The Collaborative to Advance Social Health Integration (CASHI)

Transcription

1 The Collaborative to Advance Social Health Integration (CASHI) "Let me tell you the story of one patient we worked with in Boston. He was screened for unmet health-related social needs as part of a newly instituted policy of universal screening. He screened positive for food insecurity, prescription assistance and utility needs. When we talked to him, he told us that he and his wife had recently retired and were struggling to pay for the wife s medications on their fixed income. Because all their discretionary income went to pay for medication, they didn t have enough money to afford oil to heat their home or quality food to comply with their physician s recommendations. He was about to go in for major surgery - concerned about his ability to recover in a home without heat during a New England winter, and without the kind of food he was told he needed to eat post-surgery. He considered not having the surgery. She considered skipping doses of her medications to save money. Neither of which they had to do because he was lucky enough to be seen at a practice that screened for social needs and provided referral and navigation services. Had that not been true, they would be labeled non-compliant." Problem Statement Only 10% of health outcomes are directly attributed to medical care, whereas close to 70% are driven by social, environmental, and behavioral factors 1. Despite this, the United States spends disproportionately more on medical care than other countries, with poor results 2. Evidence suggests that addressing patients social needs can reduce costs and improve care. Some examples: CareOregon s health resilience program, which pairs patients with a resource specialist who helps them address social determinants of health, boosted primary-care visits, reduced unnecessary emergency room visits, and generated $1.65 million in annual savings 3. People who are enrolled in the USDA Supplemental Nutrition Assistance Program (SNAP) program have health care expenditures that are $1400 less per year compared with similar people who are not enrolled in SNAP 4. 1 Healthy People/ Healthy Economy Report Card 2011, Network for Excellence in Health Innovation. Accessed at on Nov Alley DE, Ph.D., Asomugha CN, M.D., Conway PH, M.D., and Sanghavi DM, M.D. Accountable Health Communities Addressing Social Needs through Medicare and Medicaid N Engl J Med 2016; 374:8-11January 7, 2016DOI: /NEJMp Livingston, S. (2017). Bending the cost curve on high-risk patients. Modern Healthcare, 47(24), 12 4 Berkowitz SA, Seligman HK, Rigdon J, Meigs JB, Basu S. Supplemental Nutrition Assistance Program (SNAP) Participation and Health Care Expenditures Among Low-Income Adults. JAMA Intern Med. 2017;177(11): doi: /jamainternmed

2 At Massachusetts General Hospital, it was shown that screening for and attempting to address unmet basic resource needs in primary care was associated with improvements in blood pressure and lipid, although not blood glucose levels 5,6. Within Health Leads programs, it has been shown that 68% of patients are more likely to recommend their clinic due to this program 7. Because of increasing recognition that social needs impact health outcomes and utilization, federal and state-level transformation efforts such as the CMS Accountable Health Communities, Comprehensive Primary Care Plus, and many state Delivery System Reform and Incentive Payment (DSRIP) initiatives are testing payment models for social needs integration, sometimes including services provided by community-based partners. These aligned efforts point to a set of emerging best practices. These include: implementing strategies to identify patients with unmet social needs, enabling care providers to make referrals to community resources and social supports, providing navigation in some cases, developing and enhancing the efficiency of community partnerships, and using data to support improvement. This increasing evidence, knowledge and policy momentum has driven healthcare systems to pilot more systematic approaches to addressing patients social needs. However, little is known about when and how to spread these changes within health systems, especially in a way that is integrated into standard primary care for all patients. In addition, the health care sector needs more insight on how to make social needs integration operationally sustainable so that it can be spread widely. Organizations still struggle with the best ways to measure impact, achieve efficiencies, and secure funding to sustain and spread this work. Collaborative Purpose This collaborative, run by Health Leads with generous support from the Commonwealth Fund, seeks to learn effective diffusion strategies for improving primary care patients social support. Participating organizations will plan and execute spread of successful strategies to one or more sites and create a business case that both informs these strategies and encourages investment in helping patients overcome social impediments to health. For institutions who express the need and demonstrate the capacity to develop a financial model to support the business case, technical assistance will be available. Learning from business case development is accessible to all participants. 5 Berkowitz SA et al. Addressing Basic Resource Needs to Improve Primary Care Quality: A Community Collaboration Programmed. British Medical Journal Quality and Safety. 2015, 30 November. 6 Berkowitz SA et al. Addressing Unmet Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management. Jama Internal Med 12 December Health Leads Reach, Sept, Feb 2017

3 Within the span of this 18-month learning collaborative, primary care teams with an existing social health intervention will improve upon it so that their clinic sees 50% increases in the percentage of patients who report that they have the resources to improve their social health and well-being and that they are confident that they can control and manage most of their health problems. Clinics will spread changes to one or more sites within their institution or health system. As mentioned above, the collaborative will help participants make a business case that supports sustaining and spreading social needs integration. This collaborative is action-oriented, not benchmarking or research. Collaborative faculty and Health Leads will help participating organizations achieve the collaborative goals by sharing the best available evidence and knowledge around helping patients with social needs, and by teaching and applying improvement science. Collaborative Aim Statement By October 2019, participating healthcare organizations will integrate social health into primary care so that there is a 50% increase in patients who report that they have resources to improve their social health and well-being and 50% increase in patients who report they are confident that they can control and manage most of their health problems. This will be accomplished by Increasing the % of patients screened in PCP visits each month to 95% or more Increasing the % of patients who request support and who are offered 1 or more links to community supports for social health and well-being in a timely manner to 95% or more Increasing the % of patients who report that they worked with the care team on issues important to them to 95% or more While maintaining or improving care team staff satisfaction. In addition, teams will spread their approach to 1 or more clinical sites. Methods. Each participating organization is expected to adopt the AIM statement and the specific goals set forth. Each clinic has a goal to spread the improvements to 1 or more other sites. This spread will require active involvement from the senior leaders of each institution.

