Car­ing for the com­mu­nity

Re­gional pro­grams tak­ing con­cept of ACOS to a much broader level

Modern Healthcare - - SPECIAL REPORT - Jessica Zig­mond

About four years ago, Nick Mac­chione, who over­sees San Diego County’s pub­lic health sys­tem, had an idea to ex­pand the ac­count­able care or­ga­ni­za­tion con­cept in a way that would in­volve a much broader range of stake­hold­ers work­ing to­gether to im­prove the health of an en­tire re­gion.

Dur­ing a meet­ing that fo­cused largely on the role of health­care providers in re­duc­ing hos­pi­tal ad­mis­sions, Mac­chione says he re­mem­bers think­ing that the ACO ap­proach alone will do lit­tle to fix frag­mented health­care. “I said we can do bet­ter than ACOs,” Mac­chione re­calls. “We’ve got to do an ac­count­able care com­mu­nity.”

That’s the phi­los­o­phy be­hind the county’s Live Well, San Diego! pro­gram, a com­pre­hen- sive strat­egy that re­lies on in­volve­ment from a va­ri­ety of play­ers other than health­care providers—in­clud­ing schools, busi­nesses, lawen­force­ment agen­cies and faith-based or­ga­ni­za­tions—to im­prove the health of the county’s pop­u­la­tion of more than 3 mil­lion. The con­cept—which doesn’t have the for­mal struc­ture of an ACO—is also tak­ing root in other parts of the coun­try where civic lead­ers are us­ing the “all in” ap­proach to health­care that looks be­yond a com­mu­nity’s hos­pi­tals and physi­cian prac­tices.

That’s hap­pen­ing through San Diego’s pro­gram, which the county board of su­per­vi­sors ap­proved in 2010. The to­tal bud­get for San Diego County is $5 bil­lion, in­clud­ing $2 bil­lion for Mac­chione’s Health and Hu­man Ser­vices Agency. Of­fi­cials didn’t pro­vide spe­cific spend- ing fig­ures for Live Well, but say ev­ery­thing in the agency’s bud­get aligns to ad­vance the pro­gram’s var­i­ous com­po­nents. One ini­tia­tive is

Healthy Works,” which de­vel­ops and im­ple­ments poli­cies that pro­mote bet­ter life­style choices. Through Healthy Works, more than 6,000 peo­ple have signed up for Fresh Fund, a pro­gram for low-in­come res­i­dents on pub­lic as­sis­tance. Mem­bers re­ceive a match of up to $20 a month for ev­ery $20 they spend on fresh pro­duce grown by lo­cal farm­ers.

In Ore­gon, the state launched a health-im­prove­ment ini­tia­tive two years ago that also de­pends on strong com­mu­nity part­ner­ships. Dr. Bruce Gold­berg, di­rec­tor of the Ore­gon Health Au­thor­ity, says Gov. John Kitzhaber, also a physi­cian, had the idea for co­or­di­nated-care or­ga­ni­za­tions, which later re­ceived bi­par­ti­san sup­port from the state Leg­is­la­ture. To­day, 90% of the state’s Med­i­caid pop­u­la­tion re­ceives care through 15 co­or­di­nated-care or­ga­ni­za­tions, gov­erned lo­cally to meet com­mu­nity needs and also op­er­ate on a fixed bud­get.

“The no­tion is that it’s much more than doc­tors and hos­pi­tals that con­trib­ute to our health—it’s hous­ing, it’s where and how we live,” Gold­berg says, adding that the state has re­ceived fed­eral ap­proval to use Med­i­caid dollars flex­i­bly to pay for non­tra­di­tional health­care ser­vices. For ex­am­ple, Gold­berg says the funds could be used to help res­i­dents with hous­ing. Gold­berg says he hopes the CCOs will ex­pand and “en­com­pass more of the ser­vices that con­trib­ute to peo­ple’s health.”

Through­out the ef­fort, Ore­gon is mak­ing sure that qual­ity-of-care in­cen­tives are also part of the CCO model. The 15 or­ga­ni­za­tions will be eval­u­ated each year on 33 out­comes met­rics. The state will give the or­ga­ni­za­tions 98% of the fund­ing, adding the re­main­ing 2% only if per­for­mance tar­gets are met. Gold­berg says the pro­gram is ex­pected to save the state and fed­eral govern­ment a com­bined $4.8 bil­lion over 10 years. As an ex­am­ple of where the sav­ings will come from, Gold­berg says CCOs help pre­vent costly emer­gency depart­ment vis­its from, say, a home­less pa­tient who has chronic con­di­tions and men­tal-health prob­lems.

