Care Collaboration Success: How Payers, Providers and Local Resources Innovate and Collaborate for Effective Care Management

Transcription

1 Care Collaboration Success: How Payers, Providers and Local Resources Innovate and Collaborate for Effective Care Management

2 Introduction The nature of our healthcare ecosystem has been that of care provided in silos. Health insurers, providers and community resources all have their own relationships with the member, patient and consumer, but rarely do the three come together with the patient s well-being prioritized as a unifying mission. Insurers are in a unique position with their capture of and access to critical and voluminous data. Claims data, information on chronic conditions, and medications and treatments are all part of the data set they collect. Providers typically have the best encounter data, based on their direct contact with patients. And community resources often build a true relationship, based on trust, dependence on services and improved well-being. When insurers tap into the storehouses of data they have, and make it available in a meaningful way to providers and local resources, the three entities can come together and materially impact health outcomes for individuals. This e-book includes some great examples of how insurers, providers and local resources are working in combination for the good of their members, patients and consumers. But first, let s go over a crucial ingredient that is becoming recognized across healthcare: SOCIAL DETERMINANTS OF HEALTH.

3 Defining Social Determinants of Health What are they? social determinants of health 1. the structural determinants and conditions in which people are born, grow, live, work and age. They include factors like socioeconomic status, education, the physical environment, employment and social support networks, as well as access to health care. 3 Care Collaboration Success

4 Defining Social Determinants of Health Figure 1. A closer look at some of the most popular factors that comprise social determinants and impact health outcomes 1 ECONOMIC STABILITY NEIGHBORHOOD AND PHYSICAL ENVIRONMENT EDUCATION FOOD COMMUNITY AND SOCIAL CONTEXT HEALTH CARE SYSTEM Employment Income Expenses Debt Medical Bills Support Housing Transportation Safety Parks Playgrounds Walkability Literacy Language Early Childhood Education Vocational Training Higher Education Hunger Access to Healthy Options Social Integration Support Systems Community Engagement Discrimination Health Provider Availability Provider Linguistic and Cultural Competency Quality of Care HEALTHY OUTCOMES Mortality, Morbidity, Life Expectancy, Health Care Expenditures, Health Status, Functional Limitations 4 Care Collaboration Success

5 Defining Social Determinants of Health Based on a meta-analysis of nearly 50 studies, researchers 2 found that social factors, including EDUCATION RACIAL SEGREGATION lack of social supports POVERTY accounted for over a third of total deaths in the United States in a year. R.I.P. R.I.P. R.I.P. 5 Care Collaboration Success

6 Defining Social Determinants of Health In the United States, the likelihood of premature death increases as income goes down. Similarly, lower education levels are directly correlated with lower income, higher likelihood of smoking, and shorter life expectancy. Children born to parents who have not completed high school are more likely to live in an environment that poses barriers to health. Their neighborhoods are more likely to be unsafe, have exposed garbage or litter, and have poor or dilapidated housing and vandalism. They also are less likely to have sidewalks, parks or playgrounds, recreation centers, or a library. There is also growing evidence demonstrating that stress negatively impacts health for children and adults across their lifespan. Recent research showing that where a child grows up impacts his or her future economic opportunities as an adult also suggests that the environment in which an individual lives may have multi-generational impacts. 6 Care Collaboration Success

7 Defining Social Determinants of Health Among the all-time worst social determinants of health: social isolation, particularly among the elderly 3, where loneliness and lack of companionship drive prevalence of depression and its effects on chronic conditions. It is said that isolation carries the same health risk as smoking and double that of obesity. It s largely because a senior with depression makes other chronic co-morbidities up to four times as expensive. 7 Care Collaboration Success

