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Healthcare Transformation in Oregon: A Collaborative Approach to
Healthcare Transformation in Oregon: A Collaborative Approach toA Collaborative Approach to
Weathering the Storm & Implications f i
A Collaborative Approach to Weathering the Storm & Implications
f ifor Designfor Design
Erin Fair Taylor, MPH, JD
Director of CCO Partnership & DevelopmentCareOregon
ObjectivesObjectivesObjectivesObjectives• Develop understanding on new Integration & Collaboration strategies for healthcare organizations
• Develop understanding of how new accountability measures will affect healthcare organizations
• Develop understanding of how healthcare reform i ill ff h h l h d i d i istrategies will affect the healthcare design decisions
and selection of their new venues
About
• Medicaid & Medicare managed care organizationMedicaid & Medicare managed care organization– Changing identity in the CCO context
• More than 180,000 Oregon Health Plan andMore than 180,000 Oregon Health Plan and Medicare Advantage members– Most MA members are enrolled in Special Needs Plan
• 76% of members live in the Portland metro area • 54% of members are female • 59% are 19 & younger; 19% are 4 & younger • 26% do not speak English as their first language p g g g• 46% self identify as non‐Caucasian
Oregon’s North Star: h l
Oregon’s North Star: h lThe Triple AimThe Triple Aim
Better health (Population Health)
Better care (Experience of Care)
Lower costs (Cost Containment)( )
Population Health (PH)
Instructions1 Gi li 1 5 f h Health (PH)
4
5
1.Give policy a score 1‐5 for each of the three Triple Aim goals in the table below;
2. Plot the score on the Triangle3. Connect the dots
(5 A hi b t ibl t PHExamples:
3
4Good Policy: achieves all three goals of the Triple Aim
PH EC CC
(5 = Achieves best possible outcome; 1= does NOT achieve at all)
PH EC CC
5 5 5
PH
EC CC
1
2
Mediocre Policy: A policy that achieves only one or two goals of the Triple Aim
PH EC CC
PH
1
1
2 Bad Policy: one that does not achieve the goals Triple Aim
5 2 4 EC CC
PH
2
3
4
4
5
3 PH EC CC
2 1 3EC CC
Cost Containment (CC)
Experience of Care (EC)
Why Transform? Why Now?Why Transform? Why Now?• Fragmented, siloed systems• Unsustainable health care costsUnsustainable health care costs• Not great health outcomesS b d• State budget woes
Oregon ContextOregon Context• Resource withdrawal: 20% State Budget Shortfall
– 11% rate reduction in 2011– Another 19% shortfall in 2012 (eventually filled with federal investment in transformation, with strings)
• Oregon is a relatively efficient marketg y– Traditional ‘low hanging fruit’ is picked
• Creative disruption, innovation and rapid adaptation now must be core business strategiesadaptation now must be core business strategies
How to reduce the cost of health care:How to reduce the cost of health care:Traditional Method: Cut, cut, cut• Reduce how much we pay for services
– e.g: cut provider rates
R d th b f l d• Reduce the number of people covered– e.g: cut OHP Standard enrollment
• Reduce the benefits covered• Reduce the benefits covered– e.g: move the “Line” on the Prioritized List
OR...OR...Implement an innovative, long‐game method:
Fundamentally change the way care is organized y g y gand delivered
Support from the Feds: Change is Good!
…..You Go First!…..You Go First!$1.9 Billion in federal funding over 5 years, $ g y ,
contingent on performance
Vision of HB 3650 and CCO Implementation (2011 Legislative Session Oregon Legislature)
Vision of HB 3650 and CCO Implementation (2011 Legislative Session Oregon Legislature)(2011 Legislative Session, Oregon Legislature)(2011 Legislative Session, Oregon Legislature)
Integration & di icoordination of
benefits & services
Local Healthier Local accountability
for health & resource allocation
Redesigned Delivery
population
Improved
Standards for safe & effective care
System Outcomes
Reduced Costs
Global budget indexed to
sustainable growth
[The Triple Aim]
g
[A CCO]
Challenge + Urgency = OpportunityChallenge + Urgency = Opportunity
“I think you should be more explicit here in Step two.”
