Medicaid Accelerated exchange Series and Medicaid Accelerated exchange New York (MAXny) Series Program Overview June 12, 2018 2017 New York State, Department Of Health, Office of Health Insurance Programs. All rights reserved.
2 MAX and MAXny The MAX Series Program is offered by the New York State Department of Health (NYS DOH) and facilitated by NYS DOH contracted facilitators as part of the Delivery System Reform Incentive Payment (DSRIP) program. As part of the Delivery System Reform Incentive Payment (DSRIP) program, the NYS DOH launched the Medicaid Accelerated exchange (MAX) Series Program, to redesign the way care is delivered for New York State s most vulnerable patients. The DSRIP program is designed to stabilize New York s healthcare safety-net system, and realign its delivery system by shifting the focus from service volume to quality for its Medicaid population. Ultimately, the statewide goal is to reduce avoidable hospital use by 25% over five years. 2017 New York State, Department Of Health, Office of Health Insurance Programs. All rights reserved.
2 MAX and MAXny The MAX Series is a rapid cycle continuous improvement (RCCI) program, which aims to bridge the gap between how-we ve-always-done-it traditional healthcare and the provision of interdisciplinary services at the community level, by bringing together frontline care providers from across the care continuum. Through highly structured and dynamic workshops and action periods, change is implemented and results are driven at the local level. The MAX Series was launched in the summer of 2015 2017 New York State, Department Of Health, Office of Health Insurance Programs. All rights reserved.
2 MAX and MAXny The MAX Series was complemented by the Train-the-Trainer (TTT) program, which was designed to scale and sustain process improvement work by training participants in the same RCCI methodology used in the MAX Series. These TTT participants will continue to implement the RCCI methodology throughout their respective PPS s through the MAXny Series: MAX New York! The MAXny Series is offered by the PPS, and facilitated by qualified MAXny facilitators as part of the DSRIP program. 2017 New York State, Department Of Health, Office of Health Insurance Programs. All rights reserved.
6 Train The Trainer Participant Role To become experts in RCCI Methodology To enhance facilitation skills and techniques To develop a Sustainability Plan outlining the next RCCI Workshop Series (to be independently lead upon completion of the program) See One Do One Lead One
MAX Series Roles and Responsibilities MAXny Series Executive Sponsor: Provides overall sponsorship and championing of the MAXny Series, including the development of new Sustainability Plans and ongoing reporting to the NYS DOH. Site Executive Sponsor: Provides leadership, sponsorship, and championing of the MAXny Series at the site enrolled into the program. Action Team Members: Frontline care providers directly involved in meeting the needs of the target population Action Team Lead: Provides leadership on the Action Team and serves as the MAXny Series Lead s primary point of contact
Medicaid Members with 4 or more hospitalizations in 1 year HU Readmission Rate = 40% Non-HU Readmission Rate = 8% Jiang et al. HCUP Statistical Brief #184 Nov 2014
The MAX & MAXny Series are rapid cycle continuous improvement (RCCI) program that brings together frontline providers to redesign the way care is delivered to those who need it 5 MAXny Series Methodology Objectives6.2018 Leveraging a highly structured methodology, approach and coaching Utilizing data to measure and drive performance Facilitating system integration by breaking down silos and bringing together multidisciplinary providers Focusingon sustainability Programs 1) Decrease High Utilizer s of ED and inpatient hospitalization 2) Improve provider quality of life 3) Increase integration across the care delivery system 4) Develop and build rapid cycle continuous improvement capability 2017 New York State, Department Of Health, Office of Health Insurance Programs. All rights reserved.
MAXny Series Workshops MAXny Series Medicaid Accelerated exchange New York (MAXny) Series Phase 1: Assessment and Preparation Phase 2: Workshops and Action Periods Phase 3: 3: Reporting Aug 1, 2017 Sept 28, 2017 Sept 28, 2017 Oct 27, 2017 Jan 1, 2018 Mar 9, 2018 Site and Participant Enrollment MAXny Workshop 1 MAXny Workshop 2 MAXny Workshop 3 Final Report Action Team Members 30 day Action Period 60 day Action Period 60 day Action Period Note: Action Periods are rapid Plan Do Study Act continuous improvement cycles Data collection, analysis, evaluation, and reporting will be critical throughout the duration of the MAXny Series Workshops June 2017 2017 New York State, Department Of Health, Office of Health Insurance Programs. All rights reserved.
