Is your clinic upstream ready? Are you happy? Rishi Manchanda MD MPH @RishiManchanda Burned Out 37.5% 1
Patient Experience Hope Satisfaction Trust Outcomes Effective interventions Prevent illness Advance equity Quadruple aim Costs Less waste Lower per capita costs Less avoidable utilization Provider Experience Professionalism Joy at Work Purpose 2
The problem: Our healthcare workforce is asking for help I'm a primary care pediatrician in [a rural county]. Highest teen preg rate, meth addiction, high school drop out rate... Many more issues. Understand upstream approach for years. Try my best but falls by the wayside as I don't have resources - No help, city/ county overwhelmed. Patients lost to follow up- I'm seeing over 30 a day. How to manage? Would like to discuss. Social factors account for 60% of premature death & impact the Quadruple Aim Robert Wood Johnson Foundation Health Care s Blind Side December 2011 But only 1 in 5 MDs have confidence to address them Schroeder S. N Engl J Med 2007;357:1221-1228 3
The best bathroom on the block business model Public Health SDOH research & intervention Health Care Individual Level Disease Research & Intervention 4
Lopsided US has a lopsided health: social services ratio Bradley, E.H and L.A. Taylor, 2013. The healthcare paradox: Why spending more is getting us less. New York: Public Affairs. Burnout & clinic capacity to address social determinants of health Survey of over 500 primary care clinicians My clinic has the resources, such as dedicated staff, community programs, resources or tools to address patients social needs After multivariate analysis, lower perceived capacity of clinics to address social needs was the strongest predictor of clinician burnout. Source: Olayiwola et al. from presentation. Arizona Alliance of Community Health Centers, Phoenix, AZ. Feb 2016. 5
Outcomes Less effective interventions Preventable illness Health disparities Patient Experience Frustration & Helplessness Costs of Care Distrust No social determinants integration = No Quadruple aim Provider Experience Eroding Professionalism Poor recruitment & retention Burnout Costs Wasteful spending Opportunity costs Avoidable utilization I get it. Population health is important. Everyone s talking about social determinants. But how do we do this? 6
A new story of us 7
A workforce model for US healthcare By 2020, 25,000 Populationmedicine responsibility 260,000 450,000 1) Get Ready Assess the maturity of your clinic processes & environment to address social determinants of health (Self-Assessment) 2) Get Set Engage colleagues, key stakeholders, and community partners to plan (Staff & stakeholders) 3) Go Upstream Launch targeted campaigns using Upstream Quality Improvement (Systems/Process Design) Implement robust tools/best practices to address patients social needs & connect to resources (Solutions) 8
Before you start 1) Find a buddy Doing an upstream readiness assessment alone is not effective. And it s no fun. 2) Identify a population Is there strong agreement within your organization about the need to advance the Quadruple Aim for a specific population? Start there. Be precise. 3) Get out of the building Jumpstart your understanding of social determinants by interviewing 5 patients in your target population. Need help? We have scripts. Upstream Readiness Assessment For Health Care Systems Limited or unclear Moderate Robust 1. Is the environment favorable for your organization to address social determinants of health? 2. What s the perceived value of a change to assess and address social determinants of health? 3. Do you have executive sponsorship to advance social determinants interventions? 4. How established are team roles and ownership for your social determinants intervention(s)? 5. How well defined is (are) the scope of your social determinants intervention(s)? 6. How well managed is (are) your social determinants intervention(s)? 7. How well integrated are social determinants of health with care delivery? 8. How well developed are your Continuous Quality Improvement (CQI) processes? 9. How mature are your information systems and human resources systems? 10. What is your financial readiness for social determinants of health interventions? Total 9
