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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

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)


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?
Veenu or Hunter? Image © Nina Bagley

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