February 26, 2016 11
12 Theory: PLAN-DO-STUDY-ACT Small, focused, measured changes can have significant positive impact on your daily processes. It is important to: 1. Plan Develop a plan 2. Do Try it! Identify a specific action a specific person(s) will take and how many time/how long to test. 3. Study How did this change work and what did we learn from it? 4. Act Should we adapt, adopt or abandon the change? What s our next step? June 2017 2017 New York State, Department Of Health, Office of Health Insurance Programs. All rights reserved.
PDSA Ramps A P A P S D Breakthrough Results S D A P Theories, hunches, & best practices A S P D S D
NYS DOH MAX Series: Five Lessons Learned About Improving Care for High Utilizers Improving care for high utilizers requires we know who to focus on. view frequent utilization as a symptom of an unaddressed or unmet need. do something different. successfully engage with and intensively serve patients after they leave the hospital setting. actively collaborate with community providers and agencies.
February 26, 2016 https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/pps_workshops/docs/2017-janjul_imp_care_for_high_utilizers.pdf 15
Change Management
2 MAX Series: E3 A-Team Mary Whalen, COO, Samaritan Medical Center Aaron Campbell, DO, Director of Hospitalist Program, Samaritan Medical Center Sarah Delaney-Rowland, MD, Emergency Department Physician, North Country Emergency Medical Consultants Kim Thibert, RN, CNO, Samaritan Medical Center Tim Ruetten, Executive Director, Jefferson County Office for the Aging Jeri Fuller, LCSW, Medical Social Worker, Jefferson County Public Health Services Jilayne Salisbury, RN, Clinical Director of Physician Practices, Samaritan Medical Center Kathy Hunter, RN, Manager of Case Management & Discharge Planning, Samaritan Medical Center
E3 A Team Our Goal Statement: To improve the quality of life of high utilizers by collaboration across the spectrums of the individual s life including psychosocial, economic, and clinical factors.
Who are high utilizers? Four (4) or more inpatient admissions within the last year (131) Combination of medical, behavioral health, and social needs Social isolation Lack of family support Lack of engagement with preventative care Behavioral health Social determinants Lack of advanced care planning
SMC Super-Utilizers in the last 12 Months Baseline Data 11/15/2015 11/14/2016 PATIENTS 131 ADMISSIONS 641 Average ADMISSIONS/PATIENT 4.9
16 Count of Admissions 14 12 10 Number of Admissions 8 6 4 2 0 0 20 40 60 80 100 120 140 Number of Patients
PAYERS Samaritan Medical Center 11/15/2015 11/14/2016
AGE Mean 75 th Percentile Median 25 th Percentile
SMC Super-Utilizers 11/01/2015 10/31/2016 Average Cost/Admission TOTAL COST $14,989 $9,113,502
Admission Location 96% admitted from Home 2% admitted from a Nursing Home
Discharge Location 80% discharged to Home 10% discharged to a Nursing Home
What can be done? Identify the drivers of utilization do not over medicalize. What is the root cause? Ask why Assess for clinical behavioral social needs
Getting Started Electronic notification of all members of the action team Provider engagement plan Expanding care coordination meeting Interview patients with consistent tool to identify the drivers of utilization
Collaborate Across the Care Continuum. Case conferencing Definitive linkage to outpatient services Develop Intensive Care Transition Team Increase the number of HU interviews Identify the HU in multidisciplinary rounds and discuss the drivers of utilization
30 E3 A-Team NCI, Samaritan Medical Center Inpatient High Utilizer Care Pathway Identify Send dynamic twice daily high utilizer report to Samaritan Medical Center, Jefferson County Public Health, Jefferson County Office for the Aging (automatic via Meditech) Assess Link Identify Drivers of Utilization through discharge planning assessment Monday through Friday; conducted by discharge planners Share identified DOUs with care team Identify HUs in interdisciplinary rounds and discuss DOUs* Identify advanced directives Hold monthly advanced care coordination meeting with CBOs, Primary Care Practices and the hospital Create linkages to Jefferson County Public Health, Northern Regional Center for Independent Living, Health Home, PCP Care Managers Manage Conduct interagency case conferencing Develop intensive care transitions process/team* to ensure long-term follow up in the community * Denotes workshop action plan
45% Decrease in HU IP Hospitalizations 20 Percent Change in HU IP Hospitalization 8 0-20 -40 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sept 17 Oct 17 Nov 17-21 -29-29 -33-60 -80-100 -85-78 -71-59 -57
Lessons Learned # Topic Description 32 1 There is no single solution A majority of this population engage in behaviors that are difficult to change overnight. We recognize we must take an individualized approach and look at DOU differently than we have in the past, but also be mindful that ultimately the patient/family have to be willing to make a change. 2 Competing priorities and incentives There are competing priorities and incentives in the healthcare system that can impede process improvement. 3 This isn t a project- it is a process change It is important to have caregivers understand this is a long-term and on-going process improvement. 4 CBOs have unrealistic expectations of the role of the hospital There is still a need to change CBOs expectation of care provided in the hospital vs. outside the hospital.