8 Defining Social Determinants of Health Figure 2. There is a disconnect between what truly makes us healthy and what we actually spend on being healthy. While 50 percent of healthy behaviors impact our health for the better, a whopping 88 percent of healthcare spending is dedicated to medical services, compared to a mere 4 percent on supporting healthy behaviors. WHAT MAKES US HEALTHY WHAT WE SPEND ON BEING HEALTHY Environment 20% Other 8% 4% Healthy Behaviors Genetics Access to Care 20% 10% 50% Healthy Behaviors 88% Medical Services 8 Care Collaboration Success

9 How Social Determinants of Health Impact Government Programs Everyone in healthcare knows the 80/20 Rule: 20% of patients account for 80% of healthcare expenditures Recently, John Gorman of the Gorman Health Group wrote on the need for a new 80/20 rule for for those involved with Medicare Advantage and Medicaid health plans. According to Gorman s new 80/20 Rule, 80% of the services we provide beneficiaries should address social determinants and make the health services we provide more effective. 80% of the services we provide beneficiaries should address social determinants and make the health services we provide more effective. 9 Care Collaboration Success

10 How Social Determinants of Health Impact Government Programs Going a step further, the U.S. Department of Health and Human Services (HHS) recently reported to Congress 5 on how social determinants of health (or social risk factors) impact patient outcomes and provider performance. The study found that both patients and providers are impacted negatively by social determinants of health. Notably, while value-based payments can help patients with poor outcomes resulting from receiving poor care, the usual benefits of this payment model do not help when a patient has poor health outcomes because of social determinants of health. This is a major argument for socioeconomic status being factored into provider performance results so as to avoid the potential risk of providers refusing to see poorer, sicker patients. REPORT CARD 10 Care Collaboration Success

11 Care Coordination is a Team Sport In today s world, the traditional, clinical care team must combine with a holistic care team, taking into consideration the additional aspects of a member s health that we ve discussed, along with a community care team providing non-clinical yet critical services that often determine access to the other two teams altogether Care Collaboration Success 25 42

12 Care Coordination is a Team Sport Figure 3. Health outcomes are significantly and positively impacted when the clinical, holistic and community care teams work together for the benefit of the consumer. CLINICAL CARE TEAM Physicians Nurses Pharmacy Patient/Caregivers HOLISTIC CARE TEAM Mental Behavioral Physical Therapy Long-Term Care Diet/Nutrition COMMUNITY CARE TEAM Homecare Transportation Housing Food Security Adult Day Care Recreational Facilities Patient Navigation 12 Care Collaboration Success

13 Care Coordination is a Team Sport It is now widely recognized that the health outcomes of populations often are determined more by social factors than by medical care. Much of the most innovative recent work on social determinants and population health demonstrates the value of partnerships across sectors, with health care systems partnering with community-based organizations ranging from housing authorities to nutrition support programs and beyond. HEALTH AFFAIRS BLOG It s becoming imperative, as demonstrated by a recent piece in the Health Affairs Blog 6 for health systems and health plans to collaborate with social service providers and community resources to serve members needs and improve outcomes. In fact, Health Affairs has dedicated a whole series of posts focused on the Culture of Health, which promotes health, well-being, and equity. The series explores how improving population health requires attention to factors beyond the scope of traditional health care and public health systems and embraces the interconnected nature of health and social issues. 13 Care Collaboration Success

