Collaborative Health Improvement: A Rural Community s Journey. Mimi Khin Hall, MPH Plumas County Public Health Agency

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1 Collaborative Health Improvement: A Rural Community s Journey Mimi Khin Hall, MPH Plumas County Public Health Agency NACo Healthy Counties Forum January 30-31, 2014

streams 70% of land is federally owned Strong Maidu

2 Plumas County 2,553 square miles > 1 million acres of national forest > 100 lakes > 1,000 miles of rivers and streams 70% of land is federally owned Strong Maidu culture and tradition Rich history of mining, logging, ranching

3 Demographics Pop. Est. 2011: 19,765, <8 people per sq. mile 84.5% white non-hispanic (CA: 39.7%) 2.5% foreign born (CA: 26.2%) 21.6% > age 65 (CA: 11.7%) Children s poverty 24% (CA: 20%) Single parents households 36% (CA:29%) Unemployment 16% (CA: 12%) Vacant housing 43% (CA:8%) U.S. Census Bureau

4 In other words NO mall NO fast food chains NO Wal-Mart NO Costco

5 Rural Challenges Geography Staff capacity Resources Difficult history in collaboration Political climate and conservative views

6 The Triple Aim of Health Reform Improved Population Health Improved Quality of Care Reduce Per Capita Cost of Care

7 SO how are we doing? At keeping the cost of health care affordable? At improving our health status?

8 Results: Cost/Affordability: US and Selected Countries, 2008 $7,538 Source: Organization for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: /data en 14 February 2011).

9 Growth in Total Health Expenditures per Capita, US and Selected Countries, 2008 Source: Organization for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: /data en on 14 February 2011).

10 USA in World Health Rankings Per capita spending on health Life expectancy Source: World Health Organization World Health Report, 2006

11 So, What Do We Do? (Re)Transform Every system is perfectly designed to achieve exactly the results it gets. Therefore: new levels of performance can only be achieved by re-design of existing systems Neal Halfon, MD, MPH UCLA

12 Counties Can Seize Momentum and Opportunity Continual alignment with national and state efforts Meet multiple organizations and systems requirements Collectively impact Triple Aim: quality, population health, cost of care

13 Section 9007 of PPACA Requires that 501(c)3 hospitals: conduct a CHNA every three years adopt an implementation strategy to meet the identified community health needs

14 IRS Form 990, Schedule H $50,000 excise tax for failing to meet the CHNA requirements for any taxable year noncompliance with this, or other new requirements, may result in loss of exemption.

15 Public Health Accreditation Prerequisites A collective approach to: Community Health Assessment Community Health Improvement Plan Strategic Plan Leads to: Improved quality Improved population health Reduced health care costs

16 Building Capacity Robert Wood Johnson Foundation/NACCHO One of 12 CHA/CHIP Demonstration Sites Network of LHD s Training, technical assistance and consultation University of WI Population Health Institute, County Health Rankings Association of Community Health Improvement MarMason Consulting Holleran Consulting Paul Erwin

A QI Approach to Community Health Improvement A Framework for Alignment and Shared Accountability Community Health Assessment Tools (CDC: MAPP, CHANGE, Community Guide; HRSA 330 Assessments;

) SHDs/LHDs Community Health Assessment Implementation Plan Development Implementation/ Outcomes Monitoring Reporting and Compliance Key Questions to be Addressed in order to Promote Alignment

17 A QI Approach to Community Health Improvement A Framework for Alignment and Shared Accountability Community Health Assessment Tools (CDC: MAPP, CHANGE, Community Guide; HRSA 330 Assessments; Community Tool Box; etc.) Federal/State grant making (CDC/CTGs, HUD, etc.) SHDs/LHDs Community Health Assessment Implementation Plan Development Implementation/ Outcomes Monitoring Reporting and Compliance Key Questions to be Addressed in order to Promote Alignment between Accreditation, NP Hospital CB, and other Community- Oriented Processes What is shared ownership, and how is it operationalized (e.g., formal agreements)? What are the issues and options in determining and reconciling diverse stakeholder roles/contributions? What are the breadth, depth, and forms of community member involvement? -How do we define community (e.g., geo parameters), and what are the determining factors? -What are essential data sources and what are the issues and opportunities in securing them? -What is the scope of the assessment (e.g., social determinants, community assets)? -Does it identify small areas for targeted investment? -What criteria and processes are used in setting priorities? - In what ways do we use evidence to guide decision making? -What are the alignment opportunities for hospitals and other community interests? -What are strategies to leverage institutional resources? -What is the scope of content issues to be addressed in CHI? -What are issues and options in comprehensive approaches to CHI (e.g., intersectoral)? -Is there alignment of institutional priorities with shared goals and objectives? -What organizational oversight mechanisms are needed to ensure broad institutional engagement? -What are current and potential impacts of technology on outcomes monitoring? -What are challenges and opportunities in shared policy advocacy? -What are approaches and required elements of formal public reporting processes? - What are roles and links to national and state accreditation processes? -What is the role of federal grant monitoring? -What is the role of private sector philanthropy? -What is the role of federal & state oversight of NP hospitals? -What is the oversight role of public officials, advocacy groups, and the general public at the local/regional level? Improved Community Health Outcomes Hospitals CHNA Implementation Plan Community Benefits CHA. Guide ACHI (AHA) Toolkit Consultants Strategy Development Other Stakeholder and Sector Investments 501(r) Requirements, Form 990 Schedule H Tax-exempt Hospital Reporting & Compliance 26 USC 501(c)(3), IRS Ruling , and Form 990 Schedule H Kevin Barnett, DrPH, MCP Public Health Institute

