Integrating health and social services Health in Context

1. Integrating health and social servicesHealth in Context Tom Granatir

2. First, a confession • In favour of system-ness • Not because of “aligned incentives” but because of clear lines of accountability • Evaluation studies look for cost offsets • But variation studies cast doubt on substitution effects • And the real reason to do it is to promote independence, aging in place, LRPP

3. Antecedents • Dartmouth and FIMDM • Variations • Preference based care • The power of engagement • Picker • Personal values • Coordination, continuity, & management of transitions • Communication and decision support • Pain and physical comfort • Anxiety and depression • Family and friends • Choice, transparency, and independence

4. Integration for Frail Elderly • SHMOs – the Program of All-inclusive Care for the Elderly • Integrated delivery systems/PGP: the medical home • Administrative integration – Wisconsin Partnership, MN LTC • Common themes • Integrated funding • Individualised assessment • Team-based treatment • Coordinated care • Rebalancing HCBS and institutional care • Common problems • Medical lens • Definition and standards for social services • Risk Adjustment • Still forgetting something: mental health and AODA

5. PACE evaluations • Cost offsets? • Increased life expectancy • Reduced hospital and nursing home days • Increased (self-reported) health status • Higher general satisfaction with life • Greater satisfaction with overall care

6. PACE v unmanaged HCBS in Washington State • Noncomparable populations – PACE population is sicker, costlier, and at higher risk • Yet PACE significantly reduces risk of dying – by year three, 29 percent of PACE enrollees had died compared to 45 percent of control group • Measurable improvement in physical functioning • Although PACE clients are more costly, rising nursing home costs for the unmanaged population narrow the gap Source: Mancuso et al. 2005. PACE – An Evaluation

7. PACE v. Wisconsin Partnership Programme • Tightly managed v. loosely managed plans • Study compared use of hospitals • PACE enrollees had fewer • hospital admissions • preventable hospital admissions • hospital days • ER visits • preventable ER visits • But no difference in the length of hospital stays. Source: Kane et al 2006. Variations on a theme called PACE

8. Medicare Modernization Act Pilots - GRH - • Competitive Bidding Process • 8 pilot programs chosen • Financial Terms • CMS pays program fees over 3 years on a PPPM • Awardees guarantee 5% net savings off Medicare costs • 100% of fees at risk for achieving savings target • Fee risk also tied to clinical and satisfaction metrics

9. Outcome Analysis Data and Outcome Analysis Part A & B Claims Partner/Lab Data GRH Questionnaires Data Sources Beneficiary-reported Provider-reported Social Security Adm/AHCA Part D

10. Diabetes/ Cardiovascular/ Respiratory Frailty/Immobility 27% 62% 11% Other Clinical Cost Drivers of GRH Beneficiaries Potential co-morbidities associated with: Diabetes/ CVD Respiratory 62% Frailty/ Immobility 27% • Why is this important? • GRH population will age in place • Health Risk increases with age Other 11% *Source: INP, OUT, SNF, DME, HHA, Hospice, Carrier claims. Sum of paid amount for PY1 (11/05-10/06), across all claim types. Claims costs incurred while eligible only.

11. Issues of Frailty Drive Cost in GRH Beneficiaries 100% $25,000 91% 88% 78% $19,118 80% $20,000 $18,676 71% $17,283 61% $14,713 $14,743 60% $15,000 PMPY Costs $12,755 $12,656 $12,496 $12,367 $12,203 Cost Drivers 39% 40% $10,000 29% 22% 20% $5,000 12% 9% $0 0% Yes Yes Yes Yes Yes No No No No No Falls in past 6 months? Skin breakdowns or wounds recently? Pain that interferes with your life? Problems with eating recently? Problems with sleep recently?

12. Deficiencies in Daily Living Activities Drive Cost $25,000 100% 87% 85% 85% $22,208 83% $20,000 80% $20,793 74% 71% $18,694 $18,326 $17,460 63% $16,854 $15,444 $15,000 60% $12,674 $12,184 $12,032 $12,020 $11,470 $11,533 $10,000 37% 40% $9,672 29% 26% $5,000 20% 17% 15% 15% 13% 0% $0 No Yes No Yes No Yes No Yes No Yes No Yes No Yes Doing light housework, like washing dishes? Heavy housework, such as scrubbing floors? Lifting or carrying objects as heavy as 10 lbs? Difficulty bathing or showering? Managing money, like paying bills? Reaching or extending arms above shoulder level? Shopping for personal items, like toiletries?