...and everyone is watching
LEGACY HEALTH
Kitz is Oregon Governor John Kitzhaber, who is the father of the Oregon Health Plan and a former ER physician
What is a Coordinated Care Organization ( )
What is a Coordinated Care Organization ( )(CCO)?(CCO)?
• A CCO is a single organization that accepts responsibility for the cost of health care within a global budget and for delivery, management and quality of care delivered to the specific population of patients enrolled with the organization.p p p g
CCO
MCO, DCO, MHO, Rx, County Programs, Medicare, Medicaid,
Specialty, Hospital, PCPCH
CCOShared Systems &
LearningCoordination & CommunicationCommunication
Local AccountabilityGlobal Budget
Fragmented, Siloed System Coordinated “Commons” System
Key Principles for Governing the Commons:Key Principles for Governing the Commons:Key Principles for Governing the Commons:Key Principles for Governing the Commons:Commons as metaphor for Coordinated CareCommons as metaphor for Coordinated Care
1. Individuals know the boundaries and limits– Of the resource (“Common Pool Resource”)
Of the community of users (“Appropriators”)– Of the community of users ( Appropriators )
2. Rules are locally made and adapted to context3. Decisions are made togetherg4. Active measurement and monitoring5. Effective sanctions6. Mechanisms for conflict resolution7. Latitude from higher authorities to act locally8. Nested Commons
Source: Elinor Ostrom quote by Don Berwick in 2009 IHI Forum Plenary
CCO Theory • Demands a more horizontal approachapproach– Democratizing systems that promote health, not just health
CCOShared Systems &
L ip , jcare
• Dependent on a network model
LearningCoordination & Communication
Local AccountabilityGl b l B d t
– Interdependent / Inter‐independent agents
Global Budget
• Requires involvement and input of a multitude of stakeholders
bl h k h ld– Is accountable to those stakeholders• Is a community solution, as opposed to an industry
l tisolution– No longer every man (organization) for itself
Accountability measures and financial pressures on CCOs will require us to go upstream andon CCOs will require us to go upstream and
intervene earlier and differently
Environmental 5%
Influence Factors on Health Status
Social 15%%
Human Biology 30%
Lifestyle & Behavior 40% Medical Care 10%
Source: McGinnis J.M., Williams‐Russo, P., Knickman, J.R. (2002). Health Affairs, 21(2), 83
Key Components of CCO DevelopmentKey Components of CCO Development• Geographic/Demographic
Scope• Model of Care
– Physical, mental, oral health
• Business & OperationsInformation Systems
yintegration
– Social service networking/integration
l– Information Systems– Utilization Management– Administration
Claims Processing
– Delivery system transformation
– Keeping people healthy– Claims Processing– Customer Relations– Workforce Development
• Financing– Global Budget
• Local Governance– Board of Directors
g– Capitalization– Risk– Revenue
– Community Advisory Council – Alternative Payment Methodologies
CareOregon Affiliated CCOsCareOregon Affiliated CCOs
Health Share of Oregon
Columbia Pacific CCO
Jackson Care Connect
Yamhill County Care Organization
PrimaryHealth of Josephine County
What does What does Transformation look
like?Transformation look
like?
• The fundamental questions we have been asking ourselves and stakeholders in our communities:– Can we do more with less? – Can we do more of what works? – Can we let go of what doesn’t? – How do we together foster communities that support g ppthe best possible lives for everyone in Oregon?
Minimum Standards to Evaluate CCO Transformation
Minimum Standards to Evaluate CCO TransformationCCO Transformation
Integration, Primary Care, PaymentsCCO Transformation
Integration, Primary Care, Payments
1. Implement a health care delivery model that integrates mental health and physical health care and addictions.
2 I l t P ti t C t d P i C H2. Implement Patient‐Centered Primary Care Homes.
3 Implement consistent alternative payment3. Implement consistent alternative payment methodologies that align payment with health outcomes.