18 San Francisco Department of Public Health

19 A likely partnership Because we have to allowed partners to fulfill roles for collective community impact Build on existing partnerships and goals Access to data and increased knowledge base we didn t have before While LHD serves the entire county population, the lines have been blurred on the communities hospitals and tribal health serve Provided a context for shared, not forced, coordination for project activities

20 Plumas County Approach Three district hospitals Tribal Health Public Health

21 Other approaches Approaches are unique to each collaborative: Hospitals and clinics Tribal Health NGO s Academic Institutions United Way PHI Regional approaches

22 Our way is just one way Choose a collaborative approach that increases LHD and community capacity Assures sustainability and long term success Is built on shared philosophy, goals and core values

23 CHIP Collaboration Common vision and shared approach for local partners to carry out our work governing board support Foundation to stimulate strategic partnerships towards a broad agenda to collectively influence a healthier Plumas County. Action-oriented, living document to mobilize the community in areas where we can be most impactful on improving the health. Encompasses social determinants of health such as education, health insurance, employment and income, and living and working conditions that shape the overall health and vitality of our communities. CHIP guides the health department, hospitals and clinics and our community partners, in aligning our program development, activities, and resources to collectively improve community health status over the next three years and beyond. 23

24 Community Engagement 9 Town Hall meetings 10 focus groups 15 key informant interviews Shared Strategic Visioning process Issues Prioritization training 9 in-person health care partnership meetings 6 Data Indicator Group (DIG) meetings 4 Improvement-Measures-Planning- Accountability-Team (IMPACT) meetings 2 Strategic Planning Kick-Offs 2 selected public viewings of Unnatural Causes, the award winning documentary, and countywide, two-day Public Health Summit on the Power of Prevention 24

25 Broad Participation 400+ residents in 9 Town Hall meetings 3 hospitals and 1 tribal clinic 3 local non-profits (research, safety-net, WIC) 4 county HHS agencies, housing Alcohol Tobacco Other Drug Coalition, Community Corrections Partnership

26 CHIP Process Timeline (Jan-Dec 2012) CHA First Draft CHIP Priorities, Action Items, Report Indicator Selection CHA Key Informant Surveys Natl Public HealthWk CHA Draft Assessment May 30, 2012 CHIP Action Plan Sept 14, 2012 Final Report December 2012 Apr 2-8, 2012 Jan Feb Mar April May June July Aug Sept Oct Nov Dec 2012 Bi-weekly meetings Jan 17: Vision, roles, indicators Jan 31: Indicators and measures Feb 14: Indicator selection Feb 28: Measures and methodology Social Determinants of Health Education Viewing of Unnatural Causes Film April 3: Quincy April 5: Greenville Prioritization Town Halls October 17: Greenville October 18: Portola October 24: Chester October 25: Quincy

27 Sustainability Ongoing effort blended into the daily work of partners through MOU s and Letters of Commitment Reviewing and refining the strategies in the CHIP Action Plan Develop a more detailed plan for standard data collection tools, monitoring and ongoing evaluation efforts Implementation of the action plans inherently strengthen the public health infrastructure, enhance shared planning, build on community health partnerships, and promote and support the health, wellbeing, and quality of life of Plumas County residents. CHIP partners have agreed to review the CHIP on an annual basis to update the information and to continually, and collaboratively, improve the health of Plumas County. 27

28 Foundation of Collaboration Support from CEO s and Boards of hospital districts and Tribal Council Dedicated staff with strong connections to communities Recent demonstrations of successful collaborative projects across the LHD/Community/Health Care Delivery system with mutually beneficial results

