1. for High-Utilizing Patients
Building
Systems of Care
in the Safety Net
for High-Utilizing Patients
A program from CCI,
the Institute for Healthcare Improvement,
and the California HealthCare Foundation
PROGRAM LAUNCH MARCH 13, 2014

2. Agenda Welcome and framing Introductions
Quick 3 questions
Clinic name, # sites, # providers, team members
Current targeted services for HRHC population segment/s, if any
One question at the outset, for faculty, other clinics, both
Overview of collaborative and Phase 1
Aims, Measures, Changes to improve care and lower costs
Successful business case formulations
Assignment for April 8 webinar
Discussion

3. A unique program partnership
California HealthCare Foundation
Center for Care Innovations
Up to ten California clinics
Clinics’ partners in quality, cost control, community health (i.e. plans, consortia, etc.)
Institute for Healthcare Improvement
National experts from the field
Veenu slide, this is reused from the application support webinar

4. Today’s discussion
Meet your improvement community!
Establish program goals and assumptions
Get clinics started on the first most important partnership development
Introduce an approach to business case formulation

5. Building Systems of Care in the Safety Net for High-Utilizing Patients
Phase 1 Faculty
TIME: Slides 1-5 need to take no more than 10 minutes.
Catherine Craig
Faculty
Cory Sevin
IHI Director
Rebecca Steinfield
Improvement Advisor
Hunter Gatewood
IA, Coach

6. The brave pioneers AltaMed Health Services Corporation – Los Angeles
CommuniCare Health Centers –Sacramento area
Golden Valley Health Centers – Central Valley
Hope Center/Alameda Cty Health System – Oakland
Neighborhood Healthcare – San Diego, Riverside
San Francisco Health Network
Santa Rosa Community Health Centers – Sonoma
St John's Well Child and Family Center – Los Angeles
St Vincent de Paul Village Fam. Health Ctrs – San Diego
Clinic name, # sites, # providers, team members
Current targeted services for HRHC population segment/s, if any
One question at the outset

7. .
Better Health and Lower Costs for Patients with Complex Needs; An IHI Triple Aim Collaborative

8. Percent of Total Health Care Expenses Incurred by Different Percentiles of U.S. Population: 2002
Rebecca
Sources: Statistical Brief #73. March Agency for Healthcare Research and Quality

9. Persistence In Spending
Rebecca

10. Crucial Question for Primary Care
“Why wouldn’t a person with a chronic condition do everything in their power to live long and feel well?”
Rebecca

11. Determinants of Health and Their Contribution to Premature Death
15% 5%
10%
40%
30%
Social
Environmental
Medical
Behavioral
Genetic
Alan
Here we are pointing out that if we are to impact risk and cost, we have to pay attention to behaviors, social and environmental factors
Next we will build the case for approaches that take into account these variables...
Schroeder, NEJM 357; 12

12. The Collaborative will:
Help you plan and implement comprehensive care designs that serve the needs of your most complex, high-risk, and costly patients, resulting in better health outcomes, a better care experience, and lower total cost.
Whether your organization has already established a program or is just starting this work, our goal is to help you make a positive and sustainable difference for this population.

13. Learning Collaborative
12 month Learning Collaborative
30-40 organizations
3 Learning Sessions, one will be face-to-face
Bi-monthly community calls plus measurement calls
Use of QI methods-MFI and rapid, iterative learning
Starts July 2014
Cory

14. Collaborative Faculty
Kevin Nolan
Improvement Advisor
Catherine Craig
Faculty
Cory Sevin
IHI Director
John Whittington
IHI Team
TIME: Slides 1-5 need to take no more than 10 minutes.
SPEAKER: Kathryn hand off to Ninon
Alan Glaseroff
Faculty
Ann Lindsay
Faculty
Rebecca Ramsey
Faculty

15. Phase 1 Goals
Partner with a health plan to get useful data for your population.
Better understand your business case for spending resources on this area of improvement.
Learn barriers to less costly and more effective health care services for this population.
Use data to identify community resources and agencies for partnerships.

