Post on 11-Apr-2020
EMERGING INTEROPTIMABILITY ECOSYSTEM IN FURTHERING POPULATION-BASED WELLNESS
June 4, 2014
STEWARDS OF CHANGE SYMPOSIUM 2014
Nick Macchione, FACHE
Director
County of San Diego Health and Human Services Agency
Mr. Donald Ryan
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His wish is simple, NOT to sleep in any more hospital beds!
What’s at stake?
One Person Many Facets
3March 19, 2008 Team San Diego GMU Module 1
Draft
33
Donald’s “Grand Canal” Reality
Horizontal Integration & Silo Busting
In-HomeServices
DayHealthCare
AcuteHospital
TransitSkilled
NursingFacility
MedicalSpecialty
MealsService
PrimaryCare
PATIENT
Patients/caregivers provided social support services, by referral or direct provision, to reduce the risk of avoidable readmission.
Emerging Service Delivery Ecosystems
Admin
Neighborhood
Patient-Centered Health Home
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Within 30Days
Within 60Days
Within 90Days
12.6%17.0%
24.3%
2.3%5.7% 8.0%
SMH Readmission Rate for 2009
“Transitions
Care Coach first,
nurse second.”
“Personalized
Technology”
“Healthy Bottom Line”
Treating the Cause, Not the Illness!
FEW CONSIDERATIONS
Opportunities from welfare reform to health reform to public health accreditation in improving lives and being more cost effective in the evolving fields of human services, healthcare, public health and behavorial health services.
Highlight current ACA examples in California and San Diego County and their implications.
Outline a “population health and social wellness” framework for system transformation and its possibilities.
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KEY COMPONENTS OF THE AFFORDABLE CARE ACT
INSURANCE REFORM
TITLES I AND II
• Expand coverage
• Improve benefits &
protections, including
mental health
• Increase affordability
• Create insurance
exchanges
• Expand Medicaid
HEALTH SYSTEM REFORM
TITLES III - VIII
• Create new delivery &
financing models
• Improve quality & value
• Improve care coordination
• Focus on public health &
prevention
• Develop workforce
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THE TRIPLE AIM
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Better Health for the Population
Lower Cost per Capita
Better Care for Individuals
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• Center for Medicare and Medicaid Innovation (CMMI)
Moving from Volume to Value
• Accountable Care Organizations (ACOs)
Care Coordination (including linking medical care and social services)
• Community-Based Care Transitions Program (CCTP)
• Dual Eligibles Coordinated Care
State Innovation Models (SIM)
• Value-Based Payment
Hospital Value-Based Purchasing
Price/Payment Data Transparency
• Hospital Community Benefit Requirements
• Population Health/Social Determinants
National Prevention Strategy/Prevention & Public Health Fund
HEALTH SYSTEM TRANSFORMATION IN ACA: SELECTED EXAMPLES
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FROM VOLUME TO VALUE: KEY STRATEGIES
• Accountable Care Organizations Responsible for total care, cost, and quality of an
assigned population.
“Shared savings” model provides incentive to limit
total expenditures.
Quality measures and reporting, both process and
outcomes, monitor performance.
Medical Homes/Health Homes
Primary care foundation of many ACOs.
Team-based care, often including Community
Health Workers to extend reach into community
Opportunity to integrate and coordinate medical
care, behavioral health, social services for
complex patients
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CARE COORDINATION
COMMUNITY-BASED CARE TRANSITIONS PROGRAM (CCTP)
• Section 3026 of the ACA
Goal: reduce all-cause 30-day readmissions for fee-for-service (FFS) Medicare patients by 20% in 2 years.
$500 million over 5 years to test models for improving care transitions from inpatient hospital to home or other settings.
Link social service organizations to hospitals.
Partnership between HHSA and San Diego Health System – 11 hospitals/13 sites.
Goal: serve ~21K FFS Medicare patients per year for 2 years, starting January 2013.
Activate patients and caregivers to better manage chronic conditions.
