Too Big to Solve Alone: Minnesota Collaboratesapp.ihi.org/FacultyDocuments/Events/Event-2930/Presentation-15894/... · •Risky to be the market leader ... 4) Inter-organization trust

Too Big to Solve Alone: Minnesota CollaboratesClaire Neely, MD; Keith Olson, DO; Shaun Frost, MD; Bruce Sutor, MD

Session: C11These presenters have

nothing to disclose

December 12, 2017 1:30-2:45

#IHIFORUM

Session Objectives

Participants will:

Describe strategies used to launch a collaborative

engaging health plans and care systems

Learn to use the Collaborative Action Framework to

support their own work

Understand when collaborative action is a beneficial

method to solve complex problems

P2

#IHIFORUM

Speakers

Claire Neely, MD, Chief Medical OfficerInstitute for Clinical Systems Improvement

Keith Olson, DO, Regional Medical DirectorAllina Health Systems

Bruce Sutor, MD, Chair, Clinical Practice

Department of Psychiatry and Psychology,

Mayo Clinic

Shaun Frost, MD, Associate Medical DirectorHealthPartners

All speakers have nothing to disclose

P3

#IHIFORUM

Agenda

This Collaborative: Context

Claire Neely

Opioid Crisis: Prescribing Practices

Keith Olson

Mission Impossible: Mental Health

Bruce Sutor

Engines and Amplifiers: Health Plan Perspective

Shaun Frost

Behind the Curtain

Claire Neely

This Collaborative

Claire Neely, MD

Chief Medical Officer

Institute for Clinical Systems Improvement

[email protected]

• Regional Health

Care Improvement

Collaborative

• 50+ care delivery

organizations

• 3 non-profit health

plans

• Founded 1993

• History of

collaboration


Is there a compelling

reason for our

organizations to

collaborate in this

market?

What problems are we

facing that we’ve not

been able to solve on

our own?

The Beginning

• Responsibility to

improve health

• Pledge to collaborate

on persistent

problems

• Not solvable by

single entity or by

competition

• Success depends on

our personal

leadership

The Pledge

Why Collaborate

• Problem complexity

• System fragmentation

• Shared population

• Risky to be the market leader

• Support emergent solutions

• Change the market for the region-sustainability

• Avoid the “Tragedy of the Commons”

• It’s been successful before

9

• Children’s Hospital and

Clinics of MN

• HealthPartners

• HealthEast Care System

• North Memorial Health

Care

• University of MN

Physicians

• UCare

• Fairview Health Services

• Essentia Health

• CentraCare Heath

System

• Hutchinson Health

• Medica

• Mayo Clinic

• Hennepin County

Medical Center

• Ridgeview Medical

Center

• Allina Health

10

Collaborative Members

Criteria

• Private sector control and

influence

• Enduring problems

• Aligned with

organizational priorities

• Experts and resources

available

11

Areas of Focus

Collective Impact

• Common agenda

• Shared

measurement

• Mutually reinforcing

activities

• Continuous

communication

ICSI’s role:

• Steward of resources

• Neutral convener

• Relationship mediator

• Manage risk (anti-trust)

• Nurture emergence of

new ideas

• Catalyst

• Keep focus on

collaborative action

12

ICSI’s Role: Backbone Organization

Tasks

• Experts convened

• Scope

• Topic refinement

• Aims and goals

• New teams

convened

• CEO review, revision

and support

ICSI’s role:

• Building a collaborative

platform

• Logistics

• Building trust

• Modeling transparency

• Facilitation

• Evidence review

• Promoting collective

accountability for action

13

Getting Started: January-April 2017

Mental Health• Integrating behavioral

health and primary care

• Improving the care for patients in mental health crisis in the ED

Opioid Crisis• Improve access to chronic

pain treatment

• Improve prescribing practices

• Identify high-risk

• Increase disposal options

ICSI’s role

• Environmental scanning

• Sharing practices

• Problem clarification

• CEO engagement

• Increasing

participation/engagement

• Timelines

• Streamlining processes

14

Discovery & Development: May-Sept 2017

Activities

• Call to Action

packages being

implemented

• Design, prototyping,

testing, spread and

scale

• Measurement

• Evaluation

• Communication and

dissemination

ICSI’s role

• Relationship management

• Re-framing problems

• Transferring leadership

• Environmental scan

• Alignment

• New stakeholders

• Learning networks

• Evidence creation

• Bias toward action

15

Calls to Action: October-Current

• 9 working groups

– MH-Acute

– MH-IBH

– Opioid-Chronic use

– Opioid-Acute

– Opioid-Peds

– Opioid-High risk

– Opioid-Disposal

– Communications

– Measurement

• 3 advisory councils

– Evaluation

– Measurement

– Govt Relations

• Aligned organizations

– Public sector

– Private

• >150 expert volunteers

• CEO convening

16

Current Status

© ICSI 2013

Opioid Crisis: Prescribing Practices

Keith Olson, DO, MHA, FACHE, FACOFP

Regional Medical DirectorAllina Health

[email protected]

• 1.5M OP admissions

• 109K IP admissions

• 60K OP surgeries

• 32K IP surgeries

88 Clinics

• 4.5M clinic visits

13 Hospitals

1919

20

COO=Chief Opioid Officer

21

• The complexity of the opioid crisis requires a multi-faceted, rapid, coordinated effort

• Recognize that everyone in the community has a role to play

• Collaboration• Work on multiple parts of the problem simultaneously• Clarity on the risks of prescription opioids• Re-education of health care professionals• Recognition that addiction is a chronic disease and

treating it appropriately• Agree to a minimum set of standards by health systems

Health Affairs Blog, June 13, 2016

A Systems Approach Is The Only Way to Address the Opioid Crisis

22

• Under treatment of pain• Increase in number of heroin deaths• Provider burnout• Increased use of recreational cannabis• Punitive approach to opioid patients• Increased workplace violence• Increase in Emergency Department visits• Kick the can• Additional demand for services that will further

strain the current healthcare system

Unintended Consequences/Collateral Damage

23

• CEO charge Aim #1: “Achieve significant reduction in the number of pills or morphine milligram equivalents (MMEs) prescribed for acute pain to opioid naïve patient over one year”

• Workgroup composition

• Approach?

o Initial - Decrease acute opioid prescriptions by 20-25% by June 2018 o First Rxs, Post-operative Rxs, ED Rxs, Dental Rxs

oMeasurement - # of pills vs. MME?

Acute Pain Prescribing Work Group

24

• Final Prescribing Recommendations:o Initial patient assessment, realistic expectations of pain,

shared treatment goals, start with non-opioidso If opioids appropriate, lowest possible effective strength

short-acting opioid for shortest period of timeo First opioid Rx for acute pain not to exceed 100 MME

total, instruct patient 3 days or less is enougho For patients presenting in acute pain already on chronic

opioids, opioid tolerant, or on methadone consider Rx for an additional 100 MME with plan to return to baseline

o Geriatric patients assessed for risk of falls, cognitive decline, respiratory or renal impairment. Consider reducing initial opioid dose by 50%


25

• Postoperative Pain Rx Recommendations:o Minor surgeries? – APAP, NSAIDS, multimodal options

as part of pain management plano Patients taking opioids pre-op should have postop

pain management plan agreed upon before surgeryo If opioids deemed appropriate to manage post-op

pain – low dose, short acting, with plan to taper after 3-5 days

o Surgeon should manage all post-op paino Individualized postop care and treatment but still

possible to recommend maximum postop MME dose


26

Review data from health plans:

26

Process to Operationalize?

