Well Megan thank you so much for joining us on the move to value podcast and we're really excited to talk with you today about the great work that you're doing at the population health at Advocate Health so, can you tell us a little bit about your role at Advocate Health and what you guys do?

Yes, thanks for having me Melissa. So I'm assistant vice president with population health in the Midwest region with Advocate Health. We have recently merged, I should say combined, back in December of 2022, and you know population health and moving to value is a strong tenant of Advocate Health and we've been doing this work for some time and excited to share our journey with you.

Great! So I know that you kind of mentioned there's been a few changes in the past year or so with Advocate Health, so can you explain a little bit about what's happening at the population health level?

Yes. So we are coming together across both the Midwest and the southeast region. I will talk - so Advocate, which is the legacy Advocate Aurora in the Midwest and then Atrium in the southeast - what I'll speak to today is specifically the Midwest, that's really where my history is from and the work that we've been doing there.

So can you tell me a little bit about Advocate Aurora the areas that they came from? I know it's two separate states and I always I tend to get them confused so I'm just curious

Sorry about that so that's a problem it's Illinois and Wisconsin. We have about 6500 physicians that are participating in value-based care. Wisconsin is mainly an employed Medical Group with some independent tins that that participate in value and then Illinois is a strong pluralistic model with both a Medical Group and independent, what we call aligned physicians, that participate in a large clinically integrated network. We have about 1.3 million lives participating in value-based care contracts across both Illinois and Wisconsin, and we've been doing this as I said for some time. The clinically integrated network in Illinois has roots back to 1995 and became a clinically integrated network, one of the first in the country in the early 2000s. So currently have over 40 different value based care contracts that we participate in. We do have, we've moved a lot towards risk, so we have $1.2 billion in capitation risk that we currently take and that's actually where we we started a lot of our journey taking that risk, so you know and then have moved on to other programs as well within shared savings etcetera.

So I'm curious you talked about capitation. What does that journey look like for providers? For your independent providers versus your employed providers? Has that been difficult? Just curious about that that journey for Advocate?

So we started in capitation in 1995, so we've been at this for for quite some time, probably a different story than others across the country who have started with the shared savings platform and then moved to capitation or are looking to move to capitation. We really started with full risk and then also as the as the country started to take on more value based care contracts um started to get into those as well. So we have always looked at a support model that has wrap around services to our physicians participating in value based care contracts and how we really help support them be successful, and it's a true partnership between operations at the local level and...]]>In this episode Melissa Pollock, CHESS Director of ACO Compliance and Regulatory affairs has a conversation with Megan Reyna, System Vice President of Population Health Midwest for Advocate Health about how they approach value-based care through wrap around services for the provider allowing better care for the patient.

Well Megan thank you so much for joining us on the move to value podcast and we're really excited to talk with you today about the great work that you're doing at the population health at Advocate Health so, can you tell us a little bit about your role at Advocate Health and what you guys do?

Yes, thanks for having me Melissa. So I'm assistant vice president with population health in the Midwest region with Advocate Health. We have recently merged, I should say combined, back in December of 2022, and you know population health and moving to value is a strong tenant of Advocate Health and we've been doing this work for some time and excited to share our journey with you.

Great! So I know that you kind of mentioned there's been a few changes in the past year or so with Advocate Health, so can you explain a little bit about what's happening at the population health level?

Yes. So we are coming together across both the Midwest and the southeast region. I will talk - so Advocate, which is the legacy Advocate Aurora in the Midwest and then Atrium in the southeast - what I'll speak to today is specifically the Midwest, that's really where my history is from and the work that we've been doing there.

So can you tell me a little bit about Advocate Aurora the areas that they came from? I know it's two separate states and I always I tend to get them confused so I'm just curious

Sorry about that so that's a problem it's Illinois and Wisconsin. We have about 6500 physicians that are participating in value-based care. Wisconsin is mainly an employed Medical Group with some independent tins that that participate in value and then Illinois is a strong pluralistic model with both a Medical Group and independent, what we call aligned physicians, that participate in a large clinically integrated network. We have about 1.3 million lives participating in value-based care contracts across both Illinois and Wisconsin, and we've been doing this as I said for some time. The clinically integrated network in Illinois has roots back to 1995 and became a clinically integrated network, one of the first in the country in the early 2000s. So currently have over 40 different value based care contracts that we participate in. We do have, we've moved a lot towards risk, so we have $1.2 billion in capitation risk that we currently take and that's actually where we we started a lot of our journey taking that risk, so you know and then have moved on to other programs as well within shared savings etcetera.

So I'm curious you talked about capitation. What does that journey look like for providers? For your independent providers versus your employed providers? Has that been difficult? Just curious about that that journey for Advocate?

So we started in capitation in 1995, so we've been at this for for quite some time, probably a different story than others across the country who have started with the shared savings platform and then moved to capitation or are looking to move to capitation. We really started with full risk and then also as the as the country started to take on more value based care contracts um started to get into those as well. So we have always looked at a support model that has wrap around services to our physicians participating in value based care contracts and how we really help support them be successful, and it's a true partnership between operations at the local level and that's operations with the hospital, that's operations with the Medical Group, and that's also the practicing physicians and their practicing teams as well back at their practices and how we are able to innovate and come up with new solutions to issues that we're trying to solve and how we can show success within value based care contracts - capitation or shared savings.

That's really interesting because it's almost like you guys did it backwards, I think, than what most of the healthcare systems in the country are, you know, they're trying to progress towards capitation. As far as population health data and analytics, you mentioned a little bit about helping wrap around services for the providers. What does that look like for Advocate? what kind of services have you guys provided and analytics to help the providers in value-based care?

So analytics and data is the root of everything that we do in population health. It's how we tackle our issues it's how we tackle our problems and really overcome our obstacles. We not only have data and really look at data across at the enterprise level but then we also look at data really locally. So locally at a hospital area and then locally within a physician practice as well, and what we try to do is really take a medical economics perspective of where, from a larger system perspective, do we have areas of opportunity that we need to go deep on, and then also from that practice perspective about where do they need support, and where do they need to focus. And so we have an infrastructure within the hospital and the local practicing physician area that looks at data to say, where do we have an opportunity with readmissions and then we start to go deep. And what do we need to do to really improve that admission those readmissions. Is it on a specific disease state, is there something with access that we need to fix, what is it that we need to get to that root cause? And then in a practicing physician level really where are their issues with being able to close care gaps and where do they need to focus? And we have an entire team that really works with our practices to say you have an opportunity in this care gap or how you know what's your workflow look like and how can we can how can we help support that? One of the programs that I am most proud of that we started a little over a year and a half ago is our comprehensive annual visit which came out of looking at data and realizing that after we completed Medicare Wellness visits we still have 45% of our care gaps open. And we looked at how can we provide an innovative program which is taking a nurse practitioner seen as a an extender of that physician practice to help go into patients’ homes and close those care gaps that were still open after the Medicare Wellness visit and so we're proactively working with our physician practices and sending nurse practitioners out into patients’ homes and closing those care gaps and we've seen great success within that program. We also have physicians who are able to refer into that program and really see that program as an extension of their practice and help them succeed within value.

That's a really amazing program to hear about. Just the fact that they're going to the patient’s home and trying to you know close those care gaps at a place that maybe you know patients aren't always able to come in and we've seen those barriers over the years. Have you done a lot of visits this way? Have you seen it be pretty successful?

Yes. So last year we completed over 700 visits and we were able to reevaluate over 1400 chronic conditions, close over 650 quality care gaps that that were still open, and we're looking to expand that program. So saw a lot of success with that program and that was just within our Medicare Advantage space and now how do we expand that program to our other value contracts to continue to close those gaps in care and make sure that patients make sure that patients are able to get the services that they need? And one of the great things about that program, like you had just said Melissa, is that sometimes these are patients who aren't coming into the primary care practice and so how do we get them connected with services such as advanced practice at home or how do we get them if they need home health etcetera, to be able to manage their chronic conditions? We also a core tenant of this program is really making sure that patients get that needed primary care visit if they don't already have one, and so one of the things that we do before we leave the home is actually schedule that appointment for that patient and make sure that they have the needed transportation, it's on a day that they can get there, to get back into care so that there isn't that gap. We're not just going to the patients home and then leaving and continuing to have gaps in care.

That's really great, kind of meeting the patient where they're at I really love that idea and it makes me think about kind of the buzz term that we're hearing now about health equity, which also makes me think about a contract that you and I have worked together on that CHESS is involved in, and Advocate as well, which is the ACO REACH program through the Innovation Center. I'm curious how you guys have seen this innovative model that CMS has put out as kind of a catalyst for population health in communities? I think that's from you know from my understanding that's really the focus of ACO REACH is something new and different in payment structure but also with a really intentional focus on health equity for populations of patients, so just curious what you guys are seeing on the Advocate Health side in that contract?

Yes. So in the Midwest we very intentionally went into this program to look at our populations of patients that would most benefit from this program. So we actually segmented out of our Medicare and shared savings program some tins and that's tax ID numbers that participate within that that are practice participates within the Medicare shared savings program which practices would most benefit and ultimately patients would benefit from ACO REACH. So we very intentionally limited and focused for that program and the idea is if we have the right value based care contract that's going to help patients succeed in managing their conditions, then we are going to also be successful. And so we looked really at different pockets of populations within Milwaukee and then the South side of Chicago and are really innovating on our care model to participate in that ACO REACH program. After we have our ROI and really a model that's going to be successful, we will continue to spread that model to our other value based care contracts the ACO REACH is one model, it does not address all inequities within the healthcare system and sometimes I even think is missing populations of patients based on how they're calculating with the area of deprivation index. And so it's really important that we take that care model and then spread it to our other value based care contracts. So things like this comprehensive annual visit are huge tenet of our ACO REACH program but then we're also going beyond just the comprehensive annual visit and continuing to look at different behavioral health issues, how are we providing wrap around services of transportation, et cetera, and really looking at what that model looks like and how we how we provide those services to patients so they're best able to manage their conditions.

Well Megan thank you so much for joining us today and I think we probably still have a lot to talk about so maybe we'll pivot to a Part 2 of this, but we really appreciate your thoughts and insights into what Advocate Health is doing and population health.

My pleasure. Thank you for having me, Melissa. Happy to come back.

At CHESS we often refer to the seven pillars of value-based care. What are these pillars and how does each impact fee-for-value?

So, we’ve tended to use these pillars, if you will, to think about the process. Really, it follows our implementation process in many ways. So, I would start with practice transformation. So, that involves ensuring that physicians, advanced practice providers, office staff from CMA to nurses to even front desk staff, has some awareness of value-based care, understand why it is important, and then are engaged in the process of transforming that practice to a infrastructure that supports the delivery of the value-based care models and success in those models, both clinically, which is ultimately what this is really all about, and financially.

From there, you can begin to layer on other services or pillars if you will. These don’t necessarily have to happen in this order, but we often start with thinking about quality. Most organizations today have some quality efforts already in place just due to primarily to the fact that CMS and other payors are pushing those. And most people have at least some pay-for-performance type of arrangements, where they’re paid for closing quality care gaps. But quality goes beyond just thinking about closing quality care gaps. For our quality team, we’re thinking about optimizing the annual wellness visit so that the template within the EMR is just capturing data points and discrete fields. That makes reporting easier back to CMS as well as to the private insurance companies, Medicare Advantage, as well as commercial.

We think about Care Coordination and as we define care coordination, that includes, for our teams, nurses and CMAs. They work together to assist also in quality. So, the CMAs help close quality care gaps throughout the year. They schedule annual wellness visits, that’s a big emphasis in the first half of the year. If you can already tell, that annual wellness visit is a key component of value-based care because it touches on so many different elements of value. The other role for Care Coordination would be moving with that patient, tracking that patient, outreaching the patient between transitions of care. So, patient is admitted to the hospital, discharged to the skilled nursing facility, then discharged home. Our Care Coordination teams are monitoring that patient as they transition through those different sites of service and ensuring that each transition is as safe as possible. We all know that medication errors, in particular, are a massive problem through transitions of care. So, ensuring that patients know what medications they’re taking, or supposed to be taking, and that they can afford those medications. If they can’t, then connecting them with the resources to be able to provide those medicines for them.

They also perform Chronic Care Management. So, that’s identifying. So, we can go back to population health, identifying a group of patients who are either at high risk or rising risk of a complication or with a certain disease state. Identifying those patients, and then on a regular basis, setting up telephonic or even telehealth outreach to those patients, so that between those four office visits a year, that a chronic patient might have with a provider in the office, someone is touching base with them throughout the year. As a clinician, I always think that way. That for an average chronic care patient, I might have an hour or two hours a year of face time with a chronic care patient. Whether that’s diabetes, hypertension, the combination of the two. That’s really not very much time over the course of the...]]>The second half of our conversation with Yates Lennon, MD, President of CHESS Health Solutions who discusses the seven pillars of value-based care and the benefit of moving from fee for service to fee for value.

At CHESS we often refer to the seven pillars of value-based care. What are these pillars and how does each impact fee-for-value?

So, we’ve tended to use these pillars, if you will, to think about the process. Really, it follows our implementation process in many ways. So, I would start with practice transformation. So, that involves ensuring that physicians, advanced practice providers, office staff from CMA to nurses to even front desk staff, has some awareness of value-based care, understand why it is important, and then are engaged in the process of transforming that practice to a infrastructure that supports the delivery of the value-based care models and success in those models, both clinically, which is ultimately what this is really all about, and financially.

From there, you can begin to layer on other services or pillars if you will. These don’t necessarily have to happen in this order, but we often start with thinking about quality. Most organizations today have some quality efforts already in place just due to primarily to the fact that CMS and other payors are pushing those. And most people have at least some pay-for-performance type of arrangements, where they’re paid for closing quality care gaps. But quality goes beyond just thinking about closing quality care gaps. For our quality team, we’re thinking about optimizing the annual wellness visit so that the template within the EMR is just capturing data points and discrete fields. That makes reporting easier back to CMS as well as to the private insurance companies, Medicare Advantage, as well as commercial.

