A Rural Community’s Journey - National Association of ......A Rural Community’s Journey . NACo...

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Collaborative Health Improvement: A Rural Community’s Journey

NACo Healthy Counties Forum January 30-31, 2014

Mimi Khin Hall, MPH Plumas County Public Health Agency

Plumas County 2,553 square miles > 1 million acres of national forest > 100 lakes > 1,000 miles of rivers and streams 70% of land is federally owned Strong Maidu culture and tradition Rich history of mining, logging, ranching

Demographics Pop. Est. 2011: 19,765, <8 people per sq. mile 84.5% white non-Hispanic (CA: 39.7%) 2.5% foreign born (CA: 26.2%) 21.6% > age 65 (CA: 11.7%) Children’s poverty 24% (CA: 20%) Single parents households 36% (CA:29%) Unemployment 16% (CA: 12%) Vacant housing 43% (CA:8%) U.S. Census Bureau

In other words… NO mall NO fast food chains NO Wal-Mart NO Costco

Rural Challenges Geography Staff capacity Resources Difficult history in collaboration Political climate and conservative views

The Triple Aim of Health Reform

Improved Population Health

Improved Quality of Care Reduce Per

Capita Cost of Care

SO…how are we doing?

• At keeping the cost of health care affordable? • At improving our health status?

Source: Organization for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en 14 February 2011).

Results: Cost/Affordability: US and Selected Countries, 2008

$7,538

Source: Organization for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en on 14 February 2011).

Growth in Total Health Expenditures per Capita, US and Selected Countries, 2008

USA in World Health Rankings Per capita spending on health

Life expectancy

Source: World Health Organization World Health Report, 2006

So, What Do We Do? (Re)Transform

“Every system is perfectly designed to achieve exactly the results it gets.

Therefore: new levels of performance can only be achieved by re-design of existing

systems” Neal Halfon, MD, MPH UCLA

Counties Can Seize Momentum and Opportunity

Continual alignment with national and state efforts

Meet multiple organizations’ and systems’ requirements

Collectively impact Triple Aim: quality, population health, cost of care

Section 9007 of PPACA Requires that 501(c)3 hospitals:

conduct a CHNA every three years

adopt an implementation strategy to meet

the identified community health needs

$50,000 excise tax for failing to meet the CHNA requirements for any taxable year

noncompliance with this, or other new requirements, may result in loss of exemption.

IRS Form 990, Schedule H

Public Health Accreditation Prerequisites

A collective approach to: Community Health Assessment Community Health Improvement Plan Strategic Plan

Leads to: Improved quality Improved population health Reduced health care costs

Building Capacity Robert Wood Johnson Foundation/NACCHO One of 12 CHA/CHIP Demonstration Sites Network of LHD’s Training, technical assistance and consultation

University of WI Population Health Institute, County Health Rankings

Association of Community Health Improvement MarMason Consulting Holleran Consulting Paul Erwin

Community Health

Assessment

Implementation Plan

Development

Implementation/ Outcomes

Monitoring

Hospitals CHNA

SHDs/LHDs

Strategy Development

Implementation Plan

Community Benefits

CHA. Guide ACHI (AHA) Toolkit

Consultants

§ 501(r) Requirements, Form 990 Schedule H

Other Stakeholder and Sector Investments

26 USC § 501(c)(3), IRS Ruling 69-545, and Form 990

Schedule H

Tax-exempt Hospital Reporting & Compliance

A QI Approach to Community Health Improvement A Framework for Alignment and Shared Accountability Community Health Assessment Tools (CDC: MAPP, CHANGE, Community Guide;

HRSA 330 Assessments; Community Tool Box; etc.)

Federal/State grant making (CDC/CTGs, HUD, etc.)

-What criteria and processes are used in setting priorities?

- In what ways do we use evidence to guide decision making?

-What are the alignment opportunities for hospitals and other community interests?

-What are strategies to leverage institutional resources?

-What is the scope of content issues to be addressed in CHI?

-What are issues and options in comprehensive approaches to CHI (e.g., intersectoral)?

