Transcript AM Slides - Health Commons Grant

Welcome to
Health Share of Oregon
Collaborative:
Looking to the Future
WiFi Password: ambridge1
“Looking To The Future”
Health Share Learning Collaborative
Nov 5: Ambridge Event Center
Looking back: 2 years, 11 months, 20 days:
Transforming Health Care Together
Nov 17, 2011
• 2011
– June: CCO legislation (HB
3650) passed
– Fall: OHLC hires Health
Management Associates and
Milliman to frame CCO plan
– Dec: “TriCounty Medicaid
Collaborative” (TCMC)
established
• 2012
– July: Health Commons Grant
Awarded
– Sept: Health Share of Oregon
starts operation; CMMI
Funds released
Up to $30 Million
Funding Over 3 Years
Application Due:
Jan 27, 2012
Meeting the Challenge
• Grant opportunity completely aligned with CCO
mandate to improve outcomes, lower cost
• Existing initiatives to build on
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Care Transitions team at OHSU (C Train: Honora Englander)
Intensive Transition Team in Wash Co (Kim Burgess)
ED Guides at Providence (Barry Brown)
Community Outreach Worker Program at CareOregon (Rebecca Ramsay)
Standardizing Hospital to Primary Care Transitions at Legacy (Melinda Muller)
• Previous history of working together
– Safety Net collaborative on Medical Homes
– OHLC sponsored High Value Medical Home Initiative
• “Tiger Team” Created to meet the 60 day deadline…
– CORE engaged to do evaluation
“Tiger Team”
New Integrated Model of Care - Draft 1.0 Dec 2011
Community Care System
Community
Supports
Peer
Support
Specialists –
BH
Stanford
Chronic
Disease Self
Management
Support
Health Care System
Community
Based Care
Specialty
Care
ACT
Teams
Hot Spot
Teams:
•Targeted
Pops
•Hi Needs
•Multi
Morbid
Wrap
Around
E-referral /
E -consult
Hospital /
ED Care
ED
Redirection:
•Navigation
•Case Mgmt
•Opioid Stds
Primary
Care
Case
Mgt
Mental
Health /
Addictions
Primary Care
Specialty
Support
Hospital
Transitions
Management:
•Home
•PCP
•Spec
•NH
Health Information Systems – EPIC “Care Everywhere”
Workforce Development / Learning Systems Across The Continuum
Feb – April 2011: Waiting for CMMI…
TCMC “Model of Care” Process
• “Transformation” of delivery system critical TCMC
business model and sustainability
• TCMC charge to MOC team: “look at data: define ideal
system”
• Model of Care Advisory Group formed based on
widespread provider desire for input
– Advisory group meetings
– 4 “Ideal State” Visioning sessions (advisory group + key
informants / community members
• Agreement on “Health Home” as center of new model
– 5 Tactical workgroups
• Key “data:” Provider experience…
Organizations Contributing
• Oregon Center for Children and Youth with •
Special Health Needs (OCCYSHN)
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• CareOregon
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• Legacy
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• Kaiser
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• Multnomah County
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• OHSU
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• Portland IPA
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• Virginia Garcia
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• Women’s Health Alliance
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• Northwest Cardiovascular Institute
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• Oregon Clinic
• VA
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• Marquis
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• Metropolitan Pediatrics
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• Children’s Health Alliance
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• Providence
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• Washington County
• Clackamas County
• Acumentra
Familias en Accion
Coalition of Communities of Color
Intel
Central City Concern
Coalition of Community Clinics
Cascadia Behavioral Health
Oregon College of Emergency Physicians
ODS
Family Care Health Plans
Oregon Pediatric Improvement Partnership
Alliance of Culturally Specific Behavioral
Health Providers
Lifeworks Northwest
Oregon Department of Public Health
OCHIN
Pacific Medical Group
Adventist Health
Delivery System Change
“Idea Inventory”
Health Commons Grant Award: July 2012
“A springboard for change”
Administrative
Transformation
Risk & Payment
Align incentives to achieve
the Triple Aim
Simplify administrative
services for providers and
members
Clinical Transformation