We think about Care Coordination and as we define care coordination, that includes, for our teams, nurses and CMAs. They work together to assist also in quality. So, the CMAs help close quality care gaps throughout the year. They schedule annual wellness visits, that’s a big emphasis in the first half of the year. If you can already tell, that annual wellness visit is a key component of value-based care because it touches on so many different elements of value. The other role for Care Coordination would be moving with that patient, tracking that patient, outreaching the patient between transitions of care. So, patient is admitted to the hospital, discharged to the skilled nursing facility, then discharged home. Our Care Coordination teams are monitoring that patient as they transition through those different sites of service and ensuring that each transition is as safe as possible. We all know that medication errors, in particular, are a massive problem through transitions of care. So, ensuring that patients know what medications they’re taking, or supposed to be taking, and that they can afford those medications. If they can’t, then connecting them with the resources to be able to provide those medicines for them.

They also perform Chronic Care Management. So, that’s identifying. So, we can go back to population health, identifying a group of patients who are either at high risk or rising risk of a complication or with a certain disease state. Identifying those patients, and then on a regular basis, setting up telephonic or even telehealth outreach to those patients, so that between those four office visits a year, that a chronic patient might have with a provider in the office, someone is touching base with them throughout the year. As a clinician, I always think that way. That for an average chronic care patient, I might have an hour or two hours a year of face time with a chronic care patient. Whether that’s diabetes, hypertension, the combination of the two. That’s really not very much time over the course of the year. And so, when you think about the Care Coordination team being able to touch those patients in between those visits, you really are improving the patient’s experience of care. You’re extending the provider’s reach and ability to impact the patient in between those visits. So that’s a huge component of it. Those are the areas to date that we have largely focused. There are other services that can be provided, but those are kind of our building blocks.

We also think of another pillar as Pharmacy. So, CHESS, we’ve got a team of clinical pharmacists, PharmDs, as well as pharmacy techs. Those folks together as a team are focusing on medication assistance, so again working with a Care Coordination team, identifying patients who have trouble with affording medicines. Trying to ensure that we connect them with resources. Whether that’s community resources, or drug companies that have low-income subsidy programs, grants, foundations, other ways of accessing medications. Focusing on medication adherence, so in the quality component of the value-based contracts, medication adherence is about half of your quality points in a typical Medicare Advantage contract. They tend to be triple weighted, which means they have even more importance. So, it’s very, it’s critical to success that your patients are adhering to their medication regimens. So, that the team supports that work also. But then going beyond that, thinking about groups of patients who are at risk for certain complications with medications. One that always comes to mind first for me was something called a daily oral anticoagulant report our pharmacy team runs. Looking at patients with a new evidence of renal compromise that would indicate they may need to have their oral anticoagulant adjusted. If that doesn’t happen, then that patient is at risk for a gastrointestinal bleed. If they were to fall, at risk of an intracranial bleed. Those, both of those, lead to hospitalizations and even worse, potentially death. So, trying to identify those problems before they ever occur. Work with the patient’s physician to make a dose adjustment in their medications and avoid that downstream negative event.

We think and talk a lot about accurate coding. So, there’s a lot of emphasis on that. Has been for several years. It has gotten significant negative press as well. But it is very important that providers are accurately and completely documenting, first of all, a patient’s conditions, addressing those conditions, and then coding that. That helps align the resources to care for patients with the patient’s disease state. But it also, we remind providers constantly that in many ways today, the medical record serves multiple purposes. I’m old enough to remember paper charts and I was writing notes essentially to myself for that next visit, so I knew what I said, I knew what the patient’s problem was, and what we talked about, and that note was just for me. But today, it serves multiple other purposes. It’s a legal document, it’s a financial document, it’s a medical document. A lot more emphasis is placed on that documentation by the physicians and the advanced practice providers.

There’s, within CHESS we have an operations team. So, if I go back to practice transformation just a second. And that never is over with implementation, but that’s a big focus of implementation in the early phases as we prepare providers to onboard to the services I just discussed. That transformation is ongoing but after a period of time then our operations team steps in, picks up that physician group, and then shepherds them forward through the various contracts. Making sure they understand how the contracts work, make sure they understand how care is being delivered to their patients, and that the services we are providing are impacting the patient’s care as well as the financial performance within a contract. That really is implementation passing off and saying to the operations team, here’s the ball, you keep going.

And then I think finally, and this is not certainly not least, I’m just listing it last. At foundation of all of this is data and analytics. So, being able to ingest clinical data into a platform, pull in claims data from the payors as well as data from other sources, so HIE (health information exchanges), ADT feeds through vendors that are that have in their possession ADT feeds from various hospitals. Because we need to know where our patients are and be able to identify when they hit that facility. Especially if it’s outside our network. So that we know what’s going on and can reach out to that patient in a timely manner. And I think that’s the seven pillars.

I think you asked me also, why is it, why are these things important or how do they impact providers and patients. And we can talk more about that in just a moment, but to me this is work, most of this work is work that does not get done in a fee-for-service environment. There’re just not the resources, there’s not the infrastructure to support it. So, when you do this and do it well, you’re improving the patient’s experience of care and you’re also improving the provider’s experience of care, and extending their reach in a way that they would not ordinarily have to do it in a typical office setting.

What questions should physicians and health systems be asking themselves as they undergo the transformation from fee for service to fee for value?

Well, I think I would start with who are the beneficiaries for whom we are accountable. In our prior days, in fee-for-service, you didn’t really think that way. We were thinking largely about who’s on my schedule, is my schedule full, if it’s not full can we get it full. In this new world, we should be thinking about who’s not on my schedule that should be. If the patient is in a value-based agreement and attributed, or assigned, to the providers that have the agreement with the payer, then you’re responsible for those patients and their cost of care and their quality of care regardless of whether they come to see you or not. And so, I need to know the patients who are not seeing me for whom I am responsible so that then I can deploy my care teams to reach out, see if we can understand any barriers to seeing that patient, get them in, and get them the appropriate care that they need. We just never thought that way in a fee-for-service world.

I’ve alluded to this earlier, the next question to me would be where are our patients receiving care? We often get the answer, well I know when patients are discharged from my facility. And that’s probably true. But we don’t always know when they’re discharged from other facilities. It’s a blind spot for most health systems. That is improving today but we need to make sure that we are capturing data points, to the degree we possibly can, to understand that patient’s journey through the healthcare system not just the health system. Because if we don’t have insight into that, then we’re not able to respond appropriately when they’re making their transitions, whether that’s hospital to home, or hospital to skilled nursing facility. Whatever that may look like. We need to also think about clinical and cost needs. So, what clinical situations do they have that would be driving costly or high-cost care? How can we intervene? Are their behavioral health issues or concerns that we may need to address? Do they have poorly controlled diabetes or poorly controlled hypertension? So that we can get them to the right cost of care, the right site of low-cost care to intervene. Taking that a step further, what beneficiaries are at current or future risk of complications that could lead to high-cost spend. And then understanding what gaps in care exist for patients. That might mean screening tests that are open, that could be disease-state management, A1c and hemoglobin A1c is a great example of that. But it could also be patients lost a follow-up, patient doesn’t have the ability to afford their medications. So, addressing, identifying and addressing those gaps in care, whatever they might look like, is another important question that we need to ask as we, sort of, take that shift and shift our mindset over to a new set of questions.

In summary, you know, understanding where care is received, not just within our system, integrating that clinical and financial data together so we have a 360 view of the patient, and then beginning to use that to do some predictive modeling, both clinical and financial.

Value-based care is the right thing to do, and I believe this is true because of the impact it has on, what I would consider, two primary recipients of its benefits. The first is patients. Value-based care puts infrastructure and resources in place to meaningfully impact the quality of patient’s lives on a day-in, day-out basis. We hear this consistently through patient stories. The second is the provider, both physicians and advanced practice providers. Value-based care puts infrastructure and resources in place that extends their reach and their influence and impact in their patient’s lives. And at the end of the day, that’s what providers of healthcare want, is an improved quality of life for their patients.

Yates Lennon, MD, MMM, currently serves as the President and Chief Transformation Officer for CHESS Health Solutions. He is nationally known for his work in quality, previously serving on the American Medical Group Association (AMGA) Quality Leadership Council and presently on the National Association of Accountable Care Organization’s Quality Committee. Dr. Lennon’s background includes 23 years as a practicing OB/GYN and a Fellow of The American College of Obstetricians and Gynecologists. He served as Chief Quality Officer for Cornerstone Health Care before joining CHESS in 2018 as Chief Transformation Officer. Dr. Lennon assumed the role of President in 2021. He has a deep understanding of practice transformation and how to engage physicians and their staff. His value-based care expertise allows him to translate his knowledge into initiatives that health care teams understand and can implement to ultimately transform patient care.

Episode Transcript:

Let’s start at the very beginning. What is value-based care and why does it matter?

So, what is value-based care. I tend to think about population health and value-based care side by side. And, in some ways, it’s value-based care is population health plus a payment structure that you find in value-based care models to create sustainability for those pop health efforts. So, when you think about population health, you’re thinking about groups of patients, whether that’s groups of patients by demographics, by disease state, by recent hospitalization. They’re all ways you can slice populations. And you’re thinking about caring for that group of patients. Now at the end of the day, population health is delivered one patient at a time, generally speaking, in my mind anyway. But, when you add value-based care to it, you’re creating an incentive structure that creates sustainability so that you can deliver the services you need to care for those populations of patients as they move through the continuum of care. So, from the outpatient setting, to inpatient, to home, to skill nursing facility, back home.

That’s a very broad definition, but when you dive a little bit deeper into value-based care as a clinician, I’m thinking about value-based care as a way to support resources that will assist me in caring for those patients. So, it’s not all falling on the physician or the advanced practice provider at the point of care in the office.

What is the triple aim and how does practicing value-based care help to achieve that?

So, the triple aim was coined back in 2008 and it really aims to do, as you might guess, three things. One, is to improve the patient experience of care. The second is to lower the cost of care. And then the third would be to improve quality or improve the health of populations. Value-based care, and as we discussed already, is perfectly suited to solve these.

So, if I start with improve the patient experience, or patient satisfaction. The fact that a patient is able to access a care team larger than just the provider and the nurse, I think, moves us in that direction. The other aspects of care when you think about, I think about my parents, so, and their encounters with the health care system. And how it’s been traditionally very disjointed. Still is. They live in a part of the state where value-based care is not really penetrated very well. And it’s very disjointed. My Mom gets information from her providers and her payors, and she’s confused. She doesn’t know what’s real, what she should respond to, you know, is this a scam, just all kinds of questions. So being able to reach into a care team on a consistent basis is very important. And...]]>We revisit an earlier episode with Yates Lennon, MD, President of CHESS Health Solutions who who provides a concise overview of value-based care and questions providers should be asking

Yates Lennon, MD, MMM, currently serves as the President and Chief Transformation Officer for CHESS Health Solutions. He is nationally known for his work in quality, previously serving on the American Medical Group Association (AMGA) Quality Leadership Council and presently on the National Association of Accountable Care Organization’s Quality Committee. Dr. Lennon’s background includes 23 years as a practicing OB/GYN and a Fellow of The American College of Obstetricians and Gynecologists. He served as Chief Quality Officer for Cornerstone Health Care before joining CHESS in 2018 as Chief Transformation Officer. Dr. Lennon assumed the role of President in 2021. He has a deep understanding of practice transformation and how to engage physicians and their staff. His value-based care expertise allows him to translate his knowledge into initiatives that health care teams understand and can implement to ultimately transform patient care.

Episode Transcript:

Let’s start at the very beginning. What is value-based care and why does it matter?

So, what is value-based care. I tend to think about population health and value-based care side by side. And, in some ways, it’s value-based care is population health plus a payment structure that you find in value-based care models to create sustainability for those pop health efforts. So, when you think about population health, you’re thinking about groups of patients, whether that’s groups of patients by demographics, by disease state, by recent hospitalization. They’re all ways you can slice populations. And you’re thinking about caring for that group of patients. Now at the end of the day, population health is delivered one patient at a time, generally speaking, in my mind anyway. But, when you add value-based care to it, you’re creating an incentive structure that creates sustainability so that you can deliver the services you need to care for those populations of patients as they move through the continuum of care. So, from the outpatient setting, to inpatient, to home, to skill nursing facility, back home.

That’s a very broad definition, but when you dive a little bit deeper into value-based care as a clinician, I’m thinking about value-based care as a way to support resources that will assist me in caring for those patients. So, it’s not all falling on the physician or the advanced practice provider at the point of care in the office.

What is the triple aim and how does practicing value-based care help to achieve that?

So, the triple aim was coined back in 2008 and it really aims to do, as you might guess, three things. One, is to improve the patient experience of care. The second is to lower the cost of care. And then the third would be to improve quality or improve the health of populations. Value-based care, and as we discussed already, is perfectly suited to solve these.

So, if I start with improve the patient experience, or patient satisfaction. The fact that a patient is able to access a care team larger than just the provider and the nurse, I think, moves us in that direction. The other aspects of care when you think about, I think about my parents, so, and their encounters with the health care system. And how it’s been traditionally very disjointed. Still is. They live in a part of the state where value-based care is not really penetrated very well. And it’s very disjointed. My Mom gets information from her providers and her payors, and she’s confused. She doesn’t know what’s real, what she should respond to, you know, is this a scam, just all kinds of questions. So being able to reach into a care team on a consistent basis is very important. And especially for that generation. They don’t want to bother their physicians. We could have a discussion about whether that’s the right thing to do or not. But, that’s just the way she thinks. I don’t want to bother anyone. So having a care team whose proactively reaching out to a patient, especially following an important transition, goes a long ways towards bringing comfort and to that patient. And when I hear the stories from our Care Coordination team, including our social worker, the impact their having on patient’s lives is profound. They are addressing things that I as a clinician would never get into in an office visit. In part sometimes because I was afraid to ask the question because I didn’t have any resources to deal with what I figured the answer would be.

To improve the quality or improve the health of populations, so we’re focused on quality, closing care gaps. We’re focused on an Annual Wellness Visit, which is designed to allow a provider to look at a patient’s whole picture. So, where are they receiving care, do they know who their providers are, do they know who their durable and medical equipment providers are. Are they up to date on screening procedures and are they up to date on any disease-specific quality measures that they should have addressed, like hemoglobin A1Cs, or blood pressure under control? Those types of quality measures.

