HEALTHY PEOPLE. HEALTHY COMMUNITIES. MAKING IT SO:

PUTTING THE ME INTO MESOSYSTEMS

Eugene C. Nelson, DSc, MPH

The Dartmouth Institute

The Health Assessment Lab

Maine Primary Care Association

Annual Meeting

October 4, 2018

FLOW

1. Back Story

2. Keyhole or Panoramic View

3. Health Determinants

4. Cases: Success Stories

5. Call to Action

2

1. BACK STORY

“Gene why don’t you

draw up a model for our

brainstorming session

tomorrow?”

3

COLLABORATORIES & COPRODUCTION: A NEW MODEL

4October 16, 2013

Social Systems:

Patients + Providers

Technological

Innovations:

Registries + Networks

COPRODUCTION MODEL: PATIENT-CENTEREDLEARNING HEALTH SYSTEM

5

Feed ForwardPRO Data

Feed Forward Clinical Data

Shared Information Environment

Partnership forCo-production

Electronic Health RecordsCollaborative Improvement Networks

Personal Health RecordsPatient Facilitated Networks

Registry &Research

Collaboratory

Patient & Family

Provider & Care Team

Optimal Health and High Value Care for Patients and Populations

© 2014 Trustees of Dartmouth

College and Karolinska Institutet

See BMJ July 2016, Nelson et. al.October 23, 2013

Aim: optimal health for patients & populations & highest value healthcare services

Feed Forward

Patient-Reported

Outcome Data

Feed Forward

Clinical Data

Shared Information Environment

Partnership for

Coproduction

Electronic Health Records

Collaborative Improvement Networks

Personal Health Records

Patient Facilitated Networks Research

Registries

Patient

& Family

Clinician &

Care Team

Subsystem 2 –

Registry-Based

Research

Collaboratory

Subsystem 1 –

Clinical Microsystem

Dashboards

Subsystem 3 –

Collaborative

Improvement

Network

Subsystem 4 –

Facilitated

Support

Network

6

4 Sub-Systems

7Lind Family

Mesosystem

Transportation

School

Info &

Advocacy

Community

Legal & FinanceSupport

Health

BIG IDEA #1. COPRODUCTION

8

All services, at some level, are coproduced.

CORE OF THE MODEL

9

Co-Assess

Co-Decide

Co-Design

Co-Deliver

Co-assess the patient’s health status and how

the treatment plan has been working to

improve patient’s health and well-being

Co-decide

on what the

next steps

in the

patient’s

treatment

plan should

be based on

relevant

evidence

and past

experiences

to MINIMIZE

the BURDEN

OF DISEASE

Co-design the treatment plan for daily care

and professional interventions to attempt to

minimize the BURDEN of TREATMENT

Co-deliver

the

treatment

plan that

usually

involves

daily self-

management

and

adherence

to plan and

occasional

treatments

by a

professional

clinician or

clinical team

BIG IDEA #2.

LEARNING HEALTH SYSTEM

“a learning health system… generates and appliesthe best evidence for thecollaborative health carechoices of each patientand provider … (and)drives the process ofdiscovery as a naturaloutgrowth of patient care”

- IOM Roundtable on Value & Science-Driven Health Care

10

11

Coproducing learning health systems now starting

in CF, IBD, Rheumatology, MS & Palliative Care

in US Sweden, Scotland, Canada, Netherlands

PATIENT MODULE

12

Patient’s overview

Earlier Later

<<Previous part Print the whole summary

Your disease activity

High

Medium

Low

CLINICIAN MODULE

13

2015 2016

RxPrescribed

Patient ReportedOutcomes

ClinicalOutcomes

SUMMARY OVERVIEW OF A RHEUMATOLOGY

PATIENT

14

Case in point:

Swedish National

Quality Registry …

This patient is

doing better …

N of 1 experiment…

responded to biologics

January - March

June - December

Patient Registering Data on Swollen

and Tender Joints on her Touch Screen

https://www.youtube.com/watch?v=Kmqzy1hqcOw

The SRQ Approach

RA DISEASE BURDEN IN SWEDEN DECREASING

Starting Feed Forward &Open Care vs Tight Care

2002 2012

RED Sweden

BLUE Gavle

2. LOOKING THROUGH THE

KEYHOLE OR TAKING THE

PANORAMIC VIEW

16

LOOKING THROUGH THE KEYHOLE

Keyhole View: Pathophysiology

aka Clinician’s View

• Chief complaint

• History

• Review of systems

• Physical exam

• Diagnostic tests

• Differential diagnosis

• The diagnosis

• Treatment prescribed

18

TAKING THE PANORAMIC VIEW

Panoramic View: Ecosystem aka Patient’s World

• Family & friends

• School & work

• Wealth & assets

• Physical environment

• Technical environment

• Health resources

• Social resources

• Community resources19

KEYHOLE PEEK OR PANORAMIC VIEW

Keyhole: pathophysiology aka

clinician’s view

• Chief complaint

• History

• Review of systems

• Physical exam

• Diagnostic tests

• Differential diagnosis

• The diagnosis

• Treatment prescribed

Panoramic: ecosystem aka patient’s

world

• Family & friends

• School & work

• Wealth & assets

• Physical environment

• Technical environment

• Health resources

• Social resources

• Community resources

20

Wrap Around: What are assets & needs?

Treat using health, social & patient resources

Limited service: What is clinically actionable?

Treat using formal health care resources

BRIAN’S INSIGHT: SRU

210

22

23

24

Person’s self-care system

ClinicalMicrosystem

Mesosystem

Macrosystem

Ecosystem

HEALTHCARE SYSTEM LEVELS: “CLASSIC VIEW”

MICROSYSTEMS &

MESOSYSTEMS

Aim: to coproduce high

performing clinical

microsystems that recognize

they are part of a health and

social and community

ecosystem that has the

challenge of assembling an

effective and efficient

mesoystem that meets the

needs of the patients and

families that they serve

25

Let’s put the Me into Mesosystems!

CHALLENGE

To develop attractive, affordable, personalized

mesosystems that actually coproduce high value care –

best outcomes, best experience, lowest costs to the

community – to individual patients, families &

communities

Note: Mesosystems include patients, families, health,

social and community resources relevant to the

individual and offer opportunity to leverage effective

coproduction of health, well-being and healthcare

26

MEET THE CHALLENGE BY LEVERAGING...

1. The assets, talents and capabilities of patients, families and friends to coproduce

2. Learning health system principles & methods

3. Coproduction of healthcare principles & methods

4. Information technology to track patient’s goals and needs and treatments and outcomes over time and to facilitate peer-to-peer and professional support and services

5. Artificial intelligence and other methods to answer a key question: what treatments work best for this particular type of patient under what conditions

27

28

3. HEALTH DETERMINANTS:

WHAT CONTRIBUTES TO GOOD HEALTH?

229

29

MOLLIE

CASE

• 50 years old, moved to Upper Valley to help take care of mom

• Found dishwashing job at Dartmouth

• Initial contact with Iora Health: severe back pain, depressed, occasional alcohol abuse

• Back surgery indicated

• Transportation to specialist provided

• Became homeless … found place for her dog while Mollie spent time in shelter

• Found permanent housing

• Coach helped Mollie on her resume for job hunting

• Now “holding her own”, better job, helping mom, stable housing 31

(not actual photo)

HEALTH DETERMINANTS

32

Healthcare

Genetics

Physical Environment Social Environment

Economic ResourcesLifestyle & Habits

Chance

Geography & family & community are destiny

HEALTH DETERMINANTS

33

Healthcare

Genetics

Physical Environment Social Environment

Economic ResourcesLifestyle & Habits

Chance

Iora: Dartmouth Health Connect & Orthopedics

Jobs at Dartmouth

Mother & new friends

Alcohol Abuse +/-

Upper Valley & Housing

Mollie’s Story

4. PANORAMICVIEW CASES:

MIXING CLINICAL, SOCIAL

AND COMMUNITY SERVICES

• Iora Primary Care

• Camden Hot Spotting

• TIPS Wrap Around

• Cincinnati Children’s

33

1. IORA PRIMARY CARE

“Putting humanity back into health care.”

