Transcript Slide 1

Building
Systems of Care
in the Safety Net
for High-Utilizing Patients
A program from CCI,
the Institute for Healthcare Improvement,
and the California HealthCare Foundation
PROGRAM LAUNCH
MARCH 13, 2014
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Agenda
• Welcome and framing
• Introductions
• Quick 3 questions
– Clinic name, # sites, # providers, team members
– Current targeted services for HRHC population segment/s, if any
– One question at the outset, for faculty, other clinics, both
• Overview of collaborative and Phase 1
• Aims, Measures, Changes to improve care and
lower costs
• Successful business case formulations
• Assignment for April 8 webinar
• Discussion
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A unique program partnership
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California HealthCare Foundation
Center for Care Innovations
Up to ten California clinics
Clinics’ partners in quality, cost control,
community health (i.e. plans, consortia, etc.)
• Institute for Healthcare Improvement
• National experts from the field
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Today’s discussion
• Meet your improvement community!
• Establish program goals and assumptions
• Get clinics started on the first most important
partnership development
• Introduce an approach to business case
formulation
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Building Systems of Care
in the Safety Net
for High-Utilizing Patients
Catherine Craig
Faculty
Cory Sevin
IHI Director
Rebecca Steinfield
Improvement Advisor
Hunter Gatewood
IA, Coach
Phase 1 Faculty
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The brave pioneers
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AltaMed Health Services Corporation – Los Angeles
CommuniCare Health Centers –Sacramento area
Golden Valley Health Centers – Central Valley
Hope Center/Alameda Cty Health System – Oakland
Neighborhood Healthcare – San Diego, Riverside
San Francisco Health Network
Santa Rosa Community Health Centers – Sonoma
St John's Well Child and Family Center – Los Angeles
St Vincent de Paul Village Fam. Health Ctrs – San Diego
– Clinic name, # sites, # providers, team members
– Current targeted services for HRHC population segment/s, if any
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– One question at the outset
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Better Health and Lower
Costs for Patients with
Complex Needs;
An IHI Triple Aim
Collaborative
Percent of Total Health Care Expenses Incurred by
Different Percentiles of U.S. Population: 2002
Sources: Statistical Brief #73. March 2005. Agency for Healthcare Research and Quality
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Persistence In Spending
Crucial Question for Primary Care
“Why wouldn’t a person with
a chronic condition do everything in their
power to live long and feel well?”
Determinants of Health and Their
Contribution to Premature Death
15%
30%
5%
10%
40%
Social
Environmental
Medical
Behavioral
Genetic
Schroeder, NEJM 357; 12
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The Collaborative will:
Help you plan and implement comprehensive
care designs that serve the needs of your most
complex, high-risk, and costly patients, resulting
in better health outcomes, a better care
experience, and lower total cost.
Whether your organization has already
established a program or is just starting this
work, our goal is to help you make a positive and
sustainable difference for this population.
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Learning Collaborative
12 month Learning Collaborative
30-40 organizations
3 Learning Sessions, one will be face-to-face
Bi-monthly community calls plus measurement
calls
Use of QI methods-MFI and rapid, iterative
learning
Starts July 2014
Collaborative Faculty
Catherine Craig
Faculty
Alan Glaseroff
Faculty
Cory Sevin
IHI Director
John Whittington
IHI Team
Ann Lindsay
Faculty
Kevin Nolan
Improvement Advisor
Rebecca Ramsey
Faculty
Phase 1 Goals
• Partner with a health plan to get useful data for
your population.
• Better understand your business case for
spending resources on this area of
improvement.
• Learn barriers to less costly and more effective
health care services for this population.
• Use data to identify community resources and
agencies for partnerships.
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Phase 1 activities
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Monthly online meetings
In-person workshop on business case
IHI Extranet
Email discussion group
Weekly support contact,
from CCI, with IHI back-up
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Phase 1 Webinars
1. Kickoff! You are here.
2. Sustainability, partnering with
payers
3. Data and evolving payer relationship
4. Identifying your HRHC population
5. Listening to patients to discover
barriers to less costly care
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The Model for Improvement
The three
questions
provide the
strategy
What are we trying to
Accomplish?
How will we know that a
change is an improvement?
What change can we make
that will result in
improvement?
Act
Plan
Study
Do
The PDSA
cycle provides
the tactical
approach to
work
Source:
Langley, et al. The Improvement Guide, 1996
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What are we trying to accomplish?
Within 12 months, participants will be able to do
the following:
Identify a particular high-risk population that will
be the focus of your work
Assess the assets and needs of this population
by learning from patients’ experiences
Co-create and execute new care designs to test
for impact and cost savings
Increase the scale and reach of successful care
designs in fivefold to tenfold jumps
How will we know a change is an
improvement?