And then finally, lowering the cost. So, I go back to Care Coordination again. Thinking about chronic care management, transitional care management, trying to reduce readmissions. And also to try and prevent unnecessary admissions as you engage with patients in the their the management of their disease states. I think the other thing that value-based care does is it puts the right incentives in place for provider access. When I’m talking to physicians and they ask, you know, what do we need to do, there’s always one answer that you can do tomorrow, and that is improve access. So, the idea that we’re going to be open 8 A.M. to 5 P.M. and shut our phones off at lunch is a bit antiquated. That might be ok for a fee-for-service world, when your schedules full, and that’s the thing that matters most. But, in fee-for-value, if you can provide access to patients when they need it, so that they can receive care for non-emergent conditions in a non-emergent setting, then that saves money for the system and will loop back to the first thing I talked about, and it improves the patient experience of care. I don’t think there’s anyone, very few people if any, that enjoy sitting in the emergency room waiting. And, if you’re condition is not an emergent one, if you don’t have an emergency situation, then you tend to be triaged to the end of the line and you spend more time there in the waiting room, which is not good for patient experience, which is not good for provider experience, which is not good for patient experience ratings for the provider. So, it’s kind of, it gets to be a snowball effect.

And you know, a few years ago, I’m not sure who gets credit for this, but physician burnout we all know is a huge issue and COVID has not done anything but accelerate that problem. And so, someone term the quadruple aim, adding physician or provider experience as the fourth arm of the quadruple aim. And we’ve already touched on this a good bit, but from a physician’s standpoint, value-based care aims to implement team-based care. So, they’re not the same, but they go hand-in-hand. In team-based care, the purpose, the aim there is to be sure that everyone on a provider’s team, those people in the office, those people behind the scenes who may be in a hub somewhere or perhaps embedded in their physical facility in a room where they’re not focused on the patients who are coming in and out each day, but those patients who are at home, they’re trying to outreach. All of those people together, working at the top of their license, is what we aim to do in value-based care. For physicians, we would like to see them doing the things that only physicians can do. The things that other people on the team can do, then let’s let them do those things. And let’s use protocols and evidenced-based guidelines to direct care for the 80% of the population, I always laugh and say the 80% of the population that’s read the textbook, and they kind of behave according to the textbook. There’s 20% of the population that don’t. And that’s, you know, the medical background and training that physicians and APPs have. Decision making comes into play there. You can’t necessarily follow an evidence-based guideline for whatever reason. We know that everyone won’t just fall into a nice, neat, little box. So, really putting their decision-making skills, their assessment skills, their diagnostics skills to work in that part of population that won’t fit the rules.

And then, I just learned recently that there is now the quintuple aim, which is adding in health equity. And as I think about what we’re trying to achieve by improving the outcomes of care for all patients by removing barriers that they face and typically those are, you know, social economic barriers. Value-based care is set to address that. When I look at the patient stories and hear the patient stories that come from our care coordination, pharmacy, social work hub, they are constantly working with individual patients to identify barriers to improving their care and ensuring that they have outcomes that are equal to those who are not facing the same barriers. Value-based care is perfectly set up to address each of these stakeholders. When I think about, you know, the medical industry, if you will, in it of itself, but also the providers, the patients, and the folks around them that we would call their care team.

I’ve heard you say that making the move from Fee-for-Service to Fee-for value, aka value-based care requires a new way of thinking. Can you elaborate on this?

Sure, be glad to Thomas. So, I go back to the old fee-for-service world. The world I grew up in. And I still remember asking myself that question the first time I sat through a meeting about value-based care. And, as an OBGYN by training, this was 12 years ago now. I went home after that first meeting and I thought, now what do I do differently tomorrow. And I struggled for a little while to understand the only thing that I could come up with was continue to deliver high-quality care, have access for my patients, and, you know, don’t sent people to the emergency room or labor and delivery unless they need to be there. See them in the office if its possible.

But as I understood the concepts more, I think there are several areas that we can call out and kind of make a comparison between the two worlds. We’ve touched a lot on consumer experience or the patient experience already. So, in the old world, confused, frustrated, you know, not knowing what’s going on. Provider A is not talking to Provider B. Provider A didn’t get the referral letter from Provider B when the patient was sent to the orthopedic surgeon, the cardiovascular surgeon, or the endocrinologist. And communication is just not taking place between providers. So, this leaves patients trying to navigate a very complicated system on their own. In a fee-for-value world, that patient experience should lead one to feel valued and engaged. So, there are resources at play from the care coordination teams, the pharmacy teams, our quality teams, we’re just reaching out, pulling that patient in, and making sure they feel supported throughout their care journey.

From a care delivery standpoint, we’ve always been reactive. So, we’re responding to illness in a fee-for-service world traditionally. Now, there had been progress around preventive medicine and addressing cancer screenings, for instance. Colorectal cancer and breast cancer screening. And a lot of that work has been done and is important, but I wouldn’t say that’s really geared at overall health so much. And, even in the fee-for-service world, we still were largely reactive. In a fee-for-value world, we’re more proactive. So, we’re using data, we’re using our various teams to identify patients. Like I said earlier, not just who are at increased risk today, but who we believe are at risk in the future of some untoward event. Whether that be clinical, or clinical and financial. And so, that shift in focus for deliver of care is very critical. Care coordination, just by virtue of the term, almost didn’t exist in the fee-for-service world. We didn’t have technology. We didn’t have data and analytic. Again, paper charts, telephone calls, that was about it. In this fee-for-value environment, our infrastructure’s set up to give us access to much more data, which we can then use to identify patients to be more proactive.

Finally, just thinking about cost, so I believe that a strict fee-for-service environment really is a bit of a perverse incentive. I mean, you, people say you, whatever you incent is what you will receive, what you will get. And incenting people to do more usually gets you more. And that’s the way the fee-for-service structure was set up. It’s set up to do more. See more. So, the important thing was, you know, who’s on my schedule, do I have enough people to see, am I seeing as many as I possibly can. In a fee-for-value world, the financial construct is more conducive to seeing the right patients, at the right time, and in the right location, and doing the right thing. So, it’s not necessarily doing more. But it again focus on doing the right things for patients. And so those are, there’s certainly more ways, but in my mind, those are some of the big differentiators between how we think in a fee-for-service world versus how we think in a fee-for-value world.

You know, the last time we talked, we talked about the Hospital at Home program, and you gave some great information. A back story. And so, how’s it going? Is it still a benefit to the community? Is it still being used in the ways that it’s supposed to be? I mean, how is it? How are things transpiring?

I would say we're continuing to gain momentum in the program. So, as we talked about several weeks ago, it was born out of the COVID crisis if you will. For that, I am grateful for the pandemic because in most large somewhat risk averse organizations these things don't happen very easily. You tend to meet and meet and meet and then finally maybe put together a proforma and do a small pilot. We bypassed all of that. We did a big pilot, um, out of necessity. So, what we're doing now really is pivoting from COVID, which is now less than 10% of our patients, to other diagnoses which I think I mentioned last time: heart failure, COPD, various infections, but then going into oncology, neurology, surgical trauma. Other patient categories that even some established programs I think are not pursuing. Bottom line is we've not been diagnosis specific in this program. We've been more general clinical eligibility first, by clinical condition, and then what diagnosis fit in it. And then obviously once we've got a clinical clearance, you got to look at the social determinant of health and all social determinants of health and all those other factors that play into whether the patient would be successful.

But no, it's going great. We have every intention to scale as far as we need to scale to continue to decompress our hospitals. And, your point, it is making a difference in the community. We get a lot of letters and feedback from patients that say please don't ever make me go back to the hospital, I was so much more comfortable here, I feel safe here, I got to be with my dog. You know, that sounds small but it's not small. So again, as we find our population aging with more and more chronic conditions in their senior years, hospitals can be pretty risky places for those patients who are often disoriented, tend to fall at a higher rate, they're at risk for infections, they don't typically eat as well, sleep as well, and they don't move. They tend to stay in their bed with the door shut. Who wants to go down the hall in a hospital gown? So, all of these reasons in most cases make the home a better place for healing.

So, we got some big news that hit the media about the partnership with Best Buy and Advocate Health Atrium. How did this come about and how does it work? It’s fascinating.

Two very large health systems coming together to be one. And looking for the synergies that happen when you do that. Now there are naysayers out there that say stop the madness, health systems shouldn’t be merging. They are in Milwaukee, Chicago Illinois market. We're down here in the South, in North Carolina, South Carolina, Georgia, and a tad bit of Alabama. So, we're not in, you know, competing overlapping markets. They're almost identical in size.

So let me back up a tad. Advocate and Aurora merged four years ago to become Advocate Aurora. Now that has merged with Atrium Health. So, the national name is Advocate Health, but each market will retain their brand that is known in that community. So, we're still Atrium Health. What I’ve been involved in is just integration work around nursing. So, how do we align nursing around standards both...]]>In this episode of the Move to Value Podcast we catch up with Colleen Hole, Vice President of Clinical Integration in Population Health at Atrium Health to learn about the new partnership with the retailer Best Buy, the impact of the merger of Atrium Health and Advocate Aurora Health on the Hospital at Home program and Colleen’s experience as a presenter at the global Hospital at Home Congress held in Barcelona Spain.

You know, the last time we talked, we talked about the Hospital at Home program, and you gave some great information. A back story. And so, how’s it going? Is it still a benefit to the community? Is it still being used in the ways that it’s supposed to be? I mean, how is it? How are things transpiring?

I would say we're continuing to gain momentum in the program. So, as we talked about several weeks ago, it was born out of the COVID crisis if you will. For that, I am grateful for the pandemic because in most large somewhat risk averse organizations these things don't happen very easily. You tend to meet and meet and meet and then finally maybe put together a proforma and do a small pilot. We bypassed all of that. We did a big pilot, um, out of necessity. So, what we're doing now really is pivoting from COVID, which is now less than 10% of our patients, to other diagnoses which I think I mentioned last time: heart failure, COPD, various infections, but then going into oncology, neurology, surgical trauma. Other patient categories that even some established programs I think are not pursuing. Bottom line is we've not been diagnosis specific in this program. We've been more general clinical eligibility first, by clinical condition, and then what diagnosis fit in it. And then obviously once we've got a clinical clearance, you got to look at the social determinant of health and all social determinants of health and all those other factors that play into whether the patient would be successful.

But no, it's going great. We have every intention to scale as far as we need to scale to continue to decompress our hospitals. And, your point, it is making a difference in the community. We get a lot of letters and feedback from patients that say please don't ever make me go back to the hospital, I was so much more comfortable here, I feel safe here, I got to be with my dog. You know, that sounds small but it's not small. So again, as we find our population aging with more and more chronic conditions in their senior years, hospitals can be pretty risky places for those patients who are often disoriented, tend to fall at a higher rate, they're at risk for infections, they don't typically eat as well, sleep as well, and they don't move. They tend to stay in their bed with the door shut. Who wants to go down the hall in a hospital gown? So, all of these reasons in most cases make the home a better place for healing.

So, we got some big news that hit the media about the partnership with Best Buy and Advocate Health Atrium. How did this come about and how does it work? It’s fascinating.

Two very large health systems coming together to be one. And looking for the synergies that happen when you do that. Now there are naysayers out there that say stop the madness, health systems shouldn’t be merging. They are in Milwaukee, Chicago Illinois market. We're down here in the South, in North Carolina, South Carolina, Georgia, and a tad bit of Alabama. So, we're not in, you know, competing overlapping markets. They're almost identical in size.

So let me back up a tad. Advocate and Aurora merged four years ago to become Advocate Aurora. Now that has merged with Atrium Health. So, the national name is Advocate Health, but each market will retain their brand that is known in that community. So, we're still Atrium Health. What I’ve been involved in is just integration work around nursing. So, how do we align nursing around standards both structurally and clinically? How do we align some of this space that huddle lives in, which is this space between brick-and-mortar hospitals and clinics, this home-based care space. So, we're doing some work around what do they have, what do we have, what can we learn from each other. So, a lot of it right now is what we're calling discovery. We're just learning oh you all do it like that. For example, they don't really have a hospital at home program. They did a little bit of that at the peak of COVID. saw a few patients in their home, but not much. So, they're real interested in figuring out what we're doing down here. But the different markets matter because in the South we're still largely fee-for-service, not a lot of value-based care yet. You and I would love to see that get driven forward. Up there they're further down the value-based their contracting and care models.

There are really two reasons to hospital home broadly. One is you've got a capacity issue, which is our driving force here. They have value-based care and not so much of a capacity problem. So, their reasons for doing it would be different but all being involved and evaluate does this make sense for you all and how could we stand that up. So, the Advocate Aurora thing was cooking, I don't know how long ahead, far way, before I knew about it. But that it's a thing. Separate from that is our partnership with Best Buy. So, Best Buy five or six years ago said you know we're really good at tech, we're really good at logistics, what else would we want to lean into. Is it communications? They had five or six things health being one of them. And they felt like, you know what, we'd like to get into the business of health. So, they created Best Buy Health and started looking for partners to operationalize some of their skills.

So, they’ve got as I mentioned logistics and technology, we’ve got know-how from a clinical and operational perspective. So, what could we partner on and focus really in this home-based care space? And there's a lot in there, it's not just hospital at home. It's home health, it's virtual, you know, initiatives that we take care of people managing their blood pressure at home or their heart failure. So, that's really what it's about. We're going to work on some things together and the media kind of grabbed ahold of the Geek Squad thing which is one of them. They’ve done Geek Squad for two decades. They're looking at a Health Geek Squad. So, helping people manage health-related technology in their home. That's probably the clearest, easiest one that we're talking about working together on. What it looks like past the product development I have no idea, but that that's really what it's about. Everybody wants to get into the home-based care space knowing the cost of brick and mortars is too high, we've got access issues, we've got health equity issues, we've got rural health specific access issues. This stuff actually addresses all of that.

Has it been operationalized, or is it still in more of the strategy planning development stage?

It’s really still in the strategy development planning stage. We're just beginning to meet to figure out what makes sense to do together. So, I know I sound vague but there's truly not a lot of definition yet to it. We just think there's stuff that we could marry up that they’re good at and we're good at to create something that really advances health. And we're not the only people in the country trying to do this kind of work. I think everybody agrees current health system structures they're just not work for the long haul. And I really heard it in Barcelona. They’ve got more of a national view of health far more than we do and it isn’t saying we need socialized medicine, I'm not going to get into any of that, but they really do look at the whole of it. And we still are built around how we fund healthcare. We build stuff that is billable versus what the patient actually needs to live their best life. And that's why I'm such a big fan of Hospital at Home. It is not a physician-centric model, it is not a facility-centric model, it's not a payment-centric model, it's a patient-centric model. Yay.

