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Too Big to Solve Alone: Minnesota CollaboratesClaire Neely, MD; Keith Olson, DO; Shaun Frost, MD; Bruce Sutor, MD
Session: C11These presenters have
nothing to disclose
December 12, 2017 1:30-2:45
#IHIFORUM
Session Objectives
Participants will:
Describe strategies used to launch a collaborative
engaging health plans and care systems
Learn to use the Collaborative Action Framework to
support their own work
Understand when collaborative action is a beneficial
method to solve complex problems
P2
#IHIFORUM
Speakers
Claire Neely, MD, Chief Medical OfficerInstitute for Clinical Systems Improvement
Keith Olson, DO, Regional Medical DirectorAllina Health Systems
Bruce Sutor, MD, Chair, Clinical Practice
Department of Psychiatry and Psychology,
Mayo Clinic
Shaun Frost, MD, Associate Medical DirectorHealthPartners
All speakers have nothing to disclose
P3
#IHIFORUM
Agenda
This Collaborative: Context
Claire Neely
Opioid Crisis: Prescribing Practices
Keith Olson
Mission Impossible: Mental Health
Bruce Sutor
Engines and Amplifiers: Health Plan Perspective
Shaun Frost
Behind the Curtain
Claire Neely
This Collaborative
Claire Neely, MD
Chief Medical Officer
Institute for Clinical Systems Improvement
• Regional Health
Care Improvement
Collaborative
• 50+ care delivery
organizations
• 3 non-profit health
plans
• Founded 1993
• History of
collaboration
Institute for Clinical Systems Improvement
Is there a compelling
reason for our
organizations to
collaborate in this
market?
What problems are we
facing that we’ve not
been able to solve on
our own?
The Beginning
• Responsibility to
improve health
• Pledge to collaborate
on persistent
problems
• Not solvable by
single entity or by
competition
• Success depends on
our personal
leadership
The Pledge
Why Collaborate
• Problem complexity
• System fragmentation
• Shared population
• Risky to be the market leader
• Support emergent solutions
• Change the market for the region-sustainability
• Avoid the “Tragedy of the Commons”
• It’s been successful before
9
• Children’s Hospital and
Clinics of MN
• HealthPartners
• HealthEast Care System
• North Memorial Health
Care
• University of MN
Physicians
• UCare
• Fairview Health Services
• Essentia Health
• CentraCare Heath
System
• Hutchinson Health
• Medica
• Mayo Clinic
• Hennepin County
Medical Center
• Ridgeview Medical
Center
• Allina Health
10
Collaborative Members
Criteria
• Private sector control and
influence
• Enduring problems
• Aligned with
organizational priorities
• Experts and resources
available
11
Areas of Focus
Collective Impact
• Common agenda
• Shared
measurement
• Mutually reinforcing
activities
• Continuous
communication
ICSI’s role:
• Steward of resources
• Neutral convener
• Relationship mediator
• Manage risk (anti-trust)
• Nurture emergence of
new ideas
• Catalyst
• Keep focus on
collaborative action
12
ICSI’s Role: Backbone Organization
Tasks
• Experts convened
• Scope
• Topic refinement
• Aims and goals
• New teams
convened
• CEO review, revision
and support
ICSI’s role:
• Building a collaborative
platform
• Logistics
• Building trust
• Modeling transparency
• Facilitation
• Evidence review
• Promoting collective
accountability for action
13
Getting Started: January-April 2017
Mental Health• Integrating behavioral
health and primary care
• Improving the care for patients in mental health crisis in the ED
Opioid Crisis• Improve access to chronic
pain treatment
• Improve prescribing practices
• Identify high-risk
• Increase disposal options
ICSI’s role
• Environmental scanning
• Sharing practices
• Problem clarification
• CEO engagement
• Increasing
participation/engagement
• Timelines
• Streamlining processes
14
Discovery & Development: May-Sept 2017
Activities
• Call to Action
packages being
implemented
• Design, prototyping,
testing, spread and
