Breaking Down the Silos of Patient Care: Integration of Social Support Services into Health Care Delivery Robyn Golden, LCSW Director of Health and Aging Rush University Medical Center National Health Policy Forum October 19, 2012
Just Yesterday Started the day with 36-year-old brother of a 50-year-old man with dementia Limited English speaking Low socioeconomic status Ended the day with a 99-year-old woman proud to not be using a walker High financial means, but lonely Both very different scenarios with implications on health outcomes
Social Need Social determinants influence health outcomes 1 Social gradient (SES, education, culture) Stress Early life Social exclusion Work Unemployment Social support Addiction Food Transportation
Social Factors and Health Outcomes Societal-level social determinants have individual-level impact 2 Issue Low education, lack of social support, and social exclusion Outcome Poor self-management 3 and reduced care plan adherence 4 Housing 5 and transportation 6 issues Health disparities and psychosocial issues Increased health care costs and utilization Preventable hospitalizations 7 and mortality 8
Health Care s Blind Side 2011 Robert Wood Johnson Foundation survey of 1,000 primary care physicians 9 85% feel social needs directly contribute to poor health 10 4 out of 5 not confident can meet social needs, hurting their ability to provide quality care 10 R x for social needs, if they existed, would be 1 in 7 R x s written 10 Psychosocial issues treated as physical concerns 11
What Happens to Consumers? 2012 John A. Hartford Foundation survey shows consumers feel the impact of health care s blind side 12 Not treated as a whole person Rarely asked about issues impacting well-being Activities of daily living Falls Mental health Lack of communication and coordination No one asks the caregiver how they are doing
In Health Care s Blind Spot Community-based services and supports system could be addressing psychosocial issues Community-based organizations (CBOs) Aging and disability network Long term services and supports (LTSS) Mental health services Institute of Medicine recommendation: community links 13 Assessing psychosocial issues Delivering services in the community Communicating these issues with medical team
Fragmentation as a Major Obstacle Siloed health and social service systems Separate and distinct funding streams Different delivery systems and eligibility rules Different training programs Distinct terminology Looking at diagnosis and episodic care Provider-driven Mental health forgotten Not bilingual or bicultural to bridge medical and social systems
Other Barriers to Meeting the Demand Financing barriers to integrated care Social services not reimbursed Undercapitalization of social safety net No investment in team-based care and workforce development Value of social services, social workers to health care delivery system undefined Need to valuate services, negotiate fees, determine costs, and explain ROI Business case not clear
What s Needed for Chronic Care Opportunities for improving care for people with chronic care needs (Georgetown Public Policy Institute) 14 Comprehensive primary care Assessment of person and caregiver LTSS needs Coordination of LTSS and medical care Collaboration between care coordinators, PCPs, patients, families Supportive care transitions Commitment to person- and family-centered care
Interprofessional Teams Solid outcomes for interprofessional teams in inpatient and outpatient medical systems 15 Reduction in health service utilization 16 Improvements in patient satisfaction and communication with provider team 17 Rothman and Wagner: Most successful chronic illness interventions include major roles for nonphysicians. The appropriate deployment and use of practice teams seems to be far more important to improving chronic illness than physician specialty. 18
Care Coordination Care coordination is a person- and family-centered, assessment-based, interdisciplinary, multicultural approach to integrating health care and social support services in a cost-effective manner in which an individual s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an evidence-based process which typically involves a designated lead care coordinator. (National Coalition on Care Coordination) 19
Financing the Ideal Model Routes to financing effective care coordination 20 Current fee-for-service structure limited due to episodic focus Need incentives for effective performance: quality of care, patient experience, and health spending FFS system payment options (Medicare): Modify codes or levels of payment within Physician Fee schedule Risk-adjusted monthly fee per eligible beneficiary tied to performance Shared savings model rewarding efficient, quality service delivery Within managed care systems (Medicare Advantage and Medicaid) combine financing sources to meet needs
Financing the Ideal Model Improved medical and social service funding sources Social service investment Encourage and incentivize collaboration and team Share responsibility and align goals Demonstration projects through CMS and ACL Include integrated models Show cost savings across funding streams Improve quality of life
The Healthcare Neighborhood Integrated model with the medical and social components of equal value Team-based care with the person and family on the team Service connection, coordination, and communication Boundary spanning and spanners Partnerships across sites and settings Community engagement and activation Where people live Where service providers are located Where social determinants of health begin and can be influenced
The Opportunities of PPACA Opportunities to address the social in health care through PPACA Enhanced primary care/patient Centered Medical Homes Accountable care organizations Transitional care and hospital readmission reduction Medicare and Medicaid dual eligible demonstrations Medicaid Health Homes Independence at Home demonstration Bundled payment
Important Links To learn more, visit: Accountable Care Organizations: http://innovations.cms.gov/initiatives/aco/index.html Dual Eligible Demonstrations: http://innovations.cms.gov/initiatives/state-demonstrations/index.html Medicaid Health Homes: http://www.medicaid.gov/medicaid-chip-program-information/by- Topics/Long-Term-Services-and-Support/Integrating-Care/Health- Homes/Health-Homes.html Independence at Home: http://innovations.cms.gov/initiatives/independence-at-home/index.html 17
Thank You Robyn Golden, LCSW Robyn_L_Golden@rush.edu 312-942-4436
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