27

• Select top surgical procedures

• Review current average MME and if possible 25th

percentile average MME to establish goals

• Develop consensus around expected pain/recovery – mild, moderate, severe

• Create procedure groupings that fit with 100/200/300 or 400 MME maximum totals

27

Process to Operationalize?

28

• Recommend tools in the EMR to simplify MME calculations, medication choice and dosing

• Suggested components to imbed in the EMR (alerts, order sets)

• Unified educational material for patient, pharmacists and clinicians

• Consensus on measurement specifications

• Suggestions on dissemination and implementation

• Pilot top 32 procedures in participating organizations

28

Potential components of operationalizing

29

• Written report to CEOs in January• Assess results (changes in MMEs) and

unintended consequences and modify plans• Collaborative-wide testing of top 30 procedures

Work group may apply chosen methodologies to remaining procedures to recommend MME maximums

• Develop a method to review and revise recommendations at specific intervals to hold the gains

29

Next steps?

30

• 25% reduction in # of pts receiving 8 or more opioid Rxs between 7-2015 and 10-2017 (2,547 pts)

• Shared Decision Making Opioid Tool

• Educational posters for clinic lobbies and exam rooms

• Care goal around controlled substance management

• All specialty service lines required to have a opioid goal for 2018

• Standardized order sets for IP procedural pain mgmt

30

Allina successes

3131

Sentry report

32

• Design thinking framework

• Shared accountability

• Open communication

• Common goal

• Coordination of care across the continuum

• Shared resources

• Encourage innovation

• Momentum

Benefits of working in the Collaborative?

33

[email protected]

Thank You!

Mission Impossible

Bruce Sutor, MD

Chair, Clinical Practice

Department of Psychiatry and Psychology, Mayo Clinic

[email protected]

©2017 MFMER | slide-35


CEOs’ Directive

Address the mental health care access and delivery needs in Minnesota


Getting Our Hands Around the Problem

1) Setting parameters – what are the problems

we are facing?

2) What can we do – what can’t we do?


Setting Parameters

1) Shortage of mental health providers

2) Limited access to services

a. Outpatient

b. Inpatient

3) Not enough public sector resources

4) Drugs, Housing, Poverty

5) Long ED stays


What Can We Do?

What Can’t We Do?

1) Splitting out primary care access to outpatient

care

2) We can’t boil the ocean –

bed shortage, public resources, social

issues we can’t solve


Focus on the Emergency Department:

This is Something We Can Fix

1) Identifying common pain points

2) Getting together


Identifying Common Pain Points

1) Limited access to Psychiatry

2) Housing patients in ED vs. treating patients

in the ED

3) Assessment – everyone does it differently

4) Inter-organization trust – is this a dump?


Getting Together

1) Problem-solving on access to mental health

resources

2) A move to treatment in the ED

3) Sharing best practices

4) Standardizing assessment

5) Developing a sense of trust

6) Future directions – Telepsychiatry, sharing

lessons learned with Minnesota and beyond


Working Group Roles and Responsibilities

The Work

Focus on the values needed by patients, improving safety, health, and trust

Incorporate and standardize best practice

Define common goals

Support organizations and providers by communicating, setting clear expectations, providing tools

Be inclusive of those affected by the change

Balance the tension between audacity and taking first steps


Working Group Roles and Responsibilities (cont.)

How We Work Together

Commit time and resources

Share knowledge, new ideas, and wisdom with transparency and honesty

Be ready to act and test new ideas

Serve as a conduit between the collaborative and your organization

Be accountable to values and principles

Do the work; be active


Working Group Roles and Responsibilities (cont.)

Qualities Needed

Open-mindedness, generosity, integrity, commitment, persistence, honesty, respect, and courage


Working Group Member Responsibilities

As a member of the Collaborative I will:

Commit my expertise, passion, and actions to advancing shared goals of the Collaborative, not only optimizing those of my organization.

Participate meaningfully in meetings and between-meeting work, and expressly communicate if expectations seem unachievable.