You mentioned Barcelona. So, just for reference, you recently were in Barcelona for the World Hospital at Home Congress, and you mentioned that it was quite an honor. And I can think of no one more deserving. Did you hear any other really off the wall, creative ideas about what’s happening outside of our borders that people are doing in this space that maybe we should pay attention to?

Um, I didn't hear anything like, I never would have thought that, oh my goodness. But they're further along in some of the things. But not as far along as in others, particularly around tech. You know, I think, we're ahead of them with tech enablement. Like since I've talked with you, we've implemented our remote patient monitoring. So that allows us to have 24/7 visibility, audio, video connection to our patients. That's awesome. In the countries that are doing it well, Spain, for example, it's just become the way they take care of people. We're still far more tentative about it. You know, Doctor Bruce Left started this at Hopkins 20 plus years ago aimed at seniors who he knew, as a geriatrician, didn't do well in hospitals. But his program is still pretty small. I believe the potential is gigantic and other countries have really scaled a whole lot better than we have. They are starting in Spain, a master’s degree program in hospital at home which I thought was cool. We could sure do that with our Wake Forest academic arm. I would love to see that. But, yeah, nothing revolutionary really.

The type of patients was seemingly similar across all the countries that I saw. The only thing that kind of shocked me was Israel. Where we are very careful about patient selection and making sure that it's for all, but yet that the home environment is safe enough to do this kind of care. It's become such a way of doing things that they don't screen for that as much. They talked of case studies where a patient lives alone and decreased mobility and no one there to help with food and meds and that's one of their patients. We wouldn't do that. Like we would not leave the patient without someone in the home to help them if they were that fragile. But they have to because they have no beds.

So, when I hear you say that, so from a technology standpoint we seem to be ahead but an implementation standpoint where, eh, middle of the pack.

Yeah. They've been at it, not all, but many have been out a lot longer than we have. Like decades, 30 years.

So, now that we've had this partnership unfold with Best Buy, which is I guess known for tech. I mean for nothing else they sell it right. But they've got the Geek Squad. They fix my parents’ computers time and time again. Do you see this as a really good opportunity for, of course it is a good opportunity to serve the patient, but really the things I think about is our underserved population. Folks with some economic, social determinant issues, health equity. How do you see, you know, something that's a technology barrier from a cost standpoint being implemented to serve this patient population that could really benefit from the service?

So, when you look at social determinant issues the digital divide is the thing. And you know there's a federal movement to try to address this with policy and infrastructure. But, um, that actually did come up a good bit in Spain. So, we've implemented a product called Current Health. That is our remote patient monitoring product. It's actually owned by Best Buy Health, but it carries the connectivity in the device. So, we actually said before we implemented remote patient monitoring, we're going to do it for all but we're not doing it at all. And so, we didn't want the haves and the have nots to experience this differently. So, rarely we still can't get a connection, we can resort to a phone, you know, in other words it's not a deal breaker no matter what. And there are connectivity issues urban and rural. It’s both. Some of it is just the towers aren't there, others the patient doesn't have the means to have it. But we did not want that to be a barrier for them to receive care.

So, that interestingly ,I was on a call with some folks from Mexico last week who thought I should come and help them build a Hospital at Home program in Mexico, but they were talking about the mountains in parts of South America and how that stops, you know, this is not my expertise, but signals get broken in the mountains and how would we mitigate that. And I'm like whoa, it's interesting, different parts of the world they've not built the infrastructure we have in America. And so, that's part of the tech problem. You know, any companies are going to sell it to them, but it won't work if they don't have, you know, the infrastructure in the country.

This sounds like an amazing opportunity for cost savings in patient care, which is one of the aims of value-based care. Do you see more initiatives of serving patients where there are on the horizon?

Yeah, I mean not so novel really, but just technology, virtual care, all of that I think partly empowers patients to direct their own care a little bit. Because in addition to our health systems being built around payment and largely physicians, it's paternalistic. We set it up with we know what you need and you're going to do what we say when we say and where we say to do it and if you want our help, you're going to come to us. And that's how we built it. This flips all of that on its head and by helping the patient with some technology, you empower them to actually self-manage, which does 100 million things, not the least of which is you get far better compliance and far better outcomes when the patient actually one understands and two says I can do this. So, that's what I love about the technology.

We've also shaken the paradigm of well it won't work for older people, that's intimidating to them. We haven't found that to be true at all. It's actually been fun to see older patients go oh I don't like computers, but this is really cool. So, you know, I think it doesn't replace the care, but it can certainly enable it and allow you to take care of a lot more people. So, you could monitor hundreds of patients because you get a feed from their wearable device and be able to see 24/7 real time who might be in trouble, who needs a phone call, who needs a visit by a community paramedic. You can just be more efficient with how you deploy your resources, which lowers the cost.

Thank you, Colleen, for joining us today on the Move to Value Podcast.

Thank you. It’s been my pleasure.

Doctor Elizabeth Vaughan welcome to the move to value podcast

Thanks so much for having me, it's a pleasure to be here.

So, tell me Dr. Vaughan, how did you become interested in researching the impact of community health workers?

Like many things in life, I fell into the interest. I had done the international work since I was in high school and I always had an interest of low-income healthcare, low-income populations. As a 16 year old I went to Ecuador and you know I was a what you call an army brat, my father was in the army, and really a pretty isolated world. And I saw poverty like I had never seen. I realized that Spanish was not just punishment that I had to take in high school that other people were really speaking Spanish and I really fell in love with the people in Ecuador. And then I continued traveling and you know fast forward that 20-30 years now and I've gone most of Central America, South America, and the Caribbean over and then over to Africa and India. And through those travels the people that I worked with were precious and yet I always sensed a distance between the people I worked with and me. And particularly after I finished medical school and I was now doctor Elizabeth or doctor Vaughan, most countries it was doctor Elizabeth, there was a greater separation. So there was a socioeconomic separation there was a cultural separation there was an education separation. And yet I saw the locals and the way they interacted with local individuals, and I thought there's something different here, they seem to be able to reach these individuals.

Then when I was in India in 2011 I worked with a group of promotoras, or more referred to as community health workers, in India and I anticipated that I would be the physician going into the villages and the towns and I quickly realized that they wouldn't let me because it was the HIV trip. And so I stayed back in the in the clinic and I taught this group of promotoras. And I at first was disappointed thinking man I don't get to have the fun only to be on the front lines and yet I quickly saw that teaching blood pressure, teaching hydration, teaching triage, led into a world where they could triage patients appropriately and they could reach far more patients than I could ever reach as an individual person. And so then I realized this is something and so fast forward another ten years and I became a community health worker instructor myself, started working and founded some groups here in Houston, TX of promotoras and have just seen amazing work of what they do and how they are able to connect with the patient and bring things about from a patient that I never could bring out and offer insight that I would never have.

Tell me why, in your opinion, do you feel like folks respond to other individuals in their community more than they would someone who's a physician. Someone who comes in with the technology and the knowledge from first world country. Why do you feel like there is a barrier there to the to the general population who needs those services?

It's a great question. So, there's, different cultures have different barriers. I think in the Latino culture pleasing in and kind of letting the doctor know that that you're trying to do what they said, I think is important. I think there's a there's amount of respect, they say you're the doctor you're and help me and so if they don't, I think there is some sometimes there's a feeling of shame in there. And so, my experience with the Latino culture is, many times the reason they don't - I've had one patient...]]>A conversation with Dr. Elizabeth Vaughan, associate professor and physician scientist at the University of Texas Medical Branch, as well as a Texas Community Health Worker instructor, about her research in health disparities and the role of the Community Health Worker in improving diabetes outcomes in low-income populations.

Doctor Elizabeth Vaughan welcome to the move to value podcast

Thanks so much for having me, it's a pleasure to be here.

So, tell me Dr. Vaughan, how did you become interested in researching the impact of community health workers?

Like many things in life, I fell into the interest. I had done the international work since I was in high school and I always had an interest of low-income healthcare, low-income populations. As a 16 year old I went to Ecuador and you know I was a what you call an army brat, my father was in the army, and really a pretty isolated world. And I saw poverty like I had never seen. I realized that Spanish was not just punishment that I had to take in high school that other people were really speaking Spanish and I really fell in love with the people in Ecuador. And then I continued traveling and you know fast forward that 20-30 years now and I've gone most of Central America, South America, and the Caribbean over and then over to Africa and India. And through those travels the people that I worked with were precious and yet I always sensed a distance between the people I worked with and me. And particularly after I finished medical school and I was now doctor Elizabeth or doctor Vaughan, most countries it was doctor Elizabeth, there was a greater separation. So there was a socioeconomic separation there was a cultural separation there was an education separation. And yet I saw the locals and the way they interacted with local individuals, and I thought there's something different here, they seem to be able to reach these individuals.

Then when I was in India in 2011 I worked with a group of promotoras, or more referred to as community health workers, in India and I anticipated that I would be the physician going into the villages and the towns and I quickly realized that they wouldn't let me because it was the HIV trip. And so I stayed back in the in the clinic and I taught this group of promotoras. And I at first was disappointed thinking man I don't get to have the fun only to be on the front lines and yet I quickly saw that teaching blood pressure, teaching hydration, teaching triage, led into a world where they could triage patients appropriately and they could reach far more patients than I could ever reach as an individual person. And so then I realized this is something and so fast forward another ten years and I became a community health worker instructor myself, started working and founded some groups here in Houston, TX of promotoras and have just seen amazing work of what they do and how they are able to connect with the patient and bring things about from a patient that I never could bring out and offer insight that I would never have.

Tell me why, in your opinion, do you feel like folks respond to other individuals in their community more than they would someone who's a physician. Someone who comes in with the technology and the knowledge from first world country. Why do you feel like there is a barrier there to the to the general population who needs those services?

It's a great question. So, there's, different cultures have different barriers. I think in the Latino culture pleasing in and kind of letting the doctor know that that you're trying to do what they said, I think is important. I think there's a there's amount of respect, they say you're the doctor you're and help me and so if they don't, I think there is some sometimes there's a feeling of shame in there. And so, my experience with the Latino culture is, many times the reason they don't - I've had one patient in you know 13-15 years of practice that just had the medications on the desk would not take them. Not to say there aren't others but, you know, most reasons that they don't take medications, they don't adhere to treatment, are far beyond what I would ever understand, or that they might be willing to tell me and it might be embarrassing.

We had a patient that we could not figure out why she would not apply for eligibility of the clinic, you know it's free service we thought we you know the community health workers were helping her and taking and what's going on with this? And finally we, the community health worker not me, learned that she was in an abusive relationship and that the husband would not let her have her tax papers, and that's what she needed to prove income status at the clinic to prove that she was eligible for the low income clinic. And she never wanted me to know that she wanted me to know that she's trying her hardest to do what I asked her to do and she really wants her diabetes to get better and her health to get better. It's embarrassing and maybe they know deep down the side I will never understand what life looks like in a in another world. And truly there's a world I'll never understand what it means to be undocumented. I will understand what it means to not speak English as my first language. I will understand what it means not have transportation to get to the clinic when I need to do so.

So, there's a variety of barriers but I think just wanting to do what the doctor wants to do I think that's a major barrier that that they that they face that they may feel much more comfortable talking to a community health worker who they trust who might have the same barriers and often have the same barriers as they have.

Sometimes we forget the barriers we often think about are you know literacy, transportation you know language barriers, but we often forget about some of the barriers that are much more challenging like clinic eligibility, like medication eligibility. For instance we have medication programs called PAP, prescription assistant programs, and on paper they're great. But I am not the first investigator to say that there's a lot of holes in the system. What these are, it's a way to get these expensive meds, so out of the 11 oral diabetes meds, three of them are low cost. And so how do you get the other eight to them? So some of them are eligible through this process, but every med has a different process. Sometimes you apply and you might wait a month or two or six or nine months to actually get the med and then you have to reapply after the next year. And so you know put yourself in the shoes of someone who doesn't speak English, who may not use the Internet, who doesn't understand all this paperwork, and didn't even know that after all of this, they have to renew every year. And so just imagine how, and that's one pill of the maybe five or six that you're taking and maybe you have to do this for every different pill.

And so barriers like that are things we often forget about and we say oh you know patients can just they can take these meds you got them they're available there's a supply, and it's like well put you know once you kind of walk that path, and I never walked it. I prescribe it was easy and then I realized when the promotoras brought it to my attention, well they did this this and this and they're having XYZ barrier, I realized oh my goodness. There are numerous barriers to this system. Once it works it's great, but getting there and getting it to be sustainable it is markedly extremely challenging.

So, tell me how community health workers go about effectively educating and triaging members of their community?

Well the first way for them to educate, is they have to be educated themselves and they have to have some sort of foundation of their own training. Every state is different, some states have very rigorous programs, training certifications, recertifications, some states do not, but nationally, there are national standards. And so that's one thing that is ongoing in legislation, so we've got to make national standards for this if we're going to really get these individuals on the you know on the line items of a budget.

So first it is you know what other certifications so what does it mean to be CHW? First place, if I say I'm a physician, you have a pretty good idea of what training I've done. For a CHW it's a little more nebulous. So the first after the second after their education is educating actually what they're doing. So, I learned what a CHW is in my certification process, but I don't know what HIPAA is, I don't know what PHI is, I don't know what telehealth is, or telemedicine is. I have to learn all of these terms. I'm not medical. I've never stepped foot in the hospital before unless it was for my own care, and so they need to be educated in the realms where they're going to practice.

Then they need to be educated in triage. In other words, someone calls them, my blood pressure is 230 / 110 and if they say, what do those numbers mean, we have some problems. We had a patient you know they often call the community health workers first. They're trusted individuals of the community by definition and you know by definition this this person called they didn't call their doctor they call the ER and they said I'm having this left sided facial numbness. And thankfully we had taught our community health workers what triage means, education, and you know when you know when you call and when you don't and so thankfully the community health worker knew what to do, direct the person to the ER, they were able to get this person the appropriate treatment before they had long term sequelae of what we now know was a stroke. But if a community health worker doesn't understand what blood pressure is or what normal numbers are, and we tell them you know make sure they check, make sure they recheck, we tell them how they check, they're not doctors, and they know that. There's a very very, but they have to understand how to get a history so they can help the patient.

