SOCIAL WORK LEADERSHIP: A CRITICAL COMPONENT TO HEALTHCARE TRANSFORMATION

Transcription

1 A national innovator integrating social services with medical care to improve health, reduce costs, and create a better quality of life for the moderate to high-risk and most vulnerable populations SOCIAL WORK LEADERSHIP: A CRITICAL COMPONENT TO HEALTHCARE TRANSFORMATION

2 We are a Mission-Driven Organization Changing health care systems, changing communities, changing lives Our Mission Partners shapes the evolving health system by developing and spreading high-value models of community-based care and self-management Our Partnership Partners collaborates with hospitals, physician groups, health plans, community-based organizations, and government agencies to deliver services that support adults with complex health and social services needs and their caregivers and families Evidence-based programs demonstrated to significantly reduce costly hospital readmissions, ED visits, and nursing home placements Our Focus on Innovation We shift the emphasis from illness care to preventive care, reducing costs and improving quality of life for those with chronic conditions NCQA Accreditation for Complex Case Management

3 3 Audience Question #1 And who are you? ASW LCSW/LICSW Case Manager Clinician/Therapist Manager Director Other Who works in a healthcare setting?

4 Health and Social Spending as a percent of GDP

5 Through innovative new partnerships between hospitals, physicians, plans and CBOs New home and community-based specialty models of care, a critical component across the care continuum Depth of experience, with deep local knowledge and connections Full regional coverage with consistent tools, IT and results Evidence-based programs for chronic conditions, caregivers, medication safety and post-acute coaching and support Careful targeting Together, we are achieving the Triple Aim! Powerful Value Proposition Improve discharge planning Reduce hospitalizations, readmissions, SNF & ER visits Improve quality scores Improve the patient experience

6 With a focus on the Social Determinants of Health (SDOH) What Home and Community-Based Services Do Care Coord. & Safe Handoffs Food, Housing, Transport, Benefits Access to Care: Coaching & Navigation Healthcare s Blindside The Robert Wood Johnson Foundation Survey of 1,000 PCPs 80% not confident in their capacity to address their patients social needs 86% said unmet social needs are leading directly to worse health Community Connection & Caregiver Support SDOH Patient Activation & Self-Mgt Medication Safety & Mgt. 76% wish the healthcare system would cover cost of connecting patients to services to meet healthrelated social needs 1of 7 prescriptions would be for social supports, e.g., fitness programs, nutritious food, and transportation assistance

7 7 How Social Work Leaders Close the Provide leadership to network of CBOs Programmatic, administrative, AND clinical leadership Training, policies/procedures, communications Quality assurance SDOH Gap

8 Provided through a full range of evidence-based programs and services complementing the clinical model Addressing the social determinants of health, a critical component across the interdisciplinary care team, improving health outcomes, the patient experience, and reducing costs HomeMeds (medication reconciliation) HomeMedsPlus (in-home visit, assessment & care/service plan) Care Transition Choices (post discharge, coaching/patient activation model in-home or telephonic visit) Evidence-Based, Chronic Disease Self- Management Programs

9 HomeMeds Med Reconciliation (included in HomeMedsPlus & Care Transitions Choices) Inventory all meds being taken: multiprescribers, out of system meds: drugs from other countries, borrowed, and OTC Assess for potential adverse effects including BP, pulse, falls, dizziness, confusion Document adherence issues and understanding Algorithm identifies targeted potential medication-related problems (MRPs) Pharmacist reviews potential MRPs & makes recommendations for resolution, contacts provider and/or patient Telepharmacy available in patient home For each medication, the coach asks the patient the following questions and documents accordingly: 1. Are you still taking the medication? 2. Why are you taking this medication? 3. How often and when do you take it? 4. How many do you take? 5. What happens when you take it (i.e., is it effective, are there side effects)