Step 2: What s the perceived value of a change to assess and address social determinants of health? Which of the following best describes the degree to which your organization s staff and senior leaders perceive the value of assessing and addressing SDOH? Limited or unclear Moderate Robust A loosely organized group and/or a limited number (less than1/3) of your organization s staff or senior leadership think that improving the ability to assess and address social determinants of health is needed, important, beneficial, or worthwhile. One or more individuals or organized groups with influence and a sizeable number of organization staff (less than 2/3) think that improving the ability to assess and address social determinants of health is needed, important, beneficial, or worthwhile. One or more individuals or well organized groups with influence, and an overwhelming number of organizational members (more than 2/3) think that improving the ability to assess and address social determinants of health is needed, important, beneficial, or worthwhile. Step 7: How well integrated are social determinants of health with care delivery? Limited or unclear Moderate Robust Which of the following best describes the degree to which social determinant intervention(s) are integrated and defined with other care delivery services? The intervention to address social determinants of health is a stand-alone project and/or has not been defined from end-toend. Less than 3 of the following care delivery components have been defined : - Screen - Triage - Assess/Exam - Chart/Code - Refer / Linkage - Follow-up / Care Management - Between visit support The intervention to address social determinants of health has been defined from end-to-end, leading to the identification of other related care delivery processes that require some redesign. 4-5 of the following care delivery components have been defined: - Screen - Triage - Assess/Exam - Chart/Code - Refer / Linkage - Follow-up/ Care Management - Between visit support The intervention to address social determinants of health has been designed to fit with organizational processes and IT systems and interrelated organizational processes have been redesigned to optimize performance. At least 6 of the following care delivery components have been defined : - Screen - Triage - Assess/Exam - Chart/Code - Refer / Linkage - Follow-up/ Care Management - Between visit support 10
Step 8: How well developed are your Continuous Quality Improvement (CQI) processes? Which of the following best describes how well developed your organization s continuous quality improvement (CQI) processes are? Limited or unclear Moderate Robust The organization lacks a QI officer and/or does not have an updated CQI plan that includes established processes a) for identifying QI priorities within programs and services and b) for continuous evaluation to see if programs are working as intended and are effective. 30% or fewer leaders & staff: Are trained in basic methods for evaluating and improving quality, such as Plan-Do-Study-Act. Are engaged in established, consistent efforts to integrate lessons from QI activities into daily practice and operations. Have the authority to change or influence practices to improve services within their areas of responsibility. The organization has a QI officer, has an updated CQI plan that includes established processes a) for identifying QI priorities and b) for continuous evaluation to see if programs are working as intended and are effective. Up to 50% of leaders & staff: Are trained in methods for evaluating and improving quality, such as Plan-Do- Study-Act, and redesign approaches, such as Human-Centered Design Are engaged in established, consistent efforts to integrate lessons from QI activities into daily practice and operations. Have the authority to change or influence practices to improve services within their areas of responsibility. The organization has a QI officer, has an updated CQI plan that includes established processes a) for identifying QI priorities, b) for continuous evaluation to see if programs are working as intended and are effective; and c) for identifying and addressing root causes in the social determinants of health ( Upstream QI ). More than 50% of leaders & staff: Are trained in methods for evaluating and improving quality, such as Plan-Do- Study-Act, and redesign approaches, such as Human-Centered Design Are engaged in consistent efforts to integrate lessons from QI activities into daily practice and operations. Influence organizational strategy based on Qi priorities Step 10: What is your financial readiness for social determinants of health interventions? Limited or unclear Moderate Robust Which of the following best describes the degree to which your organization s financial structure is conducive to social determinants of health interventions? Your organization: Has limited processes to support management of patients with high-volume, high-cost chronic diseases Has limited ability to aggregate clinical information across networks and between clinics, hospitals and physician practices Has a very small percentage of payments tied to value/ outcomes-based mechanisms. The majority of value-based payment models are in performance-based programs (e.g. primary-care incentives or performancebased contracts) rather than capitated or shared savings/risk models. Has established basic budgeting and accounting practices, providing ability to track capacity and costs across various units, and track expenses related to indirect costs associated with managing programs. Your organization: Has systems in place to support management of patients