Founding Organization:

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Managed by the Network Builders Team (nbt) 2017

www.MoonshotCommunityCare.com

Health Care Leaders

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TABLE OF CONTENTS• Defining Moonshot

Why, How, What and Who

• Impacting Chronic Diseases

• Health Care Leaders Roadmap

• Moonshot National WorkforcePlatform

• Community Care Teams

• Community Care Teams Continuing Education

• Care Coordination Framework

• Turnkey Engagement Networks

• Community Data Evaluation

• Proposed Next StepsNetwork Builders Team

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Defining Moonshot The term ‘moonshot’ is derived from the Apollo 11 spaceflight project, which landed the first human on the moon in 1969.

‘Moonshot’ may also reference the earlier phrase “shoot for the moon” meaning aim for a lofty target. The Google definition of a moonshot is a project or proposal that:

1. Addresses a huge problem2. Proposes a radical solution3. Uses breakthrough technologies

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U.S. Healthcare’s Huge Problem

U.S. healthcare is the most expensive system in the world (almost by double) ranking a poor 11th in quality among the industrialized nations with a healthcare cost accounting for over 17% of the U.S. gross domestic product (GDP). Total healthcare costs are estimated to grow near 20% of GDP by 2020. Of those total U.S. costs, 86% are related to population groups with one or more chronic conditions.

Sources: National Healthcare Expenditure Projections, 2010-2020. Centers for Medicare and Medicaid Services, Office of the Actuary; and Multiple Chronic Conditions Chartbook: 2010 MEPS Data

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To slow, stop or even reverse the progression of non-communicable

chronic diseases

Radical Solution: The “Why”?

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The “How”?

Building a Bridge of Trust to link Clinical Care with Community Care

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The “What”? Community Care is that

ecosystem where healthcare organizations can reduce value-based care risks and costs by relying on a trained workforce of allied health professionals, community health workers, and volunteers as Community Care Teams delivering chronic disease care programs within a high value, yet lower cost network of safe and scalable point-of-care places.

Successful healthcare organizations are rooted in

the communities they serve.

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Breakthrough Technologies That:1) Analyzes population health management (PHM)

data to stratify chronic disease population groups;

2) Refines cohort profiles and readiness for change;

3) Optimizes recruiting, training, placing, and administrating Community Care Teams for quality controlled chronic disease care program delivery;

4) Supports patient chronic care program participation, human and digital engagement duration, frequency, and intensity;

5) Evaluates chronic disease self-care management process and outcome quality measures; and

6) Facilitates value-based care performance payments.

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B. Recruit a National Workforce of 50,000 allied health professionals (AHP), community health workers (CHW), and volunteers for credentialing, program training, specialty instruction, and annual compliances to fill the roles of Community Care Teams;

C. Recognize 20,000 Safe Care Places of community-based locations to host chronic disease care programs made accessible for all payer and community populations; and

D. Evaluate Community Data by analyzing Roadmap execution, Framework implementation, and Network accessibility along with program process, outcome and self-management metrics.

Moonshot Community Care Goals for 2020

A. Support 50 Health Systems to execute Community Care Roadmap alignment, implement a behavior change Framework, and build/manage turnkey engagement Networks;

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for Healthcare Organizations

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A Key Objective of Value-Based Care

Delivering intervention care programs to chronic disease population groups in lower cost community settings

is a key objective to value-based care success.

With 86% of U.S. healthcare costs attributable to chronic diseases, it is imperative that health systems identify, as early as possible, those ‘rising-risk’ patients with chronic diseases. This particular patient population is likely to increase utilization of medical services, incurring the most cost as they migrate toward ‘high-risk’. Payers (employers, insurers, Medicaid and Medicare), are most concerned with the escalating cost of care for chronically ill patients.

Source: World Economic Forum 2010

Risks and Behaviors Drive Chronic Conditions

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Uncover Root Causes

Assess the root causes of diagnosed chronic disease population groups to gain a better understanding of which

finite resources should the groups be referred that will actually make a difference in their risk rising to the high-risk level.

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88% of U.S. healthcare dollars are spent on medical services. Medical care is only responsible for 10% of a person’s health while approximately 50% of an individual’s health is attributable to healthy behaviors. Yet healthcare only spends 4% of the nation’s total healthcare bill each year on promoting healthy behaviors.