What changes can we make that will
result in improvement?
Individual, Family &
Community Resources
Goals
Population
Segmentation
Needs
Assessment
for Segment
Coordination
Service
Delivery
at Scale
Service
Design
Integrator
Feedback
Feedback
Population
Outcomes
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Managing Services for a Population
Individual, Family &
Community Resources
Goals
Population
Segmentation
Needs
Assessment
for Segment
Coordination
Service
Delivery
at Scale
Service
Design
Integrator
Feedback
Feedback
Population
Outcomes
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Change Areas
Identify the population
– Who has both complex needs and the highest utilization rates?
Co-create care design
– Build care with people and their preferences and experiences and
consider sustainability from the beginning
Recruit people into care
– Experiment with outreach methods to successfully reach people
with a history of bad experiences with the care system
Engage people in care
– Identify strategies to effectively partner with people with complex
needs
Partner with existing community resources
– Build collaborations with external partners to ensure that social
determinants of health are a coherent part of the care plan
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Iterative Process
Step 1: Identify your population
Frail elders, people living in poverty with MH needs…
Step 2: Understand needs and root causes
Utilization data, clinician intuition, people’s stories
Step 3: Co-create and execute care plan with 5 people
Co-create care with the individual to learn for the population
Step 4: Scale to 25
What infrastructure does this require? (IT, staffing, space…)
Step 5: Scale by 5X or 10X  the entire population
Sustainability, well-functioning care systems, and infrastructure
Repeated Use of the PDSA Cycle
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Model for Improvement Resources
Whiteboard Videos
http://www.ihi.org/education/IHIOpenSchool/resources/Pages/BobLloydWhiteboard.a
spx
On-Demand Video Courses
http://www.ihi.org/education/WebTraining/OnDemand/ImprovementModelIntro/Page
s/default.aspx
IHI Open School Course (QI102)
http://app.ihi.org/lms/coursedetailview.aspx?CourseGUID=41b3d74d-f418-419386a4-ac29c9565ff1&CatalogGUID=6cb1c614-884b-43ef-9abd-d90849f183d4
Call Hunter 
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The Sequence for Improvement
Make part of routine
operations
Test under a variety of
conditions
Implementing a
change (steps 5
and beyond…)
Testing a change
(steps 3 and 4)
Developing a change
(Steps 1 & 2)
Sustaining and
Spreading a change to
other locations
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IHI.ORG
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The Key Sustainability Question
Who will derive financial benefit What data can back up your
if your interventions succeed? assertion?
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From a decrease in medical
expenditures for the population
served
 ED and inpatient cost data for
intervention group AND for
whole clinic population
From an increase in efficiency
which allows more production
and thus revenue
 Throughput and clinic cost data
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From an improvement in quality
which is financially incentivized
 Quality outcomes, ROI
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From a decrease in financial
withholds related to errors
(readmissions)
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efficiencies
 Inpatient admission data
From an increase in revenue
related to more services
 Clinic accounting
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Gold Standard Data
Total cost per member per month
– For the intervention group
AND
– For the entire clinic population
Gather and plot high cost care components:
hospital admissions
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Sustainability Planning Tips
The more expensive the
intervention the more robust
the cost savings must be to
create a return on the
investment
Identify what matters most to
(potential) funders as early as
possible
Determine the average cost of
an ED visit and/or hospital visit
for your target population
Throughput can be as
important as scale
Look for economy of scale
opportunities
 Hire lay or peer community
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health workers or behavioral
health specialists?
Talk with them about their
priorities and develop a case
as to how this work supports
them
Tally how many visits you
would need to avoid to pay for
your intervention
Track “graduation” rates and
active caseload
Look for ways to centralize
infrastructure, or to spread
capacities across sites
Action Step
Review data about this group of patients from available HIT
systems. It may be
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Claims/utilization data from payer, clinic claims, your own system encounter
information from inpatient, ED, and primary and specialty care systems
– Behavioral health encounter/claims data
– Primary care EHR notes to include problem list, diagnosis codes, care plan,
After Visit Summaries
– Clinician responses to questions about which patients are high risk/high
cost.
Be prepared to discuss the data that you currently have access to in
our next call.
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What data do you currently have access to?
What does it take to get that data?
How often do you get that data?
What do you learn from the data?
How useful is the data to you?
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Community Support
Private Collaborative Extranet-Workgroup for
CCI Group
Listserve
Questions?
[email protected]
[email protected]
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Image © Nina Bagley