scale
• Measurement
• Evaluation
• Communication and
dissemination
ICSI’s role
• Relationship management
• Re-framing problems
• Transferring leadership
• Environmental scan
• Alignment
• New stakeholders
• Learning networks
• Evidence creation
• Bias toward action
15
Calls to Action: October-Current
• 9 working groups
– MH-Acute
– MH-IBH
– Opioid-Chronic use
– Opioid-Acute
– Opioid-Peds
– Opioid-High risk
– Opioid-Disposal
– Communications
– Measurement
• 3 advisory councils
– Evaluation
– Measurement
– Govt Relations
• Aligned organizations
– Public sector
– Private
• >150 expert volunteers
• CEO convening
16
Current Status
© ICSI 2013
Opioid Crisis: Prescribing Practices
Keith Olson, DO, MHA, FACHE, FACOFP
Regional Medical DirectorAllina Health
• 1.5M OP admissions
• 109K IP admissions
• 60K OP surgeries
• 32K IP surgeries
88 Clinics
• 4.5M clinic visits
13 Hospitals
1919
20
COO=Chief Opioid Officer
21
• The complexity of the opioid crisis requires a multi-faceted, rapid, coordinated effort
• Recognize that everyone in the community has a role to play
• Collaboration• Work on multiple parts of the problem simultaneously• Clarity on the risks of prescription opioids• Re-education of health care professionals• Recognition that addiction is a chronic disease and
treating it appropriately• Agree to a minimum set of standards by health systems
Health Affairs Blog, June 13, 2016
A Systems Approach Is The Only Way to Address the Opioid Crisis
22
• Under treatment of pain• Increase in number of heroin deaths• Provider burnout• Increased use of recreational cannabis• Punitive approach to opioid patients• Increased workplace violence• Increase in Emergency Department visits• Kick the can• Additional demand for services that will further
strain the current healthcare system
Unintended Consequences/Collateral Damage
23
• CEO charge Aim #1: “Achieve significant reduction in the number of pills or morphine milligram equivalents (MMEs) prescribed for acute pain to opioid naïve patient over one year”
• Workgroup composition
• Approach?
o Initial - Decrease acute opioid prescriptions by 20-25% by June 2018 o First Rxs, Post-operative Rxs, ED Rxs, Dental Rxs
oMeasurement - # of pills vs. MME?
Acute Pain Prescribing Work Group
24
• Final Prescribing Recommendations:o Initial patient assessment, realistic expectations of pain,
shared treatment goals, start with non-opioidso If opioids appropriate, lowest possible effective strength
short-acting opioid for shortest period of timeo First opioid Rx for acute pain not to exceed 100 MME
total, instruct patient 3 days or less is enougho For patients presenting in acute pain already on chronic
opioids, opioid tolerant, or on methadone consider Rx for an additional 100 MME with plan to return to baseline
o Geriatric patients assessed for risk of falls, cognitive decline, respiratory or renal impairment. Consider reducing initial opioid dose by 50%
Acute Pain Prescribing Work Group
25
• Postoperative Pain Rx Recommendations:o Minor surgeries? – APAP, NSAIDS, multimodal options
as part of pain management plano Patients taking opioids pre-op should have postop
pain management plan agreed upon before surgeryo If opioids deemed appropriate to manage post-op
pain – low dose, short acting, with plan to taper after 3-5 days
o Surgeon should manage all post-op paino Individualized postop care and treatment but still
possible to recommend maximum postop MME dose
Acute Pain Prescribing Work Group
26
Review data from health plans:
26
Process to Operationalize?
27
• Select top surgical procedures
• Review current average MME and if possible 25th
percentile average MME to establish goals
• Develop consensus around expected pain/recovery – mild, moderate, severe
• Create procedure groupings that fit with 100/200/300 or 400 MME maximum totals
27
Process to Operationalize?
