Moving Healthcare Upstream: Using Quality Improvement to Improve Social Determinants of Health and Clinical Care

Moving Healthcare Upstream: Using Quality Improvement to Improve Social Determinants of Health and Clinical Care Rishi Manchanda MD MPH @RishiManchanda

Social factors contribute up to 60% of premature death Contribution of Social Factors to Premature Mortality Schroeder S. N Engl J Med 2007;357:1221-1228

Robert Wood Johnson Foundation Health Care s Blind Side December 2011 Propietary/ Confidential

How do we move to the NEW way while getting paid for the OLD way? and NEW the while getting paid for a way at same time?

A workforce model for US healthcare by 2020 By 2020, 25,000 Populationlevel Impact of healthcare 260,000 450,000

Moving Healthcare Upstream HealthBegins.org 1. Mobilize An online network - over 1200 members & growing 2. Equip Upstream Quality Improvement & Practice Redesign Community Health Detailing Campaigns 3. Design Identify Tools and Create Opportunities With partners: Providers, Payers, AMCs, Clinics, Health

Upstreamists apply common methods to diverse challenges Male youth with high rates of violent injuries Children with Asthma and Allergies due to Substandard Housing Obese children with school absences and depression Young high-risk pregnant women with financial illiteracy Diabetics with frequent hypoglycemiarelated hospitalizations And so on

What Makes A Successful Upstreamist? A. Starts with the perfect idea B. Finds a plan that works before running out of resources

Quality Improvement in healthcare Late 1990s: Shift from QA to QI Measuring mistakes process redesign Rapid assessment, dynamic implementation, & simpler techniques to measure progress in closing quality gaps Less academic, more results-oriented and lean Core idea = maximize patient value while minimizing waste* 12

Volume-based, biomedical views have limited sphere of influence for QI Where does clinical QI focus?

How many healthcare Plan-Do-Study-Act cycles (PDSAs) address social factors? Act Plan Study Do

PDSAs & QI Tools can be repurposed to address upstream problems Some tools are useful in planning stage Upstreamist Project Canvas Process mapping Pareto Cause and effect diagrams Others help you implement QI project Check lists Others help you study the impact of your QI project Run charts

We ll plan an Upstream QI solution for poorly controlled diabetics with food insecurity using the Upstream Project Canvas

For this case study, let s focus on food insecurity Food insecurity a household-level economic and social condition of limited or uncertain access to adequate food Hunger is an individual-level physiological condition that may result from food insecurity. One in seven Americans cannot reliably afford food USDA definition Wang EA et al (2013). A Pilot Study Examining Food Insecurity and HIV Risk Behaviors Among Individuals Recently Released From Prison. AIDS Education and Prevention: Vol. 25, No. 2, pp. 112-123. H. K. Seligman, et al Exhaustion of Food Budgets at Month's End and Hospital Admissions for Hypoglycemia," Health Affairs, Jan. 2014 33(1):116 23. Weiser SD et al. (2007) Food Insufficiency Is Associated with High-Risk Sexual Behavior among Women in Botswana and Swaziland. PLoS Med 4(10):

17 million Food insecure children 91% more likely to be in fair or poor health 31% more likely to require hospitalization Stanford Social Innovation Review, Summer 2012.

Upstream impact on Triple Aim Among low-income diabetics, food insecurity linked to 27% increase in hospital admissions at end-of-month vs beginning of month

Case Study: FoodRx for at-risk Diabetics - Improve Screening of Food Insecurity by 30% within 1 year - Improve Provider Confidence and Patient Satisfaction by 30% within 12 months - Improve Health Outcomes for Food-Insecure patients by 30% within 12 months

Upstream healthcare organizational assessment (Manchanda 2015, in press) Favorable environment (social norms/external incentives/regulations/state contracts/community partners) Perceived value of change among stakeholders Executive sponsorship Integration in clinical services and workflows Integration in sustainable financing structure Scope (Population/Geography and/or Number of SDOH addressed) Program Design Components (including Evaluation and defined Metrics of success) Team Roles/project ownership Dedicated infrastructure (including Information Systems and Human Resources) Continuous Performance/ Quality Improvement processes Total Limited or unclear Moderate Robust

An orientation to the canvas

Upstream QI Project Canvas 1. Identify Patient Population 2. Team formation 3. Analyze Current State (Define Problems and Root Causes) 4. Team Goal (Unique Value Proposition) 5. Develop Upstream QI Solution 6. Identify Key Partners & Roles 7. Identify Channels 8. Key Metrics for Evaluation & Monitoring 9. Financing

Guidelines 1. Sketch a canvas in one sitting 3. Think in the present 2. It s okay to leave sections blank 4. This is a tool for engaging clinic staff in upstream action

1. Choose Your Population List your target population Reflect on clinic and community interests

1. Population Whose needs are you not meeting to achieve the Triple Aim? Assess Clinic priorities: PCMH certification High-utilizer patients No shows Productivity Assess Community priorities: Is the community concerned about a specific set of social or environmental issues? Have you asked?

