Health Innovation Highlights: February 22, 2018

Full Edition

FROM THE CENTER & OUR PARTNERS

Authentic Consumer Engagement Remains an Elusive Goal

The Health Care Transformation Task Force, on whose board Community Catalyst Deputy Director Susan Sherry sits, has released a report on consumer engagement mechanisms utilized by providers, which found that although leaders at every level of health systems value consumer engagement, many providers still struggle to integrate consumer voices in the design and governance of their programs. As Sherry points out in a news story on the report, the practical challenges of fully engaging consumers within the context of the current way of doing business in the health care industry make meaningful consumer engagement difficult.

The report includes an analysis of:

  • Common terminology utilized by health care professionals;
  • Existing consumer engagement structures, including councils, advisory boards and taskforces; and
  • Efficacy of existing structures in meaningfully incorporating consumer voices at every stage of delivery.

The report identifies community health centers as a key model for engaging consumers that will become increasingly important as the industry moves away from fee-for-service payment models and toward a greater emphasis on quality.

CMS Simultaneously Moves in Opposite Directions

A recent Washington Post article that quotes Community Catalyst Deputy Director Susan Sherry laid out what has been evident to many advocates for some time: the Trump administration is pulling back on moving toward value-based payment methodologies. A CMS spokesperson confirmed that the Obama administration’s goal of moving 50 percent of Medicare payments to alternative payment methods is no longer the aim. Instead, the agency is sending mixed signals by touting the move toward value on one hand while pulling back on and criticizing value-based programs on the other. As Sherry notes, “You try to run a system with these conflicting incentives, and you have your feet in two different canoes.”  The Center will be closely watching new HHS Secretary Alex Azar, who has expressed general support for value-based payment, to see which direction the ship turns next.

ELDERCARE VOICES

Goal-Oriented Care Is Person-Centered Care

David B. Reuben, MD

Millions of older adults live with chronic conditions – those that last a year or more and require ongoing medical attention. Examples include arthritis, diabetes, asthma and chronic lung disease, heart failure, and dementia. Few chronic conditions are curable. Therefore, the focus turns to prolonging survival and reducing symptoms. With advancing age, the likelihood of having two or more chronic conditions increases substantially, often leading to frailty, disability and advanced illness as treatments begin to lose their efficacy and general health and functioning progressively decline.

The care of chronic conditions has traditionally focused on guideline-based care and condition-specific markers of success (e.g., lower blood glucose or blood pressure readings, cancer remission). These outcomes are what might be considered “universal” goals that would be embraced, in theory, by most people who are free of multiple medical conditions and have a long life expectancy. However, many people with multiple chronic conditions, especially those with advanced illness, may not be able (or want) to attain these goals. For them, the focus must be on maintaining or improving quality of life and preserving dignity.

In response to this need, a new approach of goal-oriented, or priority-directed, care is gaining traction. This approach focuses on identifying a patient’s individual health goals within or across a variety of dimensions (e.g., symptoms; physical functional status, including mobility; social and role functions), creating health care plans to achieve these goals and determining how well these individual goals are being met. The underlying foundation of goal setting is identification of and attention to the person’s values. When trade-offs must be made between competing goals (i.e., not all are achievable) or when a short-term goal may not reflect long-term wishes, ascertainment of the patient’s underlying values is crucial.

The goal-oriented approach to health care decision-making, care and measuring of success has a variety of advantages. First, it frames the discussion in terms of individually desired situations and health states (i.e., what a person states she or he personally wants). It also allows people to focus on outcomes that span across conditions and lets the health care team plan treatment for multiple conditions at the same time with the aim of meeting the stated personal goal rather than controlling each individual disease. Finally, by knowing what states are most desired, patients and clinicians can agree on steps that can be taken to achieve these goals and monitor progress in reaching them. This approach allows for effective shared decision-making with the patient selecting the health outcome of highest priority and the clinician determining which treatment strategies are most likely to achieve the selected outcome.

Several approaches have been taken to implement goal-directed care. For example, at UCLA we held focus groups with persons living with dementia and their caregivers to identify an inventory of goals that are important. Examples include being physically safe (e.g., avoiding household hazards or getting lost), being able to maintain a relationship with a significant other, being able to live at home and not being a burden on his or her family. In the case of dementia, caregivers’ goals, such as being able to deal with stress and minimizing family conflict are also important. For dementia, most of these goals are non-medical.