28
• Recommend tools in the EMR to simplify MME calculations, medication choice and dosing
• Suggested components to imbed in the EMR (alerts, order sets)
• Unified educational material for patient, pharmacists and clinicians
• Consensus on measurement specifications
• Suggestions on dissemination and implementation
• Pilot top 32 procedures in participating organizations
28
Potential components of operationalizing
29
• Written report to CEOs in January• Assess results (changes in MMEs) and
unintended consequences and modify plans• Collaborative-wide testing of top 30 procedures
Work group may apply chosen methodologies to remaining procedures to recommend MME maximums
• Develop a method to review and revise recommendations at specific intervals to hold the gains
29
Next steps?
30
• 25% reduction in # of pts receiving 8 or more opioid Rxs between 7-2015 and 10-2017 (2,547 pts)
• Shared Decision Making Opioid Tool
• Educational posters for clinic lobbies and exam rooms
• Care goal around controlled substance management
• All specialty service lines required to have a opioid goal for 2018
• Standardized order sets for IP procedural pain mgmt
30
Allina successes
3131
Sentry report
32
• Design thinking framework
• Shared accountability
• Open communication
• Common goal
• Coordination of care across the continuum
• Shared resources
• Encourage innovation
• Momentum
Benefits of working in the Collaborative?
Mission Impossible
Bruce Sutor, MD
Chair, Clinical Practice
Department of Psychiatry and Psychology, Mayo Clinic
©2017 MFMER | slide-35
©2017 MFMER | slide-36
CEOs’ Directive
Address the mental health care access and delivery needs in Minnesota
©2017 MFMER | slide-37
Getting Our Hands Around the Problem
1) Setting parameters – what are the problems
we are facing?
2) What can we do – what can’t we do?
©2017 MFMER | slide-38
Setting Parameters
1) Shortage of mental health providers
2) Limited access to services
a. Outpatient
b. Inpatient
3) Not enough public sector resources
4) Drugs, Housing, Poverty
5) Long ED stays
©2017 MFMER | slide-39
What Can We Do?
What Can’t We Do?
1) Splitting out primary care access to outpatient
care
2) We can’t boil the ocean –
bed shortage, public resources, social
issues we can’t solve
©2017 MFMER | slide-40
Focus on the Emergency Department:
This is Something We Can Fix
1) Identifying common pain points
2) Getting together
©2017 MFMER | slide-41
Identifying Common Pain Points
1) Limited access to Psychiatry
2) Housing patients in ED vs. treating patients
in the ED
3) Assessment – everyone does it differently
4) Inter-organization trust – is this a dump?
©2017 MFMER | slide-42
Getting Together
1) Problem-solving on access to mental health
resources
2) A move to treatment in the ED
3) Sharing best practices
4) Standardizing assessment
5) Developing a sense of trust
6) Future directions – Telepsychiatry, sharing
lessons learned with Minnesota and beyond
©2017 MFMER | slide-43
Working Group Roles and Responsibilities
The Work
Focus on the values needed by patients, improving safety, health, and trust
Incorporate and standardize best practice
Define common goals
Support organizations and providers by communicating, setting clear expectations, providing tools
Be inclusive of those affected by the change
Balance the tension between audacity and taking first steps
©2017 MFMER | slide-44
Working Group Roles and Responsibilities (cont.)
How We Work Together
Commit time and resources
Share knowledge, new ideas, and wisdom with transparency and honesty
Be ready to act and test new ideas
Serve as a conduit between the collaborative and your organization
Be accountable to values and principles
Do the work; be active
©2017 MFMER | slide-45
Working Group Roles and Responsibilities (cont.)
Qualities Needed
Open-mindedness, generosity, integrity, commitment, persistence, honesty, respect, and courage
©2017 MFMER | slide-46
Working Group Member Responsibilities
As a member of the Collaborative I will:
Commit my expertise, passion, and actions to advancing shared goals of the Collaborative, not only optimizing those of my organization.
Participate meaningfully in meetings and between-meeting work, and expressly communicate if expectations seem unachievable.
