Emerging Breakthroughs in Regional and Community-Centered Care

Tom Bigda-Peyton, Ed.DClarissa Sawyer Ed.D.

Cambridge, MAOctober 24-26, 2013

Overview

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•Healthcare System Pressure Points

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•Finding our way: understand paradigm shift

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•Finding our way: making change happen

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•IE 2013: Regional Networks of Community-Centered Care

Pressure Points

Payment Models

Clinical Outcomes &

System Performance

Measuring Innovation Rapid Change

Pressure Point 1: Payment Models

• Emerging shift to become population health managers - but how do we pay for it? (executives and providers)

• What are the best opportunities for value-based contracting?

• Is there an economically sustainable model on the horizon? Are we in the “pre-Model T” phase of disruptive healthcare system innovation?

Pressure Point 2: Clinical Outcomes and System Performance

• How do we leverage efforts to work with complex, high-needs patients?

• How do we advance toward highly reliable clinical care?

• How do we accelerate competency development in patient and provider satisfaction?

Pressure Point 3: Challenges of Measuring Innovation

• We have data but lack understanding and results (payors)

• We are in a craft model- we have stories but lack outcomes (providers)

• Can we design and practice a systematic process for making innovation operational?

Pressure Point 4: Rapid Change

• How do we get ahead of the curve and stay relevant as providers?

• Where will the next wave of change come from - the market, the government, both, neither?

• How can we invest in new business models when they may be obsolete before they are launched?

• Can we reduce costs, improve quality, and develop new products and services at the same time?

Given these pressures, how do we find a way to make a break through?

Paradigm Shift – a change of perspective. You see a picture, what are you looking at?

Health Care is changing paradigms

American Hospital Association: Shift Economics From Volume to Value

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How will hospitals successfully navigate the shift from first-curve to second-curve economics?

Institute for Healthcare Innovation: Shift Models of Care, Business, Infrastructure

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13

Time

Craft Culture

Innovation Expedition View: Shift to a Second Curve Performance System

The Gap

First CurvePerformance

(Craft Model)

(Information-Age Model )

-

Second Curve Performance

“Jumping the Curve”

Per

form

ance

First Curve vs. Second CurveFirst Curve Second Curve

Evolved around medical and hospital practices Designed around patient/ community, population need

Disease focus, one patient at a time Health prevention focus, patient plus population

Hierarchical care, physician controlled Team-based care, collaborative controlled

Performance problems are people-caused Performance problems are system-based“Culture of blame” Culture of shared accountability and

continuous adaptive learningFragmentation of care givers and health care functions, “hand-off” gaps common

Integration of all system elements, care “seamless” for patients

Medical records: paper, fragmented, “owned” by caregiver

Medical records: electronic, “smart cards” owned by patients

Complexity = frequent errors, harm to patient Integration of reliable system sciences minimizes error, harm

Quality is compliance-oriented, 2-4 sigma common

Quality, value oriented toward ideal patient care (6+ sigma), zero preventable harm

Reactive to “sentinel events” Pro-active history and pattern recognition

The evidence from Ontario

The shift to Second Curve in Ontario Phase I

Optimizing First Curve (2008- 2011)

Phase IIPreparing to Move to Second Curve

(2010- 2012)

Phase IIIMoving to Second

Curve(2013-2018?)

• Implement strategic alignment, learning programs in hospitals (ED-PIP, HTLP)

• Achieve operating efficiencies to balance budgets and generate margin (Lean)

• Prepare for next stage: Local Health Integration Networks, Community Care Access Centers

• Excellent Care For All • Ontario Quality

Council• Prep for primary care

reform• Mosaic of Stroke,

Care Connections

• Health Links• Redesigned payment

model: activity-based funding, population risk management, money follows the patient

• Active community engagement, shared accountability, and system wide resilience

Emergence of Second Curve in Backus Hospital, Connecticut

Phase IOptimizing First

Curve (2009- now)

Phase IIPreparing to Move to

Second Curve (2009?- now)

Phase IIIMoving to Second

Curve(2013-2018)

• Achieve operating efficiencies (Lean?) to generate margin

• Build bank account to cover the gap

• Obtain ACO status with potential for gainshare

• Hartford affiliation• Prep for regional

medication management• Prep for Family Health

Centers• Recruit interest from

large self-insured employers (and work through them to engage payors)

• Deploy family health centers

• Demonstrate impact as economic magnet zone?