So if I were to frame that entire question that you asked, how do we effectively educate and triage it comes back to the education. It comes back to educating them appropriately and then supporting them. When they have a question when they're out in the field who do they call? Who do they get help from? If it's a you know Tuesday night at 8:00 PM, do they have a way to get, someone a lot of times that's when they work with the patients because that's in the patients aren't working, and is there a mechanism if not we worry about them doing harm because there's no mechanism of help and support.

That leads into my next question of how do we go about verifying that these CHW's are going to do more good than harm for the patient. I realize, you know, and we think we all realize, that there's definitely a good intent and a willingness to care, but you know when you start to jump into cultural norms that might not always be the best policy for healthcare, how do we how do we go about verifying that that the information is accurate that they're providing?

Yeah so doing harm you know relates to the question we talked to before, making sure they're perfectly trained, make sure they have the appropriate education and support. I think that that key piece, a lot of times I'll see in programs they're trained. Maybe it's a one-time training, maybe it's a two-time training, oh we we've got them certified, we've got them but there's no ongoing support. You know when I did residency you know that's you know 3-4 years of you're in the hospital and you know you have this system of you know the duck and the ducklings to make sure that you weren't going to harm patients. And so I knew whenever I got in the spot where I wasn't comfortable I always knew I had someone to call, 24/7, and that's critical to do no harm. I've seen situations in medical training where residents don't have someone to call, and that's what harm is done. Because they don't they don't know who the call they don't know who to ask and there's fear there. And so the same principle with community health workers.

The training that we have we have a website now, mipromothorasalud.org, and we've posted our trainings on it and we're just kind of getting all four segments on it. So, in the first training we have an introduction. this is OK what does this mean, community health worker 101. It's like a four-hour course and this is all your HIPAA and PHI, what does it mean to be CHW, what does it mean in the specific place I'm working. You know, beyond where's the bathroom, how do I how do I work what are the kind of the rules of the land in where I'm working. The second and third training are the immersion. So for us we work in diabetes. So, the first part is we got to learn about what diabetes is. What's an A1C? What's a blood pressure? We got to learn all about that, so just the really concrete knowledge. Then that we take it after that, once they're actually working with patients, then we have in an immersion training on what are all the medications, what are the side effects, because you know they're going to be calling them and saying my legs are swollen, and if we don't know if they don't know the Actos can cause that swelling, and the patient was just put on Actos, we've got a problem.

And so they need to understand what the patients are going, just like if you're in the in the visit with your doctor and your family member. A lot of times they tell the family member, particularly if the family member is older or needs some help, they tell the family member to make sure you know this and this. Now the family member, it typically goes over their heads. But a lot like that the community health worker almost acts like a family member.

And then the last part of it is the sustainability and so we take questions that community health workers have asked us over the years and we just answer them in the last training. You know what about what why do I take a statin, these silly rules that keep changing, I don't understand, my LDL's right, it's 90, I thought they had to be less than 100, well yeah we changed the rules again on you. So you know explaining that so when the patients asking that, they know very clearly they do not make the decisions, they are not medical decision makers, they take a history and then they triage appropriately to the to the appropriate person.

That makes a lot of sense. So let's talk about you for a moment. I'd like to hear more about your research with diabetes and underserved patients and how you've used the time model and the simple model and how they differ and perhaps which is more effective.

Sure, so the TIME model is an acronym telehealth integrated community health workers medication access and education and group visits. And so if you were to simplify what is this model, it is a group visit so patients come to the clinic once a month for their care and they see a physician and they have education, everything is run by community health worker, the large group education, the small group education, they run monthly for six months, and now we actually have a model extends to a month nine and month 12, because we get to six months and we said we're not quite there yet. So we kept it kept going a little longer. And that model is very much you have almost the cream of the crop patients and so it's hard to compare it to our other model which is a SIMPLE model the simple model is OK take everything in TIME, you basically make TIME really simple.

So in SIMPLE instead of physically coming to the clinic for the group visit education or small group, they sit on a YouTube modality for about you know 5 to 15 minute videos and then you have the community health worker and instead of them physically sitting down they call them up and ask them how they how they're doing. In both of those models we have what's called a feedback loop because inevitably they will see the doctor or they will talk to the doctor in clinic on one day and the next day they call the community health worker and say I don't have my pills and you just saw the doctor well I don't know. And so there's some sort of communication gap that happened there, and it happens even though they just saw them. And so that feedback loop goes from the community health worker and there's a champion but then feeds into the clinic who has a champion and say hey patient so and so doesn't have their you know ACE inhibitor and now we need to you know what happened, oh I thought we were supposed to put this at Walgreens we called them into the wrong place. So, you know a lot of times it's just an easy communication gap and that feeds back to the community health worker and they can tell the patient. What usually happens is, I don't have my pills, I call the clinic, I get voicemail, they call the patient, the patient's phone has been disconnected, they don't have enough data, so they wait for three months to get an appointment, have high blood sugar the entire time, finally go see the doctor and hope it gets right this time, if not then wait another three months, and the same cycle continues. And you know we see in in in this population the A1C's or the other glucose levels they go up and down and up and down and up and down from really controlled to really bad really and I thought why in the world is that and I did a study one time I just looked at patient notes and I thought oh that makes sense they're on their meds off their meds on their meds off their meds. And a lot of times the gap is, like we talked about before, the medication eligibility process or it's also just communication gaps that they have.

So what's better between the two of them, it's hard to compare because they're a little bit apples and oranges where the TIME these are patients who are motivated to come to clinic and they typically have transportation to get to clinic, they have more resources, typically. We see an A1C drop you know .5 is considered significant we see drop typically of two to 2 ½. In the SIMPLE model we still lower drop. These are patients though that's more of a kind of opt out, like hey we're running this program if you don't want to join it no need to and then I'm sure I'll do it. So these are not your cream of the crop patients. These are the patients that are what if they can't come to clinic, what if they don't want to do group visit, how do we reach the people who are maybe less motivated or don't have transportation or work a lot. So these A1C drops are typically one 1-1 ½, still clinically significant and still a nice drop. And the good thing about the SIMPLE models is it is much more scalable, because it's not an intense monthly come to the clinic, you can run it with 2-3-4 times the amount of people that you could run in the TIME model. So both of them are good models. I don't have a bias I like them both. I think they're both great for but it really depends on the clinic situation and depends on the patient situation, but SIMPLE was named simple for the reason, it's simple.

With this patient population, how has deploying community health workers on the frontline changed outcomes?

There's a lot of literature out there about changing diabetes outcomes and there's a many many interventions, you know, educational interventions, medication interventions, and so I thought, you know, what CHW, what's different, you know, why have ACH in in this this part, when there's other literature that shows we could do other things. And you know we don't compare these arms, typically we typically have different studies, so it's hard to compare them. In looking back at some of the things that we've done, the community health...]]>a031de9d-54c3-4ab2-91aa-32b7514e3eccThu, 04 May 2023 00:00:00 -050029:35falsefull3030Melissa Pollock, M.Div., CHC - Going Live with ACO REACHToday we have the second in a series of conversations about ACO REACH with Melissa Pollock, Director of ACO Compliance and Regulatory Affairs at CHESS Health Solutions, who continues to navigate and lead through the intricacies of the newest CMS payment model.

So, last time we talked about a lot of the history behind the reimbursement models for CMS and went over some of the history, and what CMS is trying to achieve, and how they've moved down this timeline and value, and we've landed on an ACO REACH model. What happened from “hey let's do this,” to “we're doing this now.” Because it seems really easy to say but I know that a lot went into it. Can you walk us through that?

Yeah. So, I think we had looked at the direct contracting model and just financially it didn't make sense. So, you know, we talked a little bit about the Next Gen model coming before it and how it was never really certified as a as a full program because CMS didn't think that it created as much savings as that should have. You go to direct contracting and they've kind of put into direct contact some very steep discounts. Discount not being a good thing. Right? Discount being they're going to take money straight off the top to make sure that they get the savings that they're trying to generate in the model. When they revamped direct contracting, renamed it, refocused it as ACO REACH they kind of backed off on some of those discounts, which was helpful I think to a lot of us that were in the healthcare space. So, you know, all the Next Gens are providers. We're all providers. We're, you know, trying to do value within the health systems. We don't have, for most of them, a lot of you know commercial companies outside of this.

And so, as we started to look at ACO REACH and the requirement or the ability within the model to take on claims processing, that is a whole other realm that we had not been. In claims processing, I mean, obviously, there are entire companies that do nothing but claims processing. And so, we had to decide is this something we're going to take on? Do we outsource it? What kind of you know organization do we partner with to do this? And we have to go through the entire process of an RFP, a request for proposals, to determine OK who can do this, who's done it before in direct contracting that we can also use in this process, and how do we move forward. So, there was a lot of time spent in determining number one what is our downstream model going to look like, how are we going to reimburse these providers, and number two, can we do it, can we set it up in a relatively quick time frame and do we have the expertise in-house to do that or do we need to look outside. So, there was a lot of conversation around that.

I mean, obviously, the application process for ACO REACH was a lot. It was unlike any other application that CMMI had ever put out, the Innovation Center, had ever put out. It was very detailed. They were asking very specific questions about governance structure. They were asking a lot of questions about health equity, what are you already doing in the health equity space, which is you know what they're looking towards. They're looking at this focus of how are we going to really affect care in the underserved communities that has traditional Medicare beneficiaries. And so, there were, you know, we had to look at what do we have now, what are our gaps in care, where do we think our populations are, what zip codes are they in. It was kind of a new foray into looking at data from a lens that we hadn't really looked at before. Or if we had, hadn't done a really deep dive into. So, I think those were kind of the two big things that we had to really prepare for. From a compliance and governance standpoint, we were set. That wasn't different. And having been in Next Gen, we were very used to those types of you know the audits and the things that come with being in an innovation model that's...]]>Today we have the second in a series of conversations about ACO REACH with Melissa Pollock, Director of ACO Compliance and Regulatory Affairs at CHESS Health Solutions, who continues to navigate and lead through the intricacies of the newest CMS payment model.

So, last time we talked about a lot of the history behind the reimbursement models for CMS and went over some of the history, and what CMS is trying to achieve, and how they've moved down this timeline and value, and we've landed on an ACO REACH model. What happened from “hey let's do this,” to “we're doing this now.” Because it seems really easy to say but I know that a lot went into it. Can you walk us through that?

Yeah. So, I think we had looked at the direct contracting model and just financially it didn't make sense. So, you know, we talked a little bit about the Next Gen model coming before it and how it was never really certified as a as a full program because CMS didn't think that it created as much savings as that should have. You go to direct contracting and they've kind of put into direct contact some very steep discounts. Discount not being a good thing. Right? Discount being they're going to take money straight off the top to make sure that they get the savings that they're trying to generate in the model. When they revamped direct contracting, renamed it, refocused it as ACO REACH they kind of backed off on some of those discounts, which was helpful I think to a lot of us that were in the healthcare space. So, you know, all the Next Gens are providers. We're all providers. We're, you know, trying to do value within the health systems. We don't have, for most of them, a lot of you know commercial companies outside of this.

And so, as we started to look at ACO REACH and the requirement or the ability within the model to take on claims processing, that is a whole other realm that we had not been. In claims processing, I mean, obviously, there are entire companies that do nothing but claims processing. And so, we had to decide is this something we're going to take on? Do we outsource it? What kind of you know organization do we partner with to do this? And we have to go through the entire process of an RFP, a request for proposals, to determine OK who can do this, who's done it before in direct contracting that we can also use in this process, and how do we move forward. So, there was a lot of time spent in determining number one what is our downstream model going to look like, how are we going to reimburse these providers, and number two, can we do it, can we set it up in a relatively quick time frame and do we have the expertise in-house to do that or do we need to look outside. So, there was a lot of conversation around that.

I mean, obviously, the application process for ACO REACH was a lot. It was unlike any other application that CMMI had ever put out, the Innovation Center, had ever put out. It was very detailed. They were asking very specific questions about governance structure. They were asking a lot of questions about health equity, what are you already doing in the health equity space, which is you know what they're looking towards. They're looking at this focus of how are we going to really affect care in the underserved communities that has traditional Medicare beneficiaries. And so, there were, you know, we had to look at what do we have now, what are our gaps in care, where do we think our populations are, what zip codes are they in. It was kind of a new foray into looking at data from a lens that we hadn't really looked at before. Or if we had, hadn't done a really deep dive into. So, I think those were kind of the two big things that we had to really prepare for. From a compliance and governance standpoint, we were set. That wasn't different. And having been in Next Gen, we were very used to those types of you know the audits and the things that come with being in an innovation model that's very different from MSSP. But from kind of a structural, internal claims processing, being able to take that claims file and figure out what we're going to do with it and how are we going to set this up, I think it took it took us a long time to just OK let's walk through these steps and what is this going to look like in the future.

What do you feel like was the most difficult part of that process?

Honestly, to determine how we were going to structure the downstream contracts was difficult. I just the process of OK what is it going to look like for us to process claims, who can we partner with. I think that was really difficult because we had never done it before. I don't have expertise in that. You know, nobody specifically at CHESS did. And so, I knew we needed to bring in people that had that understanding, software that had that that ability. So, I think, trying to work with our revenue cycle teams and making sure that you know they know that the money is not coming from CMS anymore, it's coming from CHESS, and how to post that, and work within their systems that they already have to make this work, I think was pretty difficult. There's just a lot of moving parts in ACO REACH. There are a lot of different things going on at once. It's a very complex contract. And so, to make sure that we have understanding and educate on it too, I think was really difficult. We spent a lot of time on doing internal and external webinars and meetings to explain what is ACO REACH. People are hearing about it, they don't know what it is, how is this different, why does this matter. So, for me it was just a lot of education that to be done. A lot of reading on my part getting up to speed. And then, having to, you know, field lots of different questions on how it works. So that was a lot of my time was spent doing education on it as well. Not so much difficult, just time consuming.

So, we talk about in ACO REACH there's the health equity component and that's new. And I think that's a really big deal as we look into population health. Right? Because we can segment populations in so many different ways, but why was there a determined need for health equity? Who is this becoming equitable for? What types of populations are we talking about here?

