Whole-Community Cooperation Health by Design
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1 Whole-Community Cooperation Health by Design South King County Care Transitions Conference Marc Pierson June 4, 2015
2 From Prediction to Action
3 Who is We? Where is Home? How long will you care? Anything smaller than community is too small.
4 TRIPLE AIM? Population Health Per Capita Cost Experience
5 PARADIGM 1 BUSINESS COMPETITION HEALTHCARE
6 A LATE INSIGHT Perfect parts do not make a perfect whole. It is the interactions of the parts that determine the effectiveness of the whole. Russell Ackoff May 6, 2015 Cambridge Management Group 6
7 PARADIGM 2 COMMUNITY (BUSINESS) Population Health Ultimately means whole community COOPERATION (COMPETITION) Align financial incentives for cooperation and enough of it will happen? We are not anti-cooperative. We are economic optimizers and entrepreneurs. HEALTH (HEALTHCARE) Better Health (social determinants) Less healthcare needed, about half
8 CURRENT SITUATION Demographics Population Health Workforce Designed for Parts
9 IN CRISIS Inequitable Unhealthy Frustrated Unsustainable Costs Insolvent Parts
10 ALTERNATIVES AT EACH LEVEL I. Nation II. States III. Communities IV. Institutions V. Individuals
11 I. NATIONAL PURPOSE POPULATION HEALTH Triple Aim
12 ACA (Nation) Requires: Population Health Takes More Than Medicine Cambridge Management Group 12
13 Cambridge Management Group 13
14 22 State Innovation Plans Multi-payer, System Transformation Cambridge Management Group 14
15 II. STATE ENABLING POLICIES INNOVATION PLAN HEALTHIER WASHINGTON 5-10 YEARS
16 WA STATE HEALTHCARE INNOVATION PLAN (HCA) State as an INTEGRATIVE purchaser Integration of Insurers and Providers Integrated Communities for Health & Social Services Integration of Community Health Workers Integrative Design and Learning Centers for Population Health
17
18 WA State: Supports for the Triple Aim Cambridge Management Group 18
19 WA Plan for Integrating Medical Care and Community Government, Private Enterprises, Foundations Regional Design & Learning Centers Community ARBE ACH Planning for Whole System Coordination Accountable Risk Bearing Entities (ARBEs) (Providers-- Insurer) Regional Extension Centers July 2014 Cambridge Management Group 19 Accountable Community for Health (Integrator)
20 WA Plan for Integrating Medical Care and Community Government, Private Enterprises, Foundations Regional Design & Learning Centers Community ARBE ACH Planning for Whole System Coordination Accountable Risk Bearing Entities (ARBEs) (Providers-- Insurer) Regional Extension Centers July 2014 Cambridge Management Group 20 Accountable Community for Health (Integrator)
21 Accountable Communities of Health: Integrating Medical Care and Community Government, Private Enterprises, Foundations Community ARBE ACH Education, Training, Development Housing Social Services Jobs, Economic Development BH, A&R, PH Integration IDCOP, PCMH Regional Design & Learning Center Regional Extension Centers Wellness Stress, ACEs Prevention Accountable Risk Bearing Entities (ARBEs) Planning (Providers-- for Whole System Coordination Insurer) Medical Communitywide Service Lines EMR, HIE, Analytics, Metrics CHW Net, PAM & Tech July 2014 Cambridge Management Group 21 Self Care Networks, PAM Accountable Community for Health
22
23 COMMUNITY HEALTH WORKERS Curriculum Work force Grass roots ACH / ARB role? AAA role? PHD role?
24 III. COMMUNITY Under developed System Dynamics Improving Interactions
25 HARD NOT IMPOSSIBLE SWEDEN GRAND JUNCTION, CO INTERMOUNTAIN, UTAH
26 NEW TOOLS, NEW APPROACHES for COMMUNITIES System Dynamics Model Must capture savings locally for reinvestment Then critical sequencing (where to invest) CHW-network (invest first) For supporting clients between between visits, between institutions, and between EMRs For saving money For supporting chronic conditions and healthy behaviors Improving interactions between institution (ongoing investment) ACH-REC
27 CRITICAL COMMUNITY LESSIONS from Rippel ReThink Health Model 1. Capture and Reinvest 2. Whole Community 3. CHW-network
28
29 Some communities that have used the ReThink Health systems dynamics model Cambridge Management Group 29
30 Community System Levers
31 Cambridge Management Group 31
32 4 Categories for Effecting Change Medical System COMMUNITY Finance a New System Redesign the Professional Workspace Manage Health in the Community Space Focus on Upstream Community Opportunities Cambridge Management Group 32
33 Finance a New System 1. Establish Innovation Fund 2. Capture & Reinvest Savings 3. Pay Providers for Performance 4. Expand Insurance Coverage Cambridge Management Group 33
34 Redesign the Professional Workplace Create medical homes Redesign primary care practices for efficiency Recruit primary care providers for safety net clinic Prevent hospital-acquired infections Recruit primary care providers in private practice Improve hospital efficiency From ReThink Health, Fannie E. Rippel Foundation 34 Cambridge Management Group
35 Between Visits & Between Institutions: the Community Space Discharge Improve post-discharge care Coach & coordinate health care Provide adherence support for routine care Extend hospice & end of life choices Person-centric Improve routine preventive and chronic physical illness care Enable healthier behaviors Improve care for chronic mental illness From ReThink Health, Fannie E. Rippel Foundation Cambridge Management Group 35