“When given a global bud­get and in­cen­tive, the CCOs are more likely to pay for and pro­vide in­cen­tives for a va­ri­ety of com­mu­ni­ty­based health and so­cial ser­vices to keep peo­ple out of the ER,” he says.

In San Diego County, of­fi­cials de­ter­mined the path to im­proved health­care out­comes was well­ness, and soon adopted an ap­proach to

fight­ing chronic dis­ease dubbed “3-4-50.” The idea is based on the premise that three be­hav­iors—poor nu­tri­tion, lack of ex­er­cise and smok­ing—lead to four con­di­tions—can­cer, heart dis­ease/stroke, di­a­betes and res­pi­ra­tory ill­ness—that con­trib­ute to more than 50% of all deaths in a given re­gion. Ac­cord­ing to Mac­chione, three-quar­ters of those chronic con­di­tions are en­vi­ron­ment-based, while only onequar­ter is based on ge­net­ics.

County of­fi­cials be­gan to ed­u­cate pol­i­cy­mak­ers and com­mu­nity lead­ers that 3-4-50 could be ef­fec­tive in ad­dress­ing the root causes that were com­pro­mis­ing well­ness and risk­ing the health of San Diego-area res­i­dents. To make a case for how those con­di­tions af­fected health­care costs, Mac­chione says San Diego County res­i­dents spent an es­ti­mated $4 bil­lion on med­i­cal care for the four tar­geted con­di­tions in 2007. “Even if we had the best providers work­ing on this to­gether, it goes be­yond the walls of the exam room,” Mac­chione says. “It’s where we live, work and play.”

Live Well’s strat­egy is based on four core com­po­nents: build­ing a bet­ter ser­vice-de­liv­ery sys­tem to im­prove the qual­ity and ef­fi­ciency of county govern­ment and its part­ners; sup­port­ing pos­i­tive choices by pro­vid­ing more in­for­ma­tion to res­i­dents; pro­mot­ing pol­icy and en­vi­ron­men­tal changes that help make it eas­ier for res­i­dents to make bet­ter choices; and im­prov­ing the cul­ture within county govern­ment to im­prove un­der­stand­ing among county em­ploy­ees and providers about what it means to live well.

The pro­gram be­gan its first phase— “Build­ing Bet­ter Health”— in July 2010. It em­pha­sizes im­prov­ing the health of res­i­dents and sup­port­ing healthy life­style choices. That was fol­lowed in Oc­to­ber 2012 by “Liv­ing Safely,” de­signed to build safer neigh­bor­hoods by work­ing to re­duce crime and abuse and also mak­ing sure com­mu­ni­ties are pre­pared for nat­u­ral dis­as­ters and emer­gen­cies. Still to come is the for­mal roll­out of the third phase, known sim­ply as “Thriv­ing.”

A re­cent re­port high­lighted some re­sults in the first com­po­nent of the Live Well pro­gram, which cen­ters on build­ing a bet­ter ser­vice de­liv­ery sys­tem. More than 20 part­ner­ships be­tween be­hav­ioral-health and pri­mary-care providers have been es­tab­lished, and more than 30,000 res­i­dents have been en­rolled in a low-in­come health pro­gram with ac­cess to phys­i­cal and men­tal-health ser­vices, as well as case-man­age­ment as­sis­tance. In Jan­uary, the CMS named Mac­chione’s agency—along with Palo­mar Health, Scripps Health, Sharp Health­Care and the Univer­sity of San Diego Health Sys­tem—as mem­bers of the San Diego Tran­si­tions Part­ner­ship. Mac­chione says the part­ner­ship fits well with Live Well be­cause it in­cludes so­cial ser­vices and com­mu­nity-based providers to cre­ate a more com­pre­hen­sive de­liv­ery sys­tem.

When he trav­els to pro­mote the mes­sage of ac­count­able care com­mu­ni­ties, Mac­chione says he of­ten re­minds peo­ple that ACOs alone won’t be able to pre­vent health­care costs from ris­ing to a level where they will ac­count for about 20% of the na­tion’s gross do­mes­tic prod­uct by 2020. In­stead, he un­der­scores a shared ap­proach that will take a “cadre of part­ners.”

“Ev­ery com­mu­nity will have its story on how it’s mo­bi­liz­ing it­self,” Mac­chione says. “For some com­mu­ni­ties, it’s go­ing to be through the govern­ment, some it will be the not-for-profit side. The ‘who’ doesn’t mat­ter ini­tially, so long as it’s done in a way that is inclusive in the prob­lem-solv­ing.”