Yeah, that's a great question. So, I think, you know, the COVID-19 pandemic really revealed a lot about our American healthcare system, in that you're seeing some populations of patients have access to testing really fast, they know where to go, they know what to do, and other populations of patients don't. And so, I think that realization that you know you're seeing higher levels of death in certain ethnicities, those types of things, just made it very clear that health is not equitable within the United States. So, OK we need to address this and how do we do that?

So, really the population that we're looking at, and within the ACO REACH model they are using something called the area deprivation index or ADI to kind of score patients as to whether or not they're in underserved communities are considered underserved patients. It's kind of on a decile scale. You've got, you know, those that are in really affluent communities on one end and then you've got those that are in very underserved communities on the other end. And being able to take your patient population and look at them from this kind of score and determine OK I've got a lot of population of patients, probably you know minorities, in certain areas of on our map, right, certain zip codes, certain census blocks, and I know that there seems to be in our data that we're getting from CMS for this model that there is a, you know, a lack of colorectal cancer screening. OK that's a gap. So, what are we going to do about it? So, I think it's looking at those populations of patients more directly than just, “hey it's a population of ACO patients. Let's try to you know do what we can to affect care and value,” but really calling out smaller underserved communities within the population and saying, “what does the data look like for those people and how can we affect care specifically for those patients?”

Well, that that ties into a lot of the things that we work on here and that the buzzwords that we've talked about and one of those is social determinants of health. So, we talk about health equity and then we talk about social determinants. Is there flexibility since we are doing a lot of our own claims processing to make judgment calls on how we can address some of those social determinants that are outside of the clinical space? So, I know that there might be a lack of colonoscopies and mammograms and there might be a higher rate of diabetes, we talked about food deserts, we talked about hunger, we talked about transportation. Is there a leeway where we can make our own determinations about models that we set up programs initiatives that are allowable now with this new payment model?

Definitely. So, one of the benefits of being inside of ACO REACH is that you have, kind of, at your disposal a fraud, waste, and abuse, and safe harbor waivers to affect care in ways that otherwise would have been considered kind of like a kickback or of those types of things. So, there's different waivers, sanctioned waivers, within the ACO REACH model, the ones that we know like the telehealth waiver or the skilled nursing facility three-day waiver, there's a gift card program, that you can do at-home care management home waiver. These types of things. But I think broader, there is the ability to take some of the money and determine OK how can we use this money to really affect a social determinant for underserved populations. Does that look like partnering with a food bank to offer food to diabetic patients that are in this zip code because they don’t, they can't get a medically tailored meal. That's a that's a possibility, and the ACO technically could pay for that. In traditional Medicare, outside of the ACO structure, that would be considered illegal because you're providing something that Medicare is not paying for. But within the ACO structure, they know that this could be a way to turn around someone's health in a real realistic way.

And so, you have the ability to model these types of programs and to partner with community organizations that are already in this space and have the resources to be able to do this. I mean, I know I don't have the resource to stand up a food bank but there's one down the road that I could say, “hey I really need to you know to try to provide care or provide a meal to these patients because they're diabetic and they can't leave the house and they don't have transportation.” And that's another thing is transportation issues. We have the ability to provide rides to primary care offices. So, if a patient says I know I need to come in for my primary care visit or for X, Y visit and I can't make it, I don't have a car, or I can't drive, we have the ability to pay for that ride and to offer them a ride to get to their provider. Instead of the alternative being calling an ambulance and the ambulance showing up at their house and taking them to the ED, which obviously is way more expensive than if they just needed a ride to their doctor's office. So, there are a lot of a lot of creative things you can do. I think a lot of it is, man there's so much, how do we even start? Where do we start? And I think that really is where you rely on the data that you get, the claims data you get from CMS, the clinical data that you have from the you know the health systems, your value partners, and really putting that together and find that form a holistic picture of your population specifically in the underserved communities and determining OK where do we think we can really affect care with these patients.

I really like that because that is what it's all about. You hear so much about the financial components, and I realize that people need to be compensated for the work that they do. Not everyone has the means with which to be philanthropic with their time, which is the greatest gift you can give. Right? Everybody's got to eat. Even those that help other people eat. And it's nice to hear about the Feds saying hey we realized that it's not necessarily a straight clinical solution to optimal health and I think that's a huge leap. So, we began at CHESS, we began ACO REACH on January 1, 2023. How's it going so far? Do we have any data? I mean we're a couple of months into it, how's it? I'm sure that the road is bumpy and there's warts and all of those things. But, you know, as one of the first group of ACOs to be tackling this, how's it going? Is it working?

Yeah. I mean I think it has been bumpy, I'm not going to lie. It hasn't been smooth sailing just because we, you know, a lot of this is new and anytime there's new, you're doing something new and different, there's things that have to be ironed out. I think so far we're doing well. I think we, on purpose, are starting kind of slowly into the model and haven't availed ourselves of all the waivers that are out there just because I personally I wanted us to get our feet on the ground and just let's just get a really solid foundation for how we're going to do some of this stuff instead of trying to boil the ocean. Right? So, I think we're doing good. And I think we are affecting care. Some of the data’s been delayed coming from CMS, which usually happens. I mean, I get it, it's new. Some of this is new for them too, right. So, there's going to be things that have to be ironed out. But, so far, I'm really optimistic about what we're doing and how we're affecting care.

I think we have a really great opportunity within the health equity space and that's what we're really working on right now. So, for ACO REACH, we have to create a health equity plan and we have to submit that to CMS the end of March. And so, right now, really trying to determine OK based on the data that we've received from CMS so far, where are the gaps in care, what can we do to really affect underserved communities. And then, using the next three years, 24, 25, 26 to really roll that plan out and see care effective in communities. So, we're in the staging processes of health equity within ACO REACH. I'm sure there’s others that are farther down the road than us, but I think I think we're doing OK for where we should be.

So, we decided we were going to participate in ACO REACH and we went through all of the hurdles, all the rigmarole, all of the vetting. Is this something that is available every year? So that next year, some ACOs out there who were just didn't have the bandwidth because oftentimes ACOs are pretty lean run operations right and unfortunately those operations might be in communities that are best served by this type of program which is why the ACOs exist in the first place, would they have the opportunity to apply to begin next year? And if so, what advice which you give to them?

So that's a great question. Actually, there are no more applications for ACO REACH. So, this this was the last, this was the cohort. So, a lot of the direct contracting entities that started in 2022, some started part of the way through 2021, they were kind of grandfathered in, and then you had this kind of cohort of applications for the 2023 start, and they've shut down applications for the future. So, for organizations that think hey this might be something that we would want to be a part of, they would have to look at joining someone that already has a contract with CMS for ACO REACH and then you know approach those different organizations to talk through what it would look like to join in 2024 through 2026.

Well seeing as how other ACOs would need to become a partner with ACOs who are involved in REACH, how difficult would that be? How does that work?

Yeah, I think it would have to go through some type of vetting process, from my standpoint. So, you know, yes, there would be obviously contracts would have to be drawn up, but we would want to look at the people that are interested in joining a current ACO. Like if it were ours, our CHESS ACO REACH, and saying is this a good fit for this advanced of a model, you know, do they have history in value based care, are they already doing things that are affecting health equity, how do they feel about taking on downside risk, are they an organization or group of organizations that feels like they want to do that, or you know how can we model something different specifically tailored for this group that wants to join. Would it look different?

And that's the other thing within ACO REACH, you know, I talked about previously in our other podcast about it's kind of like putting a contract within a contract, but you can alter those contracts. So, one participant within the model, like one health system, their contract of how they're paid could look different from another contract of how another value partner or health system is paid. And so, you'd really have to do that that vetting process of determining is this something that looks like it would be a good fit based on you know their history and are they ready to take that leap, really. I mean, I think a lot of value-based care is more of a cultural change than anything else. It's really trying to address the mentality of providers, and educate them on what this means, and how it's going to be beneficial for the patients. And sometimes that it doesn't go over well. I'll be honest, you know, you have some that don't really latch on to it. And so, there would have to be that willingness at the executive leadership position, this is something we're really going for and we're going to drive the culture in our organization in order to make sure that we're successful in this model.

Have providers noticed those who are now with it have a patient population that is part of ACO REACH? Have they noticed a difference? Are they doing anything differently with how they provide care for their patients or is it just continuing along the standard successful value-based care workflows?

I think from a provider lens, especially with the with the organizations, health systems, that we currently have in ACO REACH, they've been doing value-based care for such a long time that they don't see a lot of the difference. And I would say a provider, on purpose, does not want to know oh this is a this insurance patient, and this is the this one, and this is this. That idea of treating each patient before you equally no matter what their insurance plan looks like, I think is very important to a provider. And that's where we, as CHESS, kind of wrap services around the provider to help drive value-based care. Yes, there is some education that has to happen, and there might be workflow changes within an EMR, or things that have to change, education that would help drive value. But I think two, a lot of this work are things that we do as CHESS to try to help them. So, you know, care coordination services and pharmacy services. A lot of those things happen a little bit on the back end, a little bit out of the spotlight of that care that is you know the 30-minute visit of a patient in front of a provider.

Our mission, and one of the basic tenets of the quadruple aim, is to help providers just take care of their patients, right? And provide the best care that they can because that's really why they got in the business. I mean because they’re caregivers. Do you feel like this new model is going to help the provider give better care to their patients?

Yes, I think it will. I think it will...]]>8fb991fb-c106-4b2a-9b25-62aafec274c3Thu, 20 Apr 2023 00:00:00 -050027:06falsefull2929Kari Curry, RN, BSN, CCM - The Role of Community Health Workers in ValueIn this episode we talk about the role of the community health worker in case management with Kari Curry, director of clinical services for Emtiro Health, where she oversees the delivery of their population health management program.

Kari Curry, welcome to the Move to Value Podcast

Thank you

Tell me about your role at Emtiro Health. Who is your patient population and how are you assisting them in obtaining the best possible outcomes?

Well my role at Emtiro Health is the director of clinical operations. We case manage the managed Medicaid population. I've been with the organization even before it was Emtiro. I was a care manager myself and I covered Davidson County. I then was a supervisor for the care managers covering Davidson County when it was Northwest Community Care, so my role with Emtiro then moved to manager of clinical services and then I moved to the director position of clinical operations. I believe the past roles I've had allowed me to truly understand the role of the care manager, including you know barriers that they encounter with patients. And working with the Medicaid population is a passion of mine as well. As Emtiro as a whole, we've worked with this vulnerable population for years and we continue to provide efficient care to the Medicaid patients. So our vision here at Emtiro is to coordinate care, improve health outcomes, build strong communities, and health equity and I truly believe we work hard every day to meet that vision and we are passionate about working with the vulnerable populations and improving their health outcomes.

So in your Move to Value Summit presentation, you mentioned that case management is like a puzzle. Tell us why this is so and how do you work to solve it.

Yeah so I'm sure my staff is tired of hearing me say that but it's true. The first thought came to me when I was doing case management in a hospital. So I was a discharge planner and I did utilization review for patients admitted to the hospital and when a patient was nearing discharge, I would need to make sure they had a safe discharge plan. So to ensure they had a safe environment, such things as utilities in the home, any medical equipment that they may need making sure they have their medications, and so on. So each part of that discharge plan was like a piece of a puzzle where each piece must fit together to see the discharge plan be successful. And that theory has carried with me here at Emtiro and I still find it true today.

So as a care manager for managed Medicaid, each area is the puzzle piece. Each patient is assessed for medical conditions education, social determinants of health, medications, etcetera. So each area must come together to see the patient situation and what steps are needed to ensure the patient receives what they need.

Well how have you seen the impact of the community health worker in care delivery and how is this impact achieved?

So when I first started my nursing career, community health workers were not a title that I was aware of or that you heard a whole lot. It has become more popular and a more popular term over the last few years. However, the work of a community health worker has always been there. So when I started in care management, I did it all. I made home visits, worked with the patients on their medical conditions, assessed for social determinants of health, and set up the patients with those services if they were needed. And I can honestly say as a nurse, I wish I would have had more time to focus on the patient's medical conditions and providing that education to reduce risk of ED visits, or readmissions, or overall living, you know, as far as a healthier lifestyle for those patients.

So the role of the community health worker of course is designed to tailor you...]]>In this episode we talk about the role of the community health worker in case management with Kari Curry, director of clinical services for Emtiro Health, where she oversees the delivery of their population health management program.

Kari Curry, welcome to the Move to Value Podcast

Thank you

Tell me about your role at Emtiro Health. Who is your patient population and how are you assisting them in obtaining the best possible outcomes?

Well my role at Emtiro Health is the director of clinical operations. We case manage the managed Medicaid population. I've been with the organization even before it was Emtiro. I was a care manager myself and I covered Davidson County. I then was a supervisor for the care managers covering Davidson County when it was Northwest Community Care, so my role with Emtiro then moved to manager of clinical services and then I moved to the director position of clinical operations. I believe the past roles I've had allowed me to truly understand the role of the care manager, including you know barriers that they encounter with patients. And working with the Medicaid population is a passion of mine as well. As Emtiro as a whole, we've worked with this vulnerable population for years and we continue to provide efficient care to the Medicaid patients. So our vision here at Emtiro is to coordinate care, improve health outcomes, build strong communities, and health equity and I truly believe we work hard every day to meet that vision and we are passionate about working with the vulnerable populations and improving their health outcomes.

So in your Move to Value Summit presentation, you mentioned that case management is like a puzzle. Tell us why this is so and how do you work to solve it.

Yeah so I'm sure my staff is tired of hearing me say that but it's true. The first thought came to me when I was doing case management in a hospital. So I was a discharge planner and I did utilization review for patients admitted to the hospital and when a patient was nearing discharge, I would need to make sure they had a safe discharge plan. So to ensure they had a safe environment, such things as utilities in the home, any medical equipment that they may need making sure they have their medications, and so on. So each part of that discharge plan was like a piece of a puzzle where each piece must fit together to see the discharge plan be successful. And that theory has carried with me here at Emtiro and I still find it true today.

So as a care manager for managed Medicaid, each area is the puzzle piece. Each patient is assessed for medical conditions education, social determinants of health, medications, etcetera. So each area must come together to see the patient situation and what steps are needed to ensure the patient receives what they need.

Well how have you seen the impact of the community health worker in care delivery and how is this impact achieved?