36 Community Health Worker Innovations Curriculum Work force Grass roots ACH role? AAA role? PHD role?
37 A Community Network View How to create conditions for EFFECTIVE care: Trustworthy Safe Equitable Timely and Efficient (affordable)
38 Q: Current State of Care Coordination?
39 Q: Current State of Client Coaching?
40 Q: Current State of Navigating?
41 Finanical Services Jobs / Employment PIECES HUMPTY DUMPTY? GLUE? Education Legal Aid / Criminal Justice Crisis Intervention Family Support COMMUNITY Transportation Food Hospitals, Skilled Nursing Facilities, Therapies, Pharmacies, Diagnostics, Housing Care COORDINATOR Physician Practice Nurse Practice Scheduler Behavioral Health Addiction & Recovers
42 Finanical Services Jobs / Employment Integrating Social and Medical Services through a Network of CHWs Community Health Workers (Neighborhood Support) Person Patient Client PIECES HUMPTY DUMPTY? GLUE? Education Volunteer Parish Nurses PEER Supporters Personal Care Workers FAMILY Care Givers Legal Aid / Criminal Justice Family Support Crisis Intervention NEIGHBORHOOD Community Based NAVIGATOR COACH HOME COMMUNITY OR NETWORK CONNECTIONS? Hospitals, Skilled Nursing Facilities, Therapies, Pharmacies, Diagnostics, Transportation Housing Food Care COORDINATOR Physician Practice Nurse Practice Scheduler Behavioral Health Addiction & Recovers SOCIAL SERVICES PRIMARY CARE MEDICAL SYSTEM COMPONENTS
43 4 3 Cambridge Management Group - West
44 BETWEEN Life occurs in the large spaces Between visits Between organizations Between EMRs Which organizations and technology will support people in between?
45 SOME COMMUNITIES WILL CHOOSE TO MANAGE THE INTERACTIONS. NOT FOR THE FAINT OF HEART Attempts by Non-trustworthy Parts will Fail Competitors must become allies Integration trumps improvement Right sequence essential Courage and experience
46 May 6, 2015 Cambridge Management Group 46
47 Linkage Mapping Work Together for Population Health Create Shared System Purpose Map System Connections Focus on Interactions Criteria for Prioritizing Improvements Ideal Design May 6, 2015 Reinvest Savings on Interactions Cambridge Management Group 47
48 It Takes a Community 48
49
50
51 Linkage Mapping Session May 6, 2015
52 WORTH THE EFFORT & RISK? Mindset Mood Scale Time Sequence
53 Organizations will emerge to manage the interactions, above the competition. BUT it will be sustainable only when there is an ability to capture the savings and reinvest locally! Enlightened Local Payer Function
54 Three Silver Bullets Integrated Communities for Health & Social Services Accountable COMMUNITY for Health A PLACE for innovation and development Integration of Community Health Workers Build the bridges BETWEEN the parts Integrative Design and Learning Centers for Population Health
55 Final Gentle Reminder It is about people working together It is about place. It is about conversations that lead to commitments. We all have the know how. Only the stakes and the scale are higher than usual. Good luck! You can do this!
56 THANK YOU FOR WHAT YOU WILL DO MARC PIERSON CAMBRIDGE MANAGEMENT GROUP (WEST)
57 A Phased Approach for Community-level Change Pre-work Establish Sponsorship Project Work Streams 1: Form Guidance Group; Design Communications Methods & Plan 2: Develop System Linkage Maps 3: Strategic Community Care Services 4: Design an Ideal Community Health Worker Network 5: Explore/Design All-Payer Community Financing 6: Conceptually Design an Accelerated Solutions Environment 7: Engage Local Employers in Supporting Whole System Innovation Cambridge Management Group (West) 57
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