Be proactive in speaking up and signaling any concerns about the Collaborative’s direction or activities, and support others in doing the same.
©2017 MFMER | slide-47
Working Group Member Responsibilities (cont.)
As a member of the Collaborative I will:
Work to gain active, ongoing commitment from my organization by engaging other individuals and groups whose interests align with collaborative goals, and serving as a vocal champion within my organization and the community.
Share information and data (both qualitative and quantitative) to support and track the progress of the work.
Recognize that no one person knows everything about the topic. I will listen carefully, be curious about new points of view, speak from my own expertise and experience, and appreciate that complex topics may require time to come to shared understanding and action.
©2017 MFMER | slide-48
Oversight Group Responsibilities
Assure that subgroup activities align to meet specific topic goals and to support the overall success of the topic area and the Collaborative
Take a lead role in assuring that organizational work supports Collaborative goals and vice versa
Assess whether the scope of activity for all Working Groups is within the span of control of the Collaborative, and if not, make recommendations to the CEOs
©2017 MFMER | slide-49
Oversight Group Responsibilities (cont.)
Monitor the external environment to assure that topic activities remain salient and valuable to the community
Monitor relevant activities by other stakeholders in the topic area, making recommendations about widening participation in the Collaborative as appropriate
Provide leadership for the Working Groups
©2017 MFMER | slide-50
TimelinesMH Acute Work Plan 2017-2018
©2017 MFMER | slide-51
How will this help Mayo? How will it help all ICSI organizations?
• More rapid access to care in the ED and to appropriate disposition
• Avoiding inpatient care when it isn’t necessary
• Patient and staff safety
• Developing and distributing best practices
Engines and Amplifiers
Shaun Frost, MDAssociate Medical DirectorHealthPartners Health Plan
Engines and AmplifiersThe Power of CollaborationShaun Frost, MDAssociate Medical DirectorHealthPartners Health [email protected]
An integrated health care organization
Why Community Collaboration?Health insurance plan perspective
COLLABORATION
Standardization
Empathy
Generative Dialogue
Commodification
of Value
Shared Accountability
HEALTH PLAN ROLES
Contemporary Health Plan RolesAmplify community collaboration work
Convener
Analyst
Consultant
Data reporter
Disseminator
Educator
Behind the Curtain: Being a Backbone
Claire Neely, MD
Chief Medical Officer
Institute for Clinical Systems Improvement
Behind the Curtain
Surprisethem
But not too much.
Make sure you know where you are going
Because it’s not a straight
path.
IMPACT
Dissemination
Sustainability
Systems Thinking Evaluation
Action
Knowledge
Sharing
Aims & Goals Commitment
Collaborative Action Framework
65
Aims & Goals
• Important
• Relevant
• Inspiring
• Challenging-but possible
Solve the right problem
66
Commitment
• CEOs
• Working group members
• Volunteers
Collaboratives yield new
strengths and are fragile
67
Systems Thinking
• Logic models
• Driver diagrams
• Ecosystem scan
Monitor for unintended
consequences
68
Action
• Design
• Proto-type
• Confirm
• Spread
• Scale
Answer different questions
69
Evaluation
• Developmental
• Performance
• Summative
• Research
Data gathered and use differ
70
Sustainability
• Clinical• Outcomes
• Patient satisfaction
• Operational• Feasibility
• Staff satisfaction
• Financial
All conditions must be
satisfied
71
Knowledge Sharing
• Transparent measurement
• Learning networks
• Success
Learn quickly, together
72
Communication & Dissemination
• Internal• Ongoing
• Shared messaged
• External• Audience-based
IMPACT
Dissemination
Sustainability
Systems Thinking Evaluation
Action
Knowledge
Sharing
Aims & Goals Commitment
Collaborative Action Framework
Logistics
…build trust
Get on the balcony
To understand the larger
dynamics at play
See possibilities
To reuse current structures
Pace the action
Not too fast, but faster than
they think they can
Iteration is the norm
Perfection is the enemy of
action
The Unexpected
Be fierce