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12 For High-Risk Patients Risk characteristics for Home Evaluation and Care Transition programs Medi-Cal + Duals not enrolled in Cal MediConnect Category Clinical Conditions Medications Criteria 2+ chronic 6+ or anyone on a psychotropic or other high-risk medications Individual & Family Plan (On and Off Exchange) Adults (complex health & social service needs) Cal MediConnect Acute/LTPAC (Long-Term & Post-Acute Care) Functional Impairment Cognitive Impairment ED visit within 6 months Unplanned hospitalization or SNF within 6 months Personal Care assistance needed (i.e. bathing, laundry, shopping) Mild ~ Moderate Commercial (Self-Insured & Fully- Insured) Medicare (MA & FFS) Social Determinants/F actors Literacy / Health Literacy Inadequate caregiver, transportation, housing, income Translation services or explanation Self- Management Clinical signs at risk for decline or significantly outside goal

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14 SPMSQ PHQ-9

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16 Care Coordination Example Dual Eligible Beneficiary Male, age 66, Spanish speaking, lives alone, hospitalized and frequent utilizer of the ER; has not seen his PCP or Specialist in the past 12 months Chronic Conditions: Diabetes and Heart Disease Intervention: Care Management Coordination through Partners in Care In-home assessment by Spanish-speaking Health Coach and development/implementation of person-centered care plan with close coordination across the care continuum Patient scheduled and transportation coordinated to PCP office four times per year monitor HbA1c Patient adherence with medication dispenser/reminder system Patient adherence with diet-compliant meals (home-delivered) Patient activation : reduced avoidable ED visits and hospital admissions, increased PCP/Specialist visits

17 CARE TRANSITIONS CHOICES Achieving Proven Results CCTP results through October 2016 Care Transitions using Dr. Eric Coleman s Coaching & Rush University Bridge Patient-Activation Models Partners participation in CMS Demonstration Project, Community-Based Care Transition Program (CCTP) - Readmission Rates for Pre-Intervention Baseline, All Cause, All Condition Patients Compared to Post-Intervention CCTP Participants across 11 hospitals 28% 29% 41.5% reduction 2 reduction 2 reduction 2 Best in CA Source: HSAG, CA QIO, November 2016 CCTP Collaborative Participants Served % Reduction in Readmissions Program to Date through October Baseline (Pre): All-Cause, All-Condition, Medicare FFS: Westside & Glendale = Jan Dec 2012; Kern = Apr 2012-Mar CCTP (Post): Medicare High-Risk FFS Population, Readmission Rate to Date (Westside= May 2013 Jul 2016; Glendale = May 2013-Mar 2016; Kern = Nov 2013 Jul 2016 # Readmits Averted Program to Date Westside 14,086 28% 831 Glendale 6,745 29% 391 Kern 10, % 904 Source: CMS Quarterly Monitoring Report Released March 21, 2017

18 Medical Group Results Post-acute high-risk Medicare and Commercial Population Medical Group Results for 250 post-acute high-risk seniors Medical Group Results for 345 post-acute high-risk MA and Commercial population Without Partners Intervention With Partners Intervention High Risk Patients Day Readmissions % Readmitted 28% 10% Compared to patients who did not receive a home visit Compared to patients who did not receive a home visit

19 Health Plan Results Network IPA High-Risk Medi-Cal and CMC Population 30-Day Hospital Readmission Results for Targeted Medi-Cal and CMC Population

20 Health Plan Outcomes In-home medication reconciliation with pharmacist review reduces hospital readmissions and ER visits Suggest Revise Dosage Therapeutic Duplication Adverse Drug Reaction Indictation w/o Drug Therapy Issues Taking Med 4% 9% 12% 16% 37% Potential Impact from Recommendations ER Visit Avoidance Hospital Avoidance Physician Visit Avoidance Drug Interaction Adherence-Behavior 3% 2% High Member Satisfaction High Value in Programs Improper Drug Selection Sub-therapeutic Dosage Adherence-Access None 1% 1% 0% 14% Would Recommend Comfortable Discussing Needs Staff On Time Population: 369 high-risk members in case management Staff Helpful Staff Respectful Overall Satisfied Extremely Dissatisfied Extremely Satisfied

