Integrating health and social services Health in Context

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Integrating health and social servicesHealth in
Context

• Tom Granatir

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First, a confession

• In favour of system-ness
• Not because of aligned incentives but because
  of clear lines of accountability
• Evaluation studies look for cost offsets
• But variation studies cast doubt on substitution
  effects
• And the real reason to do it is to promote
  independence, aging in place, LRPP

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Antecedents

• Dartmouth and FIMDM
• Variations
• Preference based care
• The power of engagement
• Picker
• Personal values
• Coordination, continuity, management of
  transitions
• Communication and decision support
• Pain and physical comfort
• Anxiety and depression
• Family and friends
• Choice, transparency, and independence

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Integration for Frail Elderly

• SHMOs the Program of All-inclusive Care for the
  Elderly
• Integrated delivery systems/PGP the medical home
• Administrative integration Wisconsin
  Partnership, MN LTC
• Common themes
• Integrated funding
• Individualised assessment
• Team-based treatment
• Coordinated care
• Rebalancing HCBS and institutional care
• Common problems
• Medical lens
• Definition and standards for social services
• Risk Adjustment
• Still forgetting something mental health and
  AODA

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PACE evaluations

• Cost offsets?
• Increased life expectancy
• Reduced hospital and nursing home days
• Increased (self-reported) health status
• Higher general satisfaction with life
• Greater satisfaction with overall care

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PACE v unmanaged HCBS in Washington State

• Noncomparable populations PACE population is
  sicker, costlier, and at higher risk
• Yet PACE significantly reduces risk of dying by
  year three, 29 percent of PACE enrollees had died
  compared to 45 percent of control group
• Measurable improvement in physical functioning
• Although PACE clients are more costly, rising
  nursing home costs for the unmanaged population
  narrow the gap

Source Mancuso et al. 2005. PACE An Evaluation
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PACE v. Wisconsin Partnership Programme

• Tightly managed v. loosely managed plans
• Study compared use of hospitals
• PACE enrollees had fewer
• hospital admissions
• preventable hospital admissions
• hospital days
• ER visits
• preventable ER visits
• But no difference in the length of hospital
  stays.

Source Kane et al 2006. Variations on a theme
called PACE
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Medicare Modernization Act Pilots - GRH -

• Competitive Bidding Process
• 8 pilot programs chosen
• Financial Terms
• CMS pays program fees over 3 years on a PPPM
• Awardees guarantee 5 net savings off Medicare
  costs
• 100 of fees at risk for achieving savings target
• Fee risk also tied to clinical and satisfaction
  metrics

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Data and Outcome Analysis
Part A B Claims
Partner/Lab Data
GRH Questionnaires
Data Sources
Beneficiary-reported
Provider-reported
Social Security Adm/AHCA
Part D
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Clinical Cost Drivers of GRH Beneficiaries
Potential co-morbidities associated with
Diabetes/ CVD Respiratory 62
Frailty/ Immobility 27

• Why is this important?
• GRH population will age in place
• Health Risk increases with age

Other 11
Source INP, OUT, SNF, DME, HHA, Hospice,
Carrier claims. Sum of paid amount for PY1
(11/05-10/06), across all claim types. Claims
costs incurred while eligible only.
11
Issues of Frailty Drive Cost in GRH Beneficiaries
100
25,000
91
88
78
19,118
80
20,000
18,676
71
17,283
61
14,713
14,743
60
15,000
PMPY Costs
12,755
12,656
12,496
12,367
12,203
Cost Drivers
39
40
10,000
29
22
20
5,000
12
9
0
0
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Falls in past 6 months?
Skin breakdowns or wounds recently?
Problems with eating recently?
Pain that interferes with your life?
Problems with sleep recently?
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Deficiencies in Daily Living Activities Drive Cost
25,000
100
87
85
85
22,208
83
20,000
80
20,793
74
71
18,694
18,326
17,460
63
16,854
15,444
15,000
60
12,674
12,184
12,032
12,020
11,470
11,533
10,000
40
37
9,672
29
26
5,000
20
17
15
15
13
0
0
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Doing light housework, like washing dishes?
Heavy housework, such as scrubbing floors?
Lifting or carrying objects as heavy as 10 lbs?
Difficulty bathing or showering?
Managing money, like paying bills?
Reaching or extending arms above shoulder level?
Shopping for personal items, like toiletries?
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Medication Adherence
18,000
1.00
16,117
14,429
.86
14,066
13,408
0.80
13,254
13,142
13,232
.64
13,215
12,000
.66
.67
.63
0.60
.62
.61
.62
.61
.57
PMPY Costs
PMPY Admits Visits
.51
.44
.45
.44
0.40
.44
.43
6,000
Cost
0.20
ADL and Medication compliance correlate with
increased costs in managed population.
IP Admits
ER Visits
0
0.00
No
Yes
No
Yes
No
Yes
No
Yes
Forget medication?
Ever cut back/ stop taking, b/c felt worse?
Past 2 weeks, any days you did not take meds?
Forget to bring along your meds?
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Screening, Stratification
Green Ribbon Health Intervention Model
Identifying Total Patient Needs Through Unique
Assessment Stratification Strategy
Domain Assessment Tool (DAT)
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Unique assessment of seven domains to support
integrated treatment model
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Stratification of Patients for Intervention Based
on DAT and Claims Data
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Targeting and Tailoring
Getting the Right People the Right Intervention
Stratification
Identification
DOMAIN RISK
1
ICD9 Code Filter
High
Medium
Low
Identification of Frailty
Monitor
Prevention
Prevention
2
Identification of Home Visit Qualifier Co-Morbidit
y Index EOL Predictors Beers List and Medication
Possession Ratios
Low
Prevention
Prevention
High
-
impact
COST/UTILIZATION RISK
Medium
High Impact
High
-
Impact
High
-
Impact
High
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Marrying Acute and Chronic Care Management
On-site
Telephonic On-Site
GRH FCM
Personal Nurse
GRHCHE