So when I first started my nursing career, community health workers were not a title that I was aware of or that you heard a whole lot. It has become more popular and a more popular term over the last few years. However, the work of a community health worker has always been there. So when I started in care management, I did it all. I made home visits, worked with the patients on their medical conditions, assessed for social determinants of health, and set up the patients with those services if they were needed. And I can honestly say as a nurse, I wish I would have had more time to focus on the patient's medical conditions and providing that education to reduce risk of ED visits, or readmissions, or overall living, you know, as far as a healthier lifestyle for those patients.

So the role of the community health worker of course is designed to tailor you know and meet the needs of communities they serve. Community health workers have made a huge impact on the services provided to patients because they focus on the social determinants of health in ways to make sure the patients receive the appropriate community resources and appropriate services. It makes the job of the care manager a bit easier because it is more streamlined, and the roles are more defined. So, like I said earlier you know we could all be considered a puzzle piece because we all have a specific role to play to improve that patient outcome.

Emtiro manages primarily a Medicaid population so if you would, tell me some of the responsibilities the community health worker has in working with this population.

There's always been a stigma attached to Medicaid patients and the Medicaid populations and the patients feel that. So the Medicaid population can be considered a vulnerable population. But it does not mean that they deserve any less care or services than other populations. So here at Emtiro, we work hard to reduce and redefine that stigma. We advocate for our patients and ensure they get the services they need in order to live a healthy successful lifestyle. And I can say I've had times where I go to see a provider and they have their laptop or iPad in hand, and they never look at me while I'm talking to them and let them know what's going on with me. So that could be very disheartening even for me much more for a vulnerable population.

Our community health workers at Emtiro help focus on the patient as a whole. They build rapport with the patient they meet the patient where they are in their current situation. They advocate for their patients and work hard to ensure the patient has the community resources they need. But it doesn't just stop there. They follow up with the patient to assess that the community resources were successful and make the patient know that they care about their health and want to see them succeed. Having a personal relationship with the patients can go a long way.

So Emtiro employs community health workers?

Correct

Was having community health workers always part of the strategy or was that something that was implemented as the need arose? Can you speak to that a little bit?

So when we were Northwest Community Care, it was more RN focused and the RN did it all. So when we went with Emtiro Health and knew that we were going to manage managed Medicaid patients, we took a look at what all services we could provide as a whole. So that included RN's, it included a pharmacist for a while, community health workers, even LPN’s. So we wanted to encompass all of that to provide our you know services to the patients to the best of our ability. And what we have found doing that care model is the patients are receiving better care. They're having that one-on-one conversations the one-on-one attention that they need to really focus on their health, so I think it's been a great thing to have.

Well would you mind sharing a story about how you've seen a community health worker impact the outcome of a patient in a positive way?

So I'm sure the community health workers can offer lots of stories, but one of them came to me and provided a story about how she had been working with a patient who was living in a homeless shelter. And a situation happened, occurred and the patient had to leave the homeless shelter. So she was living in her car. Well, the community health worker engaged her, reached out to her, come to find out she had a mental health diagnosis and that prevented a lot of the shelters from taking her. So, the community health worker took the extra step. Partnered with the community resources within that county. They are currently looking for her a permanent place to live but they did find a shelter that was willing to take her and she's allowed to stay there until her permanent residence is set up. So that was a really great thing a very positive story.

We have another story to where one of the community health workers was working with the mom with small children in the home and the mom wasn't worried about herself so much but feeding her kids. So the community health worker worked with her and a local food bank and food pantry and set her up to receive food every two weeks and that continues to happen now. In that circumstance, the care manager is also working with her and she has reduced her amount to the ED, which is great, so we've had a really good outcome with that.

So, while these folks are doing all of this amazing work, it has to be difficult and there are plenty of barriers that pop up in various ways, either with a patient or with a collaborative organization or just rules and regulations.

Right.

What have you seen that are some of the issues or barriers that the community health worker faces?

So, I really like this question because I think we can talk all day about the amazing work that the community health workers do but it's also important to assess the issues and barriers they face. So I think one of the biggest challenges for the community health workers is just unable to reach patients with the phone numbers provided. So when the wrong contact information is listed, the community health workers have to do more research on their end to try to engage the patient. So that can be looking for information in an HER, maybe looking at claims data to see if there's a pharmacy listed, call the pharmacy to see if they have an updated number for the patient, and also just engaging the patients can be a difficult task. This is where motivational interviewing comes into play, especially when you were actually able to engage them. So some of the other challenges could be social conditions, mental health status of the patient is a big one, because I think we lack a lot of community resources based off that. So I believe it's important to continuously to assess those barriers and brainstorm of ways to reduce them if at all possible.

So, as you are well aware, health care is making a shift to fee for value and it is proven that the community health worker impacts a lot of the work flows in a positive way, such as reducing utilization, helping to reduce cost. How do you see the community health worker making a difference in value based care?

So with North Carolina Medicaid they continued to reform you know delivery of care, and payment, with the goal of improving the health of patients overall. I think it's important to keep the focus on the whole person and centered care whole person centered care and ensure those services not only address medical but non-medical conditions as well. So, assessing those social determinants of health is a key part of providing well-coordinated care to the Medicaid population. I believe being an advocate for the patient is also a key driver, having to be that bridge between providers patients and community resources is crucial in having positive desired outcomes for any vulnerable population.

So, when you talk about community resources what do you see as one of the most utilized resources out there? What do people need the most?

I think food. Food banks, food pantries right now. Even now with the cost of food going up. A lot of patients can't afford it. So you know then you run into what the pandemic you know the effects of the pandemic had on those resources as well. You know we had a lot of food banks that just didn't have enough food to cover those patients. So that's when churches got involved, that was always helpful. But I think food insecurity is probably the top. The most needed is mental health, by far.

Why?

I think the majority of our population has a mental health diagnosis. There's not enough resources for these patients. There's too many and a lack of resources even in trying to get them involved in a behavioral health facility or mental health provider. It can be difficult because, one, the patient, sometimes they require group therapy and the patient doesn't feel like talking in front of others. So that's always a problem. Transportation to those facilities is always an issue, but I do think there's just a lack of mental health availability to these patients.

Has there been an uptick in this mental health crisis that we're in, or has it always been there and just not acknowledged? Or do you feel like there is a catalyst for this that's only going to get worse or has been making things worse?

I think it's always been there. It's always been an issue when it comes to healthcare especially care management. So, I think it's always been there, but I think it has gotten worse and especially with the pandemic as well. You know, even health care providers, you know look what we had to go through as well, and the burnout. So, I think it continues to be a need. However, I do think it has increased due to the pandemic. I also think just with the way the world is now, you know things are different than they were even ten years ago, and I think I can see an increase in the younger population, too, as well. So, school age kids from elementary to high school you know have really struggled because we did remote learning, and you know they were isolated for so long and the fear of going out. So, you know that doesn't just go away overnight because we didn't get into it overnight. So, I think that it continues to be a high need and I don't see it changing. I really don't. I think if anything there needs to be more of a spotlight on mental health.

Are you, as a leader at Emtiro, thinking forward about how the pandemic is going to impact care delivery for your organization over the next 5-10-15 years?

Absolutely, because I think when you talk mental health, your body responds to that as well. So you know you could see such things as you never had high blood pressure before but now you do. Well was it anxiety driven? Is it just behavioral driven? So I think that with the younger population we're seeing now, they're going to have a lot more when it comes to medical conditions as they continue to get older. We just have to be ready. You know we have to be ready to provide those resources to them, educate them, get them set up with the providers and whatever that they need in order to manage that, but I also think with mental health and even with children, education is also key. You know there's a lot of unknowns, so I think when you provide that education and let them know that you do care you know you're not just providing them education to you know provide it to them you are truly caring about what happens to them, that is a key driver in the future of healthcare in general.

What do you see as the future for community health within the healthcare system and do you feel there is a need for a shift in healthcare as a whole to compensate for these issues?

So, community health workers have emerged as key players in value-based care and a value-based care model because they're responsible for not only supporting patients and addressing social determinants of health and improving care coordination as a whole. I would honestly like to see more certified community health workers. So, making sure they receive that appropriate training and building that confidence, it's there, sometimes I just don't think people, especially community health workers know where to find it. So, you know I want to be an advocate for that and you know say here it is you know it's waiting on you. Because I think the more knowledge and education you have the more confidence you have in providing good patient care.

I would also like to see the increase in community resources available to patients and I believe it's a constant need to research and link more community resources to organizations so that patients can receive appropriate care. So, I do see the role of the community health worker expanding through healthcare. The work is being done but there's just not a title to it. So I think there's always room for improvement in healthcare, it's ever changing, nothing stays the same but I do see an increase in the role of a community health worker across all of healthcare organizations.

Outstanding! Kari Currie, thank you for joining us today on the Move to Value Podcast.

Thank you so much. Have a great day.

Colleen, in our last episode we left off talking about holistic patient care in the home. Having cared for several elderly family members myself, I have seen the difference that it made for them to be in familiar surroundings versus being in the hospital. I guess home is where the heart is, right? Would you share with us the Hospital at Home Scope of services being provided?

So essentially anything you could receive in a brick and mortar facility, we can do in your home. Short of an invasive procedure or surgery, obviously, we don't do that and advanced imaging like MRI and CT scan, although that technology exists, we're not quite that there yet. But you can get pretty much any medical nursing intervention that you would get in a hospital, respiratory treatments, oxygen therapy wound care, IV fluids, IV antibiotics, chest X-ray, ultrasound, I mean though that's mostly what you're going to hospital for, obviously your medications we provide all of that is provided by 24/7 virtual nursing team. That patient can hit a button and have my nurse pop up on a screen just like a call bell in a hospital. They also get two visits by our community paramedicine or mobile integrated health team, you might hear it called both things, they're in the home twice daily for anywhere from 45 minutes to an hour twice daily. That is absolutely more time than you've got a clinician in your hospital room. You also have a daily virtual visit with the provider who is on camera real time doing an assessment while the paramedic is in the home. We've got electronic stethoscope, they could listen to your heart and lungs, they write orders, and then our nursing and community paramedic team carry out those orders. We also have, just like in a in a hospital, pharmacy, care managers, social work, respiratory therapy, physical therapy, occupational therapy, behavioral health, chaplains, all of those things mostly provided virtually, which we learned how to do now after three years of COVID. The other in-home service sometimes is our therapist, our physical therapy and occupational therapist. But a good bit of their work is done just literally on camera in a virtual visit. So it's hospital level care delivered in the safety and comfort of a person's home

I didn't realize that it was such a comprehensive program. That's pretty amazing that the capabilities for that are there. I think that's definitely a good thing and can you tell me how this model enhances value-based care and what is the typical savings here?

So, the purest definition I know of value is the same or better quality at a lower cost. I mean that's maybe oversimplified, but the hospital home actually does that. Our Ed visit, readmissions, mortality, all of those are lower than brick and mortar and our patient experience is higher significantly higher, not surprising probably, right? But when you have the opportunity to actually go where patients actually live, you can address some of those issues that are causing this repeat readmission. When we go to the home and we look in their pill box and it's empty or there's no food in their refrigerator or it's 100 degrees and their air conditioner is broken, you can hopefully address some of those things. Cost wise significantly less costly and there's research out there Mount Sinai has published several have, it’s estimated 20% to 30% and maybe more less costly than brick and mortar hospitalization. So again if you think about the drive value how do you deliver the same or better outcomes at a lower cost. This is certainly that.

You also just by being in a physical facility utilization tends to be higher. For example, you're in the...]]>In this episode we continue our conversation with Colleen Hole, Vice President of Clinical Integration in Population Health at Atrium Health, about how the Hospital at Home care model contributes to value-based care and better patient outcomes.

Colleen, in our last episode we left off talking about holistic patient care in the home. Having cared for several elderly family members myself, I have seen the difference that it made for them to be in familiar surroundings versus being in the hospital. I guess home is where the heart is, right? Would you share with us the Hospital at Home Scope of services being provided?

So essentially anything you could receive in a brick and mortar facility, we can do in your home. Short of an invasive procedure or surgery, obviously, we don't do that and advanced imaging like MRI and CT scan, although that technology exists, we're not quite that there yet. But you can get pretty much any medical nursing intervention that you would get in a hospital, respiratory treatments, oxygen therapy wound care, IV fluids, IV antibiotics, chest X-ray, ultrasound, I mean though that's mostly what you're going to hospital for, obviously your medications we provide all of that is provided by 24/7 virtual nursing team. That patient can hit a button and have my nurse pop up on a screen just like a call bell in a hospital. They also get two visits by our community paramedicine or mobile integrated health team, you might hear it called both things, they're in the home twice daily for anywhere from 45 minutes to an hour twice daily. That is absolutely more time than you've got a clinician in your hospital room. You also have a daily virtual visit with the provider who is on camera real time doing an assessment while the paramedic is in the home. We've got electronic stethoscope, they could listen to your heart and lungs, they write orders, and then our nursing and community paramedic team carry out those orders. We also have, just like in a in a hospital, pharmacy, care managers, social work, respiratory therapy, physical therapy, occupational therapy, behavioral health, chaplains, all of those things mostly provided virtually, which we learned how to do now after three years of COVID. The other in-home service sometimes is our therapist, our physical therapy and occupational therapist. But a good bit of their work is done just literally on camera in a virtual visit. So it's hospital level care delivered in the safety and comfort of a person's home

I didn't realize that it was such a comprehensive program. That's pretty amazing that the capabilities for that are there. I think that's definitely a good thing and can you tell me how this model enhances value-based care and what is the typical savings here?

So, the purest definition I know of value is the same or better quality at a lower cost. I mean that's maybe oversimplified, but the hospital home actually does that. Our Ed visit, readmissions, mortality, all of those are lower than brick and mortar and our patient experience is higher significantly higher, not surprising probably, right? But when you have the opportunity to actually go where patients actually live, you can address some of those issues that are causing this repeat readmission. When we go to the home and we look in their pill box and it's empty or there's no food in their refrigerator or it's 100 degrees and their air conditioner is broken, you can hopefully address some of those things. Cost wise significantly less costly and there's research out there Mount Sinai has published several have, it’s estimated 20% to 30% and maybe more less costly than brick and mortar hospitalization. So again if you think about the drive value how do you deliver the same or better outcomes at a lower cost. This is certainly that.

