Reflections on Implementation Innovations and Strategies to Maintain the Momentum

Presented by:Karen W. Linkins, PhD and Jennifer J. Brya, MA,

MPP

HHIF Overview

• 8 Fully Funded Programs (collaboratives)

• 2 Health Plan Lead (Inland Empire Health Plan, Health Plan of San Joaquin)

• 4 Consortium Lead (CCC of San Diego, North Coast Clinic Network, Coalition of Orange County, SFCCC)

• 2 Hybrid Models (Shared lead between Consortium and Health Plan – HIP/Alliance in Santa Cruz, RCHC and Partnership in Sonoma)

Clinic and Collaborative Accomplishments and Changes

• Completed organizational readiness assessments for PCMH certification• Engaged external consultants to facilitate & guide change (via training, practice coaching, PDSA cycles)• Empaneled patients • Established care teams (color coded, “pods”, huddles)•Expanded scope of services (nurses, MAs, front desk)

Clinic and Collaborative Accomplishments and Changes• Used data (consortium/plan generated) and QI metrics (clinic level) to inform practice

• Panel management (outreach, in-reach, follow up)

• NCQA recognition for PCMH

• EMR/registry implementation and use; shared data between clinics, hospitals, consortia and health plan partners

• Facilitated meeting across partners to coordinate joint initiatives, review and validate data

Clinic and Collaborative Accomplishments and Changes

• Implementing care management programs/navigator programs

• Actively defining and revising the role of care manager or navigator

• Understanding how to identify target populations that will benefit from intervention

• Understanding skill sets and characteristics required for effective care teams; mapping intervention model to staff/provider skills and patient needs (clinical expertise, psychosocial connections, navigation/coordination)

Highlights: IEHP

• Tenacity Award -- implementation affected by external factors out of collaborative’s control (governance changes that affected staff capacity, EHR implementation)

• Remained committed to health plan purchasing i2i Tracks to expand capacity of county clinics

• Despite real world challenges, clinics made progress on PCMH transformation through PDSA, QI process, implementing huddles, data sharing etc.  

• Consistent leadership from HP/county clinics, shared vision to improving care for the safety net, and committed partnership

Highlights: North Coast Clinic Network

• Partnership with county social services to streamline and expand access to insurance coverage and other benefits through Patient Assistance Worker

• Improved patient experience through new clinic design, a web-based portal where patients can access their medical records, and inclusion of patients on clinic performance improvement teams to advise on PCMH practice changes

Highlights: Coalition of Orange County

• Resiliency Award – Collaborative persevered despite HP partner leadership changes/instability, withdrawal of 2 clinic partners 1 year into implementation, and mid-stream new clinics partner recruitment

• Created common infrastructure to establish cross-clinic comparability – standardized navigator job description, reporting template for navigator encounters and patient outcomes  

• Developed a tool-kit for PCMH (codified standards, templates, workflow processes, P&Ps) to assist clinics in pursuing NCQA recognition.

Highlights: Santa Cruz Health Improvement

Partnership• Deliberate planning process to develop Health

Navigator Program that combines EBP/best practices with local knowledge and prior experience of PCMH

• Focus on hospital transitions – working with DPH and 2 hospitals to embed nurse care managers at hospitals for HN program, connecting patients back to PCMH in the community

• Developed a "program fit" assessment for new referrals

Highlights: Redwood CHC/Partnership Health Plan• Health plan support of PCHH transformation for

all RCHC clinics through: clinic self assessment tool examining factors associated with PCMH readiness, practice coaching, learning sessions, and financial incentives for PCMH recognition

• Best practices: Support groups for CM teams, regular trainings, sharing lessons learned across the 3 models. PHP coordinating role – offering and sponsoring relevant training content, sharing data, learning from variation across 3 models to inform how to “scale up” .

Highlights: San Diego CCHN

• Investment in an external, local evaluation• Specific commitment to measuring patient and

provider experience beyond the annual satisfaction survey.  (Use of Net Promoter Score (4 questions at the end of each visit), focus groups, phone interviews/surveys)  

• Super Convener – “Meet & Greets” between hospitals, clinics, local health plan to discuss care transitions, data sharing and access points (health plan web portal)

• Always asking provocative questions: “Once the clinics achieve NCQA recognition, then what?”

Highlights: SFCCC

• CEPC (10 Building Blocks of High-Performing Practices, analysis of “burnout”) Making significant contributions to the field of PCMH transformation

• Partnership strength between SFHP, CEPC, SFCCC, SF depart of PH, clinics, capacity to leverage concurrent transformation initiatives

• Practice coaching -- providing in depth, tailored on site TA to clinics to advance their goals toward PCMH

Highlights: Health Plan of San Joaquin

• Stanford Model for patient self management: 2 master trainers and successfully recruited multiple peer leaders

• Controlling costs of care through incentives – HP is looking at both provider incentives (increasing access, coordination of care, improved outcomes), member incentives (self-management)

• Working with county mental health clinic partner, despite limited infrastructure for QI reporting and other HP data analytics, commitment to bidirectional integration. 

Common Barriers & ChallengesCommon Barriers & Challenges

• Maintaining momentum

• Staff engagement

• IT and data sharing/reporting

• Payment reform & discussions around “shared savings”

• Sustaining partnerships

• Capacity & infrastructure to implement team-based care and CCM models  

What does sustainability look like??What does sustainability look like??

• Expanding CM to other clinics

• Expanding data analysis and QI efforts to broader patient population

• Continuing to convene collaborative partners  

• Moving from clinic PCMH recognition to care transitions between hospital and clinics  

• Expanding/implementing technologies -- EHR, registries

What will it take to address sustainability challenges and

maintain momentum toward Health Home transformation?