35

Rushika Fernandopulle

Care Support Tools and Mechanisms:

• Daily Huddle and Review of Worry List Patients

• Custom Built Electronic Health Record for Longitudinal Care

• Systematic and Repeated Health Assessments Using Patient

Reported Measures

• Post-visit Patient Experience Survey

• Patient advisory Group Quarterly Meetings

Person and Family

• Mollie

• Mental Health

• Orthopedics

• Homeless Shelter

• Employment

• Resources

• Pet Shelter

Community Resources

Primary Care Team

• Physician

• Coach• Behavioral Health Specialist

• Office Staff

• Drive to specialist• Dog sitter • Home health for frail

mother• Job skills counseling• Better job• People who really cared

... a team

MOLLIE’S STORY: A COACH & A TEAM & PANORAMIC VIEW

36

IORA HEALTH: REDESIGNING PRIMARY CARE TO

DO WHAT EVER NEEDS TO BE DONE

37

IORA HEALTH 2018

35 Practices

450 employees

27K patients

US$100m

revenue

37

USING INNOVATIVE

PATIENT-CENTERED

DESIGN TO ...

• Improve Outcomes for Themselves

• Improve Outcomes for Other Patients

• Improve the Design of the Microsystem

• Tap into the Mesosystem

38

PATIENTS IMPROVING OUTCOMES

FOR THEMSELVES

Coproduction promoted by:

• Shared Care Plans

• Personal Health Coach

• Right Setting

• Open Medical Records

40

IMPROVING OUTCOMES FOR OTHER PATIENTS

41Support groups, health promotion events (massage & Paps), yoga ...

IMPROVING THE DESIGN

OF THE MICROSYSTEM

• Continuous short-loop feedback

• Net Promoter Score

• What did we do well?

• What can we do better?

• Close monitoring of Social Media

• Patient and Family Advisory Boards 42

EARLY RESULTS

• Better Experience

• Net Promoter Scores > 91% (vs. < 60% for US primary care practices)

• Better Outcomes

• Control of hypertension improved from 50% to 81%

• Lower costs

• 33% decrease in hospital stays, 24% fewer ED visits, and 5% lower per capita costs

43

IORA DESIGNED TO

• Coproduce primary care (including patients, coaches, mental health, education, social support)

• Coordinate social and community services to provide humane care

• Identify patient’s goals, to improve outcomes and to reduce total costs

• Use a novel longitudinal EHR that both patients and clinicians use for coproduction

44Special Sauce: Coproducing primary care and coordinating Mesosystem

2. CAMDEN PROJECT: HOT SPOTTING & WHOLE PERSON CARE

44

AIM: TO DESIGN A

NEW SYSTEM TO CUT

COSTS OF HEALTH CARE

FOR SUPER UTILIZERS

ORIGINS

• Jeff Brenner: MD working in Camden primary care center

• Discovery: large % of dollars spent on small number of Medicaid patients

• Failed system: primary care designed for average patient & failed the super utilizers – indigent, complex chronic, homeless, mental illness, addiction, jail …

• Data: Used data for hot spotting super utilizers

• Whole Person: Developed wrap around system: housing first, primary & social care, coordinated care & health coach, motivational interviewing, all done “on site”

46

CONTEXT: CAMDEN COALITION OF HEALTH CARE PROVIDERS

MECHANISMS: HOW IT WORKS

• Data: Use data to discover the outliers: super utilizers

• Design: Understand the problem, dedicate resources, and design effective interventions

• Deliver Whole Person Care: Start new system of multi-disciplinary, coordinated care that treats the whole patient, and

• Deliver Social Care: Meet the non-medical needs that affect health: housing, mental health, substance abuse, emotional support

