Improving Outcomes for individuals with high needs and highcosts: there? Eleni Carr Alan Glaseroff Douglas McCarthy Rebecca Ramsay Cory Sevin

Transcription

1 L26 These presenters have nothing to disclose Improving Outcomes for individuals with high needs and highcosts: what help is there? Eleni Carr Alan Glaseroff Douglas McCarthy Rebecca Ramsay Cory Sevin December 4 th :00-4:30 ET #IHI27FORUM Housekeeping 2 1

2 Session Objectives P3 Discuss what is known about what works for the care management of individuals with high needs and high costs Describe a tested process for redesigning care programs for high-needs, high-costs individuals Identify the resources available to support the work of redesigning care for high-needs, high-costs individuals #IHI27FORUM Approach to this meeting. 4 Cambridge Health Alliance A Useful Framework Stanford Coordinated Care What do we know in the field and literature? Your Questions and Experience CareOregon Resources Sustainability 2

3 Introductions and Your Questions 5 Better Health and Lower Costs for People With Complex Needs-A Useful Framework Roadmap 6 3

4 High-Need, High-Cost Patients: Who Are They? What Works? Douglas McCarthy Senior Research Director, The Commonwealth Fund IHI National Forum Learning Lab Orlando, Florida December 4, 2016 Who are high-need, high-cost adults? 8 Multiple chronic conditions plus activity limitation; many with co-occurring behavioral health conditions Much higher healthcare spending and out-of-pocket costs; more likely to have persistently high costs More likely to be older, less educated, lower income, publicly insured, fair/poor health, socially isolated Use more health care, e.g., 5X more admissions More often experience gaps in care, e.g., unmet needs, medical mistakes, coordination problems 4

5 Adults with High Needs Have Higher Health Care Spending and Out-of-Pocket Costs Average annual out-of-pocket spending Average annual health care expenditures $21,021 $7,526 $4,845 $702 $1,157 $1,669 Total adult population million Three or more chronic diseases, no functional limitations 79.0 million Three or more chronic diseases, with functional limitations (high need) 11.8 million Note: Noninstitutionalized civilian population age 18 and older. Data: Medical Expenditure Panel Survey (MEPS). Analysis by C. A. Salzberg, Johns Hopkins University. Source: S. L. Hayes, C. A. Salzberg, D. McCarthy, D. C. Radley, M. K. Abrams, T. Shah, and G. F. Anderson, High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? The Commonwealth Fund, August Adults with High Needs Have Unique Demographic Characteristics Total adult population Three or more chronic diseases, no functional limitations Three or more chronic diseases, with functional limitations (high need) 83% 83% 55% 52% 58% 63% 52% 31% 28% 30% 27% 28% 41% 26% 38% 17% 16% 14% Age 65+ Female No high school degree Income below 200% FPL Public insurance Fair or poor health status Notes: Noninstitutionalized civilian population age 18 and older. Public insurance includes Medicare, Medicaid, or combination of both programs (dual eligible). Data: Medical Expenditure Panel Survey (MEPS). Analysis by C. A. Salzberg, Johns Hopkins University. Source: S. L. Hayes, C. A. Salzberg, D. McCarthy, D. C. Radley, M. K. Abrams, T. Shah, and G. F. Anderson, High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? The Commonwealth Fund, August

