Research to Reform : Research to Reform : Achieving Health System ChangeAchieving Health System Change AHRQ 2009 Annual Conference

September 13-16, 2009September 13-16, 2009

Progress of a Learning Network: Progress of a Learning Network:

Working to Reduce Disparities by Improving Access to Working to Reduce Disparities by Improving Access to CareCare

Monday, September 14, 2009Monday, September 14, 2009

Sherry E. Gray, M.A.Sherry E. Gray, M.A.

Director: Rural and Urban Access to HealthDirector: Rural and Urban Access to Health

St. Vincent HealthSt. Vincent Health

Focusing on OutcomesFocusing on Outcomes

Confirm Evidence Based Intervention

Identify Individual at Risk

Measure Outcome Health and Cost Savings

1 2 3= +

The Pathway ModelThe Pathway Model

The Pathways Model

Identify areas of greatest needgeomapping, analyzing existing databases, needs assessments

Establish a community hub centralized community group: communication; data collection; tracks services provided by community health workers

Develop Pathways - start with “agreed upon” outcome; build steps from desired end-point; capture steps to completion; capture barriers and successes for intervention/ problem-solving

-connect funding mechanisms to outcomes vs. activity-based reimbursement

Identify and train community health workers Implement established Pathways until the outcome is accomplished

Conduct ongoing quality assurance and evaluation monitor the progress and outcomes

““Oh no…another program!”Oh no…another program!”

Pathways are NOT:Pathways are NOT:

→ → Part of a “canned program” Part of a “canned program” → → Simple and quick solutions to Simple and quick solutions to

complex problemscomplex problems→ → Built/developed in a “silo” and Built/developed in a “silo” and

then “introduced” to other then “introduced” to other agencies, providers, programs, agencies, providers, programs, funders, for adoption and funders, for adoption and implementationimplementation

→ → A fadA fad

Pathways ARE:Pathways ARE:

A proven care A proven care coordination model coordination model

Community based Community based Adaptable to a variety Adaptable to a variety

of “at-risk” populationsof “at-risk” populations Evidence-based Evidence-based

interventions at the interventions at the grassroots levelgrassroots level

Used to create outcome Used to create outcome -based accountability -based accountability and reimbursement vs. and reimbursement vs. activity-based activity-based reimbursementreimbursement

The Learning Network The Learning Network and Pathwaysand Pathways

RUAH HistoryRUAH History RUAH Partnership initiated: 2000RUAH Partnership initiated: 2000

– SV Health In patient, Out patient, Community Based Care

– Indiana Health Centers, Inc. Federally Qualified Health Care Center (FQHC)

– Health and Hospital Corporation of Marion County County Health Department

– ADVANTAGE Health Plans, Inc. Insurance Provider (public and private plans)

– Butler College of Pharmacy, later added PharmD students Pharmaceutical Assistance Program (PAP) Consultation Project Management/Oversight

– Community Interface Groups: local partner groups responsible for program implementation. health centers, health departments, physician offices, civic groups,

and health, human and social service agencies

Funded by HRSA, Ascension Health from 2001-2005 Sustained through local hospital funding and captured

reimbursement through enrollment efforts

Current Service Areas: Clinton CountyClinton County

– St.Vincent Frankfort *St.Vincent Frankfort * Howard County *Howard County *

– St. Joseph HospitalSt. Joseph Hospital Madison CountyMadison County

– St. Vincent Mercy *St. Vincent Mercy *– Saint John’s Health SystemSaint John’s Health System

Randolph County *Randolph County *– St.Vincent Randolph St.Vincent Randolph

Clay CountyClay County– St.Vincent Clay St.Vincent Clay

Jennings CountyJennings County– St.Vincent JenningsSt.Vincent Jennings

Fountain and Warren CountiesFountain and Warren Counties– St.Vincent WilliamsportSt.Vincent Williamsport– * Original CAP grant program sites* Original CAP grant program sites

* Original CAP grant program sites* Original CAP grant program sites

RUAH TodayRUAH Today

PurposePurpose: :

To connect our friends, family, and neighbors to a comprehensive, integrated delivery network of To connect our friends, family, and neighbors to a comprehensive, integrated delivery network of health, human and social services resulting in improved access and removal of barriers to health, human and social services resulting in improved access and removal of barriers to

needed resources.needed resources.