14 Real-World Examples Eastern Virginia Care Transitions Partnership Summa Health Systems St. Barnabus Hospital

15 Real-World Example Payers and Providers Joining Forces with Community Resources We ve learned how the most powerful predictor of poor performance in health outcomes was dual eligibility status people who are eligible for both Medicare and Medicaid, as they are typically some combination of disabled, elderly and low-income. This example, run by the EASTERN VIRGINIA CARE TRANSITIONS PARTNERSHIP, (EVCTP) focused on dual members and took place as a collaboration between payers, providers and local agencies on aging in eastern Virginia. The participants make up a unique partnership dedicated to improving the outcomes of their constituents. EASTERN VIRGINIA CARE TRANSITIONS PARTNERSHIP Developed by AAAs with representatives from Health Systems, Skilled Nursing Facilities, independent Physicians Groups, and other public and private health and human service providers. Expanded to provide service to Medicare Medicaid Plans. Managed Care Organizations > Humana > Virginia Premier Health > Anthem, Inc. Health Systems > Riverside Health System > Bon Secours > Mary Washington Health Care > Sentara Health Care Area Agencies on Aging > Bay Aging Lead Community- Based Organization > Eastern Shore Area Agency on Aging and Community Action Agency, Inc. > Peninsula Agency on Aging > Rappahannonck Area Agency on Aging, Inc. > Senior Services of Southeastern Virginia 15 Care Collaboration Success

16 Real-World Example Payers and Providers Joining Forces with Community Resources The program included a team of highly trained health coaches who focused on patients transitioning out of hospital stays. The coaches were tasked with home visits, with those encounters being key to assessing and acting on behalf of the patients well-being while taking into account all of their varied needs. The group enrolled in this program had a hospital readmission rate of 9.1%, compared to a target of 14.4%. Each readmission utilizes significant resources, incurs expenses and causes a setback for the patient. By doing in-home assessments and armed with critical data provided by the payers, this program yielded significant results in The dual demonstration, via home visits, identified what the program administrators deemed as the most important social determinants of health. Note that many of these are non-clinical services that account for basic daily needs, and that the #1 need is transportation. Without transportation, access to care is limited, if not cut off completely. IN-HOME ENVIRONMENTAL ASSESSMENT IS KEY TO IDENTIFYING NEEDS Beyond health and discharge plan, what is needed for well-being? 16 Care Collaboration Success

17 Real-World Example Payers and Providers Joining Forces with Community Resources PATIENT SERVICE NEEDS IDENTIFIED AT A HOME VISIT Top 10 Housing Needs Adult Day Care Meals on Wheels In-Home Care Services Advance Care Planning As You Wish Behavioral Health Screening & Enrollment Chronic Disease Self-Management (CDSM) In-Depth Options Counseling on Available Community Services (ADRC) Tele-Education, Including Bay Rivers Telehealth Partnership Transportation 17 Care Collaboration Success

18 Real-World Example Payers and Providers Joining Forces with Community Resources And let s be clear: it s not just about providing services. Even for these challenged members, self-sufficiency is key to true well-being. When asked if they could confidently manage most of their health problems, those who came through the dual demonstration showed a significant increase in confidence. PATIENT CONFIDENCE SCORES On a scale of 1 to 10, with 1 being not at all confident and 10 being completely confident, consider the following: I am confident that I can manage and control most of my health problems. At the start of EVCTP At the end of EVCTP Care Collaboration Success

19 Real-World Example Improving Care through Collaboration: Integration of the Aging Network and Acute and Post-Acute Medical Care Services The second example of outstanding collaboration is in Ohio, with Summa Health Systems, a provider and payer, teaming up with the local Area Agency on Aging for the benefit of their members. The S.A.G.E. PROJECT (Summa Health System/Area Agency on Aging/Geriatric Evaluation Project) is an example of how acute hospital and medical care services partnered with a community-based Area Agency on Aging to improve the health, functional status and to prevent institutionalization of older adults at risk for nursing home placement. 19 Care Collaboration Success S.A.G.E. PROJECT Who were the partners? Summa Akron City Hospital, Summa Western Reserve Hospital, Summa St. Thomas Hospital and SummaCare, Inc. Six Hospital System > 2,027 licensed beds > 61,800 admissions Level 1 Trauma > 113,059 ED visits Community Locations > 4 outpatient health centers > Wellness Institute > medically-based fitness Health Plan > 110,000 Covered Lives > 16,000 Medicare Risk HMO Major Teaching Residency and Fellows Post Acute/Senior Service Line > 10 Certified Geriatricians > 12 Geriatric Certified APNs Continuum Of Care > Acute Care/Acute Rehad/LTAC/ SNF Beds > Home Care/Hospice/Home Infusion/HME