Change the delivery system
Decrease overtreatment
Increase reliability
Improve patient-centeredness
Address social determinants
Other
opportunities
CMMI
Health
Commons
Grant
 Leverage existing
interventions at some of
the partner organizations
 Focus on areas we
need to spread across all
organizations
 Bring reporting and
evaluation resources to
Health Share
 Build infrastructure
across the whole: IT
platform, common
metrics, communication
pathways
What We Have Accomplished
• Improving Discharge Transitions:
– For Hospital Admit / Primary Care (medical)
• Redesigned Standard Transition for medical D/C and Follow
up Legacy and Providence with connection to LHS, MCHD
and Prov clinics; OHSU in implementation
• Spread C Train within OHSU and to Legacy hospitals
– For Psychiatric Admits
• Spread and customized intensive transition teams from
Washington Co to Clackamas and Multnomah Cos
– For Emergency Dept
• Spread “ED Guide” program from Prov Portland to other
area Prov hospitals with increasing focus on Medicaid
What We Have Accomplished
• Community Based Care
– Established a new out reach workforce to better
connect high needs Medicaid enrollees with their
providers and practices
• Including a growing number of peer outreach workers from
community based peer organizations (Urban League, Folk
Time)
– Established a Tricounty 911 team for frequent users of
the 911 system
– Established an Emergency Dept Based team for
frequent ED users with intensive behavioral health
needs
By The Numbers
• Number of Health Share members touched: 10,577
– Number in intensive management: 3200
• Number of organizations involved:
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Clinics: 17 (MCHD, OHSU, LHS, Prov, TOC, VG, CCC)
Hospitals: 6
BH Organizations: 3
Community Organizations: 4
• Number of FTE hired: 75 (104 people)
• Decreased ED / Hospitalization (pre- post) for Health
Resilience Program: 35%
• Consistent decreases in PMPM in intensive management
programs
What We Have Accomplished:
• Created A Learning System based on data
– Built a “population management system,” PopIntel
(CareOregon) to track work and integrate effort
– Partnered with Center For Outcomes Research and Education
(Providence CORE) for evaluation and reporting
• Ongoing quantitative and qualitative feedback to identify “optimal
impact” and refocus work
– Established basis for outcomes based sustainability dialog
• Created a regional “collective impact” structure: Aligning
multiple organizations to a common goal -- improving
health for our most vulnerable members
– Demonstrated that given the opportunity and resources we
know how to “transform” health care
Collective Impact:
Common Agenda
• Coming together to collectively define the
problem and create a shared vision to solve it
Shared Measures
• Agreeing to track progress in the same way,
allowing for continuous improvement
Mutually Reinforcing • Coordinating collective efforts to maximize the
end result
Activities
Continuous
Communication
Backbone
Organization
Stanford Social Innovation Review. John Kania,
Mark Kramer. Winter 2011
• Building trust and relationships among all
participants
• Having a team dedicated to orchestrating the
work of the group
Expanding the Health Commons
Administrative
Transformation
Risk & Payment
Aligning incentives to
provider-driven care and
provider accountability
Simplification of administrative
services for providers and
members
Mental Health
Health System
Transformation
Housing
Community Services
Crisis Response
Addictions
CMMI
Health
Commons
Grant
Transformation Fund Health Share
Projects:
 “Advanced Primary Care” Teams
 Project ECHO
 Project Nurture
 Culturally Specific CHWs/Peers
 Addictions Provider Education
 Healthy Homes
 Member Engagement
 Future Generations
Collaborative
 Chronic Disease SelfManagement
 Behavioral Health
Promotion/Prevention
Other:
 Forensic ACT Team
 Culturally Specific ACT Team
 Children’s Wraparound
Expansion
Today: Looking Forward…
• What have we learned that will help us
continue “Transforming Health Together?”
– About the people we are trying to serve?
– About our strengths, weaknesses? What do we
need to take on next?
– About how multiple organizations work together
toward a common goal – a “collective impact”
effort?
Agenda
 Morning: What have we learned?
• 8:45-10:15
• 10:15-10:30
• 10:30-11:45
CMMI Interventions Panel
Break
Adverse Life Event Study
 Lunch
 Afternoon: How do we move forward?
