA

Non-Clinical Staff

Pharmacist

Other specialties

Medical and care facilities (e.g. Hospital, SNF, LTCF, Rehab, etc.)

Public Health

Community based organizations

Continuous Improvement

Collaboration + Accountability

Results

Connecting the PCMN via Risk Stratified Care ManagementImpact to Cost Savings:• Management of chronic conditions

1 ½:1• Management of a high cost population

3:1• Palliative Care

9:1Other cost impacts:

Reducing high cost care (e.g. 30-day all cause readmissions, ED use, ambulatory sensitive admissions, etc.)

Impact to Quality:Active care planning, health coaching, self-monitoring and self-management support, patient engagement, and condition-specific action planning can have significant impact on patient activation, reduce chronic flares, and impact overall population outcomes (e.g. QPP, eCQMs, etc.)

Impact to Patient Experience:• As the health care system becomes more complex, being a patient can be confusing. A care

manager working with a patient who has been newly diagnosed, is in poor health, is experiencing multiple transitions across care settings, or is in need of social supports benefits is essential to reducing that confusion. This may require episodic and longitudinal care management approaches.

Risk Stratified Care Management

• Empanelment• 2 Step Risk

Stratification• Resource allocation• Integrated team• Care Pathways

Identifying patient needs

• Navigation• Episodic/Longitudinal• Evidence based

coaching• Shared care plans• Care conferences

What

• Begin with the end in mind… what is the desired outcome?

• Impact – Quantitative and Qualitative• Sustainability – ROI• Scalability – investing in the infrastructure

So What…

CM Scorecard, Defining Focus and Impact

Where does the other work go?

Access to DataMeasure Alignment

AutomationQuality Improvement Team

PracticeNetwork

to Effective Care Management

1. Absence of a proactive infrastructure strategy with clear objectives prior to implementation/investment,

2. Lack of consensus on CM expectations and measures of success across the organization (scorecard), and

3. Inadequate investment (with ROI to support sustainable impact and scalability).

Health Neighborhood as Mojo

Mary Jo was not forgotten—story by tracer• 2-Factor Risk Stratification report—sounding the alarm, office no

show• Just dial “1”—meeting the patient where she is at• Eyes for both medical and social context• Community-based therapeutic fabric—BH, LCSW, ride-share,

caregiver support• Utilization impact…compassion

It Takes a Community…

Finis