-Is there alignment of institutional priorities with shared goals and objectives?

-What organizational oversight mechanisms are needed to ensure broad institutional engagement?

-What are current and potential impacts of technology on outcomes monitoring?

-What are challenges and opportunities in shared policy advocacy?

-How do we define community (e.g., geo parameters), and what are the determining factors?

-What are essential data sources and what are the issues and opportunities in securing them?

-What is the scope of the assessment (e.g., social determinants, community assets)?

-Does it identify small areas for targeted investment?

Key Questions to be Addressed in order to Promote Alignment between Accreditation, NP Hospital CB, and other Community-Oriented Processes

Improved Community

Health Outcomes

-What are approaches and required elements of formal public reporting processes?

- What are roles and links to national and state accreditation processes?

-What is the role of federal grant monitoring?

-What is the role of private sector philanthropy?

-What is the role of federal & state oversight of NP hospitals?

-What is the oversight role of public officials, advocacy groups, and the general public at the local/regional level?

Reporting and Compliance

What is shared ownership, and how is it operationalized (e.g., formal agreements)?

What are the issues and options in determining and reconciling diverse stakeholder roles/contributions?

What are the breadth, depth, and forms of community member involvement?

Kevin Barnett, DrPH, MCP Public Health Institute

San Francisco Department of Public Health

A likely partnership • “Because we have to” – allowed partners to fulfill roles

for collective community impact • Build on existing partnerships and goals • Access to data and increased knowledge base we didn’t

have before • While LHD serves the entire county population, the lines

have been blurred on the communities hospitals and tribal health serve

• Provided a context for shared, not forced, coordination for project activities

Plumas County Approach Three district hospitals Tribal Health Public Health

Other approaches Approaches are unique to each collaborative: Hospitals and clinics Tribal Health NGO’s Academic Institutions United Way PHI Regional approaches

Our way is just one way… Choose a collaborative approach that increases LHD and community capacity Assures sustainability and long term

success Is built on shared philosophy, goals and

core values

CHIP Collaboration

Common vision and shared approach for local partners to carry out our work – governing board support

Foundation to stimulate strategic partnerships towards a broad agenda to collectively influence a healthier Plumas County.

Action-oriented, living document to mobilize the community in areas where we can be most impactful on improving the health.

Encompasses social determinants of health such as education, health insurance, employment and income, and living and working conditions that shape the overall health and vitality of our communities.

CHIP guides the health department, hospitals and clinics and our community partners, in aligning our program development, activities, and resources to collectively improve community health status over the next three years and beyond.

Community Engagement

9 Town Hall meetings 10 focus groups 15 key informant interviews Shared Strategic Visioning process Issues Prioritization training 9 in-person health care partnership meetings 6 Data Indicator Group (DIG) meetings 4 Improvement-Measures-Planning- Accountability-Team (IMPACT)

meetings 2 Strategic Planning Kick-Offs 2 selected public viewings of Unnatural Causes, the award winning

documentary, and countywide, two-day Public Health Summit on the Power of

Prevention

Broad Participation • 400+ residents in 9 Town Hall meetings • 3 hospitals and 1 tribal clinic • 3 local non-profits (research, safety-net,

WIC) • 4 county HHS agencies, housing • Alcohol Tobacco Other Drug Coalition,

Community Corrections Partnership

Jan Feb Mar April May June July Aug Sept Oct Nov Dec 2012

Sept 14, 2012 CHA Draft Assessment

Natl Public HealthWk Apr 2-8, 2012

December 2012

Final Report Indicator Selection

CHA Key Informant Surveys

CHA First Draft CHIP Priorities, Action Items, Report

CHIP Action Plan May 30, 2012

Bi-weekly meetings Jan 17: Vision, roles, indicators Jan 31: Indicators and measures Feb 14: Indicator selection Feb 28: Measures and methodology

Social Determinants of Health Education Viewing of Unnatural Causes Film April 3: Quincy April 5: Greenville

Prioritization Town Halls October 17: Greenville October 18: Portola October 24: Chester October 25: Quincy

CHIP Process Timeline (Jan-Dec 2012)

Sustainability

Ongoing effort blended into the daily work of partners through MOU’s and Letters of Commitment

Reviewing and refining the strategies in the CHIP Action Plan Develop a more detailed plan for standard data collection tools,

monitoring and ongoing evaluation efforts Implementation of the action plans inherently strengthen the public

health infrastructure, enhance shared planning, build on community health partnerships, and promote and support the health, well-being, and quality of life of Plumas County residents.

