CONCEPTUALIZING A LEARNING SYSTEM ...aequitasllc.org/wp-content/uploads/2017/09/ECope-IAPHS...Akaki...

CONCEPTUALIZING A LEARNING SYSTEMFORMULTISECTOR COLLABORATION

ELIZABETH L. COPE, PHD, MPHPRINCIPAL, AEQUITAS LLC

22

Acknowledgments

Arbor Research

Tony Cuttitta

Charley Gaber

Kaden Milkovich

Ramya Naraharisetti

Danielle Norman

Amanda Szymanski

University of Michigan

Carlos Mendes de Leon

Hal Morgenstern

Belinda Needham

Healthcare Mgmt Solutions

Christina Compher

Tina Hammack

CMS Project Team

Dawn Alley

Laura deNobel

Mollie Howerton (PO)

William Kassler*

Tiffany McNair

Darshak Sanghavi*

Linda Streitfeld

Alice Thompson (PO)

PCORnet/PCORI

OCHIN/ADVANCE

Public Health RIG

Soc Det Health RIG

Maryan Zirkle (PO)

Experts/Stakeholders

John Auerbach

Peter Briss

Helen Burstin

Mary Crimmins

Jennifer DeVoe

Maria Durham

Andrew Hertz

Erin Holve

Patrice Holtz

David Kindig

Denise Koo

Akaki Lekiachvili

Karen Llanos

Rose Madden-Baer

Sanne Magnan

Marc Manley

Lloyd Michener

Katherine Papa

Sara Rosenbaum

Katherine Sapra

Marisa Scala-Foley

Pamela Schwartz

Elizabeth Skillen

Christa Speicher

Michael Stoto

Andrew Suchocki

Steven Teutsch

*Formerly at CMS.

Project History3

Phase I: Mapping the Strategy (Mar 2015-Sep 2016)

Project: Population Health Measures: Assessment & Design

Support: Centers for Medicare & Medicaid Services (CMS)

Team: Arbor Research; University of Michigan; HMS LLC

Goal: Develop a strategy for multisector collaboration (MSC)

performance measurement in CMS programs & models

Phase II: Launching the Strategy (Ongoing)

Project: A Learning System for Cross-sector Collaboration

Support: Patient-Centered Outcomes Research Institute (PCORI)

Team: Aequitas, OCHIN, PCORnet Social Determinants of Health RIG

Goal: Create a research engine to advance MSC measurement

3

Copyright © 2017 Aequitas LLC. All rights reserved.

WHAT ARE WE TRYING TO DO?

44


Imperative to Change5

Population health model of delivery Treat sick patients manage people’s risk & wellbeing

Person-centered design Equality-oriented equity-oriented

Systems for learning & innovation Adopt best practices adapt good practices

“We’re better together” mentality Additive impact synergistic impact

555


Barriers to Change6

Stewardship: shared responsibility has not resulted in

shared planning & decision-making.

Coordination: disciplinary, operational, & bureaucratic

silos inhibit efficient assessment & implementation.

Responsiveness: evidence/governance gaps undermine fit

& effectiveness (what works? where? for whom? when?)

Dissemination: communication gaps hinder awareness,

uptake, & tailoring of evidence-based practices.

6


WHY DO WE NEED A STRATEGY?

77


The Breadth Challenge: Sectors

*Adapted from: Pop.

Health Measurement:

Assessment & Design

TEP Report (2015).

8888

Clinical Care Seeking/Plan

Clinical Care Receipt

Patient Follow-up/Self-care

Patient Health

Clinical Needs Assessment

Patient Goals & Objectives

The Public’s Health

Needs Assessment

Identify Goals & Objectives

Develop Strategies

Implement Interventions

Evaluate Interventions

Community Health

Needs Assessment

Identify Goals & Objectives

Develop Strategies

Deliver Services

Evaluate Services

Individual Risk &

Prognostic Factors

Social & Physical

Environment

Public Health

Sector

Community & Social

Services Sector

Clinical Care

Sector

HEALTH IMPROVEMENT LANDSCAPE


POPULATION HEALTH

COLLABORATION

PERFORMANCE

9

Tactic Implementation

Local Needs & Priorities

Collective Needs & Priorities

Strategy Implementation

Learning & Innovation

The Depth Challenge: Levels

*Adapted from: Cope EL. AMIA Annual Symposium (2015).