6 High-Need Adults Have More Emergency Department Visits and Hospital Stays Total adult population Three or more chronic diseases, no functional limitations Three or more chronic diseases, with functional limitations (high need) Emergency department visits Rate per 1,000 Inpatient hospital discharges Rate per 1,000 Note: Noninstitutionalized civilian population age 18 and older. Data: Medical Expenditure Panel Survey (MEPS). Analysis by C. A. Salzberg, Johns Hopkins University. Source: S. L. Hayes, C. A. Salzberg, D. McCarthy, D. C. Radley, M. K. Abrams, T. Shah, and G. F. Anderson, High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? The Commonwealth Fund, August Adults with High Needs Are More Likely to Incur and Maintain High Health Care Spending In top-spending category one year only In top-spending category two years in a row 32% 27% 20% 29% 12% 7% 4% 2% Top 10% of spending Top 5% of spending 6% Top 10% of spending 11% 2% Top 5% of spending Top 10% of spending 15% Top 5% of spending Total adult population Three or more chronic diseases, no functional limitations Three or more chronic diseases, with functional limitations (high need) Notes: Noninstitutionalized civilian population age 18 and older. Percentages are based on total individuals in each cohort for whom there were 2 years of data. Data: Medical Expenditure Panel Survey (MEPS). Analysis by C. A. Salzberg, Johns Hopkins University. Source: S. L. Hayes, C. A. Salzberg, D. McCarthy, D. C. Radley, M. K. Abrams, T. Shah, and G. F. Anderson, High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? The Commonwealth Fund, August

7 Older adults with high needs more often report problems with access to and quality of care 13 Percent Other U.S. older adults High-need U.S. older adults Cost-related access problem* ED visit for condition that could be treated by regular doctor** Coordination problem** Medical mistake** Source: D. O. Sarnak and J. Ryan, How High-Need Patients Experience the Health Care System in Nine Countries, The Commonwealth Fund, January Data: U.S. respondents (ages 65 and older) to the Commonwealth Fund 2014 International Health Policy Survey of Older Adults. *In the past year. **In the past 2 years. Some comprehensive care models exhibit promising evidence of impact, but few have been widely spread 14 CATEGORIES MODELS OR EXAMPLES EVIDENCE OF POSITIVE IMPACT QoC QoL FA Surv Use Cost 1. Interdisciplinary Primary Care Guided Care, GRACE, IMPACT, PACE X X X X X M 2. Enhanced Primary Care Care and case management X X M Disease management X X Preventive home visits X X X Geriatric evaluation and management X X X M Pharmaceutical care X X Chronic disease self-management X X X Proactive rehabilitation X X Caregiver education and support X X 3. Transitional Care Hospital to home X X X 4. Acute Care in Patients Homes Substitutive hospital-at-home X LOS X Early-discharge hospital-at-home 5. Team Care in Nursing Homes Minn. Senior Health Options, Evercare X M 6. Comprehensive Care in Hospitals Prevention/management of delirium X LOS Comprehensive inpatient care X X X Source: adapted from C. Boult et al. Journal of the American Geriatrics Society 2009;57: Examples: GRACE = Geriatric Resources for Assessment and Care of Elders; IMPACT = Improving Mood: Promoting Access to Collaborative Treatment; PACE = Program of All-Inclusive Care for the Elderly. Impact: QoC = quality of care; QoL = quality of life; FA = functional autonomy; Surv = survival; LOS = length of stay; M = mixed evidence. X 7

8 15 Source: D. McCarthy, J. Ryan, and S. Klein, Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis, The Commonwealth Fund, October Success depends on effective implementation Interdisciplinary teamwork (e.g., defined roles, trusting relationships, team meetings) Care managers trained to build rapport with patients and collaborative relationships with physicians Coaching and behavior-change techniques to teach self-care skills (e.g., motivational interviewing) Standardized processes for medication management, advanced care planning, etc. Health information technology to provide timely and reliable information Source: D. McCarthy, J. Ryan, and S. Klein, Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis, The Commonwealth Fund, October

9 These are patients who are systematically disenfranchised because of the chaos of their lives They have grown to distrust the health care system because it hasn t delivered what they need. Paul Johnson, MD, medical director, Hennepin Health Coordinated Care Center For health system leaders, no need to reinvent the wheel. 9

