1. SIMPLICITY CARE COORDINATION Integrating the Health Care Home with Home and Community Based Services Laura Ackman, Essentia Health

2. Enter Title Text Here | December 3, 2015 | 2 Scope of the Project Began the process in Spring 2008 with brainstorming ideas of how to help our nursing homes remain viable Applied for and was awarded an Iron Range Resources grant for a feasibility study in Fall 2008 regarding combining 4 nursing homes Applied to the Minnesota Department of Human Services Three-year Demonstration Projects for Older Adult Services Grant was awarded, contract signed and collaborators began working on implementation plans in 2010 Two years in the making to get us to that point

3. Enter Title Text Here | December 3, 2015 | 3 Two Main Purposes of the Grant: organizational redesign and a direct community service component –Organizational redesign by combining the four nursing homes with the goals of realizing economies of scale and improving and maintaining quality and services What type of governance structure What type of operating entity What assets would be included Employees/union issues What about ancillary services (laundry, housekeeping, dietary)

4. Enter Title Text Here | December 3, 2015 | 4 –Direct community service component Health care navigator to provide case management and support in the community to maximize the ability of aging community members to age in place –What will the program look like –Who will create and implement it –Who will be served –How will the Project be measured –How can we identify gaps in services –How can those gaps be filled –How can the facilities, the community based service providers and the health care providers work with the Health Care Navigator

5. Enter Title Text Here | December 3, 2015 | 5 In the beginning……. “It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.” --Charles Darwin

6. Enter Title Text Here | December 3, 2015 | 6 Evolution In Spring 2009, we learned that we were selected as a recipient of one of the two grants awarded. During that time two of the original collaborators determined that it was in their best interest to withdraw from the project The two remaining collaborators began looking for additional partners. Current members of our consortium are: –Virginia Regional Medical Center –Benedictine Health System St. Michael’s health and Rehabilitation Community St. Raphael’s health and Rehabilitation Community –Essentia Health-Northern Pines Medical Center

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8. Enter Title Text Here | December 3, 2015 | 8 Aging

9. Enter Title Text Here | December 3, 2015 | 9 The Number of People With Chronic Conditions Is Rapidly Increasing  In 2000, 125 million Americans had one or more chronic conditions.  This number is projected to increase by more than one percent each year through 2030.  Between 2000 and 2030 the number of Americans with chronic conditions will increase by 37 percent, an increase of 46 million people. Number of People With Chronic Conditions (in millions) Source: Wu, Shin-Yi and Green, Anthony. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October 2000.

10. Enter Title Text Here | December 3, 2015 | 10 Source: Centers for Medicare and Medicaid

11. Enter Title Text Here | December 3, 2015 | 11 In a new age of transparency, quality is front and ceter …

12. Enter Title Text Here | December 3, 2015 | 12 OUR CURRENT HEALTH CARE DELIVERY MODEL.....

13. Enter Title Text Here | December 3, 2015 | 13 TO A MORE EFFICENT, EFFECTIVETO A MORE EFFICENT, EFFECTIVE TO A MORE EFFECTIVE, EFFICENT DELIVERY MODEL.....

14. Enter Title Text Here | December 3, 2015 | 14 In the Middle……….. “ Do what is right, what moves our mission forward, and what--- because of its ambition, courage and potential—is really worth the disruption.” -- Frederick Douglass

15. Enter Title Text Here | December 3, 2015 | 15 Important elements of new HCH/HCBS Model  Coordinated, Comprehensive and Accessible Care  Team Approach  Quality driven  Best Practices/Evidence Based Medicine  Patient and Family Centered

16. Enter Title Text Here | December 3, 2015 | 16 Teams “A team is a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable.” Katzenbach JR, Smith DK. In: The Wisdom of Teams. Harper, 1999. page 45

17. Enter Title Text Here | December 3, 2015 | 17 We must create and support a coordinated TEAM approach to delivering health care The increasing complexity of primary care medicine makes it no longer possible for one individual or discipline to comprehensively manage all aspects of patient care.

18. Enter Title Text Here | December 3, 2015 | 18 Physician/APCs/RN/Social Worker Accountabilities  Work within a team  Utilize the EMR  Follow best practices  Manage Chronic disease registries within the team  Follow standard work flows

19. Enter Title Text Here | December 3, 2015 | 19 Who will be managed by the team? “Special Populations”  High Risk patients  Over 65  Chronic Diseases

20. Enter Title Text Here | December 3, 2015 | 20 Key Precepts of Delivery Model  Primary Care is responsible for comprehensive, coordinated care for total patient populations.  The primary care team will be the model for care delivery. Core Team Members may include Physician (Lead); APC; RN; CA/LPN; Social Worker; Scheduler/Registrar.  There will be standard processes, tools  Components of care included in final model will be available to all

21. Enter Title Text Here | December 3, 2015 | 21 Key Precepts Cont….  There will be strategic prioritization of system wide development of primary care components and supporting or augmentative specialty programs for patient populations with these chronic conditions: Diabetes Cardiovascular Disease Depression Chronic Heart Failure  Managed Care Office and Primary Care physician led team will partner in care management of special populations defined by payer contracts.

22. Enter Title Text Here | December 3, 2015 | 22 Efficiency without Quality Unthinkable Quality without Efficiency Unsustainable Clinical quality and financial performance are inseparable The Cost/Quality Debate…

23. Enter Title Text Here | December 3, 2015 | 23 Next Steps  Communication of Vision and Model Make adjustments based on feedback Visit other best practice sites and make adjustments based on their models and experiences  Add Operational Detail to Model  Begin Implementation of Standard, Core Work Process at all Sites  Conduct Pilot  NCQA and State Health Care Home Certifications  HSBS Coordinator

24. Enter Title Text Here | December 3, 2015 | 24 Never the end…… “ Even if you're on the right track, you'll get run over if you just sit there.” –Will Rogers US humorist & showman (1879 - 1935)Will Rogers