Innovations in Community Collaborations: Reaching 100% Access to Care Rural Health Network of South Central New York October 2005 Diana Resnik

Our System Ascension Health is the largest Catholic health system, the largest private non-profit system and the fourth largest system in the United States operating in 20 states and the District of Columbia.

2020 Goal of Healthcare That Leaves No One Behind= 100% Access What, and for whom, is 100% Access? 100% access means that all persons, particularly those persons who are uninsured or underinsured, receive health care services that:

2020 Goal of Healthcare That Leaves No One Behind= 100% Access 2. Are funded in an adequate and sustainable fashion. 1. Create, and support the journey to improved Health outcomes for each individual, and

Together We Promise: Healthcare that Works Healthcare that is Safe, and Healthcare that Leaves No One Behind… Ascension Health’s Call to Action

Serious Gaps in the Healthcare Safety Net Migrant Workers Uninsured Workers Immigrants Frail Elderly Homeless Adolescents Vulnerable Populations Service Gaps Affordable Drugs Access to Mental Health Services Available Dental Services

Private Public Safety net means where the uninsured receive health services. Private providers provide over half of all uncompensated care. Among the largest providers of uncompensated care, 82% are private. 72% of Medicaid patient days are provided in private hospitals. Private Providers = U.S. Safety Net

Ascension Health Virtual Access Institute: The Picture in 2020 A. National Legislative Leader D. National Public Policy Partner C. Voice of the Voiceless B. Access Model Catalyst At least $100 million of federal funds that is directed to achieving 100% access for patients served by private not-for- profit safety net providers National health reform passes assuring every American healthcare access Achievement Of 100% access in every Ascension Health community catalyzed by the Ascension Health Ministry Threshold change in public perception supporting a national policy to assure access for all

Federal and Matching Funds for Ascension Health HCAP Projects Ascension Health Submits National Unified CAP Application for Multiple Sites and Commits to Matching $ of Approximately $7 million over five years Austin $900,000 Detroit $900,000 New Orleans $899,357 Austin $675,000 Detroit $675,000 New Orleans $674,518 Binghamton $631,374 Dumas/Gould $819,264 Flint $827,230 Indianapolis $995,815 Nashville $1,080,819 Austin $472,500 Detroit $427,500 New Orleans $472,000 Binghamton $442,000 Dumas/Gould $572,000 Flint $579,000 Indianapolis $697,000 Nashville $757,000 Saginaw $961,995 Austin $998,674 New Orleans $330,000 Binghamton $309,353 Dumas/Gould $440,632 Flint $405,343 Indianapolis $487,950 Nashville $529,601 Saginaw $672,921 Tawas City $972,670 Pottsville $250,000* *appropriations Austin $699,072 New Orleans $1,200,000 Flint $483,379 Saginaw $471,045 Tawas City $680,869 Pasco $997,680 Pottsville $500,000* *appropriations pending Total Dollars Federal Funds to Matched Sites = $24,138,561 Ascension Health Match = $7,072,485 Federal and Ascension Health Match = $31,211,046

11 Daughters of Charity Services of New Orleans New Orleans, LA New Orleans Partnership for Care of the Uninsured (NOPCU) SETON Healthcare Network, Austin, TX Indigent Care Collaboration (ICC) St. John Health System Detroit, MI Voices of Detroit Initiative (VODI) Our Lady of Lourdes Memorial Hospital Binghamton, NY Southern Tier Family Health Link (FHL) St. Thomas Health Services Nashville, TN, Nashville Consortium of Safety Net Providers Genesys Health System Flint, MI, Genessee County CAP (GCCAP) Delta Healthcare Consortium Dumas/Gould, AR Central Indiana Health Systems Indianapolis, IN, Rural Underserved Access to Health (RUAH) Models for 100% Access © Ascension Health 2003 Good Samaritan Regional Medical Center Pottsville, PA Highway to Health St. Mary’s Medical Center, Saginaw, MI Healthy Futures St. Joseph Hospital, Tawas City, MI Rural Prevention Network Lourdes Health Network, Pasco, WA BFCHA Carondelet Health Network, Tucson, AZ Pima County Access Program

SYSTEMIC CHANGE = 100% ACCESS 1.Formal Infrastructure Leadership Coalition Shared Information Systems Catalyst Funding 2.Service Gaps Filled Dental/Pharmaceutical /Mental Health 3.Uninsured: Care Model 4.Private Physicians Volunteer as Medical Home 5.Sustainable Funding State, Local Govt./Business Ascension Health’s 5-Step Access Model © Ascension Health

Ascension Health’s Commitment to Producing Outcome Measures as a Path to Sustainability Reduction of unnecessary emergency room visits by the uninsured Reduction in unnecessary hospitalizations by the uninsured Increase in number of previously uninsured enrolled in public or private insurance programs Increase in number of uninsured with a primary care home Increase in number of uninsured participating in pharmaceutical assistance programs Increase in dollar value of needed pharmaceuticals provided to the uninsured Improved health outcomes in asthma, diabetes, and hypertension in the uninsured