• Group Education
• Individual Education
• Fall Prevention Assessments
• Field Support and Research
• Community
  Resources

• Home/SNF/Hospital Visits
• Assistance understanding or enrolling in Part D
• HHA/DME/Home Modification Assistance
• Cognitive assessments Support
• Caregiver Training Support
• Social Service Coordination
• EOL/Advanced Directives

• Telephonic Intervention
• Behavioral Health Referrals
• Medication Management
• Physician Care Coordination
• 24/7 Nurse Triage

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Management of Advanced Diabetes and CHF
Community Resource Integration Customised
Directory for Community/Social Services
In-Person Assessment Referral Field care
managers provide in-person services
Support for management of long-term
conditions Community health workers and peer
support groups
Mental Health Depression Screening, Mgmt,
Referral Assessment and referral to appropriate
treatment level
Physical Health Taking Action Silver Sneakers
community gym workouts at most ability levels
Evidence-Based Medicine Individualized
decision-support and coordination across all
presenting conditions
Personal Motivation Change Techniques Personal
Nurse Coach
Coordination of Care Provider coordination
alerts (e.g., End of Life, drug-drug
interaction, cognitive impairment)
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GRH Support Services

• 24/7 365 Access to an RN-Crisis Intervention
• Personal Care Manager for Care Coordination
  Education and Support
• Medication Education and Compliance Support
• In Person Home and Facility Visits by a
  Registered Nurse or Master Level Social Worker
• Physician Office, Clinic and Hospital Staffing of
  CM services
• Alzheimer's and Dementia Support
• Nutrition and Dietary Education Support
• Hospice and End of Life Education Support
• Home Health/DME and Home Modification
  Coordination

• Depression Grief Education Support
• Social Services Coordination with Community
  Resources Healthcare Agencies
• Home and Environmental Safety Assessments
  Support
• Caregiver Training Support
• Group Individual Classes Focused on Living with
  a Chronic Condition
• Physician Care Coordination
• Nursing Home Advocacy Program
• Coordination Assistance of Alternative Living
  Arrangements
• Remote Bio-Metric Monitoring in the Home such as
  Daily Weights/BP for Unstable Conditions
• Data Analytics and Research Support

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Links health and social care to address aging and
chronic illness
Creates
"Scorable Savings year after year
Measurable improvements in health
Satisfaction of patients and providers
Measurable improvements in quality of life
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Themes

• Accountability
• Management
• Data
• Risk Assessment and Adjustment
• Targeting
• Tailoring
• Measurement
• Experience

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Toward person-centred integration

• Most talk about integration focuses on
  integrating
• Financing
• Planning
• As usual, it is focused on us - the delivery
  system - and not on people the patients
• Not a model of delivery but a model of inquiry
  risk assessment, stratification, targeting and
  tailoring
• Integrated view of personal health risk and
  health trajectory
• Multiple sensors from all sorts of data
  capturing all sorts of views of experience
• Ecological view of health understanding context
• Delivering services in context that address
  context

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Next generation public health

• Expert systems
• Focused on the system
• Regulation, planning, system engineering
• Economics, medicine, engineering sciences
• Evidence-based care
• Explicit cost-benefit tradeoffs
• Value-based health benefits
• Value-based purchasing
• Cost and quality transparency
• Medical expertise is valued

• Health 2.0
• Focused on people
• Health, not health care
• Psychology, sociology, anthropology, ecology
• Choice, independence, transparency
• Personalisation, engagement, activation
• Targeting and tailoring
• Ubiquitous technology
• System thinking
• Patient expertise is valued