4 Measurement. The Collaborative measures of success include site and spread measures. Outcome Measures: Percentage of patients who report that they have resources to improve their social health and well-being each month and Percentage of patients who report they are confident that they can control and manage most of their health problems (or their families health problems) each month Process Measures: Percentage of patients screened in PCP visits each month Percentage of patients who request support who are offered 1 or more links to community supports for social health and well-being in a timely manner each month Percentage of patients who report that they worked with the care team on issues important to them Balancing Measure: Care team satisfaction Spread Measures Number of changes spread to each spread site Percentage of patients who report that they have resources to improve their social health and well-being each month and Percentage of patients who report they are confident that they can control and manage most of their health problems (or their families health problems) each month Collaborative Expectations The Collaborative Expert Staff and Faculty will offer: Expertise with collaborative s Change Package Evidence-based information on supporting patients in social health and well-being and methods for process improvement, implementation, and spread Expertise on demonstrating value and making a business case Coaching and Support Transparent sharing among collaborative teams Team assessments of progress Participating organizations are expected to commit to the following: Use the collaborative aim, changes and measures for improvement and implement changes in the change package

5 Develop a plan to spread the intervention to one or more sites and execute on this plan Develop a value or business case to support spread and to sustain the work Identify an improvement team that includes a clinical and administrative lead, a day to day leader, front line staff, 1-2 community partners, and 2 patients Identify one or more spread site(s) and the teams at these sites that will implement changes Provide a Senior Leader to serve as an executive sponsor for the team, and define a communication process between this person and the improvement team Report monthly about their changes, data, lessons learned and barriers Perform pre-work activities to prepare for the first and subsequent Learning Sessions Use improvement science to implement and spread changes Submit a monthly progress report with data Model collaborative learning citizenship by sharing and engaging in the community Senior Leaders/sponsor from participating organization are expected to: Provide staff support for their team, including time to prepare for and attend Learning Sessions, time to devote to improvement and measurement activities during the action periods (at least 25% FTE spread across team members during the Collaborative) and actively support team learning. Note that a $10K/team stipend is provided to offset cost of participation. Support and resource business case development work for success; if the organization would like to benefit from and qualifies for business case technical assistance, this includes identifying a finance staff lead and ensuring access to relevant sources of financial data Remove system barriers that inhibit related changes and improvements as well as support and resource spread Participate in periodic activities designated for senior leadership, particularly on topics related to business case development, sustainability and spread; this will include attending at least one live learning session and quarterly leadership calls Communicate with internal and external audiences the value of the project and its progress Collaborative Timeline Activity Virtual/Live, Location Date Teams complete Pre-work N/A Due: May 18, 2018 Learning Session 1 Live, Boston May 30-31, 2018 Platform Orientation Call Virtual June 6, :30-1:30pm EST Action Period Call 1 Virtual June 27, :30-1:30pm EST

6 Action Period Call 2 Virtual July 25, :30-1:30pm Learning session 2 and Regional Site Visit Virtual August 22, :00-4:00pm EST Action Period Call 3 Virtual September 26, :30-1:30pm EST Learning Session 3 Live, Location TBD October 24, 2018 Action Period Call 4 Virtual December 5, :30-1:30pm EST Action Period Call 5 Virtual January 9, :00-2:00pm EST Regional Site visit and Learning Session 4 Virtual February 13, :00-3:00pm EST Action Period Call 6 Virtual March 13, 2019, 12:30-1:30pm EST Action Period Call 7 Virtual April 10, :30-1:30pm EST Action Period Call 8 Virtual May 8, :00-2:00pm EST Learning Session 5 Live, Boston June 5, 2019 Action Period Call 9 Virtual July 17, :00-2:00pm EST Action Period Call 10 Virtual August 14, :30-1:30pm EST Action Period Call 11 Virtual September 11, :30-1:30 pm EST Closing, Learning Session 6 Virtual October 9, 2019 Learning Collaborative Structure Pre-work. Pre-work is the period between your application and the first Learning Session. During this time, the team has several important tasks to accomplish to be prepared for the first Learning Session, including baseline data collection when possible and observing the current system at work, called discovery shopping. Learning Sessions. The major integrative events of the collaborative are the scheduled Learning Sessions. Participants should plan to attend all Learning Sessions. There will be a combination of virtual and face-to-face learning sessions. Each learning session has plenary presentations, small group discussions, and team meetings. They are scheduled over the course of one or two days, where

7 participating teams will have the opportunity to gather new information on the subject matter and on its processes; get improvement ideas and experience from experts; share information with other members of the collaborative; and make detailed improvement plans. Action Periods. The time between Learning Sessions is called an Action Period. During Action Periods, collaborative teams work to implement changes in the change package, and later spread these changes. Although each participant focuses on his/her own organization, each remains in continuous contact with other collaborative participants. This communication takes the form of monthly conference calls or webinars, s, and sharing of information on a virtual site. Each team also submits monthly team progress reports on its improvement efforts to share results internally with its appointed senior leader, as well as externally with other participating teams. Participation in Action Period activities is not limited to Learning Session attendees. In fact, we encourage the participation of individuals in your organization who may not be on your core improvement team but affect the outcomes in the Action Period activities.