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12:30-1:00
1:00-2:15
2:30-3:45
3:45-4:45
Health Share 2.0
“Collective Impact” (United Way)
Addictions Panel
Organizational Next Steps
CMMI Panel
Lisa Scardina
Chief Administrative Officer – Clinical Services and PMG,
Providence Health & Services – Oregon Region
CMMI Panel
Alison Goldstein, LCSW
Clinical Services Specialist, Lead Tri-County 911 Service Coordination
Program
Jeffrey Anderson, Licensed Psychologist
Clackamas County Crisis Program Supervisor, ITT
Laurie Lockert
Community-Based Program Manager, Health Resilience Program
Honora Englander, MD, FACP
Director, OHSU Care Transitions Innovation (C-TraIn)
Mikeanne Minter, MD, FACP
Legacy C-TraIn Physician Lead
Tri-County 911 Service Coordination
(TC911)
Goal: Reduce demands on EMS systems by linking people to the
right care, at the right place (e.g. MH, A&D, PCP, housing, etc.)
Target Population:
• Clack., Wash., or Mult. Co. residents,
• Health Share of Oregon/Medicaid
• 6-10 EMS incidents in 6 mos.
Referrals: Ambulance data & crew referrals
What we Do:
• Provider Notification and Consultation
• Multi-System Care Coordination
• Short-Term Intensive Case Management
Staffing: 4 LCSWs (hired Spring 2013)
TC911 Social Workers (from left): Claudia Schroeder, Alison Goldstein,
Erin Brochu, and Kelly Goodman.
TC911 Clients Served
• 285 served to date
• Most 40-69 years of age
• 70% + have physical health
dx
• 50% + have MH dx
• 40% + A&D dependence
Most TC911 clients have multiple,
complex medical, behavioral and psychosocial issues
TC911 Case Examples
Client “Brian”
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75+ incidents/yr
ETOH and MH
Homelessness and criminality
Medical and mobility issues
Outreach in jail
70% reduction in EMS. Outreach in jail, linked to
A&D with supportive housing and MH.
TC911 Case Examples
Client ”Nathan”:
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Long time, frequent EMS use (2010+)
ETOH, untreated MH, no PCP engagement
Multiple EDs and excessive radiation exposure
Multi-system care coordination
County-wide EMS Care Plan: Assess & Decline
48% reduction in 911 responses & 80% reduction in
ED transports. Decline transport policy, + in-home
MH, and multi-agency care coordination.
Learning and Changes
Learning:
• Impact of early and cumulative trauma
• Systems not designed for these clients
• Need trauma competent systems of care
• EMS as critical, untapped part of health system
• Access to information matters
Changes Inspired by Grant:
• System level EMS care plans and info
sharing
• Long term care management programs
• Trauma-informed systems of care
ITT clients…
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Vulnerable individuals (“high utilizers”)
Unconnected to outpatient behavioral health
Historical/current trauma
Experiencing multiple barriers
May not want/trust behavioral health
Comorbidity
Environmental and psychosocial stressors
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Prioritizes acute care referrals
Behavioral health-focused intervention
case management
brief therapy
psychiatry
peer support services
psycho-education
community- and office-based services
Primary goal: Connect individuals to a community behavioral
health provider
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Optimized referral pathways with hospitals, care
coordinators
Emerged as important component in the system of
care
Developed great cross-county relationships &
efficiencies
Added peer support to ITT
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housing resources
timely residential A&D treatment
outpatient psych med resources
 ITT is sometimes stretched to accommodate large gaps in the
system of care
 ITT needs to be optimized for each system – it cannot be
easily transplanted from one community to another without
modification
Health Resilience Program ™
Trauma Informed Care
Mitigate
the
Social
Determinants
of Health
Incorporate
meditation & gratitudes
HOW MANY?
Launch of Online
Registry = More
reliable data
collection
Compared to other CareOregon Adults ...
Members served by our program are:
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Older (48 yrs vs 42 yrs)
More Diverse (26% vs 11% Black)
Female (68% vs 62%)
Higher Disease & Psycho-Social Burden
Health Resilience Program
Health Resilience Program ™
Trauma Informed Care
Mitigate
the
Social
Determinants
of Health
Incorporate
meditation & gratitudes
C-TraIn
Honora Englander, MD, FACP
Director, OHSU Care Transitions
Innovation (C-TraIn)
Mikeanne Minter, MD, FACP
Legacy C-TraIn Physician Lead
CORE: Life Study
Lauren Broffman
Research Analyst, CORE
Jennifer Matson
Project Manager, CORE