29 Collaborative Approach Triple Aim Serves as a foundation for greater community cooperation to meet health needs Allows hospitals to better coordinate and target community benefit programs Provides shared direction for deployment of public resources Stimulates strategic partnerships between healthcare providers, government agencies, and the community for collective upstream strategies

30 CHIP New era - Public Health and local government, alone do not have the ability to solve our communities towering issues. Participatory involvement of partners from business, government, non-profit organizations, philanthropic entities Engage community members throughout the process to systematically address community needs. Shared philosophy: The journey ahead will require continuous innovation, commitment to excellence, and engagement of not only those within government but Plumas County s entire citizenship

31 Philosophy A new approach to solving community problems Everyone works together Government Business Foundations Nonprofits Schools Clubs You To tackle most pressing challenges To take advantage of opportunities

32 New Fundamentals Leverage private and public partnerships built on mutual goals Frame problems and solutions as systems, not service delivery, issues Negotiate agreements to realign financing to reach mutual goals Align incentives and outcomes with political and program goals

33 Redefining the Role of Counties Policymakers and local communities can lead the way in how communities fund, define and promote health. County leaders and HHS can bring national and statewide efforts to local level scale Greater recognition that comprehensive efforts can have far-reaching effects Environments and the behaviors they foster have more influence over our health than medical care does. Health depends on more than individual access to medical care. It requires that: communities that are clean and safe. opportunities for local residents to do meaningful work. community members having strong social connections and working together to build and maintain lasting solutions to local problems.

34 Call to Action Counties as conveners of partners who build lasting relationships Utilize HHS network to facilitate, link and leverage resources to improve population health Model an investment of time, expertise and energy for partners Partnership is essential given the current landscape

35 Plumas County Public Health Agency Mimi Hall, MPH Director 270 County Hospital Road, Suite 206 Quincy, CA

36 Improving Health in a Climate of Change NACo San Diego, California January 31, 2014 A. Clinton MacKinney, MD, MS Deputy Director and Assistant Professor RUPRI Center for Rural Health Policy Analysis University of Iowa College of Public Health clint-mackinney@uiowa.edu

2 Price reduction threats and volume reduction pressures Changes in payment policies and financing sources Continually evolving quality measures and expectations

37 2 Price reduction threats and volume reduction pressures Changes in payment policies and financing sources Continually evolving quality measures and expectations Alternative models of care (e.g., telehealth, different care sites, new providers types) Local health care collaborations and regional affiliations Clint MacKinney, MD, MS

3 New ACA emphases Insurance coverage Primary care Financing innovation (incremental) Major ACA themes Demand for health care value Transfer of

38 3 New ACA emphases Insurance coverage Primary care Financing innovation (incremental) Major ACA themes Demand for health care value Transfer of financial risk Collaboration and competition Not just the ACA! Macro economic forces will continue to drive health care reform Clint MacKinney, MD, MS

39 Clint MacKinney, MD, MS 4

40 5 Value = Quality + Experience Cost But does our current volume-based payment system impede delivering health care of value? Clint MacKinney, MD, MS

41 6 Successful physicians and hospitals seek to maximize: Office visits per day Average daily inpatient census Admission percent from the ER Profitability Is this how to identify and reward a great physician or a world-class hospital? No, but what to do? Clint MacKinney, MD, MS

42 7 You can always count on Americans to do the right thing after they ve tried everything else. Fee-for-service Capitation Market Single payer What about paying for health care value? Clint MacKinney, MD, MS

43 8 Hospital Stay $200 Office Visit $2,000 ER Visit $20,000 Better yet, how about care in the home, workplace, or not at all? Preventive care may reduce the need for acute care! Clint MacKinney, MD, MS

44 9 Bath water Cost-based reimbursement Fee-for-service Few quality demands Inefficiency tolerated Turning up the heat Decreased per unit price Pressure to reduce volumes Quality demands Competitive market How to avoid getting cooked? Clint MacKinney, MD, MS

10 Volume-based Pay-for-service (volumes) Cost-based reimbursement Hospital/physician independence Inpatient focus Stand alone care systems Illness care Value-based

45 10 Volume-based Pay-for-service (volumes) Cost-based reimbursement Hospital/physician independence Inpatient focus Stand alone care systems Illness care Value-based Pay-for-results (quality/efficiency) Shared risk Partnerships and collaborations Continuum of care consideration Community health improvement (HIT) Wellness care Clint MacKinney, MD, MS

46 Clint MacKinney, MD, MS 11

47 12 How do we move toward delivering value when our revenue is primarily volume-driven? How do we not get soaked during the transition? We can test the waters with a new set of tools. Clint MacKinney, MD, MS

48 13 Patient-Centered Medical Homes Accountable Care Organizations Regionalization County-Based Purchasing Connected Community Resources Information and Innovation Clint MacKinney, MD, MS

14 Patient-centered medical homes are primary care practices that offer around-the-clock access to coordinated care and a team of providers that values patients' needs.

