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

49

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

50

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!