21 Health Happens at Home Common needs and problems identified from home visit 1. Medication Issues 2. Depression 3. Home safety issues/modifications 4. Community resources a. Meals b. Transportation to PCP/medical appointments 5. Need for self-care/health coaching 6. Eligibility for governmental benefits a. Financial assistance/ssi b. Legal services c. VA Services d. Disability Assistance Services e. LTSS/IHSS 7. Need for caregiver/supervision 8. Assistance with DME Addressing these issues have: Hospital 30-day readmissions Avoidable ED visits Individuals in their homes and communities longer with dignity and respect

22 Programs & Services delivered through a Coordinated Multi-Payer Strategy Partners has created a multi-payer strategy by contracting with health plans, medical groups (MG), and hospitals. Payment for services generally follows which entity is carrying the risk by product line 1. Total Pop. to Partners Triage Engagement 2. Waivers Qualified members enrolled in waivers 3. Med Gp. Contracted physician groups & hospitals carrying risk Medicare TCM/CCM collaboration 4. Health Plan Pay highest risk per contract

23 Our Multi-Payer Relationships Delivery System UCLA Ronald Reagan UCLA Santa Monica Providence Saint John s Glendale Memorial Glendale Adventist USC Keck Verdugo Bakersfield Heart Bakersfield Memorial Kern Medical Center Mercy Hospital Bakersfield Mercy Hospital Southwest San Joaquin Community Hospital AppleCare Medical Group Health Care Partners MedPOINT Management Preferred IPA Regal Medical Group Citrus Valley Physician Group Alta/Prospect Culver City Hospital Health Plans Blue Shield of California Care1st Centene/California Health & Wellness Health Net L.A. Care Molina Healthcare For MSSP, Medi-Cal Home & Community-Based Services Waiver, we have contracts with all LA County Medi-Cal Plans Federal, State & Local Agencies CMS Administration for Community Living (ACL) City of L.A. County of L.A. CA Department of Aging CA Dept. of Health Care Services CA Dept. of Public Health

24 Partners at Home Network for an Integrated Community Care System

25 Who Delivers the Services Partners has created Partners at Home (PAH), a statewide specialty network of Community-Based Organizations (CBOs) leading the nation in prototyping models to provide patient-centered social services in the home and community PAH streamlines access to multiple community-based care extenders, including Health Coaches and Social Workers who are well-trained, culturally and linguistically competent, live in the local communities and have depth of experience in helping patients whose health is fragile, and whose care is complex and costly The quality of Partners complex case management program has been recognized with accreditation by the National Committee for Quality Assurance (NCQA), one of the first two CBOs in the country to receive this designation

26 Our Statewide Community-Based Network Network as of Jan 2017

27 Partners in Care Footprint Expanding our footprint to cover additional markets to meet our customer s needs Active Network Counties Alameda Riverside Butte Sacramento Contra Costa San Bernardino El Dorado San Diego Fresno San Francisco Humboldt San Mateo Imperial San Joaquin Kings San Luis Obispo Kern Santa Barbara Los Angeles Santa Clara Madera Santa Cruz Marin Shasta Mendocino Solano Merced Sonoma Monterey Stanislaus Nevada Tulare Orange Ventura Placer Yolo Network as of May 2017

28 Buy vs. Build: Why Partnerships? Community: A new specialty for Social Determinants of Health (SDOH) System of Care vs. Social Work Staff Broad geographic coverage Diversity in language, culture and skills Efficiency unpredictable spread of need Quality NCQA accreditation for complex case management; HEDIS, Medicare STARs, MACRA

29 29 Audience Question #2 How many of you feel that you re working beyond the outer limits of your role because of the increasing health needs of your complex client population?

30 Partnership. Innovation. Impact.

31 Happy to Help! Jennifer Schneider, MSW, LCSW Manager, Health Services x165