Local Access Model Leadership – 100% Access to Healthcare in Austin

Step 1: Build Infrastructure – Leadership Leadership Commitment for Successful Collaboration is Key Vision to form Collaboration Provide funding, personnel, space and equipment resources Use influence to call others to participate Give time, energy and commitment, and CEO’s must be present “at the table” – don’t delegate Be intentional on building sustainable funding Have passion to meet the needs of persons who are poor and vulnerable

Create the “business model” Collaborative “customers” are the safety net providers – the member organizations. The providers’ customers are their uninsured patients Collaborative doesn’t get involved in direct services to patients Collaborative goal is to reduce costs to member organizations that care for the uninsured, or to increase revenue to member organizations (by enrolling patients in coverage programs) so that the member organizations can provide more and better care to the uninsured population

Step 1: Build Infrastructure – Information Systems Web-based programs that help all partners improve enrollment to government funding and to resources Web-based program that builds a shared electronic record with demographic and medical data Disease management repository Case Management Web-based programs Pharmacy Assistance Web-based data base Managed Care (HMO look-a-like) programs

Step 1: Build Infrastructure – Information Systems RHNSCNY Patient Health Information Network (PHIN) is a pilot program that provides shared information on patients Questions? Who most benefits from this system? How do you engage them to help fund system? What is the value proposition for each partner in the collaborative?

ICare

Step 1: Building Infrastructure – Information Systems The I-Care system is the overall integrating structure for the Indigent Care Collaboration (ICC) Medicaider Common eligibility screening across the community Outreach to secure eligibility beyond the screening process MPI/CDR (Master Patient Index/Central Data Repository) Provides shared health data for clinical and demographic information Record includes encounter codes (ICD9, CPT) and pharmacy

Medicaider

Step 1: Building Infrastructure – Information Systems Online common eligibility tool screens for Medicaid, SSI, SCHIP and local assistance programs Average screening time: 3.1 minutes Link from Med Data Systems into Medicaider provides pharmacy assistance eligibility Program forms are printed out, signed and processed at interview Recently expanded to Williamson County

Medicaider Screening Results: Travis County 118,687 screened through 12/13/04 86% Program eligible (8.4%) 9,919 Medicaid Eligible (1.9%) 2,261 SCHIP Eligible (61.2%) 72,697 MAP/Sliding Scale Eligible

Estimated ICC Member Revenue: Travis County Medicaider Enrollees Post Enrollment N=679 Patients enrolled in Medicaid/SCHIP in 2004 for actual visits after enrollment. Assumptions: clinic $30; FQHC $150; Hospital $300

Medicaider Screening Results: Williamson County 4173 interviews through 12/13/04 84% Program Eligible 16.4% (685) Medicaid Eligible 4.2% (174) SCHIP Eligible 14.3% (608) County Indigent/City Eligible

MASTER PATIENT INDEX/CENTRAL DATA REPOSITORY MPI/CDR

Step 1: Build Infrastructure – Information Systems Provides unduplicated count of uninsured patients (by payor, gender, age, neighborhood) Tracks patients through the safety-net care system via encounters including CPT and ICD-9 codes Improves care management, reduced duplication of resources, better outcomes Provides reporting and analysis capability including mapping, incidence of diagnoses, etc. Future opportunity: Incorporation of lab data and a complete electronic medical record

Step 1: Build Infrastructure – Information Systems Patient count: 335,597 Encounters: 1,126,295 Pharmacy encounters: 196,027 prescriptions MPI/CDR utilized by: 10 Hospitals 22Clinics 2Physician Networks 1MHMR Authority

Step 1: Build Infrastructure – Information Systems There is a critical role for IT infrastructure in an effort to coordinate care models and build value propositions

The Patient Journey to 100% Access – What the Providers Don’t Know! 12/31/ – Nerve Inflammation LegBrackenridge Hospital 1/5/ – Pain in LimbBrackenridge Hospital 1/15/ – Femoral Nerve LesionCity Clinic in Manor 1/16/ – Muscle/Ligament Disease – Difficult Walk – Nerve Inflammation Brackenridge Hospital 2/14/ – Nerve InflammationCity Clinic in Manor 4/18/ – Pain in LimbCity Clinic in Manor 4/30/ – Poisoning – Medicinal – Drug Abuse – Unspecified Brackenridge Hospital 5/13/ – Poisoning – Skelet Muscle E950.4 – Suicide – Drug/Med NEC Seton Medical Center …As of 2/2003, also an Austin/Travis County Mental Health Center Patient...and who knows how many pharmacies!