13. Medication Adherence 1.00 $18,000 $16,117 $14,429 .86 $14,066 0.80 $13,408 $13,254 $13,232 $13,142 .64 $13,215 $12,000 .66 .67 .63 0.60 .62 .61 .62 .61 .57 PMPY Costs PMPY Admits & Visits .51 .44 .45 .44 .44 0.40 .43 $6,000 Cost 0.20 ADL and Medication compliance correlate with increased costs in managed population. IP Admits ER Visits 0.00 $0 No Yes No Yes No Yes No Yes Forget medication? Ever cut back/ stop taking, b/c felt worse? Past 2 weeks, any days you did not take meds? Forget to bring along your meds?

14. Green Ribbon Health Intervention Model Function Health Social Environment Cognitive Psychological Financial Screening, Stratification Identifying Total Patient Needs Through Unique Assessment & Stratification Strategy Domain Assessment Tool (DAT) 1 Unique assessment of seven domains to support integrated treatment model 2 Stratification of Patients for Intervention Based on DAT and Claims Data

15. Getting the Right People the Right Intervention Targeting and Tailoring Stratification Identification DOMAIN RISK 1 ICD9 Code Filter High Medium Low Identification of Frailty Monitor Prevention Prevention 2 Identification of Home Visit Qualifier Co-Morbidity Index EOL Predictors Beers List and Medication Possession Ratios Low Prevention Prevention High - impact COST/UTILIZATION RISK Medium High Impact High - Impact High - Impact High

16. Marrying Acute and Chronic Care Management On-site Telephonic & On-Site GRH FCM Personal Nurse GRHCHE • Group Education • Individual Education • Fall Prevention Assessments • Field Support and Research • Community Resources • Home/SNF/Hospital Visits • Assistance understanding or enrolling in Part D • HHA/DME/Home Modification Assistance • Cognitive assessments & Support • Caregiver Training & Support • Social Service Coordination • EOL/Advanced Directives • Telephonic Intervention • Behavioral Health Referrals • Medication Management • Physician Care Coordination • 24/7 Nurse Triage

17. Management of Advanced Diabetes and CHF Community Resource Integration Customised Directory for Community/Social Services In-Person Assessment & Referral Field care managers provide in-person services Support for management of long-term conditions Community health workers and peer support groups Mental Health: Depression Screening, Mgmt, Referral Assessment and referral to appropriate treatment level Physical Health: Taking Action Silver Sneakers – community gym workouts at most ability levels Evidence-Based Medicine Individualized decision-support and coordination across all presenting conditions Personal Motivation & Change Techniques Personal Nurse Coach Coordination of Care Provider coordination & alerts (e.g., End of Life, drug-drug interaction, cognitive impairment)

18. GRH Support Services • 24/7 365 Access to an RN-Crisis Intervention • Personal Care Manager for Care Coordination Education and Support • Medication Education and Compliance Support • In Person Home and Facility Visits by a Registered Nurse or Master Level Social Worker • Physician Office, Clinic and Hospital Staffing of CM services • Alzheimer's and Dementia Support • Nutrition and Dietary Education & Support • Hospice and End of Life Education & Support • Home Health/DME and Home Modification Coordination • Depression & Grief Education & Support • Social Services Coordination with Community Resources & Healthcare Agencies • Home and Environmental Safety Assessments & Support • Caregiver Training & Support • Group & Individual Classes Focused on Living with a Chronic Condition • Physician Care Coordination • Nursing Home Advocacy Program • Coordination & Assistance of Alternative Living Arrangements • Remote Bio-Metric Monitoring in the Home; such as Daily Weights/BP for Unstable Conditions • Data Analytics and Research Support

19. Links health and social care to address aging and chronic illness Creates "Scorable Savings“ year after year Measurable improvements in health Satisfaction of patients and providers Measurable improvements in quality of life

20. Themes • Accountability • Management • Data • Risk Assessment and Adjustment • Targeting • Tailoring • Measurement • Experience

21. Toward person-centred integration • Most talk about integration focuses on integrating • Financing • Planning • As usual, it is focused on us - the delivery system - and not on people – the patients • Not a model of delivery but a model of inquiry – risk assessment, stratification, targeting and tailoring • Integrated view of personal health risk and health trajectory • Multiple sensors from all sorts of data – capturing all sorts of views of experience • Ecological view of health – understanding context • Delivering services in context that address context

22. Next generation public health • Health 2.0 • Focused on people • Health, not health care • Psychology, sociology, anthropology, ecology • Choice, independence, transparency • Personalisation, engagement, activation • Targeting and tailoring • Ubiquitous technology • System thinking • Patient expertise is valued Expert systems • Focused on the system • Regulation, planning, system engineering • Economics, medicine, engineering sciences • Evidence-based care • Explicit cost-benefit tradeoffs • Value-based health benefits • Value-based purchasing • Cost and quality transparency • Medical expertise is valued