Diane Cardwell, vice pres­i­dent of health­care so­lu­tions at Trans­forMed, a Kansas City, Kan.based group that con­sults with physi­cian groups in­ter­ested in de­vel­op­ing pa­tient-cen­tered med­i­cal homes, sees great po­ten­tial in the com­mu­nity-based ap­proach. She says ACOs are still try­ing to fig­ure out their own struc­tures and are look­ing first to tra­di­tional part­ners, such as pri­mary-care providers and spe­cial­ists. A great chal­lenge for com­mu­nity stake­hold­ers is they have no for­mal ties to an ACO’s le­gal or fi­nan­cial struc­ture, Cardwell says.

“I know many en­ti­ties—men­tal health and home health—get frus­trated be­cause they want to com­mu­ni­cate and it’s not be­ing re­ceived on the hos­pi­tal end,” she says. “So when they are in­vited to the ta­ble, I think they will be ea­ger.”

Cardwell also says there are par­al­lels be­tween the med­i­cal-home model and the ac­count­able care com­mu­ni­ties ap­proach. She sees the ACO as a le­gal and fi­nan­cial um­brella, and the med­i­cal home as the cat­a­lyst to the com­mu­nity.

“The con­cept of the ac­count­able care com­mu­nity is ex­tend­ing that le­gal and fi­nan­cial struc­ture to out­side stake­hold­ers,” Cardwell says. “If I’m—as a med­i­cal home—try­ing to serve my pa­tient pop­u­la­tion and I need a part­ner with home health or men­tal health, but this pa­tient is cov­ered un­der the ACO model, how do we con­tract for those ser­vices, be­cause they can pro­vide those re­sources more ef­fec­tively and have re­la­tion­ships?” she asks. “We don’t want to re-cre­ate the wheel.”

That’s true in Madi­son, Wis., says Dr. Philip Bain, chief of in­ter­nal medicine at Dean Clinic East, part of SSM Health Care. Last year, Dean Clinic formed an ACO with Madi­son-based St. Mary’s Hos­pi­tal. While Bain says he hasn’t heard of the ac­count­able care com­mu­nity con­cept, he says it’s a good idea and sim­i­lar to some ex­ist­ing pro­grams in his re­gion that in­volve or­ga­ni­za­tions out­side of health­care, such as United Way of Dane County.

As part of the United Way’s “Safe & Healthy Ag­ing” pro­ject, the ACO works with the Wis­con­sin Phar­macy Qual­ity Col­lab­o­ra­tive to of­fer a soft­ware pro­gram com­mu­nity phar­ma­cists can use to help man­age pa­tients’ med­i­ca­tions. United Way is also a mem­ber of a fall-preven­tion task force that’s part of Safe Com­mu­ni­ties of Madi­son-Dane County, a not-for­profit in­jury-preven­tion coali­tion. Cheryl Wit­tke, ex­ec­u­tive di­rec­tor of Safe Com­mu­ni­ties, says she would love to see a for­mal part­ner­ship be­tween hos­pi­tal sys­tems and com­mu­nity or­ga­ni­za­tions.

Wit­tke’s group was es­tab­lished 14 years ago, so it has worked with health­care or­ga­ni­za­tions well be­fore the ACO model be­gan to emerge. As part of her group’s fall-preven­tion pro­gram, the or­ga­ni­za­tion works with lo­cal hos­pi­tals to train oc­cu­pa­tional ther­a­pists, phys­i­cal ther­a­pists and nurses to of­fer classes on how to pre­vent falls. It also serves as a sort of match­maker be­tween health­care providers and other com­mu­nity mem­bers, such as churches, to ed­u­cate res­i­dents about pro­grams. Wit­tke says she hopes the ef­forts will bol­ster com­mu­nity re­la­tion­ships.

“There’s a par­a­digm shift,” she says, “and more of a fo­cus on care tran­si­tions and com­mu­nity part­ner­ships that are look­ing at more ev­i­dence-based, out­comes-based ini­tia­tives.” TAKE­AWAY: A grow­ing num­ber of com­mu­ni­ties are look­ing be­yond health­care providers in their ef­forts to stay healthy.

Mem­bers of San Diego County’s FilipinoAmer­i­can Em­ploy­ees As­so­ci­a­tion go hik­ing to pro­mote phys­i­cal fit­ness as part of the county’s “Live Well” pro­gram.

Com­mu­nity gar­den­ing pro­grams help pro­mote the healthy-choices goals of San Diego County’s well­ness ef­forts.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.