Practice Transformationat CommUnityCare

Jaeson T. Fournier, DC, MPH

President and Chief Executive Officer

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Toward Value Based, Accountable Care …What most patients confront:

1. A complex, fragmented, and confusing system.

2. Providers and care systems that lack effective care coordination and care management.

3. Insurers (if they are insured) that are typically “hands off” with activation based on significant spend thresholds.

What CommUnityCare has emphasized on its journey to become a value driven, accountable health care provider:

1. Expanded care teams with enhanced responsibilities for all team members.

2. Assessment of current resources and needed resources to support a longitudinal patient management approach …. i.e. population approach.

CommUnityCare – Shifting our Care ModelCritical Goals and Elements

Triple Aim + 2:1. Reduced total cost of care.

2. Improved clinical quality.

3. Improved patient and family satisfaction.

4. Emphasis on primary care services and relationship.

5. Enhanced Care Coordination and patient activation.

Key Program Components:1. Population health management infrastructure and

robust data analytics.2. Performance improvement & clinical transformation

that is provider and quality focused and led.3. Care coordination across care settings including care

transition and ED follow-up.4. Risk stratification that accounts for utilization patterns,

diagnostic criteria and social factors.5. Effective population empanelment at the care team

level .6. Patient receptivity to change.7. Hot spotting.8. Executive commitment and program governance.

Population Health

Experience of Care

Per Capita Cost

Better

Care

Better

Health

Lower Cost

Expanded care coordination:

Manages across care settings

Population health management

infrastructure:

Provides clinical intelligence

Clinical transformation through

expanded care teams:

Drives measureable results

Leadership:

Drives operating

discipline

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Primary prevention outreach that includes:

- Immunizations

- Recommended screenings

- Annual well exams

Team Members- Care Coordinators, Care Teams, Patient Navigation

Center

Chronic Conditions

Secondary prevention and delayed disease

progression/onset:

- Condition specific screenings

- Disease specific education and outreach

- Patient engagement and goal creation

Team Members- Behavioral Health Consultants, Dieticians,

Care Coordinators, Community Health Workers

Complex Cases

Improved quality of life and reduction in total cost

of care :

- Monthly check-ins from your care team

- Assigned team to navigate social barriers

- Personal team to address care plan questions

Team Members

- Nurses, Social Workers, PharmacistsCare

Management

Care Coordination and

Disease Management

Population

HealthWell

CommUnityCare’s Approach to Population Health Management

Data Informed: CHNA FindingsHealth Outcome Disparities

1.79

1.69

1.25

1.13

1.63

1.89

1.601.54

1.19

1.07

1.49

1.65

1.00 1.00 1.00 1.00 1.00 1.00

Diagnosed withDiabetes: Adults 18 +

Experienced a Stroke:Adults 18 +

High Blood Pressure:Adults 18 +

High Cholesterol:Adults 18 +

Mental Health Not Good ≥ 14 Days:

Adults 18 +

Physical Health Not Good ≥ 14 Days:

Adults 18 +

Vulnerable Population (31 CT)

Eastern Crescent (70 CT)

Non-Eastern Crescent (117 CT)

BRFSS Health Outcomes in Austin:

Risk Ratio by Indicator and Geographic Area

Data Informed: CHNA FindingsPrevention Disparities

0.800.68

2.83

0.61

0.890.840.76

2.37

0.69

0.921.00 1.00 1.00 1.00 1.00

Cholesterol Screening:Adults 18 +

Colorectal CancerScreening: Adults 50 to 75

Current Lack of HealthInsurance: Adults 18 - 64

Dental Visit in Past Year:Adults 18 +

Mammography Use:Females 50 to 74

Vulnerable Population (31 CT)

Eastern Crescent (70 CT)

Non-Eastern Crescent (117 CT)

BRFSS Prevention in Austin:

Risk Ratio by Indicator and Geographic Area

7

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Clinical Transformation Already Underway❖Expanded Care Team

❖Alternative Care Models:

▪ Alternative Visits

▪ Mobile

▪ Home VisitsPatient Centered.

Population Focused.

Monitoring Utilization

Monitoring Utilization

Frances Isbell, CEO

Healthcare for the Homeless – Houston

Contracted with Health Management Associates to conduct an assessment with report to Board and staff leadership

Began planning process in fall, 2016 with first pilot implementation in spring, 2017

Planning team consisted of representatives from each department, some front-line staff and some department heads

➢Team Based Care

➢Risk Stratification Process &Methodology

➢Care Management Models

➢Enhance Primary Care Access

➢Maximize Clinical Model

➢Update QI Plan & Performance Dashboard

➢Standardized Processes, Policies & Efficiencies

➢Operations and Infrastructure

EXTENDED TEAM

CORE TEAM

Behavioral Health ConsultantsCase Managers

Community Health WorkersPsychiatrist/tele-psych

Pharmacy staffClinical Admin (Lead MA, Dir. Clinical

Services)

Volunteers

Reception/RegistrationRegistered Nurse

PCPMA

teamlet

student

student

PCPMA

teamlet

student

student

PCPMA

teamlet

student

student

Team-Based Care Pilot:

Core and Extended Team Structure for

Caroline Street Clinic

Considered “extreme” integration

Three crucial components:

▪ co-location – placing the behavioral health service within the primary care setting