10 Care Management for Complex Patients The CHA Story Eleni Carr, MBA, LICSW Sr. Director, Care Integration December 4,

11 Our Population & Payer Landscape Take care of 105, ,000 underserved patients, >60% of whom speak a language other than English 82% public payors Medicaid FFS, Managed Medicaid, Medicare High prevalence of patients with BH conditions Percentage of population in increasingly more significant risk contracts Target 20% 35% 40% 50% 80% The Financial Model Affects Strategy Financial Models related to investment strategies in CCM by the delivery system Less Conducive More Conducive Fee for Service Pay for Performance: Bonuses for Quality Shared Risk between Providers and Payers: Cost, quality, pay-backs Global Budget: fixed maximum expenditures for defined set of services or payback $ over budget Accountable Care Organization: Provider takes full financial accountability for enrolled patients Payer telephonic auth/denial, central RN CM function Management Strategies: Payer and Delivery centralized strategy with duplication Delivery system on point Embedded in primary care 11

12 Evolution of Care Management Payer Driven Payer Based Care Management Network Health Alliance Multi-organizational partnership Off-site; no integration Payer focused Centralized Care Management Organization focused Data driven; Off-site; Limited integration Present Payer informed Primary Care Based Care Management Embedded in teambased practice model Runs the risk of losing high risk focus Lessons Learned from a Centralized Model Locate services as close to patients as possible Increased opportunities for engaging patients (face-to-face) Warm hand offs are the gold standard Relationships with primary care teams are key Easy exchange of communication and care planning Leverage the good will patients feel towards their clinic and providers Care Teams are the best source for referrals (with training) Payer identified pt lists have important -but limited - value without context Care Teams know which pts can be most impacted by care management You need to start somewhere Start small and learn from your successes & failures Create buy-in across your system of care, including IT and HR 12

13 CCM The Basic Concept Getting the right patients into care management Doing the right work with high utilizing patients Triple Aim Outcomes The CHA Care Management Model Drivers of Risk and Cost CHW Complex Care Mgmt Team Some Rising 5% 5 $ CCM Team Acute Illness Chronic Disease Risk Patients RN 6-10% LICSW Under-use of PCP Over/Mis-use of ED/Inpatient Social disconnection Substance Abuse Mental Health Chronic Disease Management Planned Care Team Disease Management Programs PCMH Care Team Disabilities Poverty Routine Care and Prevention 13

14 Developing a 27 Standardized Response Transition back to care team: Achieved Goals Disengaged CCM provides little to no added value to triple aim goals Identification/ Referral High Risk Stratification/ Payer Lists PCP Referral Inpatient Referrals Evaluation and Re-assessment Validation and Triage Assessment and Care Plan Engagement and Outreach Tracking Progress 28 14

15 Cycle of CCM Work 29 Pre-work Evaluation Work Why use data at all? Patients don t wear signs saying, I m in the top 5% Cost Data + Utilization Data + Predictive Analytics Our Formula Clinical skill + Intuition + Patient Knowledge Referring the right patients into Care Management 15

16 Patient Identification Approaches 1. Quantitative Risk Prediction Tools: Validated and expenditure driven but can miss patients with high psychosocial need and claims lag 2. Acute Care Utilization Focused: Timely but fail to provide insight into admission factors and therefore potential interventions 3. High Risk Condition/Medication Focused: Straight forward and user-friendly but may miss patients at risk for cost and utilization 4. Health Risk Assessment Driven: comprehensive and resource intensive 5. Physician/Staff/Self Referral: Engaging but may miss high cost, high utilizing patients 6. Hybrid quantitative and qualitative: Inclusive of many approaches; more challenging to implement Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program? The Commonwealth Fund, Clemens S. Hong, Allison L. Siegal and Timothy G. Ferris. Our humble beginning One nurse CM and one list Top 100 patients with highest expenses ED_Tot ED_Tota ED_Total IP_Total_ IP_Total al_visit l_visits _Visits_P ED_Total_ ED_Total_Pa ED_Total_Pa IP_Total Visits_PR _Visits_ IP_Total_P IP_Total_Pai Rx_Total_P Rx_Total_Pai RHN MEM_ID s _PRE OST Paid id_pre id_post _Visits E POST aid d_post Rx_Total_Paid aid_pre d_post N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N

