Community Collaboration for Clinical Transformation:

Designing and Implementing the TriCounty Health Commons Grant

Rebecca Ramsay, BSN, MPH Director – Community Care Programs, CareOregon

January 8, 2013

Setting the Stage for Broader Transformation Efforts

• Oregon Medical Home Provider Initiatives (2006)– Primary Care Renewal: Managed Care / Provider collaborative;

CareOregon, OHSU Family Practice, Legacy IM Residency, Central City Concern, Virginia Garcia, MCHD

• Major Tri County Safety Net providers involved (40% network)• Organized as “Learning Collaborative” among partners based on a

model from South Central Foundation• 2009: PCR Payment model co designed

• Other Transformation Initiatives (2007)– Major TriCounty Health Plan Collaboration on key initiatives

• OHLC High Value Medical Home Care Management Initiative• OHLC Initiatives on High Tech Imaging, Early Deliveries <39wks

Just as things with CCO legislation is heating up

TriCounty“Model of Care” Process• Agreement that “changing the delivery of care” is

critical to long term sustainability– Model of Care Ctte formed to engage providers in

redesign based on their practice experience• Charged with studying population data, then

forming ideal transformative model as goal…• Everyone wants to be at the table, has ideas

– From ctte to large advisory board – “Crowdsourcing

Transformation”

Organizations contributing• Oregon Center for Children and Youth with

Special Health Needs (OCCYSHN)• CareOregon• Legacy• Kaiser• Multnomah County• OHSU• Portland IPA• Virginia Garcia• Women’s Health Alliance• Northwest Cardiovascular Institute• Oregon Clinic• VA• Marquis• Metropolitan Pediatrics• Children’s Health Alliance• Providence• Washington County• Clackamas County• Acumentra

• Familias en Accion• Coalition of Communities of Color• Intel• Central City Concern• Coalition of Community Clinics• Cascadia Behavioral Health• Oregon College of Emergency Physicians• ODS• Family Care Health Plans• Oregon Pediatric Improvement Partnership• Alliance of Culturally Specific Behavioral

Health Providers• Lifeworks Northwest• Oregon Department of Public Health• OCHIN• Pacific Medical Group• Adventist Health

“Tactical Groups”Identifying opportunities for investment

Prioritizing initiatives for implementation

1. Transitions of Care2. High Utilizers3. Emergency Department4. Health Home5. Behavioral/Physical Integration6. Specialty Care

Timeline: Basic work done by end of March, implementation planning in April.

Delivery System Change “Idea Inventory”

Up to $30 Million Funding Over 3 Years

Application Due: Jan 27, 2012

“Complete Alignment With Oregon Challenge and Assets”

• Need to take cost out of system rapidly by improving quality, efficiency, outcomes

• Established State Leadership in Health Care Reform: from OHP to CCOs

• Established history of multi party cooperation through OHLC

• Proven safety net success in Primary Care homes: established cost reductions

• Existing projects in place that can be scaled to meet challenge…

Seed Funding for CCO Development???

December 2011…

TriCounty Health Commons Grant“Transforming Health Together”

Designing the “Health Commons” Grant Initiative

• What are the major drivers of “avoidable” cost?• What are we currently doing to address cost that we

can take to scale?• How do we prioritize potential initiatives?• What provides the most return with least investment• What gives us the quickest return?

• A single organization cannot do this alone, how can we work together?

10

Very High Prevalence of Mental Health and Addictions (State of Oregon DMAP Data)

Mental IllnessChemical DependencyAttention Deficit DisorderPost-traumatic Stress DisorderDiabetesAsthma/Emphysema/COPDHeart DiseaseHepatitis CEnd-stage Renal DiseaseDementiaCancerHIV/AIDS

11

Where is the $$$ going?% of Total Billed Charges by Service

(State of Oregon Medicaid Data)

* Outpatient Behavioral includes mental health services and ER and non-ER chemical dependency services

2009 Total Billed Charges =$1,630,851,673

Hospitalizations and ER admits amount to 43%

of Billed Charges

12

William

Chronic Heart Failure

Schizoaffective Disorder

History of Addiction to IV Drugs and Alcohol

COPD

Hepatitis C

Type 2 Diabetes

Intermittent Homelessness

Developmental Disorder

62 Year Old Caucasian Man

October 2011: Admitted to the hospital for almost a month for acute complications of his

Chronic Heart Failure. Had a previous 25 day admission 5 months earlier.

13

Obvious conclusion

Even a stellar primary care home isn’t enough to meet William’s needs.

What William Needs (to lower cost

and improve health)

• Someone who is willing and has the time to deeply understand his holistic needs and health-related goals AND is accountable for coordinating needed services and teaching/coaching him (or a caregiver) in the process

• Social services such as supportive housing, daytime mental health drop-in centers, food security

• Timely, reliable access to a primary care team that knows him well, and is promptly notified and collaborated with when he accesses other parts of the health care system

• Hospital and ED care systems that can readily access information about William’s care needs and his care team; safe transitions between sites of care

• Timely, reliable access to mental health and addiction services that follow him over time

15

Hospital Care Intensive Care Transition Support

TriCounty Health Commons InitiativeImproving lives for high-acuity/high-cost patients across the care continuumPrimary Care Community Outreach Model

Behavioral Health Community Outreach “Peer” Model

Specialty CareCommunity Outreach Model

Emergency Services• ED Navigation to

Primary Care• EMS Community

Outreach Model

Workforce: Community Outreach Worker, Outreach RNs, and Outreach SW and Recovery Mentors

Workforce: ED Guides, Outreach Behavioral Health Staff

Workforce: Community Outreach RN and Respiratory Therapist

Workforce: Peer Wellness Specialists

Workforce: Transitional Care RNS and Clinical Pharmacists, Transitional Care LCSWs

16

Health Commons Grant Accountability Structure

HSO Board

Grant Oversight Ctte

Learning System Workgroup

Project Management Workgroup

Intervention Leads/

Intersection Group

ED Steering Ctte

Outreach Steering Ctte

Standard Transitions Steering Ctte

Hospital to Home Transitions

Steering Ctte

Behavioral Health Transitions

Steering Ctte

Evaluation Workgroup IT Workgroup

What Does Our Community Learning System Look Like Thus Far?

• Each intervention develops its own iterative learning methods, ie case-based conferences, team-based learning retreats, site-based programmatic operations meetings, etc

• We “visit” each other’s conferences and retreats to spread ideas and insights

• Each intervention creates a dashboard of metrics with visual management systems to track ongoing progress (in development); dashboards are shared at Intersection Group

• Evaluation “swat” team (CORE at Providence) interviews patients, providers, and administrators to understand ongoing best-practice trends and common “stuck-points”; feeds qualitative information back for iterative programmatic improvement

• Community-wide learning collaboratives bimonthly18

Collaborative Learning for The Health Commons

19

Learning Session #1February 22, 2013

Learning Session #3June 28, 2013

Learning Session #5October 25, 2013

Learning Session #2April 26, 2013

Learning Session #4August 23, 2013

Learning Session #6December 13, 2013