20 Real-World Example Improving Care through Collaboration NURSING FACILITY CARE SETTING TRANSITIONS Providing Alternatives to Transition Home (PATH) > Began meeting with staff at targeting nursing facilities to discuss the agency being an extension of their discharge planning team > Followed individuals identified by Pre-Admission Review as being 60+ years of age and Medicaid eligible > The PATH Team spent time in nursing facilities talking with residents who wished to return to the community regardless of age and assessed them for eligibility into PASSPORT and Assisted Living programs Multiple hospital Geriatric Departments across the Summa Health System were part of this program, which spanned multiple years. Summa demonstrated an understanding of this type of collaboration before it became more well-understood recently. Similar to the Virginia example, the focus was on helping patients go through a successful, smooth transition of care, in this case out of nursing facilities. In-person visits helped assess the patient s ability to transition back into the community, which involved a measure of self-sufficiency, combined with the provision of key services. The results are dramatic, with members of the program steadily disenrolling from Nursing Facilities. Over a four year period, the percentage of participants transitioning from hospital settings to nursing facilities decreased by over 20%. The key was designing a personalized care plan that would keep them out of the Nursing Facilities, and enable them to function as a member of the community. The S.A.G.E Project has significantly decreased the patient-intensive resources needed to care for this group, and has created a population of members with dramatically better quality of life. 20 Care Collaboration Success

21 Real World Example: Helping the Community Help Itself The third example is of a hospital in a low income community, ST. BARNABUS HOSPITAL (SBH) in Bronx, New York, thinking innovatively and proactively about how it can extend its reach to the surrounding population and positively impact their use of services. More than 80% of SBH s patient population are either Medicaid enrollees or uninsured. In recent years, the organization purchased nearly a city block and partnered with a developer to build 314 homes for low-income residents. The structure of the relationship is such that health and wellness services are provided onsite including an urgent care center and other outpatient care options to reduce emergency department and hospital admissions Care Collaboration Success Whatever has been done in the past has not been working, and we really have to think very differently. DAVID PERLSTEIN, M.D., CEO ST. BARNABUS HOSPITAL

22 Conclusion Care coordination, like all healthcare, is local. Payers are uniquely equipped to provide meaningful data to providers and community service providers, helping both individuals and populations live better lives. Payers, providers and local community resources form a powerful combination when working together creating impact that has not been seen in our healthcare system thus far. Underlying technology that allows data to flow seamlessly, and analyzes the characteristics of communities needing key services, is necessary to allow these partnerships to form.

23 1. Beyond Healthcare: The Role of Social Determinants in Promoting Health and Health Equity, Kaiser Family Foundation, Harry J. Heiman and Samantha Artiga, November 4, Beyond Healthcare: The Role of Social Determinants in Promoting Health and Health Equity, Kaiser Family Foundation, Harry J. Heiman and Samantha Artiga, November 4, How Social Isolation is Killing Us, New York Times, Dhruv Khullar, December 22, The New 80/20 Rule in Government Health Programs, Gorman Health Group Blog, John Gorman, January 4, Report to Congress: Social Risk Factors and Performance Under Medicare s Value-Based Purchasing Programs, Office of the Assistant Secretary for Planning & Evaluation, December 21, Defining the Health Care System s Role In Addressing Social Determinants And Population Health, Health Affairs Blog, By Lauren Taylor, Andrew Hyatt and Megan Sandel, November 17, Bronx hospital invests in low-income housing to improve public health, by Paige Minemyer, FierceHealthcare, January 5, 2017 For more information about how HealthEdge helps payers succeed in today s world of collaborative care coordination, visit healthedge.com or call HealthEdge, 30 Corporate Drive Burlington, MA T F E info@healthedge.com W healthedge.com