49 14 Patient-centered medical homes are primary care practices that offer around-the-clock access to coordinated care and a team of providers that values patients' needs. Access and communication Coordination of care Patient and family involvement Clinical information systems Revised payment systems Sources: Commonwealth Fund and 2007 Joint Principles of Patient-Centered Medical Homes. Clint MacKinney, MD, MS

15 All team members practice at the top (optimum) of their license and experience Best evidence is the best and only way we deliver care Care is the same, regardless of the provider Continuous

50 15 All team members practice at the top (optimum) of their license and experience Best evidence is the best and only way we deliver care Care is the same, regardless of the provider Continuous performance improvement of our care is rigorously driven by data There are no non-compliant patients, only those we have not reached An electronic health record is critical to managing patient/population health Let care protocols do (at least some of) the work (e.g., lab orders, med refills, vaccines) Crete Physicians Clinic Crete, Nebraska Clint MacKinney, MD, MS

Medicare shares savings with ACO if Medicare s total costs are less than predicted.

51 16 A coordinated network of providers who share responsibility to provide high quality and low cost care to their patients.* Medicare requires excellent clinical quality and patient satisfaction based on 33 outpatient measures. Medicare shares savings with ACO if Medicare s total costs are less than predicted. *Source: Robert Wood Johnson Foundation. Accountable Care Organizations: Testing Their Impact Call for Proposals. Clint MacKinney, MD, MS

52 Clint MacKinney, MD, MS 17

optional Affiliation is not an end in itself Independence is not a mission Success measured by clinical

53 18 Act locally; think regionally Economies of scale demand a contracted cottage industry Yet, future health care payment linked to local covered lives Goal: To care for populations expertly, efficiently, equitably Options are optional Affiliation is not an end in itself Independence is not a mission Success measured by clinical integration Resource: Lupica and Geffner. Enlightened Interdependence. Trustee. November/December Clint MacKinney, MD, MS

In 1990s, rural counties were concerned about Medicaid HMOs Ignoring county needs, interests, and culture Excluding local providers from networks Denying payments and shifting cost to counties Not

54 In 1990s, rural counties were concerned about Medicaid HMOs Ignoring county needs, interests, and culture Excluding local providers from networks Denying payments and shifting cost to counties Not reinvesting profits locally Not integrating public health, social services, and medical providers A county-based health plan: owned, governed, and managed by 13 rural Minnesota counties Over 28,000 public health insurance enrollees and over 8,000 contracted providers Clint MacKinney, MD, MS

Accountable Rural Community Health (ARCH) integrates public health, social services, behavioral health, and medical providers using value-based reimbursement Video-conferencing to increase mental

55 Accountable Rural Community Health (ARCH) integrates public health, social services, behavioral health, and medical providers using value-based reimbursement Video-conferencing to increase mental health care access Technology to improve care coordination Reduced preventable institutionalizations and other unnecessary health care costs $10 million in profits reinvested locally as grants to improve access, quality, and health status 2 NACo Achievement Awards (2006): Innovation and Best in Category Clint MacKinney, MD, MS

56 21 What is available locally to improve health care value? Public Health Social Service Agency on Aging Community health workers Care transition programs Churches and foundations Do not duplicate Collaborations are less expensive than new services and build good will! Clint MacKinney, MD, MS

57 22 Excellent data and resources Morbidity Mortality Health Behaviors Clinical Care Social & Economic Factors Physical Environment Clint MacKinney, MD, MS

23 Rural Health System Analysis and Technical Assistance Assess the rural implications of policies and demonstrations Develop tools and resources to assist rural providers and communities Inform and

58 23 Rural Health System Analysis and Technical Assistance Assess the rural implications of policies and demonstrations Develop tools and resources to assist rural providers and communities Inform and disseminate rural health care innovations Share an innovation with RHSATA that has moved your organization (or another) toward delivering value. Continue to be a leadership voice for rural health care value. Our glass is at least half full. A positive attitude is infectious! Clint MacKinney, MD, MS

59 Clint MacKinney, MD, MS 24

60 Clint MacKinney, MD, MS 25

Improving Health in a Climate of Change NACo San Diego, California January 31, 2014

Improving Health in a Climate of Change NACo San Diego, California January 31, 2014 A. Clinton MacKinney, MD, MS Deputy Director and Assistant Professor University of Iowa College of Public Health 2 Price