Health Innovation Highlights: April 10, 2019

Full Edition

FROM THE CENTER & OUR PARTNERS

Vlogging and Blogging on Health System Transformation!

In our first-ever Video Blog (Vlog), Pennsylvania volunteer leader Debbie McCarthy-Arnone discusses the power that older adults can have when they acquire advocacy skills that can help them speak up to improve programs that serve them.

In this (more traditional) blog post, Center Deputy Director Renée Markus Hodin writes about her participation at a recent Oregon Health Authority Transformation Center meeting focused on the state’s CCO Community Advisory Councils (CACs). In the blog she outlines how policymakers can create a solid framework for authentic engagement and the ways states can use that structure as a starting place to improve consumer health overall.

Analyzing CMS’s Top Ten Opportunities to Better Serve Dual Eligibles

A recent Center publication looks at CMS’s December 2018 State Medicaid Director Letter outlining ten opportunities to better serve the 12 million people enrolled in both Medicare and Medicaid (dual eligibles). This letter groups these opportunities into three categories:

  • Medicare-Medicaid integrated care
  • Medicare data
  • Improving beneficiary experiences and reducing administrative burden.

Our publication summarizes this letter, provides the Center’s “take” on the options, and rates each as “Yes, but Monitor Details,” “Proceed with Caution” or “Risky” in order to provide a fuller understanding of the implications of CMS's opportunities. Our goal with this analysis is to provide advocates a fuller understanding of the options CMS is presenting to states. We urge advocates to reach out to their state agencies to better understand which, if any, of these options they are considering and to work to protect the interests of dual eligibles.

IHI Open School Hosting Center’s Video Series on Care for Individuals with Involved Disabilities

In February, the Center released a new video series that explores the ways traditional medical systems fail people with involved disabilities, and how the values of the Independent Living model and home-based primary care can create real, meaningful improvements in quality of life. The series is offered in four parts and features Dr. Robert Master, Founder of the Commonwealth Care Alliance, as well as other clinicians and consumer leaders with expertise in accessing or delivering medical, behavioral and social services designed for people with complex needs. The videos are now also being hosted on the Institute for Health Improvement’s (IHI) Open School  where they are accompanied by several learning objectives and discussion questions.

NOTEWORTHY NEWS & FEATURES

NASHP Blog and Chart Show How 12 States are Structuring Accountable Health Entities

The National Academy for State Health Policy (NASHP) has developed a comparison table of accountable health entity governance structures in 12 states. This table examines the goals and functions of each entity’s governing body and the language that was used to ensure meaningful community engagement in the operations of the accountable entity. A companion blog post provides an overview of the methods used in these new models.

Multi-Stakeholder Consortium Releases Consumer Engagement in Care Delivery Resource

The Health Care Transformation Task Force (HCTTF), a consortium of patient, payer, provider and purchaser representatives, released an implementation framework to support providers in delivering person-centered, value-driven care. The framework is organized around three core elements: 1) coordination of care and systems of care; 2) shared and empowered decision-making; and, 3) individual activation for self-management. Each element also includes a checklist of best-practices. This resource is meant to provide "a guidepost for providers as they develop and expand all-important patient engagement capabilities."

New Study Examines Impact of Collaborations Between Health Care and Social Service Organizations on Improving Health

A new study published in Medical Care, investigates the features of collaborative ties between health care and social service organizations and their impact on avoidable health care use and spending for older adults. Results show that these cross-sector engagements may reduce preventable health care use and spending. The study recommends leveraging Area Agencies on Aging when looking to foster effective partnerships. [paygated content]

NYC Dept. of Health Making Investments in Addressing Longstanding Health Inequities 

An article in Health Affairs profiles an important initiative by the New York City Department of Health and Mental Hygiene (DOHMH) that grew out of its decision four years ago to commit to a deliberate effort to create more racial equity in health care and outcomes throughout New York City. In 2014, DOHMH decided to change how it evaluates its programs by adding equity as a lens through which it studies public health outcomes. The article examines one of three Neighborhood Health Action Centers created by the initiative in New York City areas that bear the highest disease burdens – the Brownsville section of Brooklyn. The article describes promising indicators to date, but also the many challenges involved, and the need for long-term commitment to achieve longer-term equitable health outcomes.ELDERCARE VOICES