47Source: https://hotspotting.camdenhealth.org/

OUTCOMES

EVIDENCE OF IMPACT

• Camden hot spotting method “exported” to Arizona by Jeff Brenner & United HealthCare

• Worked with state Medicaid & affordable housing owners

• Started new system: housing first & integrated wrap around services & in home delivery

• Results for first n=41 patients

• Hospital admissions down 71%

• Hospital days down 81%

• ER visits down 55%

48

Source: United HealthCare Community & State Services. Used with permission.49

WHOLE PERSON WRAP AROUND

50

Patient & Coach

Housing

Health Services Social Services

Better Health & Value

Hot Spotting

Needs Assessment

CAMDEN PROJECT DESIGNED TO

• Find hotspots

• identify high need, high cost people

• Work Maslow’s hierarchy

• Safety, food and shelter first

• Assess needs

• provide wrap around health and social services including skills training

• Deliver value

• Track use of healthcare and delivery costs to show positive ROI

51Special Sauce: Hot spotting > Wrap around housing, health and social services

TIPS

Overview

“High Tech Meets

High Touch”

3. TIPSTELEHEALTH INTERVENTION PROGRAM

FOR SENIORS

52

TELEHEALTH VITAL SIGNS MONITORING & COACHES

We provide the TIPS service for the sickest and neediest in our community, targeting

• Over 65

• Medicaid/Medicare

• 2 or more chronic conditions

• Living at or below the poverty line

53

“High Touch”: Wraparound Social Services

Benefits Check Care Circles for Seniors

Caregiver Coaches Chronic Disease Self Mgt

Speakers Bureau Exercise

FitBit tracking Information & Referral

Elder Abuse Screen Falls Prevention, etc. 54

TIPS INTEGRATED SERVICES

55

Mesosystem

Entry Points

Workplace

*Public

Housing

*Senior

Housing Health Care,

Hospitals,

Home Care

Houses

of Worship

*Homebound

TIPS Locations and Partners

Continuing

Care

*Senior Centers

& Nutrition Sites

*Libraries* “Villages”

RFD Volunteer

Fire/Ambulance

* Currently operational 56

> Metrics collection at TIPS site> Wrap-around services assessment

> Triage (if necessary)> Information & referral

Start

• Blood pressure• Weight• Heart rate• Blood oxygenation• Five questions about

subjective wellness

TIPS PROCESS

57

> Metrics collection at TIPS site> Wrap-around services assessment

Remote evaluation by RN

Secure data transfer to server

> Triage (if necessary)> Information & referral

Start

• Blood pressure• Weight• Heart rate• Blood oxygenation• Five questions about

subjective wellness

TIPS PROCESSOvertimeOver time

58

Increased quality of care

Expanded healthcare access

Reduced system and individual healthcare costs

Benefits

MAJOR OUTCOMES

AT FIRST-GLANCE

• Tracked N=735 participants over an average of 300 days

• 88% participation rate in weekly coaching visit

• Average 30% reduction in pre-/post- ER visits

• In Medicare cohort:

• 60% reduction in hospitalizations

• 75% reduction in under-30 day readmissions

59

TIPS DESIGNED TO

• Use Telehealth and volunteer graduate student coaches to coproduce wrap around health and social services

• Offer longitudinal care coordination and foster a bond between the client and the coach to coproduce personalized service plan

• Improve health and well-being and to reduce costs

61Special Sauce: coaches coordinating the Mesosystem

Contact

John Migliaccio, PhD: maturitymk@aol.com

David Sachs, PhD: dsachs@pace.edu

David Putrino, PhD: dputrino83@gmail.com

www.seniorcitizens.westchestergov.com/telehealth-tips

WANT TO LEARN MORE???

62

4. CINCINNATI CHILDREN’S:IMPROVING COMMUNITY HEALTH

“Focusing on the first 9 years of life.”