We then implemented goal-oriented care by following a series of steps. Prior to a clinical visit, the list of goals was provided to the patient or caregiver to prioritize them. Then a nurse practitioner with specialized training as a Dementia Care Manager met with the patient or caregiver and facilitated the identification of the top goal, determined what success (e.g., living at home with a 24-hour caregiver) or failure (e.g., living in a nursing home) in meeting the goal would look like and developed a plan to attain the former. At six months, we measured how well the goals were met and people were given the opportunity to set new goals or revise the previously set goals. Most were able to meet their goals and the vast majority of patients and their caregivers felt that the approach was helpful in planning future care and that the goals set were meaningful. They also felt that this process was capturing something different from usual care.

Other approaches have tried to bring goal-setting and the organizing of care around goals into primary care practices by training physicians and other health professionals to elicit and act upon overarching and disease-specific goals.

Although individualized, goal-oriented care has received attention, it has not become widespread. There remain substantial barriers that include a workforce inadequately prepared to elicit individuals’ goals through conversation and listening, to work with older persons to set meaningful, personal measures that capture success or failure and then to actually create plans to achieve them. To do so takes training as well as one-on-one time in clinical settings. Health and payment systems need to recognize that these goals are as important as traditional medical goals for older persons who are frail or have advanced illness. This requires a culture shift from the predominant aim of health care to cure or control diseases. And cultural shifts take time. Yet for those who cannot achieve universally desired goals, the shift towards aiming care at meeting personal goals is essential.

David B. Reuben, MD is Director, Multicampus Program in Geriatrics Medicine and Gerontology and Chief, Division of Geriatrics at the University of California, Los Angeles (UCLA) Center for Health Sciences. He is the Archstone Foundation Chair and Professor at the David Geffen School of Medicine at UCLA and Director of the UCLA Alzheimer’s and Dementia Care program. Dr. Reuben is a past President of the American Geriatrics Society and former Board Chair, American Board of Internal Medicine. 

In 2012, Dr. Reuben received one of the first CMMI Innovations Challenge awards to develop a model program to provide comprehensive, coordinated care for patients with Alzheimer’s Disease and other dementias. In 2014, he was one of three principal investigators to be awarded a multicenter clinical trial (STRIDE) by the Patient-Centered Outcomes Research Institute (PCORI) and the National Institute on Aging (NIA) to reduce serious falls related injuries; it is the largest grant that PCORI has awarded. In addition to his leadership in geriatrics, Dr. Reuben continues to provide primary care for frail older persons, including making house calls.

NOTEWORTHY NEWS & RESOURCES

Scripting Discussions about End of Life Care

Kaiser Health News profiles a program aimed at helping doctors talk to patients about terminal diagnoses. Massachusetts General Hospital in Boston is training hundreds of clinicians to talk early and frankly with patients about terminal prognoses in order to help patients and their families plan more holistically for end of life care. As part of their training, clinicians learn to create a space for patients to talk about their values and goals, as well as to go through the emotional process of receiving a terminal prognosis. In addition to the primary care physicians in the first training cohort Ariadne Labs, VitalTalk and the Center to Advance Palliative Care, the organizations partnering to offer the training, are hoping to train 200 program trainers by 2019.

Mapping the LANscape for Alternative Payment Models

A new brief from State Health and Value Strategies offers a primer on the CMS-funded Health Care Payment Learning and Action Network (LAN) Alternative Payment Models framework. The goal of the brief is to establish a common vernacular for and understanding of the categories of payment models in the framework, including:

  • Fee-for-Service—No Link to Quality and Value;
  • Fee-for-Service—Link to Quality and Value;
  • APMs Built on Fee-for-Service Architecture; and
  • Population Based Payment.

In addition, the brief provides real-world examples of each model for advocates and researchers to draw on in their own work.

Social Determinants of Health with a Hip Hop Beat

The Center for Vulnerable Populations at UC San Francisco has teamed up with young poets at Youth Speaks, a local youth development organization, to create a public health campaign focused on social determinants contributing to Type 2 Diabetes. The video campaign, called “The Bigger Picture” features young people in their communities describing conditions of poverty, food scarcity, wage inequality, housing instability and community disinvestment that contribute to higher and growing rates of Type 2 diabetes for low-income youth of color. Campaign organizers are collaborating with youth groups, physicians and public health communications experts, as well as health advocacy organizations, to engage youth in discussing social determinants of health and to challenge traditional assumptions about how families and communities can address risk factors for preventable disease.