17 33 Effectiveness for FY 14 14,440 pts 468 pts 190 pts 78 pts 112 pts Total 1 st Payer Cohort Analytics The top 3% by utilization, high ED and Inpatient activity 9 patients enrolled in CHA care management 28 patients deceased, moved, or not CHA PC 241 patients were not validated by PCP or Triage process Appropriate (validated) for Care Management Declined, Unable to Reach Enrolled in Care Management 47 Patients enrolled during SFY 2013 efforts 65 Newly enrolled patients from SFY 2014 efforts 77 pts $809,645 Evaluated for Cost Avoidance 43 Patients enrolled during SFY 2013 efforts 34 Newly enrolled patients from SFY 2014 efforts At least 6 months of pre/post claims data Annualized Cost Avoided 43 patients enrolled in SFY 2013 with actual costs avoided over 12 months of $589, patients enrolled early in SFY 2014 with estimated costs avoided of $219,679 Where is the greatest opportunity? 17

18 Case Finding Selection and Drivers 35 PCP & Care Team Referral Payer High Risk Lists (Claims) High ED use Lists Hospitalis ts and Specialist s Complex Care Management Authorizatio n and D/C Lists Hospital to Home Staff Inpatient Case Mgrs & Social Workers Readmissio n Reports Disease Registrie s Hybrid Example Quantitative and Qualitative methods for patient identification Our Bi-Directional Validation Process 36 PCPs validate data driven referrals Care Managers validate Care Team referrals 1) Would you be surprised if this patient is hospitalized or has ED visit in next 6 mo? 2) Is this patient s situation impactable by care management? 3) Is the patient likely to engage to any degree with care management? 18

19 37 High Risk Payer Lists Inclusion Criteria: High Risk Score MMP or Other High Past or Predicted Future Cost (>$25,000) Inpatient Probability Risk (>50%) High Number of ED Visits (8+ in 12 months) High Psychiatric Utilization Re-admission Risk Condition Specific CHF, COPD, Diabetes Levine Score Palliative Care Consultation 38 Pipeline Sample IP Stay Probability >= 2 IP Future Costs > >= 8 ED Secondary Row Labels MRN Age Insuarance > 50% Admits ast 12 months 35K Visits Primary Risk Category Reason for Inclusion Reason PCP Name N 63 Payer 1 (blank) 3 (blank) $12,920 2 (blank) >2 IP Admits I 45 Payer % 0 $6,517 $20, degenerative & Congenital CN >=6 ED Visits M(blank) Payer 2 (blank) (blank) (blank) (blank) 8 (blank) >=6 ED Visits (blank) G 32 Payer 1 (blank) 2 (blank) $36,670 0 (blank) >2 IP Admits Future Costs > 35K I 25 Payer 3 1.9% 1 $33,497 $20,880 0 Other mental health Med Cost > 25K EY 44 Payer 5 (blank) 0 (blank) (blank) 7 (blank) >=6 ED Visits Pipelines are refreshed quarterly 19

20 CCM Pipeline High Utilizer Criteria 2+ inpatient visits (anywhere) in last 12 months 6+ ED visits (anywhere) in last 12 months or or > $25,000 in TME in last 12 months (not including Rx) or > 50% probability of inpatient stay in next 12 months or > $35,000 in predicted costs in next 12 months. Combining Data from Multiple Sources + + Payer 1 Payer 2 Payer pts 600 pts 1,500+ pts 21% 28% 4-12% Enrollment rate declined as payer streams increased 20