with high-volume, high-cost chronic diseases Has some ability to aggregate clinical information across networks and between clinics, hospitals and physician practices Has up to 20% of payments tied to value/ outcomesbased mechanisms, including a mix of performance-based programs (e.g. primary-care incentives or performancebased contracts), bundled/episode-based models, and/or capitated or shared savings/risk models. Has robust budgeting, accounting, and financial management practices, showing both financial and nonfinancial indicators for different management areas Your organization: Has demonstrated positive outcomes and ROI for patients with high-volume, high-cost chronic diseases Has established ability to aggregate information across networks and between clinical AND nonclinical partners Has more than 20% of payments tied to value/ outcomes-based mechanisms, including largely capitated or shared savings/risk models. Has robust budgeting, accounting, and financial management practices, showing both financial and nonfinancial indicators for different management areas The chart of accounts structure has multiple levels, providing detailed analysis (for instance by organizational units, regions, or projects/programs). 11
Get Set: Whose job will it be to implement your upstream solution? Who are your healthcare-based upstreamists? Who are your strategic community partners? Go Upstream using QI 12
How many healthcare Plan-Do-Study-Act cycles (PDSAs) address social factors? Act Upstream? Plan Study Do Value-based Upstream Quality Improvement Health Systems Improvement PI/QI Practice Transformation Payment Reform Population Medicine Community Preventive Social Population Health Public Health Community Development Social Services 13
Compared with higher-income diabetics, lower-income diabetic adults have a 27% higher rate of hospital admissions due to end-of-the month food insecurity In 2013, 1 in 5 children lived in a home that met the US Department of Agriculture (USDA) definition of a food-insecure household. October 2015: The AAP enters the fight against hunger 14
. Plant your flag FoodRx: A campaign to end hunger and improve outcomes among our patients - Improve Screening of Food Insecurity by 30% within 6 months - Improve Provider Confidence & Patient Satisfaction to address Food Insecurity by 30% within 6 months - Reduce Hospital Readmissions related among Food-Insecure patients by 30% within 18 months 15
Upstream Project Canvas: Develop upstream QI interventions Pick a starting point: Upstream QI matrix Example: Diabetes & Food insecurity (R. Manchanda 2014) Patient-Level Health Care Organization Population-Level General Population- Level Primary Prevention Secondary Prevention Financialliteracy, support, & nutrition programs for lowincome families with strong family history of DM Povertyscreening & financial assistance for DM patients at-risk of end-of-month hypoglycemia TertiaryPrevention Reduce ED use among high-utilizer severe diabetics using food and income support referrals Provide on-site Farmers Market, gym, walking trails, or financial counseling for families at risk for DM Subsidize vouchersto local Farmer s Market or hire a financial counselor for lowincome DM patients Coordinatewith local banks, collectors, lenders, to reduce debt burden for utilizer diabetics Advocatefor local increase in minimum wage and supports for low-income families, particularly those at risk of DM Change timingand content WIC & school food programs to avoid food insecurity among DM Support legislation/ regulations to provide financial and hotspotter services to severe diabetics 16
Upstream QI Workflow Care Team Member Role/ Process Tools/ Data Source Metric Social Need - Food insecurity Upstream QI committee Project Team oversees & tracks PDSAs Screen Medical Assistant Ask during vitals of diabetics Upstream Project Canvas 2-item food insecurity screener Triage Medical Assistant Flag in EMR Triage Protocol #participant #PDSAs % screened % positive % flagged Exam PCP Adjust / create treatment plan Chart/Code Medical Assistant Scribe, standing order to refer to SW Refer Social Worker or RN Assess / Food bank referral EMR care plan EMR e.g. Healthify % plans updated % internal referrals % referred Follow-up Social Worker or RN Q1month or more check-in based on risk EMR Healthify % decrease in food insecurity UPSTREAM TOOLS Screen Find Resource Social Screening Tools SAAS Healthify Referral Manage EMR Integration + + + # Health Leads + + + # Help Steps + + Community/ Patient Participation Purple Binder + + Aunt Bertha/ OneDegree + Community Detailing- HB + + HealtheRX + +/- + Enterprise Built County / Other + + + + +/- + 17
Be Happy: With upstream quality improvement, we can create communityintegrated healthcare systems that make sense. Baseline After 11 months Healthcare provider confidence to address housing & other social needs 18
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 19