999


Data & Practice

Theory & Policy

Intra-site Assessment

Inter-site Assessment

• Shared Accountability

• Collective Impact

• Shared Value

• Collective Learning

• Shared Authority

• Collective Action

• Shared Responsibility

• Collective Vision

Engaged

STEWARDSHIP

Efficient

COORDINATION

Effective

RESPONSIVENESS

Extensible

DISSEMINATION

4E’s of Collaboration Improvement1010


*Adapted from: Population Health Measurement: Assessment & Design TEP Summary Report (2015).

WHERE DO MEASURES FIT IN?

1111


Capacity is necessary but not sufficient & impact is not immediate.

What does this mean for performance measurement?

Collaboration is a “black box”12

1. Ensure Capacity

32. Assess

Need3. Develop

Strategy4. Execute Strategy

5. Outcomes

Collaboration

6. Achieve Impact

Collaborative Improvement ProcessCollaborative Health Improvement Process

121212


*Adapted from: Population Health Measurement: Multisector Collaboration TEP Summary Report (2016).

Priorities, constraints, enabling conditions vary by locale.

What does this mean for performance measurement?

What happens in the black box?13

1. Ensure Capacity

32. Assess

Need3. Develop


5. Outcomes

Collaboration

6. Achieve Impact

Collaborative Health Improvement Process

131313



Feedback is essential. What implications does that have?

How does improvement work?14

1. Ensure Capacity

32. Assess

Need3. Develop


Collaboration

141414

SpecificMeasures

P

D

S

A

5. Outcomes6. Achieve

Impact




Is the black box relevant?15

1. Ensure Capacity

32. Assess

Need3. Develop


5. Outcomes

Collaboration

6. Achieve Impact

Collaborative Improvement ProcessCollaborative Health Improvement Process

Cross-Cutting Measures

151515

Does the black box really matter?



Can measures work in harmony?16

1. Ensure Capacity

32. Assess

Need3. Develop


5. Achieve Outcomes

Collaboration

6. Achieve Impact

Cross-Cutting Measures

Detect D: > 1 yr

161616

SpecificMeasures

Detect D: ≤ 1 yr


P

D

S

A



PHASE* IMPERATIVES MEASURE CONCEPT POTENTIAL PURPOSE & VALUE

1Engaged

Efficient

Collaboration capacity set

(structures/processes in place?)

Establish common set of capacity metrics

Promote shared infrastructure & interoperability

2Engaged

Efficient

Joint needs assessment

(data- & consensus-based?)

Define priorities via evidence & impact potential

Promote inclusive, data-driven assessments

3

Engaged

Efficient

Extensible

Joint intervention planning

(authority- & evidence-based?)

Develop strategies & tactics with synergy in mind

Promote inclusive, evidence-based planning

4Efficient

Effective

Service-level set: coordination

System-level set: investment

Evaluate boundary work & collective performance

Promote efficiency & aligned strategies/tactics

5Effective

Extensible

Outcome measure set

Dissemination measure set (1)

Emphasize actionable feedback & info sharing

Promote local improvement/accountability

6Effective

Extensible

Impact measure set

Dissemination measure set (2)

Establish common set of outcome metrics

Promote landscape improvement/accountability

What gets measured? When? Why?

*Note: Phase refers to the numbered boxes in the logic model (see slide 16).


17171717

Structure: collaborative capacity

Focus on structures that are sustainable/resilient

Shared governance, infrastructure; system interoperability

Process: joint work & boundary relationships

Service hand-offs & feedback; efficiency & communication

Co-planning, co-implementation, co-learning

Outcome: collaboration effectiveness & impact

Decreased risk, improved outcomes, knowledge-base contributions

Consider short-term: collaboration experience, engagement

Measuring Collaboration18181818


HOW DO WE GET THERE?

1919


Clarify how we think about collaboration

Alignment interdependence & mutual reinforcement

Update how we think about performance measurement

Isolation-/attribution-oriented interaction-/contribution-oriented

Accept that we are building & flying a plane at once

Requires explicit coordination across research, policy, practice

Support change management & combat measure fatigue

Balance safe-to-fail community laboratories with accountability

The Road Ahead20202020


A Potential Vehicle: PCORnet®

A large, highly representative, national

patient-centered clinical research network

funded by PCORI that:

engages people, clinicians, and health system

leaders throughout.

creates infrastructure, tools, and policies to

support rapid, efficient clinical research.

utilizes multiple data sources including EHRs,

insurance claims, patient-reported, & other

sources.

Vision: to support a learning US healthcare system

& enable large-scale health research.

2121

Copyright © 2016 PCORnet. All rights reserved.

