All paths in the health and human service field seem to lead to more integrated consumer care coordination (see our recent OPEN MINDS market intelligence reports, State Medicaid Mental Health & General Pharmacy Carve-Outs and Alignment Of Medicaid Financing For Behavioral Health, Physical Health & Pharmacy). Yet participating in integrated systems of care is a very real (and difficult) strategic challenge for specialty provider organizations so it was helpful to hear practical advice for making the transition a successful reality from Diana Salvador, Psy.D., vice president for Program Evaluation, Grants & Outcomes for CPC Behavioral Healthcare, during her presentation “Managing Chronic Illness & Social Determinants of Health In A Community-Based Behavioral Health Setting” at The 2019 OPEN MINDS Technology & Informatics Institute. She discussed how CPC has evolved to provide chronic disease management services and links to social supports.
Making The Transition
To reach what she called the final frontier of integrated care, provider organizations need to mine data to identify high-risk populations, engage all departments, and ensure consumers have the right tools to improve their health (see It’s All About The Data).
This approach to care is relatively new and fueled by VBR. “We’ve never been consistently held to task for outcomes in our field,” said Dr. Salvador. “We have not been held to the same level of accountability as we are now for the social, mental, and physical health of consumers.”
Julie Hiett, MSW, senior director for Population Health Management, Netsmart, who worked with CPC on its population health initiatives and talked about data utilization, agreed. “With VBR you have to prove to your payers that you’re doing good things, and the only way to do that is to leverage and analyze data.”
Mining data—Ms. Hiett likened the use of EHRs and health information exchanges (HIEs) to fishing with a net instead of a pole in terms of querying outside clinical workflows to find consumer data. In addition to closing referral loops, data pulled from these sources drive workflow to calculate/stratify risk, and to track follow-up (see Health Information Exchange—Can Work, Isn’t Working).
“A lot of payers are looking for 30, 60, 90-day follow-up while others do long-term case management,” she said. Ms. Hiett explained this type of care can avoid hospitalizations and have a direct effect on costs, which helps provider organizations engaged in VBR.
Internally, professionals see increased efficiency associated with data-driven decisions as well as processes that save time—Ms. Hiett estimates 40% of care managers’ time is spent searching for data—and improve efficiency. “Surprisingly, some agencies struggle with caseload management and having a view into their population,” she said.
Assessing population health—With VBR, population health becomes increasingly important and much of the data you need is collected outside a system’s walls. “Being able to share data across systems is invaluable,” Ms. Hiett said, since some contracts will require care teams to contact consumers within 72 hours of hospitalization.
Accessing internal data efficiently also informs and improves care delivery and outcomes. For example, the care team identified a high co-occurrence of mental health issues and addiction disorders among consumers with chronic disease and noted that physical health issues accounted for most acute care setting admissions. “Data [allows us] to identify our high-risk patients, who have the highest needs. In the absence of delivering integrated care guided by this data, our consumers are not receiving optimal care and are spending more time in acute care settings at a higher cost to payers,” Dr. Salvador told attendees.
Addressing SDOH—Once the team had identified common issues they launched a pilot for consumers diagnosed with Type 2 Diabetes with experts across disciplines to address needs from ensuring participants had glucose kits to increasing health literacy, building self-management capabilities, and more.
“Think outside the box” when testing new approaches, Dr. Salvador advised attendees. “If a resource didn’t exist, we created it,” she said referring to a homemade social determinants of health (SDoH) scale with SDoH seminal for diabetes self-management.
The goal was to reduce avoidable risk factors, and progress was tracked through an EHR to gauge success. A few of the measures the team tracked to ensure their efforts were positively influencing care outcomes:
- H1c3—literature in diabetes management
- 50% of patients were connected to an endocrinologist
- All entries to acute care settings
- Self-reported mood over time
There were 12 participants in the program, which included 14 meetings, monthly follow-ups, and incentives (up to two $25 gift cards) to help consumers manage conditions and track progress.
While acknowledging industry fatigue with initiatives, Ms. Hiett emphasized the value of supporting change agents, who are not always enthusiastic about change. “Change-agents often struggle with change themselves” and question why the data is collected and how it will be used, she said. “It’s not to get you in trouble,” she clarified, but “to help you do your job better and identify strengths and challenges. We all want to learn how to be more efficient and improve outcomes for our clients.”
For Dr. Salvador’s team, that included using data to assess the pilot population and flag specific issues to discuss during visits and inform care plans and approaches, which can increase opportunities to intervene and influence care.
Ms. Hiett noted the value of starting small, using the data that’s available, and creating budgets that suit organizations of all sizes. “Everybody is starting somewhere,” she said. “You have to start with what you have and iterate.”
For more on how your organization can expand its care coordination skills, check out these resources in the OPEN MINDS Circle Library:
- State Medicaid Care Coordination Initiatives: The 2019 Update
- The Alignment Of Medicaid Benefits – The Health Plans Have It
- Managing Care For Complex Consumers: The Importance Of Community Inclusion
- Data Makes The Difference: Using Data To Manage Care Coordination & Value-Based Arrangements
- 2% Of Post-Acute Provider Organizations Using EHR Data For Care Coordination
- Efforts To Identify, Predict, Or Manage High-Expenditure Beneficiaries
- Innovation Adoption Among Specialty Provider Organizations: The 2019 OPEN MINDS National Innovation Survey
- How Can We Improve Behavioral Health Data Exchange? The Challenges & The Opportunities Of HIE
- Using Data Can Make Care Coordination More Efficient & Effective
- Without HIE, Participation In ACOs Is Limited
And for even more, join Monica E. Oss, chief executive officer, OPEN MINDS, and Kevin Scalia, executive vice president of corporate development for Netsmart, tomorrow, December 10, at 1:00 EST for Three Building Blocks For Person-Centered Care, a webinar focused on best practice care coordination. All webinar attendees will receive the care coordination briefing deck and a care coordination checklist developed by the teams at Netsmart and OPEN MINDS.