ELDERCARE VOICES

Embracing Population Health to Improve Care for Older Adults

Ana Tuya Fulton, MD, FACP, AGSF

Just about 25 years ago, I learned about the field of geriatric medicine and became exposed to what would become my career, and the most rewarding work I could have imagined. As a pre-med student, I was searching for summer internship opportunities. I reached out to the Department of Geriatrics at George Washington University, and they responded with a pleasant invitation to shadow their geriatricians, nurse practitioners and researchers for the summer to give me a taste of what careers in medicine might be like. As cliché as it may sound, I had no idea as I walked in on the first day of that three-month internship that the experience would alter my path forever. I left not only convinced that I would be a physician, but that I would be a geriatrician. I am excited to be part of the evolution of older adult care; the changes that have already taken place, and the continued prospects to bring improved awareness, quality of care and support to older adults.

The emergence of value-based models of care has brought increased attention to improving coordination and quality while reducing unnecessary procedures and increasing attention to quality of life and patient-centered, individualized care. This atmosphere of change is well suited to advancing models of care that are designed for older adults’ specialized needs, since those needs naturally fit these new priorities. As an example of how systems have evolved to provide this care, I’d like to share developments at Care New England health system (CNE) in Rhode Island, the second largest system in the state. In 2014, CNE embraced population health by forming a large accountable care organization (ACO), Integra Community Care Network, LLC (Integra).

As the culture in the health system became increasingly focused on improving quality of care for populations, particularly those ill and frail patients in the system, and improving care coordination and services, many needs for clinical programming were identified. One clear need was for a system-wide, comprehensive and interdisciplinary program in geriatrics. Needs assessments done with hospital-based teams, primary care teams and patients of the Integra ACO demonstrated that frail older adults were not getting the care they needed within the traditional models of care. Older adults needed more care and support at home and more care coordination resources. At the same time, primary care teams needed resources on – and help with addressing – goals of care, assessing older adults for cognitive and functional decline, and earlier identification of those patients at risk of increased utilization. Also, inpatient teams needed help managing older adults with complex needs, particularly those that developed complications such as delirium during inpatient hospital stays. 

Since 2014, the CNE comprehensive program for older adults has developed and grown to have four geriatricians, one geriatric and palliative care nurse practitioner and one social worker. The programming varies across the hospitals and operating units in the health system, and targets needs based on the patients and providers served by each respective location. These programs include an inpatient consultation service that serves patients at Kent Hospital and at Butler Hospital (an inpatient psychiatric hospital with a senior specialty unit), and an outpatient consultation practice that helps primary care teams by providing consultations for dementia evaluation and treatment and geriatric assessment for screening and treatment of geriatric syndromes. As of February 2019, Kent Hospital also has a focused, 10-bed ACE (Acute care for Elders) unit, providing interdisciplinary care aligned with the Age-Friendly Health Systems four M’s model. Those four M’s focus on the key issues and needs of older adults – mentation, what matters, mobility and medications. This unit has already shown improved patient and family satisfaction, better identification of underlying cognitive impairment, prevention of delirium and improved coordination of care.

A specialty outpatient consultation practice exists to serve older women in the gynecology oncology practice at Women & Infants Hospital. This practice works to help the primary gyn-oncologist stratify risk using geriatric assessment results to support shared decision-making with patients. Finally, geriatrics is closely involved in the programming of the Integra ACO. Clinical support is provided to the primary care teams and the numerous nurse care managers who care for the sickest, highest need patients as part of the Integra complex care management team. Additionally, since September of 2018, Integra has formed a hospital at home program (Integra @ Home). This program focuses on the care of frail older adults over age 80 who meet certain criteria and have chronic conditions and desire hospital-level care at home.

All the programs developed at CNE are ones that exist in other health systems nationwide and have long been considered geriatrics “best practices,” with strong evidence bases for improved outcomes, quality of care and patient satisfaction. The exciting development is that now, with the encouragement of the age-friendly health system culture change movement and value-based care ACO evolution, the resources to build and spread these models of care is becoming available and embraced by C-suites that in the past have been reluctant to commit to the up-front costs to build these interdisciplinary models that could only promise cost avoidance and not always increased revenue.

It’s an exciting time to practice as a geriatrician and with the increased spread of awareness by the powerful organizations behind the Age-Friendly Health Systems, a future where the field will receive increased support, growth and new interest is tangible. However, the work must not stop at health systems. Next steps will be needed to make communities, housing, transportation and other infrastructure just as age-friendly for the rapidly growing older adult population. While much work lies ahead, the challenges now seem surmountable and support for doing the work, high.