Meaning and Mission:Meaning and Mission: The word The word ruahruah, in yiddish , in yiddish

means means “Breath of Life”. “Breath of Life”.

The Goal? The Goal?

……to breathe new life into a dying to breathe new life into a dying

health care system trying to serve our most vulnerable community membershealth care system trying to serve our most vulnerable community members

Focus Areas:Focus Areas:

• Health Access WorkersHealth Access Workers––client advocates & system navigatorsclient advocates & system navigators• PharmacyPharmacy – – access to low or no cost drugs through Medicationaccess to low or no cost drugs through Medication• Access Workers (MAC’s)Access Workers (MAC’s)• Creation ofCreation of “Medical Homes” “Medical Homes” for the underserved for the underserved• Access to Access to Specialty CareSpecialty Care for the underserved for the underserved• Program enrollmentProgram enrollment ( (financial resource review financial resource review • and application assistance)and application assistance)• Reduction of inappropriate Reduction of inappropriate Emergency Room utilizationEmergency Room utilization• Assistance with Assistance with supportive social servicessupportive social services • (“wrap around”)(“wrap around”)• DiversityDiversity – – translation of core documents, medical translation of core documents, medical • interpretation, key signage, development of diversityinterpretation, key signage, development of diversity• councils, LEP Assessmentcouncils, LEP Assessment• Sustainability Sustainability

Program Outcomes:Program Outcomes:(November ‘02 – June ‘09)(November ‘02 – June ‘09)

Four community programs expand to Eight community Four community programs expand to Eight community programsprograms

Additional private sector funding obtained Additional private sector funding obtained – Anthem FoundationAnthem Foundation

29,767 client encounters29,767 client encounters 59,081 referrals, including59,081 referrals, including

– Medical Home appointmentsMedical Home appointments– Government program applications (Medicaid & Government program applications (Medicaid &

SCHIP, etc.)SCHIP, etc.) $18.2 million worth of low/no cost drugs provided$18.2 million worth of low/no cost drugs provided 800+ HIP applications = $ 2+ million captured 800+ HIP applications = $ 2+ million captured

reimbursementreimbursement

Sound Good?Sound Good? RUAH produces good workRUAH produces good work

↑↑ interaction interaction

(patients, clients, providers)

↑↑ connectivity/integration connectivity/integration (community agencies and acute care facilities/providers(community agencies and acute care facilities/providers))

↑ ↑ activityactivity(doing lots of things “to and for” people)(doing lots of things “to and for” people)

↑ ↑ accessaccess(primary care home assignments/specialty care)(primary care home assignments/specialty care)

↑ ↑ reimbursementreimbursement(received funding not previously captured)(received funding not previously captured)

So?So?

Did any of it work?Did any of it work?– Intuitively it appears that it doesIntuitively it appears that it does

How do we know?How do we know?– Did the activities produce:Did the activities produce:

Lower A1C values for Diabetics?Lower A1C values for Diabetics? Better birth outcomes for high risk pregnancies?Better birth outcomes for high risk pregnancies? Lower blood pressure and decreased cardiac risks?Lower blood pressure and decreased cardiac risks? Manage asthma symptoms and decrease ER visits and Manage asthma symptoms and decrease ER visits and

hospitalizations?hospitalizations?

1. The answer? We don’t know.2. The question: How do we find out? Find a way to connect the work to measurable outcomes that is both simple and real…

Pathway ImplementationPathway Implementation(our “beta site”)(our “beta site”)

Work withWork with

Madison County Madison County

and Saint John’s Hospitaland Saint John’s Hospital

Process:Process:

Maintain all current RUAH Maintain all current RUAH access workaccess work

Build a local CKF CoalitionBuild a local CKF Coalition Host a high level Host a high level

Stakeholder meetingStakeholder meeting Develop “behind the Develop “behind the

scene” infrastructure scene” infrastructure support: IT, agreements, support: IT, agreements, etc.etc.

Hold the initial Madison Hold the initial Madison County Community HUB County Community HUB Pathway development Pathway development summitsummit

Implement the Pathways Implement the Pathways developed by the HUBdeveloped by the HUB

Evaluation and “Fine Evaluation and “Fine tuning”tuning”

How’s it going?How’s it going?

‘Stay tuned…we are still on the pathway