The Lifestyle Behavior Impact

Why? Clinicians are not traditionally trained in health behavior change, and typically outpatient workflow constrains sufficient bandwidth for lifestyle behavior change counseling.

Community Care Teams are trained to deliver health behavior change care programs impacting lifestyles.

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Care Management

Intervention Care

Care Prevention

Wellness

5%

30%

35%

30%

HighRisk

Rising-Risk

Low-Risk

Healthy

Action

Initiate Action to Engage the ‘Rising-Risk’Add Community Care to slow, stop or even reverse the progress of chronic disease before migrating to ‘High-Risk’ Care Management

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Who are the ‘Rising-Risk’ Population Groups?

• Presence of one or more chronic diseases

• Utilization of hospital and emergency department visits are likely to increase

• Increasing chronic disease burden, treatment complexities, and total costs of care

• Escalating risk towards ‘high-risk’, high-cost care management on the care continuum

• Danger of potentially complex events and irreversible organ damage

• Continuing unhealthy keystone lifestyle habits that are the root causes of chronic diseases

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Healthy

Low-Risk

Rising-Risk

High-RiskHigh Cost

Diagnosed with one or more Chronic Diseases

Care Prevention

Chronic Disease Cost Concentration Care Continuum

Top 1% account for 21% of healthcare costsTop 5% account for 49% of healthcare costs

Top 10% account for 65% of healthcare costs

Upper 50% account for 97% of healthcare costs

Lower 50% account for 3% of healthcare costs

Care Management

Wellness

18Source: OPEN MINDS Daily Executive Briefing {internet}. Monica E. Oss. The IRS Turns Its Attention to ACO’s. April 12, 2016

Chronic Disease Risk

Intervention Firewall Progression

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I. Support Health Care Leaders in aligning Community Care Roadmap priorities and objectives

II. Recruit, educate, place and administrate a quality assured National Community Care Teams Workforce

III. Coordinate Clinical Care Teams and Community Care Teams to implement a behavior change Framework for Business Health

IV. Build and leverage turnkey engagement Networks of safe care places and high value resources to deliver chronic disease care

V. Evaluate Community Care data for Roadmap execution, Framework implementation, and Network accessibility along with program process, outcome and self-management metrics

Value Model

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ROADMAP PROCESS SYSTEM ALIGNMENT

Population Priorities • System Employees• Value-Based Care Payers• Patient Registries• Physician Referrals• Community Groups

Stratification Priorities • Chronic Diseases• Low-Risk• Rising-Risk• High-Risk• Health Determinants• Other Determinants

Coordination Priorities • Personal Preferences• Change Readiness• Change Counseling• Care Planning• Program Selection• Onboarding Transition

I. Support Health Care Leaders in Roadmap alignment (1)

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ROADMAP PROCESS SYSTEM ALIGNMENT

Continuum Priorities • Care Prevention (pre-diagnosed)• Intervention Care (diagnosed)• Self-Management Maintenance• Self-Management Sustainability• Care Management (complex)

Evaluation Priorities • Methodologies• Delivery Practices• Engagement Outcomes• Health Improvement• Self-Management Criteria• Aggregate Progression

Payment Models • Pilot/Demonstration Outcomes• Care Prevention Outcomes• Intervention Care Outcomes• Self-Management Maintenance• Self-Management Sustainability• Care Management Outcomes

I. Support Health Care Leaders in Roadmap alignment (2)

Community Care Teams

To help fill the patient lifestyle behavior change gap, Clinical Care Teams extend chronic care delivery access by

coordinating referrals with Community Care Teams that provide a lower cost, high engagement health behavior change Framework.

For health systems, the chronic diseasepoint-of-care burden is shifting to community.

II. Recruit a National Community Care Teams Workforce

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Moonshot National Workforce PlatformAn ‘Uber’ opportunity for healthcare by deploying

available community resources to meet the increasing clinical demand for non-clinical care prevention,

intervention care, and care management services.

