SIMPLICITY CARE COORDINATION

Integrating the Health Care Home with Home and Community Based Services

Laura Ackman, Essentia Health

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Scope of the Project

• Began the process in Spring 2008 with brainstorming ideas of how to help our nursing homes remain viable

• Applied for and was awarded an Iron Range Resources grant for a feasibility study in Fall 2008 regarding combining 4 nursing homes

• Applied to the Minnesota Department of Human Services Three-year Demonstration Projects for Older Adult Services

• Grant was awarded, contract signed and collaborators began working on implementation plans in 2010

• Two years in the making to get us to that point

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Two Main Purposes of the Grant: organizational redesign and a direct community service component

– Organizational redesign by combining the four nursing homes with the goals of realizing economies of scale and improving and maintaining quality and services

• What type of governance structure• What type of operating entity• What assets would be included• Employees/union issues• What about ancillary services (laundry,

housekeeping, dietary)

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– Direct community service component

• Health care navigator to provide case management and support in the community to maximize the ability of aging community members to age in place

– What will the program look like

– Who will create and implement it

– Who will be served

– How will the Project be measured

– How can we identify gaps in services

– How can those gaps be filled

– How can the facilities, the community based service providers and the health care providers work with the Health Care Navigator

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In the beginning…….

“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.”

--Charles Darwin

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Evolution

• In Spring 2009, we learned that we were selected as a recipient of one of the two grants awarded.

• During that time two of the original collaborators determined that it was in their best interest to withdraw from the project

• The two remaining collaborators began looking for additional partners.

• Current members of our consortium are:– Virginia Regional Medical Center– Benedictine Health System

• St. Michael’s health and Rehabilitation Community• St. Raphael’s health and Rehabilitation Community

– Essentia Health-Northern Pines Medical Center

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Aging

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The Number of People With Chronic Conditions Is Rapidly Increasing

In 2000, 125 million Americans had one or more chronic conditions.

This number is projected to increase by more than one percent each year through 2030.

Between 2000 and 2030 the number of Americans with chronic conditions will increase by 37 percent, an increase of 46 million people.

Number of People With Chronic Conditions (in millions)

Source: Wu, Shin-Yi and Green, Anthony. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October 2000.

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Source: Centers for Medicare and Medicaid

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In a new age of transparency, quality is front and ceter …

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OUR CURRENT HEALTH CARE DELIVERY MODEL . . . . .

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TO A MORE EFFICENT, EFFECTIVE

TO A MORE EFFECTIVE, EFFICENT DELIVERY MODEL . . . . .

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In the Middle………..

“Do what is right, what moves our mission forward, and what---because of its ambition, courage and potential—is really worth the disruption.”

-- Frederick Douglass

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Important elements of new HCH/HCBS Model

Coordinated, Comprehensive and Accessible Care Team Approach Quality driven Best Practices/Evidence Based Medicine Patient and Family Centered

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Teams

“A team is a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable.”

Katzenbach JR, Smith DK. In: The Wisdom of Teams. Harper, 1999. page 45

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We must create and support a coordinated TEAM approach to delivering health care

The increasing complexity of primary care medicine makes it no

longer possible for one individual or discipline to comprehensively

manage all aspects of patient care. 

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Physician/APCs/RN/Social Worker Accountabilities

Work within a team Utilize the EMR Follow best practices Manage Chronic disease registries within the team Follow standard work flows

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Who will be managed by the team?

“Special Populations”

High Risk patients Over 65 Chronic Diseases

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Key Precepts of Delivery Model

Primary Care is responsible for comprehensive, coordinated care for total patient populations.

The primary care team will be the model for care delivery. Core Team Members may include Physician (Lead); APC; RN; CA/LPN; Social Worker; Scheduler/Registrar.

There will be standard processes, tools Components of care included in final model will be

available to all

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Key Precepts Cont….

There will be strategic prioritization of system wide development of primary care components and supporting or augmentative specialty programs for patient populations with these chronic conditions:

• Diabetes• Cardiovascular Disease• Depression• Chronic Heart Failure

Managed Care Office and Primary Care physician led team will partner in care management of special populations defined by payer contracts.

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Efficiency withoutQualityUnthinkable Quality without

EfficiencyUnsustainable

Clinical quality and financial performanceare inseparable

The Cost/Quality Debate…

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Next Steps

Communication of Vision and Model• Make adjustments based on feedback• Visit other best practice sites and make

adjustments based on their models and experiences

Add Operational Detail to Model Begin Implementation of Standard, Core Work

Process at all Sites Conduct Pilot NCQA and State Health Care Home Certifications HSBS Coordinator

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Never the end……

“Even if you're on the right track, you'll get run over if you just sit there.”

– Will RogersUS humorist &

showman (1879 - 1935)