PCORnet®: The Power of Partnerships

20 Patient-Powered

Research Networks (PPRNs)

13 Clinical Data

Research Networks (CDRNs)

A national infrastructure for people-centered

health research

+ =+1

Coordinating Center

2222

2 Health Plan Research Networks

(HPRNs)

+


Functions:

Primary liaison between PCORnet & broader research/stakeholder community for that topic area

Manage research interest groups (RIGs) & catalyze multi-network research

Support the Common Data Model & the Front Door


A network within a network

Leverage existing infrastructure & relationships

Learning healthcare system learning pop health system

Venue for intersecting streams of work

Research: evidence-base for multisector collaboration

Practice: structures/processes for collaboration & learning

Policy: performance measure development & implementation

Platform for transdisciplinary policy development

Participatory measure development & testing

Innovations in implementation (e.g. adaptive models, lever mix)

Extending PCORnet® to Policy24242424


Gaps in evidence & infrastructure

Collaboration structures, processes, outcomes

Resilient, multi-purpose infrastructure solutions

New measure development

Collaborative capacity, dissemination/learning

New sets of existing measures

Multi-entity by health topic, cross-cutting outcomes (impact)

Explore implementation approaches

Community-driven measure selection, phased measure sets,

horizontal accountability

An Emerging Agenda25252525


Project planning

Convene workshops for participatory strategic planning

Define scope, approach, work products

Design pilot projects & pursue additional funding

Advisory working group

Perspectives: research, practice, policy, improvement, advocacy

Technical & strategic guidance on initiative development

Inviting collaborators

PCORnet networks & other research groups

Individual stakeholder & research partners

Current Status26262626


Collaborate with us!

A Learning System for Cross-sector Collaboration

Elizabeth Cope, PI: [email protected]

PCORnet Social Determinants of Health RIG

Elizabeth Cope, Co-Lead: [email protected]

Jon Puro, Co-Lead: [email protected]

For more about PCORnet:

Website: pcornet.org

PCORnet Commons: pcornetcommons.org

27272727


BACK-UP

2828


Measure sets that promote mutually reinforcing programs

Use policy levers to create local interdependence

Consider:

Healthcare: daily controller asthma meds for children

Housing: lead abatement in homes

vs

Healthcare: home environmental assessment referrals for children

Housing: reduction of HEA-identified risk factors

Example: Multi-entity Sets29292929


PHASE MEASURE CONCEPT MEASURABLE PROXY

1. Ensure Capacity ---

2. Assess Needs ---

3. Develop Strategies ---

4. Execute Strategies

Community-based programs Participation/investment in programs

Patient-level cessation careDirect quitline referral + feedback system§

Patient-centered cessation plan

5. Achieve Outcomes

Improved awareness/access ↑ Service utilization

Successful behavior change ↑ Quit rate; ↓Tobacco use

Promote evidence-based strategies Participation in learning networks

6. Achieve Impact ---

§Direct referrals involve providers contacting quitline directly (vs making the patient responsible for initial contact).*Adapted from: Population Health Measurement: Multisector Collaboration TEP Summary Report (2016).

Example: Health Topic Sets (Tobacco)30303030


NAME AFFILIATION LOCATION

Elizabeth Cope, PhD, MPHCo-lead, PCORnet Social Determinants of Health RIGPrincipal, Aequitas LLC

Ann Arbor, MI

Mary Crimmins, MAPrincipal Research ScientistPremier, Inc

Washington, DC

Erin Holve, PhD, MPH, MPPDirector, Healthcare Reform & Innovation AdministrationDepartment of Healthcare Finance, Government of DC

Washington, DC

Sanne Magnan, MD, PhDSenior Fellow, HealthPartners InstituteCo-chair, NAM Roundtable for Population Health Improvement

Bloomington, MN

Daniella Meeker, PhD, MSDirector, Biomedical InformaticsUniversity of Southern California

Los Angeles, CA

Carlos Mendes de Leon, PhDDirector, Center for Social Epidemiology & Population HealthUniversity of Michigan

Ann Arbor, MI

Lloyd Michener, MDDirector, Center for Community ResearchDuke University

Durham, NC

Katherine Papa, MPHDirector of Public Health InitiativesAcademyHealth

Washington, DC

Pamela Schwartz, MPHSenior Director for Community Health Impact & LearningKaiser Permanente

Oakland, CA

Michael Stoto, PhDProfessor, Health Systems Administration & Population HealthGeorgetown University

Washington, DC

Steven Teutsch, MD, MPHAdjunct Professor, Fielding School of Public Health, UCLASenior Fellow, Schaeffer Center, University of Southern California

Los Angeles, CA

Advisory Working Group31313131


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