Community Care Teams

Register National

Workforce

Select Role & Prerequisites

Complete Training

Role Pool

Role Placement

Teams Active

Find

Verify

Engage

Manage

PayRate

Professionals, Workers and Volunteers

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Allied health professionals (AHP), community health workers (CHW), and volunteers for role credentialing, program training, specialty instruction,

and annual compliances to fill the roles of Community Care Teams

• Health fitness• First responders• Social workers• Dieticians• Nutritionists• Occupational therapists• Physical therapists• Health educators• Wellness coaches

Community Care Teams Roles and Education

AHP and CHW included, but are not limited to:

Teams continuing education provided by, but not limited to:

Creating healthcare jobs that reduce healthcare costs, increase healthcare access, and improves the healthcare experience!

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Chronic Disease Care ProgramsCommunity Care Teams qualified to deliver:

• Care Prevention programs for the low-risk or pre-diagnosed chronic disease cohorts

• Intervention Care programs for the rising-risk diagnosed chronic disease onset, early progression, or late progression cohorts

• Care management programs for the high-risk chronic disease cohorts

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One or More Chronic Diseases and Aging Populations

Chronic Disease Care Programs

Overweight and Obesity Classes I, II and III

Diabetes

Hypertension

Non-communicable Chronic Disease Clusters

Extended Care

Arthritis All Others

Lipid Disorders

Cardiovascular Disease

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III. Health Behavior Change Framework for Business Health

RoadmapAlignmentSystem LeadershipPHM Execs &TeamsCommunity Care TeamsChange FrameworkChronic Care ProgramsTurnkey NetworkSelf-Care OutcomesValue-Based Payments

• Active cohort care management

• Community Care Teams deliver chronic disease care designed for cohort

• Community touch points• Digital touch points• Engagement duration,

frequency and intensity• Targeted education• Self-care management

progress tracked

PROCESS

• Criteria to achieve self-management graduation

• Analyze process quality measures

• Evaluate community and digital engagement

• Re-enroll patients as needed

• Continue to maintenance phase

• Sustainability options

OUTCOMES

• Care coordinators share care pathway decisions

• Outline care plan• Not health activation

ready referred to readiness counseling

• Transition to Community Care Teams for program enrollment and onboarding

• Revise care plans as needed

TRANSITION• Screen stratified

population groups for risk drivers

• Analyze level of support needed

• Evaluated patient activation based on physical and motivational readiness along with personal preferences to reveal participation barriers

READINESS

• Appearance on chronic disease patient registry

• Payer populations health management risk identification triggers for stratified population groups requiring value-based care payer contracted chronic disease care services by health systems

REFERRALS

Stratified

Team Coordinate Care Pathways Care Plans Onboard

Referrals Readiness Refined

Chronic Disease Care Programs Methodologies Engagements Management

Community Care Datasets for Change Framework Process & Outcome Quality Measurements

Rollout Date

ChangeElements

Framework Implementation

2. Change Readiness

3. Change Transition

4. Change Process

5. Change Outcomes

Sessions Start

1. Change Referrals

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Community Care Teams in coordination with Clinical Care Teams use this Framework to implement care pathways, care plans and chronic disease care programs.

Community Care Roadmap

Health Behavior Change Framework

Bridge of Trust

Community Care Teams

Leveraging Turnkey Engagement NetworksCommunity Care Teams delivering multiple chronic disease care programs in safe and accessible lower cost community settings

withClinical Care Teams

to implement a

sustained by

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IV. Leveraging Turnkey Engagement Networks

PlacesDesignated safe and

conveniently accessible point-of-care locations that meet the criteria for hosting

group sessions to deliver chronic disease care programs for health behavior change

ProgramsChronic disease care

cohort specific assembled with health behavior change

methodologies and high-touch engagement strategies to slow,

stop or even reverse chronic disease progression

Community Care

TeamsCredentialed, program

trained, specialty instruction, and annual compliances to

deliver chronic diseasecare programs

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Turnkey Engagement Networks

Chronic Care Programs

Community Care Team Roles

Designated Safe Care Places

• Pathway Navigators• Readiness Counselors• Care Plan Directors• Community Connectors• Program Preventionists• Program Interventionists• Program Care Managers• Program Assistants• Maintenance Monitors• Sustainability Monitors