• Create new jobs and transition others?

• Redesigned payment model: from “insurance” to population risk management?

We need to view health care as a complex, adaptive system

How do we do that? The picture we use affects what we see as the problem and solutions. Does this picture work?

Or this one?

Or this one?

How you see affects what you decide to do.

Comparing the Traditional System vs. Complex Adaptive System View

Features Traditional System Complex Adaptive System

Roles Management Leadership

Methods Command and Control

Incentives & inhibitions

Measurement Activities Outcomes

Focus Efficiency Agility

Relationships Contractual Personal commitments

Network Hierarchy Heterarchy

Design Organizational design Self-organization

Source: (2008) Rouse, W. Health Care as a Complex Adaptive System, The Bridge.

Use High Reliability as a metric for performance and roadmap for change

Less Bounded System

Adaptive Living

System

Normal Reliable High-Reliability Ultrasafe

Mechanistic Organizations

Living Organizations

More Bounded System

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Highly Reliable Organizations / Systems• Operate in a complex

environment where accidents might be expected to occur frequently, but manage to avoid or seek to minimize catastrophes.

• Examples: energy, aviation/transport, military, fire/disaster response, anesthesia

Traits of HRO’sCharacteristic Example Sensitivity to operations •Get more transparent

•Make rounds to view operations•Don’t assume – ask questions

Reluctance to simplify •Examine data and metrics, be willing to challenge long-held beliefs

Preoccupation with failure •Identify what is working correctly

Deference to expertise •Redefine "meetings.“ Observe processes and meet with employees in their actual work spaceAsk about prior experiences.

Resilience •Use better evaluation tools (leadership evaluation, report cards, action plans).•Emphasize skill development.•Help people reconnect to the "why" behind what you ask them to do.

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1 st Curve2nd Curve

So how do we actually make change happen?

The Gap

Change evolves in Phases across Levels of the system (organization or network)

Strategic Create/Build Transfer Maintain/Sustain

Operational Create/Build Transfer Maintain/Sustain

Tactical Create/Build Transfer Maintain/Sustain

Change evolves through a series of iterations

Change (innovation) needs to be measured

Use both Stories and Numbers to Measure Innovation

Nature of the Task

Ambiguous/New

Routine/Familiar

Phases & Functions

IObservation

IIAssessment

IIIMeasurement

Data Format Stories Patterns Numbers

Sample Size n= 1 n = 3 n = 7

Features/Characteristics

Emergent Diagnostic Statistical

Descriptors “Anecdotal” “Qualitative” “Quantitative”31

Action Learning Systems. All Rights Reserved.

Story: “Hot Spotting” in Connecticut

Hospital CEO: “I was rounding in ER when the nurse said, ‘Oh, Joe’s here. I know his voice.’ I thought, ‘If the nurse knows him by the sound of his voice, we’re in trouble [because it means he’s here a lot].”

“This man had gone to the ED 68 times in 9 months, with no admits! No pattern of chronic disease. So, we visited him using Homecare. We discovered he had behavioral issues and diabetes, but no pattern [to explain him going] to ER so often. Until we discovered he had no access to food! He was coming to get the free sandwiches at the ER. After we coordinated with Meals on Wheels, we changed that.”

Is this a Second Curve story? What are your thoughts?

The theme of this year’s Innovation Expedition in Healthcare – Emerging Breakthroughs in Regional and Community – Centered Care

Leadership

Care Models

Systems

Featured Cases: System Transformation (the Design Challenge)

• Ontario• New York• North Carolina• Connecticut• Alaska

Featured Cases: Leading Transformation

• Helen Angus, Susan Plewes, David Levine

• Rob Greenly• Helen Meldrum• David Hain, Kellan

Moore

Featured Cases: Creating the Care Model of the Future• Frank Maletz• Greg van Winkle• Paul Curry• Lou Martin• Mike Cassidy

We will use the cases to help us design and carry out learning experiments in 2014

Disruptive Inquiry Prototyping Widen and Accelerate

New models of regional networks and community-centered care

Charting a course toward innovation: the role of leadership

Creating the Future: New Roles for Hospitals and Regional Networks

Are you ready to ride the wave of change?