63Uma Kotagal

“EXECUTION”

Cincinnati Children’s

Hospital Medical Center

64

MISSION

For patients from our community, the nation and the world, the care we provide will achieve the best:

• medical and quality of life outcomes

• patient and family experience and

• value

• today and in the future

65

CONTEXT: STARK CONTRASTS

• CCHMC had become national leader in

healthcare quality

• Winner of AHA’s best hospital award

• Trendsetter in quality and safety and learning

health systems

• But based in a neighborhood with high infant

mortality rates, high crime rates, high

poverty rates

66

START WITH AIM & DATA: WORLD CLASS MEDICAL CENTER IN POOR HEALTH

NEIGHBORHOOD

67

AIM: TO IMPROVE THE HEALTH OF CHILDREN AGE 0 TO 9 LIVING IN CINCINNATI

68

PATH FORWARD

• Strategic commitment by CCHMC leadership: live the mission

• Strong senior leader champion: Uma Kotagal

• Focus on ages 0 to 9

• Asthma 2011

• Preterm births 2013

• 3rd grade reading proficiency levels 2015

• Networking with community leaders to form health coalition: mayor’s office, school officials, police officers, housing authorities, local leaders

• QI methods fit to context: driver diagrams, key success measures, control charts, PDSAs, action learning

69

GETTING ORGANIZED

70

HOT SPOTTING IN COMMUNITY: BUILDING CODE VIOLATIONS, ASTHMA ADMITS, ED VISITS

71

PRETERM BIRTHS IN CCHMC NEIGHBORHOOD

72

Zero preterm

Births since 2015

ACT DESIGNED TO

• Focus on a good start in life: ages 0-9

• Form community coalition (complex adaptive system) to improve health of children

• Use community organizing, collective impact, coproduction, learning system & QI methods to rapidly improve outcomes

73

Special Sauce: Adapting improvement strategy &

techniques mastered at CCHMC to work for local

Population health improvement

74

5. WHAT’S TO BE DONE? A CALL TO ACTION

75

WE ARE IN A PICKLE

76We need to coproduce better outcomes, better care, lower costs

“OH BY THE WAY”

78

OH BY THE WAY ... GOOD HEALTH PAYS OFF:UPSHIFT IF HEALTHCARE USES VALUE PAYMENTS

Old Cost Stream:

Illness Pays

Patient exits home when sick

Primary Care

Specialty Care

Hospital Care

Quaternary Care

New Value Stream:

Health Pays

Person healthy doing self-care

Primary Care

Specialty Care

Hospital Care

Quaternary Care

79

$$$$$$

$$$$$$

THE FUTURE .. . MOVING FROM

OPTIMIZING CLINICAL

MICROSYSTEMS TO BUILDING

EFFECTIVE, AFFORDABLE,

PERSONALIZED MESOSYSTEMS THAT

“COPRODUCE THE GOODS” .. . WEAVING TOGETHER HEALTH, SOCIAL, LAY CARE

AND PEOPLE’S PERSONAL ASSETS,

TALENTS & MOTIVATIONS

These Mesosystems will ...

• Leverage effective coproduction

• Be authentic learning systems

• Be assisted by IT and AI

• Promote effective self-careand home-care

• Be judged on their measured ability to deliver value: outcomes, convenience, accessibility, costs

80

HOME RUN: HIT A FOUR

BAGGER

• 1st Base

• Whole person: master the mesosystem

• 2nd Base

• Coproduction: co-assess, co-decide, co-design, co-deliver

• 3rd Base

• Learning Health System: learn what works for patients & populations

• Home Plate

• Measurably improve value81

WHAT’S TO BE DONE? A CALL TO ACTION FOR MAINE’S FQHCS

1. Whole Person Services: Make foundation of your system whole person assessment and comprehensive health & social service delivery over time

2. Coproduction of Services: Leverage local assets – patients & families, health & social services, payers & policy makers – to implement coproduction of health and social services. Make competent self-care the new principal care -- convenient, attractive, supported, facilitated

3. Learning Health System: Develop a learning health system that supports learning and value measurement -- using feed forward and feedback data -- at the level of patients & families, clinical and social service programs, and the region’s health and social service ecosystem

4. Value Improvement: Redesign programs and processes to actually measure, improve and pay for value for people, patients and families

82

THANKS TO ...