Minimum Standards to Evaluate CCO Transformation
Minimum Standards to Evaluate CCO TransformationEvaluate CCO Transformation
Assessments, Improvement, & ITEvaluate CCO Transformation
Assessments, Improvement, & IT
4. Prepare a strategy for developing a Community Health Assessment and adopt an annualHealth Assessment and adopt an annual Community Heath Improvement Plan.
5. Develop a plan for encouraging electronic health records; health information exchange; and meaningful use.
Minimum Standards to Evaluate CCO Transformation
Minimum Standards to Evaluate CCO Transformation
6 Assure communications outreach Member engagement
Evaluate CCO TransformationReflecting Diversity, Addressing Disparities
Evaluate CCO TransformationReflecting Diversity, Addressing Disparities
6. Assure communications, outreach, Member engagement, and services are tailored to cultural, health literacy and linguistic needs.
7. Assure that the culturally diverse needs of Members are met; provider and new health care workers reflect membermet; provider and new health care workers reflect member diversity.
8. Develop a quality improvement plan focused on eliminating disparities in access, quality of care, experience of care, and outcomes.
Metrics & Accountability:H ill k h ’
Metrics & Accountability:H ill k h ’How will we know when we’ve
transformed?How will we know when we’ve
transformed?• The Oregon Health Authority has identified over 80 potential measures of cost quality access80 potential measures of cost, quality, access, patient experience, and health status
• Several will be tied to payment in the form of a• Several will be tied to payment in the form of a withhold[A bl ] i ifi i f d l• [Arguably] most significant metric: federal funding is dependent upon demonstrated 2
i d i di l d i hi 2percentage point drop in medical trend within 2 years.
Incentive Measures1) Initiation & engagement of alcohol/other drug dependence treatment2) Pre‐natal care3) Follow‐up after hospitalization for mental illness4) T t l d t t tili ti ( i it /1 000 b )4) Total emergency department utilization (visits/1,000 members)5) Colorectal cancer screening6) Patient‐Centered Primary Care Home (PCPCH) enrollment7) Developmental screening by 36 months7) Developmental screening by 36 months8) Adolescent well‐care visits9) Screening for clinical depression and follow‐up plan10) Controlling high blood pressure10) Controlling high blood pressure11) Mental and physical health assessment for children in DHS custody12) Elective delivery before 39 weeks13) Optimal diabetes care14) Alcohol or other substance misuse screening15) Access to care
Th h ll ’ b d i h i iThe challenge won’t be doing the measuring – it will be moving the dial
Why would Oregon’s health systems d ll h f d d
Why would Oregon’s health systems d ll h f d dagree to do all this just for Medicaid?agree to do all this just for Medicaid?
• ~18% of Oregonians are enrolled in Medicaid today18% of Oregonians are enrolled in Medicaid today– Will jump to 25% after ACA Medicaid expansion in 2014
• The Governor is working to fold all publicly funded health coverage into the CCO modelg– PEBB & OEBB– If that happened, ~40% of Oregonians would have care paid for and coordinated through CCOs
$• $1.9 Billion in federal investment accounts for 19% of the state’s Medicaid budget this biennium
Case Study in Collaboration:Case Study in Collaboration:Collaboration:
Health Share of OregonCollaboration:
Health Share of Oregon
Risk Accepting Entities (RAEs):4 Physical Health Plans4 Physical Health Plans
CareOregon, Kaiser*, Providence*, Tuality*3 Mental Health Plans
Multnomah, Clackamas, Washington Counties
Provider only SystemsProvider‐only SystemsOHSU, Legacy, Adventist, Central City Concern
*are also provider systemsare also provider systems
Individual / Family / Community
Health Share of Oregon’s Business PlanHealth Share of Oregon’s Business Plan
A Multi‐Dimensional and Collaborative Approach
A Multi‐Dimensional and Collaborative Approach
Governance‐ Vision & Mission‐ Community Engagement‐ 11 Founding Organizations
KEY INPUTS BENEFITS‐ Community‐wide Partnership‐ Mobilizing Community Assets‐ System Coordination & Integration
Accountability‐ Common Metrics‐ Outcome Focused‐ Standard Processes‐ Innovative Payments‐ Delivery System Contracting
‐ Transparency‐ Mutual Monitoring‐ Increasing Equity & Fairness‐ Bending the Cost Curve
Regional HIT
Delivery System Contracting
‐ Common IT Vision‐ Enabling Technologies‐ Aligned IT Integration‐ IT Investment
‐ Optimizing Delivery System Performance‐ Actionable Member Information‐ Sharing of Data & Information
