a program from cci, the institute for healthcare improvement, and the california healthcare...
TRANSCRIPT
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A program from CCI, the Institute for Healthcare Improvement, and the California HealthCare Foundation
Building Systems of Care in the Safety Net
for High-Utilizing Patients
PROGRAM LAUNCHMARCH 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
• 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
Cory SevinIHI Director
Catherine CraigFaculty
Hunter GatewoodIA, Coach
Phase 1 Faculty
Rebecca SteinfieldImprovement Advisor
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The brave pioneers
• 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– One question at the outset
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 Spending9
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
Schroeder, NEJM 357; 12
15%
5%
10%
40%
30%SocialEnvironmentalMedicalBehavioralGenetic
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
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Collaborative Faculty
Cory SevinIHI Director
Catherine CraigFaculty
John WhittingtonIHI Team
Kevin NolanImprovement Advisor
Alan GlaseroffFaculty
Ann LindsayFaculty
Rebecca RamseyFaculty
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. 15
Phase 1 activities
• 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
payers3.Data and evolving payer
relationship4.Identifying your HRHC population5.Listening to patients to discover
barriers to less costly care 17
The three questions
provide the strategy The PDSA
cycle provides the tactical approach to
workSource:
Langley, et al. The Improvement Guide, 1996
What are we trying toAccomplish?
How will we know that achange is an improvement?
What change can we make that will result in improvement?
The Model for Improvement
Act Plan
Study Do
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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
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How will we know a change is an improvement?
What changes can we make that will result in improvement?
Needs Assessment for Segment
Service Design
Service Delivery at Scale
Goals Coordination
Integrator
Population Outcomes
Population Segmentation
Individual, Family & Community Resources
Feedback Feedback
Needs Assessment for Segment
Service Design
Service Delivery at Scale
Goals Coordination
Integrator
Population Outcomes
Population Segmentation
Individual, Family & Community Resources
Feedback Feedback
Managing Services for a Population22
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 25What infrastructure does this require? (IT, staffing, space…)
Step 5: Scale by 5X or 10X the entire populationSustainability, well-functioning care systems, and infrastructure
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Repeated Use of the PDSA Cycle
Model for Improvement ResourcesWhiteboard Videoshttp://www.ihi.org/education/IHIOpenSchool/resources/Pages/BobLloydWhiteboard.aspx
On-Demand Video Courseshttp://www.ihi.org/education/WebTraining/OnDemand/ImprovementModelIntro/Pages/default.aspx
IHI Open School Course (QI102)http://app.ihi.org/lms/coursedetailview.aspx?CourseGUID=41b3d74d-f418-4193-86a4-ac29c9565ff1&CatalogGUID=6cb1c614-884b-43ef-9abd-d90849f183d4
Call Hunter
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The Sequence for Improvement
Sustaining and Spreading a change to other locations
Developing a change (Steps 1 & 2)
Implementing a change (steps 5 and beyond…)
Testing a change (steps 3 and 4)
Test under a variety of conditions
Make part of routine operations
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IHI.ORG28
The Key Sustainability QuestionWho will derive financial benefit if your interventions succeed?
– From a decrease in medical expenditures for the population served
– From an increase in efficiency which allows more production and thus revenue
– From an improvement in quality which is financially incentivized
– From a decrease in financial withholds related to errors (readmissions)
– From an increase in revenue related to more services
What data can back up your assertion?
ED and inpatient cost data for intervention group AND for whole clinic population
Throughput and clinic cost data
Quality outcomes, ROI efficiencies
Inpatient admission data
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
Regression
to theMean
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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 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
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Action Step
Review data about this group of patients from available HIT systems. It may be
– 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.
– 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?
Community Support
Private Collaborative Extranet-Workgroup for CCI Group
Listserve
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