21 %OF PATIENTS 11/22/2016 Heads Up What can happen when you re not looking 12 MONTH TOTAL MEDICAL EXPENSES TME (ACO Sub Population) 60.0% 50.0% 139 Pts 40.0% 30.0% Average TME for CCM sample = $21, % 47 Pts 10.0% 28 Pts 20 Pts 15 Pts 30 Pts 0.0% 0-10K 10-20K 20-30K 30-40K 40-50K 60+ TOTAL MEDICAL EXPENSE What we changed 1) Consider utilization - not simply psychosocial conditions - as the key component of impactability 2) Review High Risk lists considering future costs and inpatient utilization more carefully 3) Specific Modifications: Referrals must include high risk drivers (utilization or risk of utilization) Identify groups to automatically outreach, i.e. Patients with 8+ ED visits ACO patients with predicted future costs >$50,000 ACO patients with inpatient probability scores of 75%+ More carefully review the following patients: Patients aged 75+ with any inpatient admission ACO patients with any readmission in last 3 months Patients with CHF, COPD, A1C over 9 resulting in admission, stroke and pneumonia Any admission 4+ day LOS Levine score < 4 21

22 We can do this!! The Activation Model Designing for Intent in a Defined High-Risk Population Alan Glaseroff MD Stanford Coordinated Care 22

23 Determinants of Health and Their Contribution to Premature Death 15% 30% 5% 10% Social Environmental Medical Behavioral Genetic 40% Schroeder, NEJM 357; 12 Patient Experience vs. Trust, by Country. Trust Gap: US 3 rd in experience 24 th in trust Blendon RJ et al. N Engl J Med 2014;371:

24 Positive and Negative Outliers F R A M E W ORK B Y I D E O 5 Key Behaviors to Increase Activation Emphasizing patient ownership Partnering with patients Identifying small steps Scheduling frequent follow-up visits to cheer successes, problem solve, or both Showing caring and concern for patients Pretty obvious list. What gets in the way? J Greene, J Hibbard, et al. J Ann Fam Med 2016;14: doi: /afm

25 Cup Runneth Over Provider Medical Assistant/Care Coordinator Nurse Behavioral Health Clinical Pharmacist Physical Therapist Primary SCC Goals: Build the relationship to care coordination team Enhance patients self-management by activating the patient Transform the primary care/specialty care relationship to better serve the patient s goals: Access by tele-presence, , phone Achieve Triple Aim results Better health Better care Lower cost 50 25

26 Design Thinking Serves as a Structured Problem-Solving Process 1 IN SPIRATION 2 IDEAS 3 AC TI O N OBSERVATIONS STORYTELLING SYNTHESIS BRAINSTORM CREATE / REFINE PROTOTYPES USER FEEDBACK Design Thinking: Present State Future State 26

27 Care Model Why wouldn t a person with a chronic condition do everything in their power to live long and feel well? What the Patient Brings: Activation Level 10-15% of the population* 20-25% of the population* 35-40% of the population* 25-30% of the population* * Medicaid and Medicare populations skew lower in activation 27

28 Patient Variation What the Patient Faces Domains The Often Hidden Driver: Adverse Childhood Events ACE Score = 1 point each for positive responses to 10 questions inquiring about exposure to: Physical abuse Emotional abuse Sexual abuse Physical neglect Emotional neglect Divorce/separation Domestic violence in the home Parent that used drugs or alcohol Parent that was incarcerated Parent that was mentally ill Embed behavioral health! From: 28

29 Predicted Patient Costs ($) # of Members per Level 11/22/2016 Stanford PAM Results Comparative Values by PAM Levels Level 1 Level 2 Level 3 Level 4 Initial Repeat Predicted Average Per-Capita Costs 2 Years Later by Change in PAM Level $6,401 $6,465 Level 4 both time periods Move Level 3 to Level 4 $7,074 $7,290 Level 3 both time periods Move Level 4 to Level 3 $7,290 Move Level 1 or 2 to Level 3 or 4 $8,138 Move Level 3 or 4 to Level 1 or 2 $8,385 Level 1 or 2 both time periods Predicted costs are based upon regression models with log transformed costs that control for age, sex, chronic conditions, natural logarithm of income and percent of care that was received in-network. Costs were retransformed from log dollars using the Duan smear factor. 29

30 How to Deliver the 5 Behaviors? Don Berwick The source of energy at work is not in control, it is in connection to purpose. 30