• Care Prevention• Intervention Care• Care Management

• Medical Fitness • Hospital Wellness• Municipal Community• Park & Recreational• YMCA Branches• Public Libraries • Commercial Clubs• School Facilities• Corporate Health• Other Safe Spaces

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Claims Clinical Community

Community Data Acquisition Sources

Wearables

Observation

Mobile Apps

Self-Report

Surveys

Aggregated

Actionable Data for Health

Behavior Change

Community Process and Outcome Analysis

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V. Evaluate Community Care Data

Referred Refined Onboarded Engaged Self-Managed

PHM Stratification of Physician Registries and Payer Populations

The “Who”? Paying Community Care Teams and thecosts to administrate Turnkey Engagement Networks?

Value-based care contracted payers: Employers, Insurers, Medicaid, Medicare, the Military, and Intermediaries

From value-based carerisk bearing contracted services with payers, Community Care Teams and Network delivery costs for chronic care services are paid to the Network Administrator

Network Administrator receives invoices for each role member of the Community Care Teams and pays based on the agreed upon chronic disease care services and quality assured performance

Community Care Teams of professional and workers

paid as independent contractors by the

Network Administrator$

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Starts with Health

Systems and Payers

Contracted Services

Performance

Bridge of Trust GraphLe

vel o

f Tr

ust

Moonshot Community Care

Health Care Leaders execute Roadmap alignment

Community Care Teams trained and ready for

Framework and/or Network placement

Clinical Care Teams linked to trustedCommunity Care Teams for referrals by

Care Coordinators from the stratified and readiness refined population groups

Health behavior change Frameworkimplemented (care pathways, care plans

and replicable care programs)

Turnkey Engagement

Networkoperationalized

Evaluate process and outcome data for engagement and self-management

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Healthcare Organization Proposed Next Steps

• Align the Moonshot Roadmap with health system priorities and objectives

• With the Roadmap alignment complete, the behavior change Frameworkimplementation plan can be presented

• With an approved Framework plan, a Master Services Agreement (MSA) can be submitted to support the implementation of the Framework

• As part of the MSA, a Statement of Work (SOW) will be submitted to demonstrate the chronic disease care program(s) for evaluation

• Once the pilot satisfies evaluation requirements, an additional SOW will be submitted to build a turnkey engagement Network for chronic disease care prevention, intervention care, and care management programs

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Exercise is Medicine® (EIM) is the Founding Organization for Moonshot Community Care. EIM is managed by the American College of Sports Medicine (ACSM), the largest sports medicine and exercise science organization in the world. More than 50,000 international, national and regional members and certified professionals are dedicated to advancing and integrating scientific research to provide educational and practical applications of exercise science and sports medicine.

For more EIM information visit: www.exerciseismedicine.orgFor more ACSM information, visit www.acsm.org

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Led by Exercise is Medicine® (EIM) advisory board member, Dr Felipe Lobelo, the director of the EIM Global Research and Collaboration Center (EIM-GRCC) housed within the Global Diabetes Research Center at Emory’s Hubert Department of Global Health and the Rollins School of Public Health.

EIM-GRCC leverages the expertise of leading researchers at Emory University and the global network of ACSM/EIM members to achieve its overall goal of evaluating the real-life effectiveness of EIM implementation via standardized clinical care and community care linkages to prevent, manage or even reverse the progression of chronic diseases.

Network Builders Team (nbt) manages the Moonshot Community Care initiative for awareness, discussion, education, advocacy, and funding to solve the infrastructural, technical, logistical, analytical and financial challenges of establishing Community Care.

The nbt provides the support for:• Health Care Leaders executing Roadmap alignment of priorities and goals• Recruiting, training, placing and administrating a Moonshot National

Community Care Teams Workforce• Implementing a behavior change Framework for chronic disease care• Building/managing turnkey engagement Networks of chronic disease programs• Collecting data to Evaluate processes, outcomes and self-management criteria• Negotiating risk bearing payment methods for chronic disease care services

Network Builders Team

40www.NetworkBuildersTeam.com

Network Builders Team

For more information contact:Phil TrotterMoonshot Community CareExercise is Medicine® (EIM)Network Builders Team (nbt)Email: ptrotter@acsm.orgDirect: (317) 710-5031

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