social needs interventions from pilot to scale -...

Social Needs Interventionsfrom

Pilot to Scale

December 6, 2016

Christina Lundquist, MHS

VP Operations, University Hospitals

Kati Traunweiser, MBA

VP, Quality and Regulatory Services, Kaiser Permanente

Anna Roth, RN, MPH

CEO, Contra Costa Health Systems

Today’s discussion

• Share key lessons and strategies to address social needs

• Identify challenges and opportunities in moving from pilot to scale

• Identify actions to take in your system

@AnnaMRoth

Maya Lin

To fly we have to have resistance -Maya Lin

“Here is what we seek: a compassion that can stand in awe at what the poor have to carry rather than stand in judgment at how they carryit.”

~ Boyle

UNIVERSITY HOSPITALS:

BUILDING YOUR CASE

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• Vision 2010 Principles: Hire Local, Buy Local, Live Local

– Invest in our communities

• Used our buy and spend locally

• 5,200 jobs

• $500 million in salaries

– Revitalize our neighborhoods

– Create jobs and develop skills

– Design and develop multi-institution, city and regional partnerships

UH Anchor Mission and Strategy

Next Phase in the Evolution of the Anchor Strategy

UH Rainbow Center for Women & Children: Leveraging the power of community-centered work to create a culture of community health

• The UH Rainbow Center for Women & Children, a newly constructed facility of UH Rainbow Babies & Children’s Hospital and UH MacDonald Women’s Hospital, will serve a federally designated medical/dental underserved area. The center will be built where patients live, becoming a highly accessible medical home for the existing patient base for Rainbow and MacDonald.

• Utilizing strategic philanthropic funding to support new programs such as Health Leads.

Transitioning the Model of Care

• Multi-sector collaboration• Anchor that supports community well being—hire

local, buy local, live local• Integrating social, behavioral, and environmental

health determinants• Leverage opportunities for upstream intervention

• Isolated from the community• Come-to-us mentality

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• How would you rate your organization’s readiness to start

integrating social needs into care delivery?

Rate the following on a scale of 1 (not at all) to 5 (ready):

– Leadership is committed to making an investment in social needs interventions

(includes finances and infrastructure)

– The organization’s strategy reflects social needs as a priority

– Change management practices are incorporated in the organization’s operations

– The organization’s culture encourages continuous learning, new ideas, and learning

from experience and experiments

Discussion

Kaiser Permanente:

Implementation Journey to Address

Social Determinants of Health



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Project Description - Overview Goals

– Understand, address social needs of high utilizers

– Define the human and business case(s) based on evidence

– Learn to scale system- and sector–wide

Intervention

– Integrate KP/HL operations to screen, refer, and close social gaps

Population

– Main: patients with highest 1% of predicted costs using highly accurate clinical predictive analytics (target n = ~5000)

– Others: defined locally by opportunities at each medical center

Outcomes: Costs, Clinical (Structure/Process/Outcome), Social

Time Frame: Pilot (1-2 years) with hopes for permanent integration

Location: Pilot at three medical centers – West LA, Fontana, Kern

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Who are the Predicted 1 Percent?

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Care Across the Continuum: A scaled approach matching resource intensity to patient need

Who are the Predicted 1 Percent?

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9 Clinically Cohesive Subgroups of Predicted High Utilizers

Implementation Strategy: Region Level

Pilot at 3 Diverse Centers

West LA, Fontana, Kern

Regional Resource Hub

Remote desk or call center

Outreach and screening of predicted high utilizers

Allows for automation, higher volume, and randomized evaluation

EHR-based workflow and assessment integration

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Cold Call Screen Identify Needs Enroll

11/15/15 to 7/30/2016

N=2,330 members

called

81% agree to take

screen 52% have 1+ need

49% enroll

72% answer call

N=1687answer call

N=1373took

screen

N=712screen

positive

N=352enrolled

What happens when you cold call?

The screening funnel above shows that a majority of predicted high utilizers screen positive for a social need; additionally, our current cold call engagement shows that Kaiser Permanente have a unique opportunity to engage with members around social needs.

Project Description - Evaluation

Main Questions:

– What are the social needs of high utilizers in KP? Population and patient-level profiles.

– What is the impact of addressing social needs on clinical, cost, and social outcomes compared to controls among those high utilizers?