31 SCC Approach: The Activation Model From: What bothers you the most? To: Where do you want to be in a year? First step Next step Getting there General Rules for Team Care Panel management: responsibilities for people, not tasks Staff work to limits of their credential Non-hierarchical meeting structure 31

32 Team Meetings Mindfulness meditation rotating leaders Care Coordinator present new cases 5 minutes each Background (support, family, work) What gives them joy? Problem List (clinician) Goals and action plans Team input Difficult cases Thanks jar Book club News Burn out prevention! From MA to Care Coordinator (CC) RESPONSIBILITY for patients in their small panel rather than simply perform a set of TASKS CASE PRESENTATION BY CC at team meeting Build skill of hearing/telling the patient s story Build skill of patient assessment using SCC tools STAY WITH PATIENT throughout the entire MD visit DOCUMENT THE VISIT ONGOING TRAINING in chronic disease management, behavior change CREATE NEW JOB CATEGORY AND PAYSCALE to reflect greater skills and responsibility 32

33 Care Coordinators Provide Assistance with follow up for their empaneled patients Diagnostics Procedures Consults Medication refills and adherence Establish goals and follow up of action plans Patient Health Portrait Analysis of key patient health metrics and trends Various chart types available 66 33

34 HEDIS: SCC results Triple Aim Results Inpatient Admissions ER Visits Patient Experience Cost of Care 253 patients with at least 6 months enrollment -29% -59% 99 th percentile -13% (~$1.8 million) 34

35 From Cup Runneth Over Provider Medical Assistant/Care Coordinator Nurse Behavioral Health Clinical Pharmacist Physical Therapist To Share the Care Provider Medical Assistant/Care Coordinator Nurse LCSW/Behavio ral Health Physical Therapist Clinical Pharmacist 35

36 Break P71 CareOregon s Journey to Better Care for High Risk/High Cost Patients Rebecca Ramsay, BSN, MPH This presenter has nothing to disclose. 36

37 CareOregon Our Mission: Cultivating individual wellbeing and community health through shared learning and innovation. Our Vision: Healthy communities for all individuals regardless of income or social circumstances. Publically financed healthcare insurer for low-income citizens 234,000 Members; Medicaid and Medicare beneficiaries 85% live in the Portland Metro region; rest are spread statewide Not for Profit Contracted network Contracts with primary care providers, specialists, hospitals, medical equipment vendors, home health agencies, pharmacies About 50% of our primary care providers practice in clinics that disproportionately care for the poor Began participating in the Institute for Healthcare Improvement s Triple Aim Initiative in May 2007 Copyright: Bruce Davidson CareOregon Member Populations 234,308 members - 3 distinct populations MAPD 11,103 42% < 65 yrs 100, ,976 37

38 Our triggers to redesign care for complex patients Tri-County Area Oct 2011 ~ 11% MCO rate cut The Great Recession Federal Match $650MM Reduced General Fund Aug 2012 ~ 19% MCO rate cut (1) Recession brought huge MCO rate cuts only way to survive without cutting benefits is to reduce overall medical spend (2) Highest cost, most complex members were not getting needs met with previous approaches Telephonic case management Clinic-based care management (3) Providers needed help with costliest patients medical home model improving care for all segments except high cost patients Defining our target population 38

39 State Medicaid Claims Data % of Total Billed Charges by Service 2010 Total Billed Charges = $1,630,851,673 Hospitalizations and ER admits amount to 43% of Billed Charges * Outpatient Behavioral includes mental health services and ER and non-er chemical dependency services What can claims data tell us about our high cost/high risk Medicaid members? Very High Prevalence of Mental Health and Addictions (State of Oregon Medicaid Data) 39

40 Effect of Substance Use and Mental Illness on Cost/Utilization Average 12 mos TOTAL cost, ED and Hosp utilization by group Target Population Based on Utilization and Cost All CareOregon Medicaid Adults (19yrs+) living in TriCounty Area Claims Data for 12 Month Period % Members % Cost Total Cost No hosp or ED use 70% 30% $96.5M 2-5 ED visits 13% 11% $35.5M 6+ ED visits 3% 5% $15M Maternity hospital admits 5% 7% $20.5M 1 Medical hospital admits 6% 18% $55.5M 2+ Medical hospital admits 4% 29% $92.5M 100% 100% 13% of CareOregon members = 52% of paid cost 40

