Too Big to Solve Alone: Minnesota Collaborates

Transcription

1 Session: C11 These presenters have nothing to disclose Too Big to Solve Alone: Minnesota Collaborates Claire Neely, MD; Keith Olson, DO; Shaun Frost, MD; Bruce Sutor, MD December 12, :30-2:45 #IHIFORUM

2 Session Objectives P2 Participants will: Describe strategies used to launch a collaborative engaging health plans and care systems Learn to use the Collaborative Action Framework to support their own work Understand when collaborative action is a beneficial method to solve complex problems #IHIFORUM

3 Speakers P3 Claire Neely, MD, Chief Medical Officer Institute for Clinical Systems Improvement Keith Olson, DO, Regional Medical Director Allina Health Systems Bruce Sutor, MD, Chair, Clinical Practice Department of Psychiatry and Psychology, Mayo Clinic Shaun Frost, MD, Associate Medical Director HealthPartners All speakers have nothing to disclose #IHIFORUM

4 Agenda This Collaborative: Context Claire Neely Opioid Crisis: Prescribing Practices Keith Olson Mission Impossible: Mental Health Bruce Sutor Engines and Amplifiers: Health Plan Perspective Shaun Frost Behind the Curtain Claire Neely

5 This Collaborative Claire Neely, MD Chief Medical Officer Institute for Clinical Systems Improvement

6 Institute for Clinical Systems Improvement Regional Health Care Improvement Collaborative 50+ care delivery organizations 3 non-profit health plans Founded 1993 History of collaboration

7 The Beginning Is there a compelling reason for our organizations to collaborate in this market? What problems are we facing that we ve not been able to solve on our own?

8 The Pledge Responsibility to improve health Pledge to collaborate on persistent problems Not solvable by single entity or by competition Success depends on our personal leadership

9 Why Collaborate Problem complexity System fragmentation Shared population Risky to be the market leader Support emergent solutions Change the market for the region-sustainability Avoid the Tragedy of the Commons It s been successful before 9

10 Collaborative Members Children s Hospital and Clinics of MN HealthPartners HealthEast Care System North Memorial Health Care University of MN Physicians UCare Fairview Health Services Essentia Health CentraCare Heath System Hutchinson Health Medica Mayo Clinic Hennepin County Medical Center Ridgeview Medical Center Allina Health 10

11 Areas of Focus Criteria Private sector control and influence Enduring problems Aligned with organizational priorities Experts and resources available 11

12 ICSI s Role: Backbone Organization Collective Impact Common agenda Shared measurement Mutually reinforcing activities Continuous communication ICSI s role: Steward of resources Neutral convener Relationship mediator Manage risk (anti-trust) Nurture emergence of new ideas Catalyst Keep focus on collaborative action 12

13 Getting Started: January-April 2017 Tasks Experts convened Scope Topic refinement Aims and goals New teams convened CEO review, revision and support ICSI s role: Building a collaborative platform Logistics Building trust Modeling transparency Facilitation Evidence review Promoting collective accountability for action 13

14 Discovery & Development: May-Sept 2017 Mental Health Integrating behavioral health and primary care Improving the care for patients in mental health crisis in the ED Opioid Crisis Improve access to chronic pain treatment Improve prescribing practices Identify high-risk Increase disposal options ICSI s role Environmental scanning Sharing practices Problem clarification CEO engagement Increasing participation/engagement Timelines Streamlining processes 14

15 Calls to Action: October-Current Activities Call to Action packages being implemented Design, prototyping, testing, spread and scale Measurement Evaluation Communication and dissemination ICSI s role Relationship management Re-framing problems Transferring leadership Environmental scan Alignment New stakeholders Learning networks Evidence creation Bias toward action 15

16 Current Status 9 working groups MH-Acute MH-IBH Opioid-Chronic use Opioid-Acute Opioid-Peds Opioid-High risk Opioid-Disposal Communications Measurement 3 advisory councils Evaluation Measurement Govt Relations Aligned organizations Public sector Private >150 expert volunteers CEO convening ICSI

17 Opioid Crisis: Prescribing Practices Keith Olson, DO, MHA, FACHE, FACOFP Regional Medical Director Allina Health

18 13 Hospitals 1.5M OP admissions 109K IP admissions 60K OP surgeries 32K IP surgeries 88 Clinics 4.5M clinic visits

19 19

20 20 COO=Chief Opioid Officer

21 A Systems Approach Is The Only Way to Address the Opioid Crisis The complexity of the opioid crisis requires a multifaceted, rapid, coordinated effort Recognize that everyone in the community has a role to play Collaboration Work on multiple parts of the problem simultaneously Clarity on the risks of prescription opioids Re-education of health care professionals Recognition that addiction is a chronic disease and treating it appropriately Agree to a minimum set of standards by health systems Health Affairs Blog, June 13,