Delivery System Transformation‐ CMMI Health Commons‐ MoC Continuum‐ Collective Clinical Leadership‐ Provider Driven Change
‐ Integration of Health Services‐ Triple Aim: Evaluation of Initiatives
C it S i I t ti
‐ Convening of Stakeholders‐ Social Service PartnershipsH lth N d A t
‐ Activating Natural System of Care‐ Build on Assets of the Community‐ Elimination of Disparities
Community Service Integration‐ Health Needs Assessment‐ Communication Plan
p‐ Beginning to Address Social Determinants of Health
To create health care transformation, Health Share brings together a multi‐layered or nested enterprise approach to g y p pp
delivering health care services to its membersNested Organizational Layer Role & Accountabilities
Health Share System managementTransformation leadershipBest‐in‐value provider contracting
d b dEngage and convene members, providers, communities
Community & Cultural Segments
Community advocacy & engagementIdentifying cultural & linguistic health center and social needs of membersCommunity service provider coordination
Physical, Behavioral & Social Delivery of care and servicesyService Providers (with Dental in 2014)
yPatient engagementCoordination of careCommunicating and coordinating information to improve qualityimprove quality
Members & Families Active participation and ownership of own healthEngaging with providers and community segments
Health Share’s $17 million federal Center for Medicare & Medicaid Innovation GrantMedicaid Innovation Grant
Healthy Community Triple Aim: Key Portfolio of Changes for Impact & Success
POPULATION SEGMENTS
(By Outcome Drivers)
STRATEGIC INITIATIVES Quicker
ROICare CostHigh
Hi Needs Customized Care:• ED / Hosp Hi Utilizer Care TeamsH tHi Medical
Hi MH / ADHi Social
• ED / Hosp. Hi‐Utilizer Care Teams• Complex Case Mgmt• ED Diversion / Navigation• Rx Opioid Abuse Reduction• Supportive Service Assessment
Hot Spots Burning
Smoldering
Mod ‐ Hi Medical Mod ‐ Hi MH / AD Health Care
Delivery System Redesign:• Primary Care Home• Behav / Oral / Med Integration• Care TransitionsMod ‐ Hi MH / AD
Lower Social SystemCa e a s t o s
• Aligned Specialty / E‐referral• Healthy Birth Midwifery• LEAN Hospital • Community Standards
Community Health System
Lo MedicalLo MH / ADHi Social
Resource Integration:• Service partnerships• Community Schools• Asset Support• Public health alignment
Slower ROI
Care CostLow
Strategies for Innovation:S l I ti F d P tf liSample Investing Forward Portfolio
ents
roveme
• Mental Health and Clinical Integration
• Releasing Time to Care• Primary Care Renewal (PC3)
FocusedLean
• Child and Adult Discharge Engagements
ED N i i
se Im
p
• Commons Health Record
• Community Care Teams• Specialty E-Referral
ImprovementsChanging
Site ofCare
• ED Navigation
• Local Telemedicine
ource U • Public Health Invigoration
• SUN as Community Center
CareTechnology
Infrastructures
Environment
Reso Attitudes
Behaviors
Processes Value Chains Structures New FormationsMethods of Change
Case Study in Integration: l
Case Study in Integration: lCentral City ConcernCentral City Concern
Comprehensive solutions to endingComprehensive solutions to ending homelessness and achieving self‐sufficiency
• Changing Lives• Changing Lives– Through programs of recovery and health
• Building Communities– Through supportive housing and civic engagement
• Creating Opportunities– Through volunteer work and employmentg p y
Case Study in Integration #2: Gladstone f hild & ili
Case Study in Integration #2: Gladstone f hild & iliCenter for Children & FamiliesCenter for Children & Families
• A “birth to five” center that includes:A birth to five center that includes:– Primary care clinic that offers pre‐natal and mental health servicesmental health services
– Head Start– Pre‐school– Pre‐school– KindergartenFamily crisis center– Family crisis center
• Built in a converted grocery store shopping tcenter
Case Study in Member Engagement: h l d
Case Study in Member Engagement: h l dSouthcentral FoundationSouthcentral Foundation
• Alaska Native People Shaping Healthcare by:p p g y– Listening to the wants and wishes of those receiving servicesRedesigning services around long term trusting– Redesigning services around long‐term, trusting relationships; and
– Empowering customer‐owners to own health issues at personal and s stems le elspersonal and systems levels
• Everything at Southcentral Foundation from the buildings and facilities to services and systems is g ydesigned to be responsive to needs and issues of the Native Community. Their customers drive everythingeverything.