CHIP partners have agreed to review the CHIP on an annual basis to update the information and to continually, and collaboratively, improve the health of Plumas County.

Foundation of Collaboration Support from CEO’s and Boards of

hospital districts and Tribal Council Dedicated staff with strong connections to

communities Recent demonstrations of successful

collaborative projects across the LHD/Community/Health Care Delivery system with mutually beneficial results

Collaborative Approach Triple Aim

Serves as a foundation for greater community cooperation to meet health needs

Allows hospitals to better coordinate and target community benefit programs

Provides shared direction for deployment of public resources

Stimulates strategic partnerships between healthcare providers, government agencies, and the community for collective upstream strategies

CHIP New era - Public Health and local government, alone do not have

the ability to solve our communities’ towering issues.

Participatory involvement of partners from business, government, non-profit organizations, philanthropic entities

Engage community members throughout the process to systematically address community needs.

Shared philosophy: The journey ahead will require continuous innovation, commitment to excellence, and engagement of not only those within government but Plumas County’s entire citizenship

Philosophy A new approach to solving community problems Everyone works together

Government Business Foundations Nonprofits Schools Clubs You

To tackle most pressing challenges To take advantage of opportunities

“New” Fundamentals

Leverage private and public partnerships built on mutual goals

Frame problems and solutions as systems, not service delivery, issues

Negotiate agreements to realign financing to reach mutual goals

Align incentives and outcomes with political and program goals

Redefining the Role of Counties Policymakers and local communities can lead the way

in how communities fund, define and promote health. County leaders and HHS can bring national and

statewide efforts to local level scale Greater recognition that comprehensive efforts can

have far-reaching effects Environments and the behaviors they foster have more

influence over our health than medical care does. “Health” depends on more than individual access to medical care. It requires that: communities that are clean and safe. opportunities for local residents to do meaningful work. community members having strong social connections and working

together to build and maintain lasting solutions to local problems.

Call to Action Counties as conveners of partners who build

lasting relationships Utilize HHS network to facilitate, link and

leverage resources to improve population health

Model an investment of time, expertise and energy for partners

Partnership is essential given the current landscape

Plumas County Public Health Agency

Mimi Hall, MPH Director

270 County Hospital Road, Suite 206 Quincy, CA 95971

mimihall@countyofplumas.com 530-283-6337

A. Clinton MacKinney, MD, MS Deputy Director and Assistant Professor

RUPRI Center for Rural Health Policy Analysis University of Iowa | College of Public Health

clint-mackinney@uiowa.edu

Improving Health in a Climate of Change NACo San Diego, California January 31, 2014

Clint MacKinney, MD, MS

Price reduction threats and volume reduction pressures

Changes in payment policies and financing sources

Continually evolving quality measures and expectations

Alternative models of care (e.g., telehealth, different care sites, new providers types)

Local health care collaborations and regional affiliations

New ACA emphases Insurance coverage Primary care Financing innovation (incremental)

Major ACA themes Demand for health care value Transfer of financial risk Collaboration and competition

Not just the ACA! Macro economic forces will continue

to drive health care reform

Value = Quality + Experience Cost

But does our current volume-based payment system impede delivering health care of value?

“Successful” physicians and hospitals seek to maximize: Office visits per day Average daily inpatient census Admission percent from the ER Profitability

Is this how to identify and reward a great physician or a world-class hospital?

No, but what to do?

Fee-for-service Capitation Market Single payer

You can always count on Americans to do the right thing – after they’ve

tried everything else.

What about paying for health care value?