22 Unintended Consequences/Collateral Damage Under treatment of pain Increase in number of heroin deaths Provider burnout Increased use of recreational cannabis Punitive approach to opioid patients Increased workplace violence Increase in Emergency Department visits Kick the can Additional demand for services that will further strain the current healthcare system 22

23 Acute Pain Prescribing Work Group CEO charge Aim #1: Achieve significant reduction in the number of pills or morphine milligram equivalents (MMEs) prescribed for acute pain to opioid naïve patient over one year Workgroup composition Approach? o Initial - Decrease acute opioid prescriptions by 20-25% by June 2018 o First Rxs, Post-operative Rxs, ED Rxs, Dental Rxs o Measurement - # of pills vs. MME? 23

24 Acute Pain Prescribing Work Group Final Prescribing Recommendations: o Initial patient assessment, realistic expectations of pain, shared treatment goals, start with non-opioids o If opioids appropriate, lowest possible effective strength short-acting opioid for shortest period of time o First opioid Rx for acute pain not to exceed 100 MME total, instruct patient 3 days or less is enough o For patients presenting in acute pain already on chronic opioids, opioid tolerant, or on methadone consider Rx for an additional 100 MME with plan to return to baseline o Geriatric patients assessed for risk of falls, cognitive decline, respiratory or renal impairment. Consider reducing initial opioid dose by 50% 24

25 Acute Pain Prescribing Work Group Postoperative Pain Rx Recommendations: o Minor surgeries? APAP, NSAIDS, multimodal options as part of pain management plan o Patients taking opioids pre-op should have postop pain management plan agreed upon before surgery o If opioids deemed appropriate to manage post-op pain low dose, short acting, with plan to taper after 3-5 days o Surgeon should manage all post-op pain o Individualized postop care and treatment but still possible to recommend maximum postop MME dose 25

26 Process to Operationalize? Review data from health plans: 26

27 Process to Operationalize? Select top surgical procedures Review current average MME and if possible 25 th percentile average MME to establish goals Develop consensus around expected pain/recovery mild, moderate, severe Create procedure groupings that fit with 100/200/300 or 400 MME maximum totals 27

28 Potential components of operationalizing Recommend tools in the EMR to simplify MME calculations, medication choice and dosing Suggested components to imbed in the EMR (alerts, order sets) Unified educational material for patient, pharmacists and clinicians Consensus on measurement specifications Suggestions on dissemination and implementation Pilot top 32 procedures in participating organizations 28

29 Next steps? Written report to CEOs in January Assess results (changes in MMEs) and unintended consequences and modify plans Collaborative-wide testing of top 30 procedures Work group may apply chosen methodologies to remaining procedures to recommend MME maximums Develop a method to review and revise recommendations at specific intervals to hold the gains 29

30 Allina successes 25% reduction in # of pts receiving 8 or more opioid Rxs between and (2,547 pts) Shared Decision Making Opioid Tool Educational posters for clinic lobbies and exam rooms Care goal around controlled substance management All specialty service lines required to have a opioid goal for 2018 Standardized order sets for IP procedural pain mgmt 30

31 31 Sentry report

32 Benefits of working in the Collaborative? Design thinking framework Shared accountability Open communication Common goal Coordination of care across the continuum Shared resources Encourage innovation Momentum 32

33 Thank You! 33

34 Mission Impossible Bruce Sutor, MD Chair, Clinical Practice Department of Psychiatry and Psychology, Mayo Clinic

35 2017 MFMER slide-35

36 CEOs Directive Address the mental health care access and delivery needs in Minnesota 2017 MFMER slide-36

37 Getting Our Hands Around the Problem 1) Setting parameters what are the problems we are facing? 2) What can we do what can t we do? 2017 MFMER slide-37

38 Setting Parameters 1) Shortage of mental health providers 2) Limited access to services a. Outpatient b. Inpatient 3) Not enough public sector resources 4) Drugs, Housing, Poverty 5) Long ED stays 2017 MFMER slide-38

39 What Can We Do? What Can t We Do? 1) Splitting out primary care access to outpatient care 2) We can t boil the ocean bed shortage, public resources, social issues we can t solve 2017 MFMER slide-39

40 Focus on the Emergency Department: This is Something We Can Fix 1) Identifying common pain points 2) Getting together 2017 MFMER slide-40

41 Identifying Common Pain Points 1) Limited access to Psychiatry 2) Housing patients in ED vs. treating patients in the ED 3) Assessment everyone does it differently 4) Inter-organization trust is this a dump? 2017 MFMER slide-41

42 Getting Together 1) Problem-solving on access to mental health resources 2) A move to treatment in the ED 3) Sharing best practices 4) Standardizing assessment 5) Developing a sense of trust 6) Future directions Telepsychiatry, sharing lessons learned with Minnesota and beyond 2017 MFMER slide-42