Ana Tuya Fulton, MD, FACP, AGSF, an internist and geriatrician, joined the faculty of Brown University in 2006 and holds Associate Professorships in Medicine and in Psychiatry and Human Behavior. Dr. Fulton is Executive Chief of Geriatrics & Palliative Care for Care New England health system and Medical Director for Integra Community Care Network, LLC. Additionally, Dr. Fulton is the Care New England Co-Project Director for the Rhode Island Geriatric Workforce Enhancement Project (RI-GWEP). This is a HRSA-funded collaborative agreement to integrate geriatrics and primary care and to improve the care of older adults across the state of Rhode Island. Dr. Fulton’s clinical and academic work focuses on improving serious illness care for persons with cognitive impairment as well as integrating geriatrics best practices into primary care, hospital-based care and accountable care entities. She has done multiple national presentations in these areas and has published over 26 peer-reviewed articles.

STATE HIGHLIGHTS

California

The California Department of Health Care Services (DHCS) posted its response to stakeholder feedback on activities to help improve the Cal MediConnect Program (CMC), the state’s dual eligible demonstration project. Based on this feedback, DHCS intends to make, or has already implemented, improvements in the following areas: care coordination, connecting members to benefits, data sharing and reporting and enrollment.

Illinois

The Illinois Department of Healthcare and Family Services has formally requested that CMS grant an extension for its Medicare-Medicaid Alignment Initiative, the state’s dual eligible demonstration project. The extension would go through at least Dec. 31, 2020 with a possible extension through Dec. 31, 2022.

Pennsylvania

The Pennsylvania Department of Human Services (DHS) issued a Request for Information (RFI) to gather input and information about the application and enrollment services for beneficiaries who receive long-term services and supports (LTSS) and other benefits through the Office of Long-Term Living (OLTL). Specifically, the RFI is looking for information to assist DHS in determining how to improve its LTSS application and enrollment process, including services provided by the OLTL Independent Enrollment Broker. To improve on the current process, the Department believes that the new procurement should include the following elements:

  • Conflict-free enrollment and choice counseling
  • A more streamlined process with a single application and enrollment services entity
  • An emphasis on individualized case management through a regional presence and assignment of a personal enrollment case manager to each LTSS applicant
  • Improved customer service and assistance to LTSS applicants, including an in-home visit at the outset of the process, and help in completing and providing documentation to support the LTSS application
  • Decreased service fragmentation and more efficient, effective and consistent operations through consolidation of clinical eligibility functions
  • Improved communications and better use of technology Better engagement and communication with other community partners
  • Enhanced accountability and quality control

In other news, last month, The Inquirer reported on Pennsylvania’s Community HealthChoices (CHC) managed LTSS program. This program rolled out in Southeast Pennsylvania on Jan. 1, after first starting up in the Southwest region in 2018. As reported in the article, rollout has been confusing both for the beneficiaries, particularly for those who have complex medical situations or a cognitive impairment, and for providers. CHC will roll out in the central region in 2020.

KEY DATES

Monday, April 15 (12:30-1:30 p.m. Eastern) - Webinar: Advancing Systems of Care for Individuals with Serious Mental Illness: A Conversation with the NQP Serious Mental Illness Action Team, presented by the National Quality Forum. Please register for the webinar.    
 
Wednesday, April 17 (1:00-2:00 p.m. Eastern) - Webinar: Activating Local Communities to Successfully Address Opioid Addiction and Recovery, presented by Health Management Associates. Please register for the webinar.

Friday, April 19 (2-3 p.m. Eastern) - Webinar: Consumer-Centric Scoring of Healthcare Price and Quality Transparency Tools, presented by Altarum Healthcare Value Hub. Please register for the webinar.  
 
Thursday, April 25 (2:00-3:00 p.m. Eastern) - Webinar: Involving the Patient Voice in Serious Illness Measurement, presented by the National Quality Forum. Please register for the webinar.    

Tuesday, May 7 (2-3 p.m. Eastern) - Webinar: The Messages We Send: Stigma Towards Persons Living with Dementia and How to End it, presented by the American Society on Aging and the Administration for Community Living. Please register for the webinar.    
 
Tuesday, May 21 (3:00-4:00 p.m. Eastern) - Webinar: What Are the Top Medicaid Trends to Watch? presented by Manatt. Please register for the webinar.