• San Diego Care Transition Partnership (SDCTP)
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Past/Present
Transactional
Volume-Based
Competitive Advantage
Silos and Categorical
Connecting the Unconnected
Sick Care and Social Welfare
Present Future
Transformative
Value-Based
Co-opetition
Integrated System
InterOptimability
Wellness
PERSPECTIVES MATURE
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Local Perspective: San Diego
•Over 100 languages•Large military presence•Largest refugee resettlement site in CA•Busiest international border crossing in the world (San Ysidro/MX)
• 4,261 square miles - urban and rural regions, from coast to mountains to desert
• Larger than 21 U.S. States; same size as CT• 5th largest U.S. County, 2nd largest in CA• 18 municipalities; 17 unincorporated cities• 18 Indian Sovereign nations • 2012 Estimates - 3.2 million population
o 48% Whiteo 32% Latinoo 11% Asian/PIo 5% African Americano 1% American Indiano 3% Other
• Region is very diverse
SAN DIEGO HHSA MILESTONES
1998
2008
2010
20122014
1996
Welfare
Reform
2008
ARRA/ HITECH Act
2010
Affordable Care Act
Technology Advancements and Resulting Public Expectations17
2005
2-1-1 San Diego
2011 LWSD &
2-1-1 partnering
2014
LWSD:
Thriving
2010
LWSD: Building
Better Health
2004 & 2007 San Diego Wildfires
2012
LWSD:
Living Safely
1998 HHSA
Integrated
2012 Alliance Healthcare
Foundation funds CIE
2011 San Diego Beacon grant
1/1/2014
Medicaid/
Insurance
Expansion2014
Public Health
Accreditation
DRIVING FACTORS
WE’RE IN THE BUSINESS OF SERVING THE PUBLIC.
We need to work together to best leverage
existing resources and meet shared goals. The
management choices we make are influenced by:
Business Case – Imperatives and Visions
Economy – Budget Cuts and Accountability
Legislation and Expectations – Healthcare
Reform, Disaster Preparedness/Response
Technology Changes – Imposed/Advanced
Culture Changes – Workforce & Customers
Efficiency in Achieving Outcomes
Effectiveness in Achieving Outcomes
Regulative Business
Model
Generative
Business Model
Integrative
Business Model
Collaborative
Business Model
Human Services Value Curve, Harvard University
FRAMEWORK
The County of San Diego is servicing as a catalyst for the region,
pushing forward toward person-centered care.
Our framework:
Building
Better
Health
Living
SafelyThriving
Well-being is more than just
physical health.
Financial Stability
Social Connectivity
Career Viability
Emotional Well-Being
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Our Approach
Pursuing policy and
environmental changes
Improving the culture
from within
Building a better service
delivery system for all
Supporting positive choices
with communities and clients
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WE DON’T WORK ALONE
PERSON-CENTERED CARE THROUGH REGIONAL WELLNESS
We need to work together so we can address the complex issues.
What do we need for our region?
How do we develop value-based service networks?
Who is the shepherd?
Partners
County
State Federal
SAN DIEGO KNOWLEDGE EXCHANGE
Regional Wellness
Community Information Exchange
County of San Diego –Knowledge Integration Program
San Diego Health
Connect –Information Exchange
2-1-1 San Diego
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SAN DIEGO HEALTH CONNECT
• Funded by ARRA HITECH Act as a Beacon Community.
• $15 million over three years to use IT to improve health care delivery in San
Diego, as model for nation.
• Transitioned from University grant-funded project to self-sustaining
independent organization.
Public
Health
Agencies
Schools
EMSPharmacies
Physician
Practices
Nursing
Homes
Behavioral
Health
ProvidersPatients
and
Caregivers
Hospitals
Lab
Companies
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Community
Health
Centers
Home
Health
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211 San Diego
Homeless Service
Providers (HMIS)
Fire/EMS Paramedics
Federal Funders
(HUD)
Social Service Providers
County Health and Human
Services
San Diego Health Connect Regional Information Exchange (Beacon)Enables
information sharing
and actionable
insights across
social services and
care providers so
that San Diegans
can live well.
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CIE
COMMUNITY INFORMATION EXCHANGE
211 SAN DIEGO
Real People. Real Connections. Real Help.
• Benefits & Enrollment
• Healthcare Navigation
• Veterans and Military Services
• Disaster Information Services
• Safety net homeless services
Telephone, chat, email, and searchable online database• 400,000 connections (in 2012)
• 6,000 partnerships with service providers
• 200+ languages offered
• 92% customer satisfaction
• 98% referrals accuracy
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COUNTY OF SAN DIEGO KNOWLEDGE INTEGRATION PROGRAM
To support the County’s Live Well San Diego strategy, HHSA
has initiated the development of the Knowledge Integration
Program (KIP), which includes:
• Service delivery improvements to support person-centered, strengths-
based, and trauma-informed practice using the integrated information.