Understanding Care Use: Potential To Improve Coordination of Treatment DateConditionLocation 3/3/04DiabetesATC RZ 3/17/04DiabetesATC RZ 4/15/04Dental ExamATC NE 4/16/04Clinic VisitSeton McCarthy 4/27/04Diabetes, Renal DiseaseBrack (inpatient) 4/30/04DiabetesSeton McCarthy 5/17/04Diabetes, Muscle Dis.Brack (outpatient) 5/21/04DiabetesSeton McCarthy 6/15/04Diabetes, Chest PainSt David (ER) 6/16/04Diabetes, Renal DialysisSt David (outpatient) Patient Uses Multiple Providers for the Same Condition; without I- Care access, providers could not view to prior visits at other locations.

High Use Patient Snapshot: Patient Use Drives Up Cost DateDiagnosesLocation 2/20/04Acute URIBrack ER 2/20/04BronchitisSt David ER 3/9/04BackacheSt David ER 3/11/04Lumbago, HypertensionSt David ER 3/11/04Skin Disturb.Brack ER 4/1/04LumbagoSeton McCarthy 4/13/04NeuritisATC RZ 5/12/04Joint PainATC RZ 5/13/04LumbagoBrack Outpatient

Step 2: Fill Service Gaps RHNSCNY Family Health Link Programs: * Dental Services * Vision Assistance * Pharmacy Assistance * Health Insurance Referral

Step 2: Fill Service Gaps Other Examples: Medical Equipment Services Shared Web-site with Referral Services RN Call Center Health Promoters Medical Interpreters Health Vans Health Newsletter Food Fair and Screenings Transportation

Step 2: Fill Service Gaps Questions: 1. What are greatest needs of your patients? 2. How can providing this need help reduce expenses or improve services among your partners? 3. Which partners could benefit by collaborating with one service?

Step 3: Develop Care Model Two pilot projects in Austin, Texas: 1.Seton Care Plus (an ICC project)– –a care management model with a “closed “ population of 4000 uninsured people –the 4000 are a subset of ICC enrollees who are all assigned to primary care doctors at one of three Seton Community Health Centers –They receive ongoing case management services from clinic based case managers 2.Brackenridge Emergency Room (a public hospital project being monitored by the ICC) – –“open” population consisting of uninsured patients who have more than 6 ER visits per year or 3 IP admissions per year –may or may not be enrolled in ICC; may or may not be assigned to a primary care physician –ER case managers assigned to organize and coordinate access to needed care

Step 3: Develop Care Model Questions: 1.Do your primary care partners serve duplicate patients? 2.Are emergency rooms overcrowded with primary care visits? 3.Will packaging a benefits plan with collaborators improve inappropriate utilization? 4.Is there a value proposition?

Step 4: Engage Private Physicians Project Access model, Asheville, NC Medical Society recruits physicians to volunteer for a “fair and finite” number of uninsured people –Primary care physician = 10 patients per year –Specialty care physician = 20 patients per year Project Access physicians can view hospital, clinic and pharmacy encounters of uninsured patients entered into MPI/CDR Care is supported by case managers and pharmacy assistance programs Project Access expands the number of medical homes available for uninsured patients

Step 4: Engage Private Physicians Questions: Are there private physicians in your community willing to volunteer? Are there specialists in your community or near by? What are physician gaps? Are physicians at the table of the collaboration? What do they need?

Step 5: Achieve Sustainable Funding to Pay for Care for the Uninsured Two Key Strategies: 1. Look for public funding opportunity – Hospital District (tax support or public funding) 2. Identify value propositions that partners want to support (1+1=3 formula)

Step 5: Achieve Sustainable Funding to Pay for Care for the Uninsured Goal: Reduce costs to, and burden on, ICC member providers caring for medically indigent, through collaborative ventures Develop Value Propositions: Reduce visits to emergency departments Reduce ambulatory-sensitive admissions Effectively channel patients to funded sources Improve physician satisfaction by supporting care Provide backbone for continuity of care Provide longitudinal picture of indigent care

Seton Care Plus Outcomes – “Closed System” ER Visits/ % Rx Cost PMPM Referrals PMPM (x100)

Outcomes Closed System Seton Care Plus & MAP

Care Model Outcomes

Results: Brackenridge ER “Open” Model Projected costs of avoided ER visits and hospitalizations for uninsured patients: Network in FY04: $1.4 Million Network in FY05: $1.75 Million These represent hospital expenses that would have been written off or charity care

Step 5: Achieve Sustainable Funding to Pay for Care for the Uninsured Questions? 1.What kinds of things are all the partners doing individually that they could do together? 2.What could be solved better if it was centralized and shared? 3.What could be affordable if it was shared? 4.Who benefits from the savings of better access to care for uninsured?

In the End Everyone Wins Working together is critical – it is no longer possible to do it alone Everyone has to be at the table Once you build a culture of collaboration anything is possible Everyone has to get value from participation – win/win It takes longer