Nested Design:

– Overall: quasi-experimental design, ITS differences in differences comparing all 1% high utilizers who receive social need intervention to controls at other sites

– Sub-population: randomized trial amongst the patients enrolled through resource hub comparing those randomized to intervention vs. controls

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Screening Prevalence

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Financial (30%)

Caregiver Support (31%)

Affording healthy meals (28%)

Food didn’t

last (28%)

High

Prevalence

Medium

Prevalence

Lower

Prevalence

Health literacy / numeracy (26%)

Social Isolation (23%)

Transportation (20%)

Utilities (19%)

Medical Care Costs (18%)

Homelessness (9%)

Housing conditions (9%)

Applying for public benefits (8%)

Financial Counseling (7%)

Child-related (4%)

Employment (3%)

What are members screening positive for?

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Curation of social needs

10% of community resources = 80% benefit

27% of community resources cause harm

Many areas of need not met in the community

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Discussion

On a scale of 1 (not at all) to 5 (ready), how prepared is your organization to measure program results and outcomes?

– Analysis / evaluation expertise

– Data

– IT Systems

How can you maintain the organization’s engagement and commitment as the project team pursues program outcomes?

Contra Costa County:

Moving to Scale

Anna M. Roth, RN, MPH Chief Executive Officer

Contra Costa Regional Medical Center, Health Centers & Detention Health

Today’s Landscape/Context

Stay ahead of the game or be left behind

How we work

Who we are

• Regional Medical Center &

11 Health Centers, 5 Jails

• County’s safety net

hospital and clinics

• 4200 staff, including

• $600m

Contra Costa 2020

Value = What Matters

Addressing Social Needs

Our Progress

Icons from FlatIcon

2067patients served

2270Resource

Connections

47%of clinic

screened

A Regional Issue“East Contra Costa County has transformed

from a blue-collarsuburban enclave into a new epicenter of

Bay Area poverty in just 15 short years.”

“We’re dispersing the low-income population into places where hard

infrastructure and social services are either nonexistent or inefficient.

“We are seeing the next chapter in the story of segregation: low

income people in the suburbs and more affluent people in the urban

core.”

“It’s kind of like this vortex — the community isn’t well organized

enough to understand, let alone demand, what they need, and for

funders and investors, there’s no there there to invest in.”

Our Vision

Contra Costa will be the first county in the nation to address

basic resource needs system-wide; This will be achieved by:• Screening: Screen patients for social needs county-wide

• Connecting: Connect every patient who wants assistance to social need support

where the resources exist

• Measuring Outcomes: Collecting data to improve programs, evaluate impact and

make the national case for addressing social needs

• Community and Policy Partnerships: Using the data, better understand where

resource gaps exist and partner with community and policy stakeholders to

strengthen the existing resources and address gaps

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So where are we today? And how do we achieve these goals?

Intervention Models for Expansion

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Enable self-care through targeted outreach, mobile apps, flyersIntervention: Self Serve Kiosk & Info Desk Staff

Blend of technology & human support to enable patient successIntervention: Equipping existing workforces with Reach & Health

Lead’s Desk

High touch & personal support, tightly integrated with care teamsIntervention: Social Work, Public Health Nursing, CCHP CM

Low Need and Low Patient Complexity

High Need and High Patient Complexity

People to People

Promotora

Program

Formerly

Incarcerated

African

American

Health

Conductors

Be Bold

Think Bigger

It is not enough just to open the

gates of opportunity. All our

citizens must have the ability to

walk through those gates.

Lyndon B. Johnson

The power of imagination

makes us infinite

John Muir

Be Brilliant

Redefine Possibility

Be Brave

I Am Change

The absence of love,

belonging, and connection

always leads to suffering.

Brene’ Brown

Consider• Rate your organization’s readiness to embark on a plan to scale social

needs system-wide?

Rate the following on a scale of 1 (not at all) to 5 (ready):

– Leadership is committed to making an investment to scale social needs (includes finances and infrastructure)

– The organization’s strategy incorporates social needs as a priority

– Change management practices are incorporated in the organization’s operations

– The organization’s culture encourages continuous learning, new ideas, and learning from experience and experiments

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• Share your

challenges when

you think about

addressing social

needs

• What conversation

are you committed

to having when

you return to your

organization or

work?

By next Tuesday: Action Plan

THANK YOU

Social Needs Interventionsfrom

Pilot to Scale

December 6, 2016





Anna Roth, RN, MPH

CEO, Contra Costa Health Systems

social needs interventions from pilot to scale -...

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