• An electronic information exchange for County health, social service,
behavioral health, physical health, and probation data.
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5 FUNCTIONAL CAPABILITIES
Implement new technologies and policies to enable
automated and improved abilities to perform:
1. Look-up, Search and View Query Results
2. Referral Management
3. Collaborative Service Delivery
4. Notifications and Alerts
5. Population-Based Shared Analytics
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HOW ARE WE INNOVATING?
• We recognize regional
information exchange as an
imperative, and have already
begun building collaborative
service partnerships.
• We are not waiting for a
roadmap, we are building one.
• We are strengthening each
other as we strengthen our own
organizations in serving the
same and/or similar client!
• Importantly, keeping the person
in the center of everything we
do.
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SD Health
Connect
(Local Health Services)
CIE
(Local Social Services)
KIP
(COSD Services)
Federal
State
211
COMMON GOALS:
•Regional service collaboration
Cross-pollination: government, business, non-profit
•Person-centered service delivery
•Flexible, adaptable approach
• Improve quality of care
•Lower costs
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SHARED BELIEF:
IndividualsResources & Services
Healthier & Safer & Thriving
Community
Clinical Service Delivery
Community Prevention
Improve Health,
Safety & Equity
Outcomes
Electronic
Information
Exchange is the
vehicle used to
share patient and
customer
information among
providers to
facilitate care and
services.
Partner medical and social service professionals for person-centered
service
Reduce Demand for Resources & Services
Factor: Client’s capacity
to self-serve, ability to
manage needs
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County Services• County Departments
• County client-serving
• contractors (≈1000)
Medical• Hospitals
• EMS
• Clinics / Hospice /
• Long-term care /
• Physicians /
• County (PH)
Social/Econ• Human Service
Nonprofits (incl.
some KIP contractors)
• Mental Health
KIP
HIE CIE
3600
SC 10/03/13 (pre) p. 32
E.D
. /
EM
S
(ID
+ c
are
ho
me)
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BUILDING THE EXCHANGE INFRASTRUCTURE FOR SAN DIEGO
Street Sense
ABC.org
Case Manager
FUTURE: ONE PERSON; MORE COMPLETE VIEW
Other Medical
EMS
Hospital
Coverage
Income
Eligibility
SDHC
Information & Referrals
2-1-1 San Diego
Medical Services
County Services
Social Services
KIP CIE
CommCom 10/11/13 p. 3333
Information & Referrals
EVENTUALLY: EVEN MORE COMPLETE VIEW
Medical Services
County Services
Social Services
Street Sense
ABC.orgCase
Manager
Other Medical
Hospital
Coverage
EligibilitySDHC
KIP
CIE211
2-1-1 San Diego34
IncomeEMS
Children / Youth
• We Can’t Wait
• Positive Parenting Program
• Kickstart
Adults
• Behavioral Health / Primary Care Integration Summit
• Bridges to Recovery
• In-Home Outreach Team
Older Adults
• Aging Summit
• Community Care Transition Program
• Passport to Healthy Aging
INTEGRATED SERVICES ACROSS THE LIFESPAN
Drivers:Vision/Strategy
Service Delivery
Financing
Workforce
P3 in Action
Behavioral Health
Services
Primary
Care
Community Based Social
Services
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Live Well
Roadmap36
Live Well, San Diego is capitalizing on the inherent linkages between the public, private, and non-profit sectors and using them to promote wellness at the client and neighborhood levels.
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Collective Impact Model:
Large-scale change achieved through actions of multiple actors with a shared agenda
Leveraging existing resources and working together to create
economies of scale
INNOVATION: SEEING THE CATALYST
And preparing for what is next
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Accountable Care Organizations
Transformation of the healthcare system relationship to social services
Accountable Care Communities
ACC
Convening and Framing w/ Traditional
and non-traditional
Stakeholders
Infrastructure to Integrate Quality and Cost Data
Managing Population
Health/Social Services and Public Safety
Budgets
Infrastructure to improve
Health/Social Outcomes
ACCOUNTABLE CARE COMMUNITY
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EVOLVING HEALTH AND HUMAN SERVICES SYSTEM WELLNESS TRANSFORMATION
* Based on ‘The Evolving Health Care System 3.0’ by Neal Halfon, M.D., Director, UCLA Center for Healthier Children, Families, and Communities.