1. Identify Priority Population (your early adopters of an upstream approach) using Segmentation Split broad List the characteristics of your population target patient into population segments most to hone likely to use in on service target now. group. List the attributes of your target patient population. What do they do? do? What do they prefer? Where do they live, Where work, learn do or they play? live, work, eat, learn or play?

Population Segmentation: Bridges to Health Adapted from: Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Using population segmentation to provide better health care for all: the Bridges to Health model. Milbank Q. 2007 Jun;85(2):185 212. Population Patient and Services 1. Healthy Mr. Smith, a 37-year-old carpenter. Sees PCP for an annual checkup and screenings. Occasional sore throat 2. Maternal and infant health Mrs. Brown, a 26-year-old waitress, normal pregnancy and delivery. newborn gets checkups and immunizations. 3. Acutely ill Mr. Jones, an 18-year-old high school student, broke his femur while playing football. Got surgery, PT. returned to team after 2 months. 4. Chronic conditions, normal function 5. Stable but serious disability 6. Short period of decline before dying 7. Limited reserve and exacerbations 8. Frailty, with or without dementia Mrs. Gomez, a 49-year-old teacher, has hypertension and diabetes, occasionally out of control despite classes. See PCP regularly. Mr. White, a 56-year-old telemarketer, former paratrooper, now quadriplegic from a gunshot wound. lives with his brother, has a paid aide for personal care. Mrs. Black, a 68-year-old realtor, recently dx d with metastatic ovarian carcinoma. losing weight after chemo. accepted hospice services Mr. Simon, a 75-year-old executive, severely limited activity due to emphysema. home oxygen and complex med regimen. Has Caregivers, Frequent use of clinical care Mrs. Evans, an 88-year-old former homemaker, has dementia with incontinence, inability to walk or to communicate verbally, and a serious pressure ulcer. Has family + professional caregivers.

Segmentation: Use Triple Aim metrics to Prioritize Population Patient 1. Healthy Mr. Smith, 37, carpenter 2. Maternal and infant health Mrs. Brown, 26, waitress and infant 3. Acutely ill Mr. Jones, 18, student 4. Chronic conditions, normal function 5. Stable but serious disability Mrs. Gomez, 49, teacher Mr. White, 56, telemarketer Outcomes 1- year Good. Occasional sore throat Good. Healthy mom and infant Good. Functional recovery Poor. Poorly controlled diabetes and hypertension Fair. Quadriplegic, ADLs met. Medical Problems (1 year) low cost low-med high, acute high, chronic + acute High, chronic Quality/satisfactio n med high high Low-med med Priority Population for Upstream QI X 6. Short period of decline before dying Mrs. Black, 68, realtor Poor. metastatic ovarian carcinoma. Fatigued, losing weight. High, acute low 7. Limited reserve and exacerbations Mr. Simon, 75, executive Poor. severely limited activity High, acute + chronic Low-med X 8. Frailty, with or without dementia Mrs. Evans, 88, homemaker Fair. dementia with incontinence, High, chronic Mod X Adapted from: Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Using population segmentation to provide better health care for all: the Bridges to Health model. Milbank Q. 2007 Jun;85(2):185 212.

Adapted from: Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Using population segmentation to provide better health care for all: the Bridges to Health model. Milbank Q. 2007 Jun;85(2):185 212. Priority Population: What Social Determinants might matter? Population Patient Status 1. Healthy Mr. Smith, 37, carpenter 2. Maternal and infant health Mrs. Brown, 26, waitress and infant Stable. Low cost, high quality Good. Low-med costs, high quality Priority Population Social Determinants Hypotheses 3. Acutely ill Mr. Jones, 18, student Recovery. High, acute costs. High quality 4. Chronic conditions, normal function Mrs. Gomez, 49, teacher Poor. High acute + chronic costs. Low-med quality. Adult diabetics Food insecurity, poverty 5. Stable but serious disability Mr. White, 56, telemarketer Fair. High, chronic costs. Medium quality 6. Short period of decline before dying Mrs. Black, 68, realtor Poor. High, acute costs. Low quality 7. Limited reserve and exacerbations Mr. Simon, 75, executive Poor. High, chronic costs, low-med quality X Food insecurity, poverty, social isolation, substandard housing 8. Frailty, with or without dementia Mrs. Evans, 88, homemaker Fair. High chronic costs, med quality. X Housing insecurity, social isolation, safety

2. Team Formation Who needs to be on the team? From healthcare? From community partner(s)? What motivates each team member and what type of power can they leverage?

