Community Collaboration for Clinical Transformation: Designing and Implementing the TriCounty Health C

1. CommunityCollaboration for Clinical Transformation: Designing and Implementing the TriCounty Health Commons Grant Rebecca Ramsay, BSN, MPH Director – Community Care Programs, CareOregon January 8, 2013

2. 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

3. 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”

4. 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

5. “Tactical Groups” Identifying opportunities for investment Prioritizing initiatives for implementation • Transitions of Care • High Utilizers • Emergency Department • Health Home • Behavioral/Physical Integration • Specialty Care Timeline: Basic work done by end of March, implementation planning in April.

6. Delivery System Change “Idea Inventory”

7. Up to $30 Million Funding Over 3 Years Application Due: Jan 27, 2012

8. December 2011… “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???

9. TriCounty Health Commons Grant“Transforming Health Together”

10. 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?

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

12. Where is the $$$ going?% of Total Billed Charges by Service(State of Oregon Medicaid Data) 2009 Total Billed Charges = $1,630,851,673 Hospitalizations and ER admits amount to 43% of Billed Charges * Outpatient Behavioral includes mental health services and ER and non-ER chemical dependency services

13. William History of Addiction to IV Drugs and Alcohol Chronic Heart Failure COPD Developmental Disorder Schizoaffective Disorder Hepatitis C 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. Intermittent Homelessness Type 2 Diabetes 62 Year Old Caucasian Man

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

15. 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

16. TriCounty Health Commons InitiativeImproving lives for high-acuity/high-cost patients across the care continuum • Primary Care Community Outreach Model • Emergency Services • ED Navigation to Primary Care • EMS Community Outreach Model • Hospital Care • Intensive Care Transition Support Workforce: Community Outreach Worker, Outreach RNs, and Outreach SW and Recovery Mentors Workforce: Transitional Care RNS and Clinical Pharmacists, Transitional Care LCSWs • Specialty Care • Community Outreach Model Workforce: ED Guides, Outreach Behavioral Health Staff Workforce: Community Outreach RN and Respiratory Therapist Behavioral Health Community Outreach “Peer” Model Workforce: Peer Wellness Specialists

17. Health Commons Grant Accountability Structure

18. 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 bimonthly

19. Collaborative Learning for The Health Commons Learning Session #1 February 22, 2013 Learning Session #3 June 28, 2013 Learning Session #5 October 25, 2013 Learning Session #2 April 26, 2013 Learning Session #4 August 23, 2013 Learning Session #6 December 13, 2013