Case Study in Design Flow: l ( )Case Study in Design Flow: l ( )Releasing Time to Care (RT2C)Releasing Time to Care (RT2C)
• Methodology to engage front‐line nursing staffMethodology to engage front line nursing staff to streamline and redesign their workflow
• Innovative hospital ward layout can reduce d i i d d f h iwasted nursing time and spend more of their
shift providing direct patient care
• Developed in the UK using Lean methodology; p g gy;CareOregon is now spreading it to US hospitals
Other OpportunitiesOther OpportunitiesOther OpportunitiesOther Opportunities
• Transformation can start with a newTransformation can start with a new structures, new clinical models of care and innovative interventions but we will have toinnovative interventions, but we will have to take on much more….
Berwick’s Drivers Berwick’s Drivers oof f Unnecessary CostUnnecessary Cost
• US Health Care Waste 2011: $910 B – Fraud and Abuse: 20%
“Business Practice ”Fraud and Abuse: 20%
– Pricing Failures: 14%Administrative Complexity: 27%
Practice Opportunity
61%– Administrative Complexity: 27%– Overtreatment: 21%Failure of Care Delivery 14%
“Clinical Care Improvement ” – Failure of Care Delivery: 14%
– Failure of Care Coordination: 4%
pOpportunity
39%
The Institute of Medicine’s “f t th t i i t“factors that give rise to unnecessary costs:”y
– Unnecessary servicesUnnecessary services– Services inefficiently delivered– System fragmentation– System fragmentation– Missed prevention opportunitiesLack of patient engagement in decisions– Lack of patient engagement in decisions
– Under‐investment in population health
Design of Future Healthcare Facilities h ld
Design of Future Healthcare Facilities h ldShould Promote...Should Promote...
Collaboration EfficiencyCollaboration• Considerations
– HIPAA
Efficiency• Considerations
– Lean methodology– Welcoming and easily
accessible• Southcentral Foundation
– Front line staff input about workflow
– Large meeting spaces– “Commons” principles
Design of Future Healthcare Facilities h ld
Design of Future Healthcare Facilities h ldShould Promote...Should Promote...
Accountability/Quality IntegrationAccountability/Quality• Considerations
– Opportunities for design to
Integration• Considerations
– Co‐locating multiple types of enhance member/patient satisfaction and experience of care
service providers• May include traditional medical services: physical,
– Must include data collection, informatics, analytics, HIT infrastructure
behavioral, dental, pharmacy, etc.
• May also include social services: housing education
– Member/end user input and involvement – does it meet people where they are?
services: housing, education, early childhood, vocational training, etc.
Questions & More InformationQuestions & More InformationQuestions & More InformationQuestions & More Information
• CareOregonCareOregon– www.careoregon.org
• Oregon Health Authority• Oregon Health Authority– www.health.oregon.gov
• Email me– [email protected]