▪ collaboration –includes frequent sharing of information, joint treatment planning and a truly biopsychosocial approach to care

▪ integration – occurs when behavioral health provider is seen as a regular part of the healthcare team and is a routine part of care

Behavioral Health Consultant (BHC) sees patients with Primary Care Clinician at “point of care”

Focus on CBT, MI, brief interventions

Referrals to psychiatry, “traditional” therapist, and substance use counselor considered “specialty” referral

BHC serves as a point person for coordinating care

Shifting to

Value Based

Care: Practice

Transformation

in the FQHC

Setting

Healthier Texas Summit: Practice Transformation in the FQHC Setting

October 25, 2018

Rhonda Mundhenk, JD, MPH

CEO, Lone Star Circle of Care

The scenario …

The scenario …

Culture … and its forgotten role in practice transformation

LSCC’s Journey• Inspire

• Expect (greatness)

• Be(come) great

• Celebrate

• Renew

Culture – the forgotten element of practice

transformation

Year External Forces Internal Adaptations Internal Clinical Metrics External Validation

2012 • year 1 of Meaningful

Use

• first ACO contract

(Pioneer)

• clinical analytics

team formed

• other systems in

place:

• Centralized

call center

• TJC, PCMH

• productivity • $718K in MU

2013 • still in ACO (MSSP)

• still in MU

• DISRIP

• HRSA adds quality

awards

• PCMH • productivity • HRSA adds quality

awards; LSCC in

top 20%, Health

Center Quality

Leader

• $633K in MU

• Level 3 PCMH

Culture – the forgotten element of practice

transformation

Year External Forces Internal Adaptations Internal Clinical Metrics External Validation

2014 • same as 2013 • created provider

scorecards

(transparent)

• productivity

• clinical quality

• HRSA top 20%

Health Center

Quality Leader

• earned ACO

shared savings

• $1.3M in MU

2015 • all of the above;

additional pay for

performance contracts

with certain payers

• investments in

leadership

• productivity

• clinical quality

• HRSA: top 20% HC

Quality Leader

• HRSA: National

Quality Leader

Award in

Pre/Perinatal Care

• $455K MU

Culture – the forgotten element of practice

transformation

Year External Forces Internal Adaptations Internal Clinical Metrics External Validation

2016 • same as 2017 • added financial

incentives to

provider

scorecards

• added MA

scorecards (with

financial

incentives)

• investments in

middle managers

• productivity

• clinical quality

• patient

satisfaction

• HRSA: moved into

top 10% Health

Center Quality

leader

• Target: BP award

(AMA & AHA for

hypertension

control rates)

• $807K MU

• Re-recognized

Level 3 PCMH

Culture – the forgotten element of practice

transformation

Year External Forces Internal Adaptations Internal Clinical Metrics External Validation

2017 • same as 2016 • added centralized

RN pop health

team

• analytics supports

pop health by

creating registries

and reports

• built chronic

disease

management

template in EMR

to collate

pertinent data and

clinical decision

support logic in

one place

• productivity

• clinical quality

• patient

satisfaction (stand

alone)

• HRSA: retained

top 10% Health

Center Quality

leader

• target: BP award

• earned ACO

shared savings

• Earned $485K in

MU

Culture – the forgotten element of practice

transformation

Year External Forces Internal Adaptations Internal Clinical Metrics External Validation

2018 • same as 2016 • added patient

navigation center

scorecards

• investments in

leadership and

middle

management

• productivity

• clinical quality

• patient

satisfaction (stand

alone)

• HRSA: retained

top 10% Health

Center Quality

leader

• target: BP award

• earned ACO

shared savings

• Earned $485K in

MU

2019 • all of the above;

additional pay for

performance contracts

with certain payers

• revised executive

and management

performance

review system

• front desk

scorecards

• productivity

• clinical quality

• patient

satisfaction

LSCC UDS ScoresNational UDS

Scores

2013 2014 2015 2016 2017 2017

Total Cost Per Patient $ 760 $ 804 $ 804 $ 942

Cancer Screening

• Cervical Cancer Screening 62.5% 65.5% 69.1% 71.4% 71.9% 55.7%

• Colorectal Cancer Screening 10.0% 23.2% 33.5% 44.3% 41.7% 42.0%

Other Screenings/Prevention

• Pediatric Weight Assessment,

Nutrition/Activity Counseling66.7% 72.9% 76.2% 81.9% 65.9%

• Adult BMI Screen and Follow up 60.8% 54.9% 79.2% 88.2% 63.9%

• Tobacco Screen & Cessation

Counseling83.3% 97.7% 98.6% 87.5%

• Depression Screen & Follow up 74.6% 81.7% 87.0% 66.2%

• Dental Sealants 31.5% 39.2% 58.6% 50.7%

Chronic Disease Management

• Coronary Artery Disease: Lipid

Therapy64.6% 83.7% 87.3% 95.9% 94.9% 80.7%

• Ischemic Vascular Disease: Aspirin or

Anti-thrombotic67.9% 87.0% 85.5% 91.4% 94.6% 79.3%

• Controlling BP in Hypertension 59.0% 62.7% 66.6% 70.1% 73.9% 62.7%

• Diabetes: Poor Control (inverse

metric)35.3% 32.3% 33.0% 31.6% 30.0% 33.0%

Summary

expect (greatness)

be(come) great

celebrate

renew

inspire