16. Phase 1 activities Monthly online meetings
In-person workshop on business case
IHI Extranet
discussion group
Weekly support contact,
from CCI, with IHI back-up
Hunter

17. Phase 1 Webinars Kickoff! You are here.
Sustainability, partnering with payers
Data and evolving payer relationship
Identifying your HRHC population
Listening to patients to discover barriers to less costly care

18. The Model for Improvement
What are we trying to
Accomplish?
How will we know that a
change is an improvement?
The three questions provide the strategy
What change can we make that will result in improvement?
The PDSA cycle provides the tactical approach to work
Act
Plan
Study Do
This is the collaborative model for executing change – 3 questions and PDSA
Source:
Langley, et al. The Improvement Guide, 1996

19. What are we trying to accomplish?
Within 12 months, participants will be able to do the following:
Identify a particular high-risk population that will be the focus of your work
Assess the assets and needs of this population by learning from patients’ experiences
Co-create and execute new care designs to test for impact and cost savings
Increase the scale and reach of successful care designs in fivefold to tenfold jumps

20. How will we know a change is an improvement?

21. What changes can we make that will result in improvement?
Individual, Family & Community Resources
Coordination
Goals
Service Delivery at Scale
Needs Assessment for Segment
Service Design
Population Outcomes
Population Segmentation
Integrator
Feedback
Feedback

22. Managing Services for a Population
Individual, Family & Community Resources
Coordination
Goals
Service Delivery at Scale
Needs Assessment for Segment
Service Design
Population Outcomes
Population Segmentation
Integrator
140+organizations around the world
Feedback
Feedback

23. Change Areas Identify the population Co-create care design
Who has both complex needs and the highest utilization rates?
Co-create care design
Build care with people and their preferences and experiences and consider sustainability from the beginning
Recruit people into care
Experiment with outreach methods to successfully reach people with a history of bad experiences with the care system
Engage people in care
Identify strategies to effectively partner with people with complex needs
Partner with existing community resources
Build collaborations with external partners to ensure that social determinants of health are a coherent part of the care plan

24. Iterative Process Step 1: Identify your population
Frail elders, people living in poverty with MH needs…
Step 2: Understand needs and root causes
Utilization data, clinician intuition, people’s stories
Step 3: Co-create and execute care plan with 5 people
Co-create care with the individual to learn for the population
Step 4: Scale to 25
What infrastructure does this require? (IT, staffing, space…)
Step 5: Scale by 5X or 10X  the entire population
Sustainability, well-functioning care systems, and infrastructure
CONTEXTUAL NOT COOKIE CUTTER
Based on our change package and our experience working with teams to re-design care for HR/HC patients we have developed the following 4 step process:

25. Repeated Use of the PDSA Cycle

26. Model for Improvement Resources
Whiteboard Videos
On-Demand Video Courses
IHI Open School Course (QI102)
Call Hunter 

27. The Sequence for Improvement
Sustaining and Spreading a change to other locations
Make part of routine operations
Implementing a change (steps 5 and beyond…)
Test under a variety of conditions
Testing a change (steps 3 and 4)
Developing a change (Steps 1 & 2)

28. IHI.ORG

29. The Key Sustainability Question
Who will derive financial benefit if your interventions succeed?
What data can back up your assertion?
ED and inpatient cost data for intervention group AND for whole clinic population
Throughput and clinic cost data
Quality outcomes, ROI efficiencies
Inpatient admission data
Clinic accounting
From a decrease in medical expenditures for the population served
From an increase in efficiency which allows more production and thus revenue
From an improvement in quality which is financially incentivized
From a decrease in financial withholds related to errors (readmissions)
From an increase in revenue related to more services

30. Gold Standard Data Total cost per member per month
For the intervention group
AND
For the entire clinic population
Gather and plot high cost care components: hospital admissions
Regression
to the
Mean

31. Sustainability Planning Tips
The more expensive the intervention the more robust the cost savings must be to create a return on the investment
Identify what matters most to (potential) funders as early as possible
Determine the average cost of an ED visit and/or hospital visit for your target population
Throughput can be as important as scale
Look for economy of scale opportunities
Hire lay or peer community health workers or behavioral health specialists?
Talk with them about their priorities and develop a case as to how this work supports them
Tally how many visits you would need to avoid to pay for your intervention
Track “graduation” rates and active caseload
Look for ways to centralize infrastructure, or to spread capacities across sites

32. Action Step
Review data about this group of patients from available HIT systems. It may be
Claims/utilization data from payer, clinic claims, your own system encounter information from inpatient, ED, and primary and specialty care systems
Behavioral health encounter/claims data
Primary care EHR notes to include problem list, diagnosis codes, care plan, After Visit Summaries
Clinician responses to questions about which patients are high risk/high cost.
Be prepared to discuss the data that you currently have access to in our next call.
What data do you currently have access to?
What does it take to get that data?
How often do you get that data?
What do you learn from the data?
How useful is the data to you?

33. Community Support
Private Collaborative Extranet-Workgroup for CCI Group
Listserve

34. Questions? susannah@careinnovations.org hunter@signalkey.com
Veenu or Hunter?
Image © Nina Bagley