83

Case Studies

• Rushika Fernandopulle

• Joel Lazar

• Staffan Lindblad

• Andreas Hager

• Kristin Lind

• Jeff Brenner

• John Migliaccio

• David Sachs

• Uma Kotagal

ICOHN @ Dartmouth Team

• Paul Batalden

• Amber Barnato

• Jake Casale

• Glyn Elwyn

• Alex Gifford

• Lisa Johnson

• Alice Kennedy

• David Leander

• Kathy Kirkland

• John Mecchella

• Brant Oliver

• Kathy Sabadosa

• Corey Siegel

REFERENCES

1. Getting more health from healthcare: quality improvement must acknowledge patient coproduction – an essay by Paul Batalden. BMJ 2018; 362:k 3617 doi: 10/11/36/bmj.k3617 (Published 6 September 2018)

2. Kamal AH, Kirkland KB, Meier DE, Nelson EC, Pantilat SZ. A Person-Centered, Registry-Based Learning Health System for Palliative Care: A Path to Coproducing Better Outcomes, Experience, Vale, and Science. Journal of Palliative Medicine, November 2017. doi:10.1089/jpm.2017.0354

3. Ovretveit J, Zubkoff L, Nelson EC, Frampton S, Knudesn JL, Zimlichman E. Using patient-reported outcome measurements to improve patient care. International Journal for Quality in Health Care, August 2017. doi:10.1093/intqhc/mzx108

4. Johnson LC, Melmed GY, Nelson, EC, Holthoff MM, et. al. Fostering Collaboration through Creation of an IBD Learning Health System. American Journal of Gastroenterology. February 2017; doi: 10.1038/ajg.2017.9

5. Nelson EC, Dixon-Woods M, Batalden PB, Homa K, et. al. Patient Focused Registries Can Improve Health, Care and Science. BMJ 2016; 354: i3319 doi:10.1136/bmj.i3319.

6. Ovretveit J, Nelson EC, James B. Building a Learning Health System Using Clinical Registers: a non-technical introduction. Journal of Health Organization and Management 2016; 30(7):1105-1118; doi:10.1108/jhom-06-2016-0110

7. Linblad S, Ernestam S, Van Citters AD, Lind C, Morgan TS, Nelson EC. Creating a Culture of Health: Evolving Healthcare Systems & Patient Engagement. QJM 2016; doi: 10.1093/qjmed/hcw188

8. Nelson EC, Eftimovska E, Lind C, Hager A, Wasson JH. Patient reported outcome measures in practice. BMJ 2015;350:g7818.

9. Nelson EC, Lazar JL. Mollie’s Story: A case and a place that exemplifies person-centered care. Journal of Ambulatory Care Management, January-March 2015 38 (1):87-90.

10. Weinstein JN, Tosteson AN, Tosteson TD, Lurie JD, Abdu WA, Mirza SK, Zhao W, Morgan TS, Nelson EC The SPORT value compass: do the extra costs of undergoing spine surgery produce better health benefits? Medical Care 2014 Dec. 52(12):1055-63

11. Nelson EC, Meyer G, Bohmer R. Self-care: The New Principal Care. Journal of Ambulatory Care Management, July-September 2014: 37(3):219-25

12. Nelson EC, Batalden PB, Godfrey MG, Lazar JS: Value by Design: Developing Clinical Microsystems to Achieve Organizational Excellence, Jossey-Bass, 2011.

13. Nelson EC, Batalden PB, Lazar J: Practice-Based Learning and Improvement: A Clinical Improvement Action Guide, Second Edition, Oak Brook Terrace, Illinois: Joint Commission Resources, 2007.

14. Nelson EC, Batalden PB, Godfrey M: Quality by Design: A Clinical Microsystems Approach. San Francisco: Jossey-Bass, 2007.

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