Many specialty provider organizations are facing formidable strategic challenges as the result of the growing payer preferences for integration. Health plans are looking for best practice models that take a whole person approach to care delivery—integrating primary care, pharmacy, behavioral health, social services, and long-term services and supports. This leaves specialty provider organizations with strategic questions: Will hospital systems, primary care providers, or retail clinics become the new competition for the delivery of specialty services to complex consumers? Should we pursue some form of partnership with these types of organizations to deliver integrated care? Or should we develop our own primary care services to provide the full care continuum to our complex consumer populations?
There are many ways to leverage payer preference for integrated care to find a competitive advantage in this shifting market—co-location between primary care clinic and behavioral health care provider organization, health homes and specialty medical homes, embedding behavioral health clinical professionals in a primary care office, comprehensive integrated care delivery, and more. Last week at The 2019 OPEN MINDS Strategy & Innovation Institute, we learned about two different models for delivering integrated care to the complex consumer populations in the session, Building A Specialty Primary Care Program: New Models For Consumers With Complex Conditions, featuring Stephanie M. Murtaugh, Director of Clinical Services, Pittsburgh Mercy; and Tine Hansen-Turton, President & Chief Executive Officer, Woods Services.
While their models have many differences, both Pittsburgh Mercy and Woods use a health home model to delivery integrated primary care for complex consumer populations. And Ms. Murtaugh and Ms. Hansen-Turton shared similar advice for provider organizations considering an integrated care model—focus on performance measurement from the beginning and build your model around clinical quality outcomes. To do this, all members of the care team need access to real-time comprehensive clinical data. A common medical record allows clinical professionals to better coordinate care for consumers and allows the organization to utilize a population health management approach to managing care, while producing (and demonstrating) positive outcomes and value to payers.
The first model, Pittsburgh Mercy Family Health Center, is a person-centered health care home that integrates physical health, substance use disorder (SUD) treatment, mental health care, as well as social support services. They serve 7,000 consumers—40% of which are considered to be a “very high risk” population. They are a certified community behavioral health clinic (CCBHC), and their integrated care model utilizes a person-centered, team-based approach, focused on whole-person care. Their primary care team has access to real-time behavioral and psychiatric consultation and consulting psychiatrists are on-site to do warm hand offs with primary care physicians. They also employ five embedded specialty care managers.
The goal with this consumer population is to move consumers from the most restrictive level of care, to community-based and home-based care. Ms. Murtaugh explained to do that, the team assesses and discusses consumer risk and functioning according to biological, psychological, social, and engagement factors. This assessment allows for risk stratification and enables to team to determine the needs of the consumer population. The team conducts weekly, population-based “high risk” meetings to discuss a comprehensive care plan for highest risk consumers. The meeting includes the entire primary care team and clinical professionals operating in the community. They also have six assertive community treatment (ACT) teams, which review 100 people every morning.
The second model, Woods, is a population health management non-profit organization that supports children and adults with developmental disabilities, complex medical needs and genetic disorders, behavioral and other challenges. Last year Woods opened an expanded medical center, featuring a Patient-Centered Medical Home (PCMH) program for Keystone First members with intellectual and developmental disabilities (I/DD) and complex medical challenges (Keystone First is a Medicaid managed care plan, an affiliate of Independence Blue Cross, in five southeastern Pennsylvania counties – see A Patient-Centered Medical Home For The I/DD Population—The Woods Services Model). Woods and its 6,000 staff offer 200+ health and human service programs in Pennsylvania and New Jersey for 18,000+ children, adolescents, and adults, with referrals from 175 school districts and 23 States.
Population health management includes Woods’ “Care for the Whole Person Model” that addresses all the needs of the people it serves by coordinating social determinants of health, providing physical and behavioral health care and medication management directly or in partnership with health systems, all essential care to achieve positive health outcomes. At Woods a Nurse Navigator coordinates all the health care related services and a Care Coordinator coordinates access to all the services addressing social determinants of health, including housing services, long-term supports, job training and coaching, education, etc.
Two key points stood out from both case study presentations. First, access to comprehensive clinical data is essential. In both of these models, the organizations took a metrics-driven approach to assessing consumer risk and integrating information across the care team. To succeed in this, provider organizations need to build a pathway to capture claims data for analysis, access external records such as hospital records, criminal justice etc., share that information, and (ideally) integrate the behavioral health and physical health record.
And second, focus on outcomes and performance measurement. For these models to be successful at scale, there needs to be some form of bundled payment model. To gain capitated payment models with health plans, organizations need to demonstrate their value in outcomes. Specialty provider organizations can be at an advantage when it comes to integrated care delivery for the complex consumer population. The wider health care field usually does not understand how to serve complex consumer populations—people who are dually diagnosed with developmental disabilities and behavioral health challenges or behavioral health and addiction issues. Specialty provider organizations can utilize their expertise to deliver quality care and produce positive outcomes that demonstrate their value to payers.
There is no one, “right” model for integration. But as the market continues to move in this direction, now is the time for specialty provider organizations to consider what is the best model to serve their complex consumer populations. For more on identifying and responding to the disruptors in your market, check out these resources from the OPEN MINDS Circle Library:
- Can You Teach A Fish To Climb A Tree?
- David Versus Goliath?
- Innovation Isn’t Enough
- Don’t Let The Big Disruptors Out Of Your Sight
- What Does It Take To Outlast The Disruptors?
- The 5-4-6 Formula
- Who Do You Need To Lead An Agile Organization?
- Will Health Plan Backward Integration ‘Remake’ Specialty Care?
- From Pain Point To Revenue
- How Private Equity Investors Are Reshaping Non-Profit Strategy
And for even more, join us on August 14 at The 2019 OPEN MINDS Management Best Practices Institute, for the session, A New Value-Proposition: Primary Care & Behavioral Health Integration In A Value-Based Market, featuring Margaret M. Conner-Levin, MSW, Senior Associate, OPEN MINDS; Allen Brown, MSSW, Chief Executive Officer, Adult & Child Health; and Christy Dye, MPH, President & Chief Executive Officer, Partners In Recovery, LLC.