Team member analysis

Team Member Organization Role Upstream QI duties Terry Stotts RN Care Manager (Team Captain/Champion) Identify panel of diabetics with recent admissions. Coordinate QI effort. Arran Afflalo LVN Screen for Food Insecurity among diabetics/ chart scrubbing Steve Blake Clinic Social Worker Coordinate Food Resources and Track Referrals Alonzo Gee Food Bank Program Coordinator Accept referrals and coordinate referrals and client assessments Robin Lopez Primary Care Physician/ QI Committee Member Approves standing order to refer food insecure pts; obtains QI Committee resources Dorell Wright CIO Incorporates Food Insecurity in EMR/ Report generation/ QI measures

3. Problem List the problems facing your target population. Start with the health problem of interest. Then list upstream causes Proximate Underlying Principal Secondary

Changing Perspective on Root Cause Analysis Upstreamist Comprehensivist Partialist

Problem Proximate Cause Hospitalizations due to hypoglycemia among low-income diabetics Hypoglycemia Underlying Cause Underlying Cause of Underlying Cause (Principal) Root Cause Secondary Cause Addressable Cause Food Insecurity Less Feasible to

Problem Frequent ER visits due to migraines and URIs Proximate Cause Underlying Cause Underlying Cause of Underlying Cause (Principal) Root Cause Secondary Cause Addressable Cause Less Feasible to Address Cause Viral Infection, Chronic Sinus Congestion, stress, lack of sleep Allergen exposures in damp, moldy, roach-filled apartment Landlord fails to fix water leaks or improve ventilation Outdoor air pollution Damp, moldy housing Air pollution

3. The Problem- Existing Alternatives By target population By your health system By public health & other stakeholders How is the health problem currently addressed? e.g. adult low-income diabetics with hypoglycemia How is the addressable upstream cause of that problem currently addressed? e.g. food insecurity?

4. Unique Value Proposition A single clear compelling title and message that turns an unaware person into an interested stakeholder. (Team Goal)

4. Unique Value Proposition Then UVP into a SMART objective Specific - Measurable - Achievable - Relevant - Time-dated

A call to action: FoodRx for At- Risk Diabetics - Improve Screening of Food Insecurity by 30% within 1 year - Improve Provider Confidence and Patient Satisfaction by 30% within 12 months - Improve Outcomes for Food- Insecure patients by 30% within 12 months

5. Solution Outline a clinicallyintegrated solution for an addressable upstream cause Identify the level of prevention and scope Does it have major potential? Is it feasible?

Choosing a good Upstream intervention Staff involved in choosing & supportive? Already been done? Conflicts? Strategically aligned? Scope narrow? In your control? Do you have adequate resources? Is it an easy win? Metrics easy to obtain? Credit: Mike Haiman MD

Upstream Medicine - QI Project Matrix (R. Manchanda 2014) *After identifying an upstream cause of a problem for a specific population, select the level and type of prevention approach for your upstream QI project Primary Prevention Prevent the onset of disease or injury by reducing an upstream risk - via changing risky exposures, behaviors, or by enhancing resistance to the effects of unhealthy exposure Secondary Prevention Halt or slow the progress of disease and/or upstream problem in its earliest stages, via procedures that detect and treat pre-clinical pathology Tertiary Prevention soften the impact caused by a disease and/or upstream problem on a patient s function, longevity, and quality of life Patient-Level How can my clinic detect and reduce an upstream risk among at-risk patients in order to prevent the onset of disease for individual patients? What tools and referrals do we use for these patients? How can my clinic detect and reduce an upstream risk among patients with early stage disease? What screening tools and referrals do we use for these patients? How can my clinic address an upstream problem to improve outcomes among severely ill, high-need and high-cost patients? How we do align our hotspotting, complex care management approaches to reduce upstream problems? Health Care Organization Population-Level How can my clinic prevent the onset of disease for at-risk patients with an approach that leverages internal resources to reduce an upstream risk factor for a clinic population? How can my clinic system use and leverage internal resources to halt or soften the impact of upstream problems for patients with early stage disease? How can my clinic leverage internal resources to soften the impact the impact of an upstream problem for high-cost patients? How do we work with other upstream systems to improve services for high-need patients? General Population-Level How can my clinic system support policy or regulatory changes to reduce upstream risk factors for an at-risk population or community? How can my clinic system support policy or program changes to halt or soften the impact of upstream problems for patients with early stage disease? How can my clinic system support policy or regulatory changes to improve service delivery for high need patients with upstream problem?