43 Working Group Roles and Responsibilities The Work Focus on the values needed by patients, improving safety, health, and trust Incorporate and standardize best practice Define common goals Support organizations and providers by communicating, setting clear expectations, providing tools Be inclusive of those affected by the change Balance the tension between audacity and taking first steps 2017 MFMER slide-43

44 Working Group Roles and Responsibilities (cont.) How We Work Together Commit time and resources Share knowledge, new ideas, and wisdom with transparency and honesty Be ready to act and test new ideas Serve as a conduit between the collaborative and your organization Be accountable to values and principles Do the work; be active 2017 MFMER slide-44

45 Working Group Roles and Responsibilities (cont.) Qualities Needed Open-mindedness, generosity, integrity, commitment, persistence, honesty, respect, and courage 2017 MFMER slide-45

46 Working Group Member Responsibilities As a member of the Collaborative I will: Commit my expertise, passion, and actions to advancing shared goals of the Collaborative, not only optimizing those of my organization. Participate meaningfully in meetings and betweenmeeting work, and expressly communicate if expectations seem unachievable. Be proactive in speaking up and signaling any concerns about the Collaborative s direction or activities, and support others in doing the same MFMER slide-46

47 Working Group Member Responsibilities (cont.) As a member of the Collaborative I will: Work to gain active, ongoing commitment from my organization by engaging other individuals and groups whose interests align with collaborative goals, and serving as a vocal champion within my organization and the community. Share information and data (both qualitative and quantitative) to support and track the progress of the work. Recognize that no one person knows everything about the topic. I will listen carefully, be curious about new points of view, speak from my own expertise and experience, and appreciate that complex topics may require time to come to shared understanding and action MFMER slide-47

48 Oversight Group Responsibilities Assure that subgroup activities align to meet specific topic goals and to support the overall success of the topic area and the Collaborative Take a lead role in assuring that organizational work supports Collaborative goals and vice versa Assess whether the scope of activity for all Working Groups is within the span of control of the Collaborative, and if not, make recommendations to the CEOs 2017 MFMER slide-48

49 Oversight Group Responsibilities (cont.) Monitor the external environment to assure that topic activities remain salient and valuable to the community Monitor relevant activities by other stakeholders in the topic area, making recommendations about widening participation in the Collaborative as appropriate Provide leadership for the Working Groups 2017 MFMER slide-49

50 Timelines MH Acute Work Plan MFMER slide-50

51 How will this help Mayo? How will it help all ICSI organizations? More rapid access to care in the ED and to appropriate disposition Avoiding inpatient care when it isn t necessary Patient and staff safety Developing and distributing best practices 2017 MFMER slide-51

52 Thank you 2017 MFMER slide-52

53 Engines and Amplifiers Shaun Frost, MD Associate Medical Director HealthPartners Health Plan

54 Engines and Amplifiers The Power of Collaboration Shaun Frost, MD Associate Medical Director HealthPartners Health Plan

55 An integrated health care organization

56

57 Why Community Collaboration? Health insurance plan perspective Commodification of Value Shared Accountability Empathy Standardization Generative Dialogue COLLABORATION

58 Contemporary Health Plan Roles Amplify community collaboration work Data reporter Analyst Disseminator Consultant Convener Educator HEALTH PLAN ROLES

59 Thank you

60 Behind the Curtain: Being a Backbone Claire Neely, MD Chief Medical Officer Institute for Clinical Systems Improvement cneely@icsi.org

61 Behind the Curtain

62 Surprise them But not too much.

63 Make sure you know where you are going Because it s not a straight path.

64 Collaborative Action Framework Systems Thinking Action IMPACT Evaluation Knowledge Sharing Dissemination Sustainability Aims & Goals Commitment

65 Aims & Goals Important Relevant Inspiring Challenging-but possible Solve the right problem 65

66 Commitment CEOs Working group members Volunteers Collaboratives yield new strengths and are fragile 66

67 Systems Thinking Logic models Driver diagrams Ecosystem scan Monitor for unintended consequences 67

68 Action Design Proto-type Confirm Spread Scale Answer different questions 68

69 Evaluation Developmental Performance Summative Research Data gathered and use differ 69

70 Sustainability Clinical Outcomes Patient satisfaction Operational Feasibility Staff satisfaction Financial All conditions must be satisfied 70

71 Knowledge Sharing Transparent measurement Learning networks Success Learn quickly, together 71

72 Communication & Dissemination Internal Ongoing Shared messaged External Audience-based 72

73 Collaborative Action Framework Systems Thinking Action IMPACT Evaluation Knowledge Sharing Dissemination Sustainability Aims & Goals Commitment

74 Logistics build trust

75 Get on the balcony To understand the larger dynamics at play

76 See possibilities To reuse current structures

77 Pace the action Not too fast, but faster than they think they can

78 Iteration is the norm Perfection is the enemy of action

79 The Unexpected

80 Be fierce

81 Questions? Claire Neely, MD