Caring for the community
Regional programs taking concept of ACOS to a much broader level
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.