Acute Health Care System
1.0
Coordinated Seamless
Health Care System 2.0
Community Integrated
Health Care System 3.0*
Community Wellness System
(Generative approach)
• High quality acute care
• Accountable care systems
• Shared financial risk
• Case management and preventive care systems
• Population-based quality and cost performance
• High quality acute care
• Population-based health outcomes
• Care system integration with community health resources
• Accountable care systems
• Shared financial risk
• Case management and preventive care systems
• Population-based quality and cost performance
• High quality acute care
• Population-based health outcomes
• Care system integration with community health resources
• Accountable care systems
• Shared financial risk
• Case management and preventive care systems
• Population-based quality and cost performance
• High quality acute care
• Accountable Care Community
• Person-centric, Community-led
• Integration of physical health, behavioral health & public health
• Integrated delivery of health and social services toward shared outcomes
• Indicators of community wellness shared across private and public sectors, including military/VA
• Health (and safety) in all policies
• Intergenerational caring communities
• Economic development across region
• Eliminating health and social inequities43
“TRIPLE AIM 2.0”
Improved Health and Social Well Being for the Entire Population
Lower Cost per Capita
Better Services for Individuals
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COLLECTIVE ACTION TO COMMUNITY IMPACT
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Military
Community & Faith-Based Organizations
Schools
Business
Other Local Jurisdictions
Law Enforcement and Courts
Health Providers
County Government
Actions We Take Collectively
Across Sectors
Results We Seek
or Community Impact
• Long Term: w/in 10 years
Outcome Changes in Population
• Mid-Term: w/in 7 years
Risk Factor Changes in Population
• Short Term: w/in 3 years
Behavior Changes in Population
I
N
D
I
C
A
T
O
R
MEASURING RESULTS
Areas of Influence Definition Top 10 Indicators
Enjoying good health and
expecting to live a full life
- Life Expectancy
- Quality of Life
Learning throughout the lifespan - Knowledge
Having enough resources for a
quality life
- Unemployment Rate
- Income
Living in a clean and safe
neighborhood
- Security
- Physical Environment
- Built Environment
Helping each other to live well- Vulnerable Population
- Community Involvement
Between 2005 and 2010, the total % of children overweight/ obese decreased by 3.7% in San Diego County---the largest percentage decline among the 10 most populated counties in California.
Source: Babey SH, Wolstein J, Diamant AL, Bloom A, Goldstein H. A Patchwork of Progress: Changes in Overweight and Obesity Among California 5th-, 7th-, and 9th-Graders, 2005- 2010. UCLA Center for Health Policy Research and California Center for Public Health Advocacy, 2011.
ENCOURAGING TREND: OBESITY
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0
50
100
150
200
250
300
350
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Cancer Heart Disease
Heart Disease Deaths vs. Cancer Deaths in San Diego2000-2009
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ENCOURAGING TREND: HEART DISEASE
0
1000
2000
3000
4000
5000
6000
7000
8000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Nu
mb
er
in F
ost
er
Car
e (
in t
ho
usa
nd
s)
San Diego County
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Foster care data: Adoption and Foster Care Reporting System: http://www.acf.hhs.gov/programs/cb/stats_research/index.htm#afcarsUC Berkeley (http://cssr.berkeley.edu/ucb_childwelfare/PIT.aspx)
51% decrease(6,810 to 3,330)
ENCOURAGING TREND: KIDS IN FOSTER CARE
51W e b s i t e : L i v e We l l S D . o r g
QUIET OPTIMISM
Policy makers, providers, customers, advocates and media are becoming more aligned and committed
Relationships are expanding and being built on trust
Shifting from collaboration to more integration/generation
Data sharing & Technology have become effective enablers for improving knowledge
Winnable battles on chronic health and safety conditions are showing improvements with meaningful results
Realistic approach with implementation – marathon, not a sprint
Public is beginning to believe and engage
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Live Well San Diego!