The Next MAX.. Medicaid Accelerated exchange New York (MAXny) Series 2017 New York State, Department Of Health, Office of Health Insurance Programs. All rights reserved.
2 MAXny Series: E3 A-Team Mario Victoria, MD, Chief Medical Officer, Samaritan Medical Center Sarah Delaney-Rowland, MD, Emergency Department Physician, North Country Emergency Medical Consultants Kathy Hunter, RN, Manager of Case Management & Discharge Planning, Samaritan Medical Center Kim Thibert, RN, CNO, Samaritan Medical Center Aileen Martin, Executive Director, NRCIL Christen Norris, ED Nurse Manager, Samaritan Medical Center Michelle Treadwell, ED Clinical Discharge Planner, Samaritan Medical Center Linda Hayes, LPN, Family Practice Administrator, North Country Family Health Center Anne Hodkinson, Patient Relations Manager, Samaritan Medical Center Lisa Hedger, Community Outreach Specialist, Children s Home of Jefferson County
SMC ED Data 7/1/2016-6/30/2017
ED Stats 7/1/2016-6/30/2017 48,589 Visits 28,580 Patients 81% Discharged to Home 15.6% Admitted as Inpatients 3.8% LWBS/AMA
Mon Tues Weds Thu Fri Sat Sun
Home
Count of ED HU Patients (51.3%) (25.4%) (10.1%) (13.2%)
(55.7%) (25.7%) (9.4%) (2.7%) (1.1%) (1.1%) (0.8%)
Mon Tues Weds Thu Fri Sat Sun
(79.9%) (10%)
High Utilizers
Patients with a PCP Visit N= 142
Samaritan Medical Center: Overview Target population: Patients with 10+ ED visits in a 12 month period = Process improvements: 189 Patients 2741 ED Visits 275 IP Admissions PATIENT IDENTIFICATION PLANNING MANAGEMENT FOLLOW UP Flag in EMR Real time alert to hospital and community care team Needs assessment to identify social and behavioral needs ED resources mobilized for initial patient engagement Care management engages with patients after discharge Community Social Worker/Care Manager connects patient to services Definitively connect patients to critical social services Bi-weekly interdisciplinary care plan meetings
Drivers of Utilization
Final Thoughts Challenges with sustainability: it seems like more work, takes resources, new things eventually become old The definition of insanity : making the same discharge plan for the patient every time they come to the hospital even though it clearly doesn t work. This is a journey with lots of exits and detours
Final Thoughts (cont.) It s about improving quality of life, helping our patients and families to be safer, reducing suffering while at the same time being fiscally responsible It s not a project, its about doing something different, rethinking, revamping, trying something new Focus on patients that are impactable
Any change, even a change for the better, is always accompanied by drawbacks and discomforts. Arnold Bennett
When you re finished changing, you re finished. - Benjamin Franklin
The price of doing the same old thing is far higher than the price of change. Bill Clinton
What are you going to do differently?
Questions
Thank you! Change Management The most important single condition for success in quality of healthcare is the determination to make it work June 2017 2017 New York State, Department Of Health, Office of Health Insurance Programs. All rights reserved.