Be proactive in speaking up and signaling any concerns about the Collaborative’s direction or activities, and support others in doing the same.


Working Group Member Responsibilities (cont.)

As a member of the Collaborative I will:

Work to gain active, ongoing commitment from my organization by engaging other individuals and groups whose interests align with collaborative goals, and serving as a vocal champion within my organization and the community.

Share information and data (both qualitative and quantitative) to support and track the progress of the work.

Recognize that no one person knows everything about the topic. I will listen carefully, be curious about new points of view, speak from my own expertise and experience, and appreciate that complex topics may require time to come to shared understanding and action.


Oversight Group Responsibilities

Assure that subgroup activities align to meet specific topic goals and to support the overall success of the topic area and the Collaborative

Take a lead role in assuring that organizational work supports Collaborative goals and vice versa

Assess whether the scope of activity for all Working Groups is within the span of control of the Collaborative, and if not, make recommendations to the CEOs


Oversight Group Responsibilities (cont.)

Monitor the external environment to assure that topic activities remain salient and valuable to the community

Monitor relevant activities by other stakeholders in the topic area, making recommendations about widening participation in the Collaborative as appropriate

Provide leadership for the Working Groups


TimelinesMH Acute Work Plan 2017-2018


How will this help Mayo? How will it help all ICSI organizations?

• More rapid access to care in the ED and to appropriate disposition

• Avoiding inpatient care when it isn’t necessary

• Patient and staff safety

• Developing and distributing best practices


Thank you

[email protected]

Engines and Amplifiers

Shaun Frost, MDAssociate Medical DirectorHealthPartners Health Plan

[email protected]

Engines and AmplifiersThe Power of CollaborationShaun Frost, MDAssociate Medical DirectorHealthPartners Health [email protected]

An integrated health care organization

Why Community Collaboration?Health insurance plan perspective

COLLABORATION

Standardization

Empathy

Generative Dialogue

Commodification

of Value

Shared Accountability

HEALTH PLAN ROLES

Contemporary Health Plan RolesAmplify community collaboration work

Convener

Analyst

Consultant

Data reporter

Disseminator

Educator

Thank you

[email protected]

Behind the Curtain: Being a Backbone

Claire Neely, MD

Chief Medical Officer


[email protected]

Behind the Curtain

Surprisethem

But not too much.

Make sure you know where you are going

Because it’s not a straight

path.

IMPACT

Dissemination

Sustainability

Systems Thinking Evaluation

Action

Knowledge

Sharing

Aims & Goals Commitment

Collaborative Action Framework

65

Aims & Goals

• Important

• Relevant

• Inspiring

• Challenging-but possible

Solve the right problem

66

Commitment

• CEOs

• Working group members

• Volunteers

Collaboratives yield new

strengths and are fragile

67

Systems Thinking

• Logic models

• Driver diagrams

• Ecosystem scan

Monitor for unintended

consequences

68

Action

• Design

• Proto-type

• Confirm

• Spread

• Scale

Answer different questions

69

Evaluation

• Developmental

• Performance

• Summative

• Research

Data gathered and use differ

70

Sustainability

• Clinical• Outcomes

• Patient satisfaction

• Operational• Feasibility

• Staff satisfaction

• Financial

All conditions must be

satisfied

71

Knowledge Sharing

• Transparent measurement

• Learning networks

• Success

Learn quickly, together

72

Communication & Dissemination

• Internal• Ongoing

• Shared messaged

• External• Audience-based

IMPACT

Dissemination

Sustainability

Systems Thinking Evaluation

Action

Knowledge

Sharing

Aims & Goals Commitment

Collaborative Action Framework

Logistics

…build trust

Get on the balcony

To understand the larger

dynamics at play

See possibilities

To reuse current structures

Pace the action

Not too fast, but faster than

they think they can

Iteration is the norm

Perfection is the enemy of

action

The Unexpected

Be fierce

Questions?

Claire Neely, MD

[email protected]