Upstream QI Solutions Matrix (Example: Diabetes & Food insecurity (R. Manchanda 2014) Patient-Level Health Care Organization Population-Level General Population-Level Primary Prevention Financial literacy, support, & nutrition programs for lowincome families with strong family history of DM Provide on-site Farmers Market, gym, walking trails, or financial counseling for families at risk for DM Advocate for local increase in minimum wage and supports for low-income families, particularly those at risk of DM Secondary Prevention Poverty screening & financial assistance for DM patients atrisk of end-of-month hypoglycemia Subsidize vouchers to local Farmer s Market or hire a financial counselor for lowincome DM patients Change timing and content WIC & school food programs to avoid food insecurity among DM Tertiary Prevention Reduce ED use among high-utilizer severe diabetics using food and income support referrals Coordinate with local banks, collectors, lenders, to reduce debt burden for utilizer diabetics Support legislation/ regulations to provide financial and hotspotter services to severe diabetics

Clinical opportunities to leverage upstream interventions and achieve the Triple Aim Community- Centered Health Home Community-Centered Health Home Clinic, public health, policy and community stakeholders coordinate to address upstream social and environmental conditions. Upstream Rxà Engage clinic staff and patients in datadriven advocacy R. Manchanda MD ACOs/ Medical Neighborhood PCMH AICU Accountable Care Organizations (ACOs)/ Medical Neighborhood Clinical neighbors share costs and/or savings to coordinate care for a population. Upstream Rx à Include social service providers in ACOs. Patient-Centered Medical Home (PCMH) Clinic primary care redesign to improve access, continuity, and coordination. Upstream Rxà Use QI framework to integrate upstream data and interventions in redesign Ambulatory Intensive Caring Unit (AICU) Intensive multidisciplinary outpatient care management for complex, high-utilizer patients. Upstream Rxà Use QI framework to integrate upstream data and interventions in redesign Propietary/ Confidential

Solution: FoodRx For Diabetics Sources Screen Triage Exam Chart/Cod e Refer Follow-up

Social Screening Tools Actionable data? Paper vs EMR-based Self-reported vs staff-assisted Evidence-base Data sharing and tracking Frequency

UPSTREAM TOOLS Screen Find Resource Social Screening Tools SAAS Healthify Referral Manage EMR Integration + + + # Community/ Patient Participation Health Leads + + + # Help Steps + + Purple Binder + + Aunt Bertha/ OneDegree + Community Detailing- HB + + HealtheRX + +/- + Enterprise Built County / Other + + + + +/- +

Upstream Risks Screening Tool v1.3 Question Response Scoring GENERAL 1. How is your health in general? [ ] Poor [ ] Not so good [ ] Fair [ ] Good [ ] Very Good +1 for Poor or Not so Good 2. How well do you speak English? Circle one answer: [ ] Not at all [ ] Not well [ ] Well [ ] Very well +1 for Not at all or Not well 3. Do you have concerns about your family s immigration status? YES NO +1 for YES 4. Do you want to register to vote or ever had difficulty registering to vote? YES NO +1 for YES FINANCES 5. Do you ever have problems making ends meet at the end of the month? YES NO +1 for YES

6. Key Resources and Partners List internal & external stakeholders & initiatives Do a stakeholder analysis. Is an economic and/or business case helpful?

Stakeholder analysis: Key Partners & Resources

7. Channels How will you reach your target population? Clinic Community

8. Key Metrics List key numbers that will tell you how well your upstream QI intervention is working. Identify Process And Outcome Measures Screen Triage Exam Chart/Code Refer Follow-up Quick Pass: Do a AARRR! Acquisition Activation Referral Retention Results

8. Key Metrics Acquisition Activation Referral Patients come to project through multiple channels Patients screen positive and are triaged Patients referred to partners Retention Results Patients remain engaged in project Patient receive benefits individual health, clinic & community benefits

9. Financial Let stakeholder analysis inform need for economic and/or business case Economic Case Patient/Population Benefits Health Impact among Target Population Health Impact among social network of Target Population Economic Impact on Target Population Business Case Organization Benefits Costs Avoided for Organization Revenue Added to Organization Value Created for Patients

Budget Basics: Breakeven Analysis Determines when you will be able to cover project expenses and (maybe) generate revenue. To calculate the Breakeven # of patients (BEP): BEP = Total Fixed Costs (Avg Revenue/pt) (Avg. Variable Cost/ pt) e.g. $10000 / ($110/pt) ($10/pt) = 100 pts BEP

With upstream quality improvement, providers can create systems that work better Provider confidence to address housing & other social needs (v1.0) Baseline After

To improve social determinants, it is necessary, but not sufficient, to engage and transform health care We can't get health care as a right without addressing social determinants We can t get health care right without addressing social determinants of health