41 Learning about our target population Number of High Cost/High Risk* Medicaid & Dual Eligible Adults by ZipCode Median Household Income, by ZipCode 0 $45,800 $45,800 - $53,000 $53,000 - $62,000 $62,000 - $85,500 $85,500 - $219,000 LEGEND: = ICCT participating clinics = participating hospitals = EMS outreach teams * High Cost / High Risk = meet Level 1 or Level 2 criteria 82 41

42 Illness Burden Compared to the overall CareOregon adult Medicaid and Dual member population Health Resilience Clients are more likely to experience high disease burden Health Resilience Program Health Resilience Program CO Adult Mbrs Health Resilience Program CO Adult Mbrs Health Resilience Program CO Adult Mbrs The Often Hidden Driver of Illness Burden: Adverse Childhood Events ACE Score = 1 point each for positive responses to 10 questions inquiring about exposure to: Physical abuse Emotional abuse Sexual abuse Physical neglect Emotional neglect Divorce/separation Domestic violence in the home Parent that used drugs or alcohol Parent that was incarcerated Parent that was mentally ill From: 42

43 The real Story of our Complex Patients Childhood toxic stress / ACEs >4 55% Physical and / or emotional abuse 50% Sexual abuse 43% Physical neglect 54% Household substance abuse 49% Household mental illness 43% Other childhood adversity: Family homelessness 29% Alcohol or street drug abuse as child 43% Ran away from home 47% Dropped out of school 47% Did not graduate HS / no GED 33% As adult: Struggled to find regular work 30% Substance abuse ever 60% Incarcerated: Jail 55% Incarcerated: Prison 15% Homeless ever: 56% Prevalence of Social Determinant Risks Health Resilience Clients are more likely to experience psycho-social challenges. Current Housing Situation 43

44 Care Team Perspective Patients Perspective: We need more help, not more medical treatment. 88 Jihad Moore, Health Resilience Client and Peggy Parker, Health Resilience Specialist 44

45 Changing the Care Model by Utilizing a Unique Workforce with Non-Traditional Competencies Health Resilience Specialists (Master s level Social Workers) are embedded with primary health homes and specialty practices to enhance the practices ability to provide community-oriented individualized high touch support to high risk/high cost patients Health Resilience Specialist Skillset Extensive outreach experience with high risk and vulnerable populations Mental health/addictions training Understanding of trauma dynamics & trauma informed care Ability to work across cultures and systems Working knowledge of local social service resources Ability to think individually & systemically Excellent communication skills and assessment skills Strong Motivational Interviewing aptitude Ability to set professional boundaries with compassion Exceptional advocacy and interpersonal skills Social justice values, extreme empathy, and non-judgmental nature 45

46 Recruiting and Engaging Clients Into Care Curtis Peterson, Health Resilience Specialist and Gordon Rasmussen, Health Resilience Client Engagement is on our clients turf and terms 46

47 Each Client s Care is Individualized and Outreach Interventions are Integrated into the Primary Care Plan Joannie McVey, Health Resilience Client and Quinne Salmeh,Health Resilience Specialist Choosing & Identifying Individuals Within Our Target Population High ED and Hospital Utilization individuals Assigned to Participating Primary Care Clinics -approx Individuals per clinic Community-wide adoption of ED and Hospital Information Exchange Platform sends daily notifications Provider knowledge & input helps to narrow, then staff attempt outreach and clinical assessment of individuals 47

48 Supporting the Workforce & Learning as we go Gathering the stories helps us learn and evolve the program Not Just A Project-People Need Help P96 Growing to meet the needs of all who need it and Sustaining your program for the long haul.. 48

49 Thank You! P97 Cory Sevin, RN, MSN Director, IHI 49