STATE HIGHLIGHTS

New York

The OneCity Health Performing Provider System, which is participating in New York’s Delivery System Reform Incentive Program, has established a $5 million fund to support efforts of its community partners. The application process will be open until March 2. Applicants can apply for funding to design and implement programs to reduce avoidable hospitalizations, improve community health outcomes and address social determinants of health, like housing and food security.

In other news, the New York State Department of Health announced the release of the Health Home Supportive Housing Program Request for Applications. Applicants would be community-based organizations able to provide rental subsidies and non-medical services to homeless Medicaid members participating in state’s Health Home Program.

Finally, New York State Medicaid Director Jason Helgerson has announced that he will leave his position in the Cuomo administration in April. Helgerson, who has directed the state’s Medicaid program for eight years, has had an outsized impact on New York’s efforts to transform its health care system overall, and particularly on the Medicaid program.  He has led the effort to lower spending per Medicaid beneficiary in the state by pursuing strategies that seek to improve care and address the social and economic determinants of health. “Jason Helgerson’s vision has transformed Medicaid in New York state,” said Becca Telzak, Director of Health Programs at Make the Road New York. “His departure marks a big change, and whoever replaces him will have big shoes to fill.”

 

South Carolina

 

The South Carolina Department of Health and Human Services posted the latest stakeholder update for the Health Connections Prime program, the state’s dual eligible demonstration project. Key updates include:

  • Information about new Medicare cards that the Centers for Medicare & Medicaid Services will be mailing out. The new cards will not impact enrollees in this program – they will continue to use the ID card provided when they enrolled in the duals demonstration program.
  • The state and SC Thrive (service provider organization in the community) will host a basic introductory webinar for providers about the duals demonstration program.
  • 2017 compiled enrollment information for the program

Virginia

The Virginia Department of Medical Assistance Services awarded a three-year contract to LogistiCare to continue managing Non-Emergency Medical Transportation (NEMT) services for Fee for Service (FFS) Medicaid-eligible individuals.

KEY DATES

 

Tuesday, Feb. 27 (12-1 p.m. Eastern) – Webinar: Identifying Food Insecurity in Health Care Settings This webinar will webinar present findings from SIREN’s systematic review on health care-based screening for food insecurity. Presented by SIREN, the Social Interventions Review & Evaluation Network. 

Please register for the webinar.

New Disability-Competent Care Webinar Series for 2018

Resources for Integrated Care is excited to announce the 2018 Disability-Competent Care Webinar Series. This series is intended to aid providers and health care professionals in improving the delivery of care to persons with disabilities. Individuals with disabilities enrolled in both Medicare and Medicaid are at higher risk for poor health outcomes when compared to individuals without disabilities. This seven-part series will explore key concepts of the Disability-Competent Care (DCC) model and how organizations can best implement these concepts to empower providers and participants with disabilities to best meet their care needs. The next three webinars are:

Wednesday, Feb. 28 (2-3 p.m. Eastern) – Webinar: Serving Adults With Disabilities On the Autism Spectrum. This webinar will provide a basic understanding of the autism spectrum and will examine the unique care management needs of adults with disabilities who are on the autism spectrum. The discussion will highlight the experience of being autistic and the disparities and barriers these participants experience in obtaining care.

Please register for the webinar.

Wednesday, March 7 (2-3 p.m. Eastern) – Webinar: Palliative and Hospice Care for Adults with Disabilities. This webinar will discuss palliative and hospice care services and the delivery of these services to participants with disabilities. Our discussion will address advanced care planning and strategies for empowering participants and their providers to initiate these discussions.

Please register for the webinar.

Wednesday, March 14 (2-3 p.m. Eastern) – Webinar: Supporting Participants with Complex Behavioral Health Needs. More information about this webinar will be provided soon online at link below.

Please register for the webinar.

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Tuesday, March 6 (2-3 p.m. Eastern) – Webinar: Strengthening Long-Term Services and Supports: Reform Strategies for States.  Presented by the Center for Health Care Strategies, Inc.

Please register for the webinar.

Monday, April 2 through April 30 – The Kresge Foundation will be accepting applications during April for its Emerging Leaders in Public Health (ELPH) initiative. ELPH is an ongoing leadership development initiative launched in 2014 as a way to equip local public health officers with knowledge and skills to lead in today’s changing health care environment. More information is available here.

Monday, April 16 – Deadline for submission of applications for 2018-2019 Health and Aging Policy Fellows program, to begin October 2018. The program aims to create a cadre of leaders who will serve as change agents in health and aging policy to ultimately improve the health care of older adults. Full program and application information here.