Hospital Stay

ER Visit

Office Visit

$20,000

$2,000

Better yet, how about care in the home, workplace, or not at all? Preventive care may reduce the need for acute care!

Bath water Cost-based reimbursement Fee-for-service Few quality demands Inefficiency tolerated

Turning up the heat Decreased per unit price Pressure to reduce volumes Quality demands Competitive market

How to avoid getting cooked?

Volume-based • Pay-for-service (volumes)

• Cost-based reimbursement

• Hospital/physician independence

• Inpatient focus

• Stand alone care systems

• Illness care

Value-based • Pay-for-results

(quality/efficiency)

• Shared risk

• Partnerships and collaborations

• Continuum of care consideration

• Community health improvement (HIT)

• Wellness care

How do we move toward delivering value when our revenue is primarily volume-driven?

How do we not get “soaked” during the transition?

We can “test the waters” with a new set of tools.

Patient-Centered Medical Homes

Accountable Care Organizations

Regionalization

County-Based Purchasing

Connected Community Resources

Information and Innovation

Patient-centered medical homes are primary care practices that offer around-the-clock access to coordinated care and a team of

providers that values patients' needs.

Sources: Commonwealth Fund and 2007 Joint Principles of Patient-Centered Medical Homes.

Access and communication

Coordination of care

Patient and family involvement

Clinical information systems

Revised payment systems

All team members practice at the top (optimum) of their license and experience

Best evidence is the best and only way we deliver care

Care is the same, regardless of the provider

Continuous performance improvement of our care is rigorously driven by data

There are no non-compliant patients, only those we have not reached

An electronic health record is critical to managing patient/population health

Let care protocols do (at least some of) the work (e.g., lab orders, med refills, vaccines)

Crete Physicians Clinic Crete, Nebraska

A coordinated network of providers who share responsibility to provide high quality and low cost care to their patients.*

Medicare requires excellent clinical quality and patient satisfaction based on 33 outpatient measures.

Medicare “shares” savings with ACO if Medicare’s total costs are less than predicted.

*Source: Robert Wood Johnson Foundation. Accountable Care Organizations: Testing Their Impact. 2012 Call for Proposals.

Act locally; think regionally

Economies of scale demand a contracted cottage industry Yet, future health care payment

linked to local covered lives

Goal: To care for populations expertly, efficiently, equitably Options are optional Affiliation is not an end in itself Independence is not a mission Success measured by clinical integration

Resource: Lupica and Geffner. Enlightened Interdependence. Trustee. November/December 2012.

In 1990s, rural counties were concerned about Medicaid HMOs Ignoring county needs, interests, and culture Excluding local providers from networks Denying payments and shifting cost to counties Not reinvesting profits locally Not integrating public health, social services,

and medical providers

A county-based health plan: owned, governed, and managed by 13 rural Minnesota counties

Over 28,000 public health insurance enrollees and over 8,000 contracted providers

http://www.primewest.org

Accountable Rural Community Health (ARCH) – integrates public health, social services, behavioral health, and medical providers using value-based reimbursement

Video-conferencing to increase mental health care access

Technology to improve care coordination

Reduced preventable institutionalizations and other unnecessary health care costs

$10 million in profits reinvested locally as grants to improve access, quality, and health status

2 NACo Achievement Awards (2006): Innovation and Best in Category

http://www.primewest.org

What is available locally to improve health care value? Public Health Social Service Agency on Aging Community health workers Care transition programs Churches and foundations

Do not duplicate Collaborations are less expensive than new

services – and build good will!

Excellent data and resources

Morbidity

Mortality

Health Behaviors

Clinical Care

Social & Economic Factors

Physical Environment

Rural Health System Analysis and Technical Assistance Assess the rural implications of

policies and demonstrations Develop tools and resources to assist

rural providers and communities Inform and disseminate rural health

care innovations

Share an innovation with RHSATA that has moved your organization (or another) toward delivering value.

Continue to be a leadership voice for rural health care value. Our glass is at least half full. A positive attitude is infectious!

www.RuralHealthValue.org

A Rural Community’s Journey - National Association of ......A Rural Community’s Journey . NACo...

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