You also just by being in a physical facility utilization tends to be higher. For example, you're in the hospital bed and you need a chest X-ray. oh but while you're here we might as well do that CT scan, and we might as well run that other panel of labs while you're here, you can see how costs will escalate because of the availability of services. And that's a that's a gray line, one could say well they really need all of this. Maybe, but if we can deliver the same outcomes and not do all that stuff, it it's probably the right thing to do

That's definitely a cost savings. You know in value based care we talk a lot about the triple aim and that's moved into the quadruple aim. How have you seen if at all with that fourth quadrant being provider burnout, have you seen any movement in the provider satisfaction with the hospital at home program?

I believe we absolutely have. I've got six provider FTE's designated for this program. So this is all they do. They provide this care and they all came out of traditional hospital medicine within our health system, and they love hospital medicine but you know just being up on a nursing unit in a hospital, it's noisy and it's distracting and it's a wheel, I mean they're just constantly running. They're very busy in our program. They care for as many patients as they do in the hospital. They round if you will on anywhere from 14 to 16 patients each every day. But they find that they've got more time to focus and spend with the patient and also the nurse and the paramedic are in the home when they are doing that virtual visit so it really feels multidisciplinary. And they're able to see the patient in their own environment so they make a better assessment and a better plan of care.

One of the most compelling examples of this, we also are an academic health system, so we've sent some or that by their selection some residents through our family medicine program residency have come through as an elective in their coursework, and one of them wrote the most beautiful letter about her experience actually caring for patients in their home and she called it a sacred trust. She said it's so true it's true of home health nurses and anyone who has the privilege of delivering care in the patient’s environment it's a complete power shift. In a hospital we put you in our gown in our bed and we tell you when you're going to eat and sleep and bathe. But in the home environment, there is a power shift to where the patients in charge, as they should be. So the physicians that we, and we use some APP's, I think that's going to be even more in the future, they love this model of care because like me they learned about holistic care in medical school and rarely have a chance to practice it in our traditional care settings

That's powerful. I guess the patients are better off in this setting, in your in your mind, and I tend to agree. Do you have a story that you can share where hospital at home impacted a patient?

Yes. I have a lot. We have our quantified data that comes from our patient experience surveys so that's scored, but the best stuff comes from our anecdotal letters or comments within there. So we've countless stories from the patients themselves, from family members, even from neighbors who said you know we were so scared with our neighbor how sick they were but it was so comforting to see the Atrium vehicle pull up in their driveway because we knew oh they're getting what they need today. And many patients, particularly more elderly fragile patients have had very negative experiences in hospitals to where they didn't do well and did so much better at home.

A recent example and I think I did share this on our recent Move to Value Summit, but was an elderly couple, the wife had pretty advanced Alzheimer's, but the daughter wrote us a letter thanking us. Both parents had COVID, so if you remember early COVID, you were isolated family could not visit and many patients died alone, which I think is the greatest tragedy of the whole thing. But here was the couple with COVID the husband had had very bad experiences with delirium and confusion in the hospital in the past. But they were able to be at home. The daughter was able to visit them in their home. They had their pets which is a huge part of healing, honestly, able to be at home. So the husband recovered and did well and was back to gardening and enjoying his life in the summertime. The wife did pass away but she was able to be there with her family when that happened. So I've told that story a zillion times because it really pulls together the whole sense of community and family and dying alone and so that should never happen.

I just you know it's not perfect. We're still learning and iterating on this model, but if you just go from the basic principles of value based care, holistic care, lower cost care, and better outcomes, I know this is the best thing since sliced bread to do that in healthcare. So I'm excited to kind of see where this goes over the next few years I wish this had happened when I was in my 30s, and I'd have more of a runway to see it through, but I think we're on to something here.

The last thing I'll mention is partnering with community agencies. So when we go in and we see the issues that are keeping patients from living the best life they can despite poverty, despite chronic conditions, we can actually do something about it. So we are partnering with some community agencies around food insecurity that extends past their hospital stay, frankly, to make sure they can continue to do well, nutritionally. And also safe housing so where we identify a leaking roof, or unsafe stairwell, or they need a shower bar, we can work with some community agencies to get those things put in to avoid the falls, to avoid you know the diabetic who isn't eating perfectly. All of those things help patients live their best life and frankly put our money where our mouth is. If we if we say we believe in health equity and lowering the cost of care and we believe in access, then we have to do it differently than the way we built it half a century ago.

I like that. What's the plan going forward?

So, as I mentioned, we are currently running a census around 30. Our next milestone is 50, which is just around the corner I hope by year's end where it's 75 or perhaps even 100 patients on service. Again from a operational administrative perspective our whole reason for being is still largely capacity management. Our hospitals remain beyond full and I don't see that changing anytime soon, particularly as the community continues to grow at about 100 hundred people a day I think or something crazy. We do also though believe that this is transformative care, which again in the drive to value that's what we're supposed to be building toward. So I do think much like Mass General Brighams is planning, this could be 200 plus. If you think of 20% of your market beds could approach 500. So to be seen and determined.

I don't know but I know we're not stopping here. We didn't talk about payment models, but a lot of this is contingent on what CMS decides to do at the end of the two year CMS waiver extension. So Medicare will be covered at full inpatient DRG through the end of 2024. We still have to work within our state licensure and CON restrictions to figure out what this means, because quite frankly they don't know either. And then payers are coming along with covering the service, again, I would say they need to put their money where their mouth is and work with us to deliver care differently and better. So all of that legislative and payment work is still underway and it's a pretty heavy lift but we decided as a health system we're doing this regardless of the payment model because it's the right thing to do.

I couldn't agree more, and I look forward to checking back in with you in the near future and seeing how things are going if you would be so kind as to join us again to talk more about this program. I think this is outstanding work that you're doing.

I would be more than thrilled to come back hopefully I've got even more wonderful stories to tell.

Well, you've been a delight. Colleen Hole, thank you for joining us today on the Move to Value Podcast!

Thank you for having me.

Colleen Hole, welcome to the move to value podcast

Well thanks Thomas I'm really glad to be here

I'm curious Colleen, how did you become interested in population health?

Not to show my age but I've been at nursing for many decades and most of those years were spent in acute care in a hospital. And to be honest I think most folks in a hospital just work to get through their shift without really any visibility upstream or downstream as to what brought that patient in or what we're sending them off to. So, we often, not often, always do incredible care in that moment but it's really hard to have visibility into what else is happening in that patient's life that's making them struggle and circling back through our Ed and our hospital. And really, I could see miracles where we save lives every single day but largely in silos, but our patients don't actually live in a silo, they live everywhere else but the places that we take care of them.

So about 10 years ago or so clinical integration became a thing, and I was intrigued by that because I saw it as aligning care really across the continuum. Now our focus was more internal, how do we align care within our health system, but it was about providing care like we had been doing but more about coordinating that care among silos. And I always thought gosh there's got to be more to this than just what we're doing here. And then about seven years ago here at Atrium Health we launched population health and it kind of hooked that to the drive to value. And I was lucky enough to be part of that pretty early on and really loved seeing how health systems were starting to take responsibility for what happened outside of hospitals, around food insecurity and livable safe housing etcetera and then the social determinant of health thing became a thing. So, I guess it's evolved over many decades but really excited I think where I see health systems going now with pop health.

So, I know that you're involved with the Hospital at Home program can you tell me about this program as just an overview perhaps about how this concept came about?

Sure so if you go back 100 years ago where there weren’t brick and mortar hospitals much, many patients received what you might call hospital level care in their home. But with Hill-Burton and post-World War Two we built a whole bunch of brick and mortar across the world. But about I guess 30-35 years ago, the concept kind of came back around more in Europe and even Australia, where for various reasons health systems were starting to go back into homes to deliver hospital level care. And then here in America at Hopkins, Dr. Bruce Leff, a gerontologist, started a program there focused on the fragile elderly primarily recognizing that hospitals presented some risk to this population. So he started a small program and even today, it it's not 100 patients per day, but I think of him as the father of hospital at home if you will. And then when the pandemic hit many health systems were challenged with capacity. So it gave all programs a lift and here we are today with over 200 health systems approved for the CMS waiver which covers at full inpatient DRG, a Medicare hospital stay. So lots more to tell about that but it's kind of evolved over the past several decades, but never with the momentum that it us now

Can you tell me a little bit about and give me a timeline about the Atrium Hospital at home program and why it's been so successful?

Sure so I was busy doing my population and health work, I also serve as the chief nurse executive of our very large...]]>In this episode we learn about the Hospital at Home care model from Colleen Hole, Vice President of Clinical Integration in Population Health at Atrium Health, responsible for integrating the principles of Population Health and value-based care into clinical and operational practice.

Colleen Hole, welcome to the move to value podcast

Well thanks Thomas I'm really glad to be here

I'm curious Colleen, how did you become interested in population health?

Not to show my age but I've been at nursing for many decades and most of those years were spent in acute care in a hospital. And to be honest I think most folks in a hospital just work to get through their shift without really any visibility upstream or downstream as to what brought that patient in or what we're sending them off to. So, we often, not often, always do incredible care in that moment but it's really hard to have visibility into what else is happening in that patient's life that's making them struggle and circling back through our Ed and our hospital. And really, I could see miracles where we save lives every single day but largely in silos, but our patients don't actually live in a silo, they live everywhere else but the places that we take care of them.

So about 10 years ago or so clinical integration became a thing, and I was intrigued by that because I saw it as aligning care really across the continuum. Now our focus was more internal, how do we align care within our health system, but it was about providing care like we had been doing but more about coordinating that care among silos. And I always thought gosh there's got to be more to this than just what we're doing here. And then about seven years ago here at Atrium Health we launched population health and it kind of hooked that to the drive to value. And I was lucky enough to be part of that pretty early on and really loved seeing how health systems were starting to take responsibility for what happened outside of hospitals, around food insecurity and livable safe housing etcetera and then the social determinant of health thing became a thing. So, I guess it's evolved over many decades but really excited I think where I see health systems going now with pop health.

So, I know that you're involved with the Hospital at Home program can you tell me about this program as just an overview perhaps about how this concept came about?

Sure so if you go back 100 years ago where there weren’t brick and mortar hospitals much, many patients received what you might call hospital level care in their home. But with Hill-Burton and post-World War Two we built a whole bunch of brick and mortar across the world. But about I guess 30-35 years ago, the concept kind of came back around more in Europe and even Australia, where for various reasons health systems were starting to go back into homes to deliver hospital level care. And then here in America at Hopkins, Dr. Bruce Leff, a gerontologist, started a program there focused on the fragile elderly primarily recognizing that hospitals presented some risk to this population. So he started a small program and even today, it it's not 100 patients per day, but I think of him as the father of hospital at home if you will. And then when the pandemic hit many health systems were challenged with capacity. So it gave all programs a lift and here we are today with over 200 health systems approved for the CMS waiver which covers at full inpatient DRG, a Medicare hospital stay. So lots more to tell about that but it's kind of evolved over the past several decades, but never with the momentum that it us now

Can you tell me a little bit about and give me a timeline about the Atrium Hospital at home program and why it's been so successful?

Sure so I was busy doing my population and health work, I also serve as the chief nurse executive of our very large Medical Group, and I thought I was plenty busy. But on March the 13th, I was called to a meeting with seven people couple of physicians, couple of administrators, me representing nursing, and we recognized we had a tsunami of patients coming with COVID. We frankly didn't know much about how to take care of them. We didn't know much of anything all we knew was our hospitals in the winter were already full and then some. Traditional flu and all of those viruses, and really in in almost a panic mode of what are we going to do? We were watching Europe and Italy and New York and figured we got to do something quick. So it was kind of like an Apollo 13 moment where they throw all the stuff on the table, here's what we have what are we going to do and failure was not an option, honestly. So about seven days later on March 20th of 2020, we saw our first patient in hospital at home. Part of the benefit of being a large health system is you have a lot of stuff to cull together to make something. So we had clinicians who were available partly because we had closed some services, at least for a time. We also had a pretty robust mobile integrated health or community paramedicine program. So honestly threw all that stuff together, wrote some clinical protocols, work with our IS folks to build them in our EMR and got busy.

So we've been on a 3 year journey to iterate that program which essentially was an outpatient program for which we didn't send a single claim for a whole year, to a full blown inpatient level of care covered under the Medicare waiver. I often say it was the funnest silo busting I've ever done in my 40 years, because everybody leaned in to help. I picked up the phone and said Hey pharmacy I need some help we need medications. We’ll help. Respiratory therapy. We’ll help. It's kind of like a code and a hospital where regardless of the tension that there might be among you know respiratory and nursing, everybody leans in and saves the patient. That's what it felt like and that honestly the adrenaline rush that comes from doing that kind of work has really been the fuel, I think, to sustain the program. Because quite honestly, we're still in a capacity crisis. Our hospitals remain 110% to 120% occupied. And so, we still at least in this market have a have a capacity crisis. So that's still is the burning platform but obviously there are numerous other reasons why we're still at this business.

How is the hospital at home program doing now? Tell me how things are going now that we're sort of, I don't want to say on the backside of the pandemic because I do realize that there's still a lot of issues, but now that things have have become a new normal where do we go moving forward from here?

Yes so we were all COVID in the beginning and we were so unsure that when a patient showed up at the ED, they knew about hospital at home, and it was an automatic, oh good send them home with hospital home. COVID? Send them to hospital home. Over the past three years the pandemic has waxed and waned obviously. In January of 21 so almost one year in we had a peak census of 130 patients on census. That was our highest COVID peak in in our market. So you know literally chest pain in that moment, but since then COVID has only about 10% of what we're taking care of. So we've had to figure out how do we draw patients with heart failure, COPD, various other infections. So really we've seen probably 150 different diagnostic groups if you will of patients still mostly medical but we also will do some post-op surgical patients who often stay in the hospital for lab you know labs to settle or frankly even to have a bowel movement. That that's not a really good reason to tie up hospital beds so we're really constantly looking at what other populations would do better in a home recovery than in a hospital.

I will tell you it's still a challenge to find those patients we've got over 2000 inpatient beds in this greater Charlotte region, and I'm budgeted for a census of 32. So we run high 20s low 30s census daily but most experts in this space believe that 20 to 25% of a market beds could be done with hospital at home. So we've got a long way to go that would be a couple of 100 patients on surface at least. I think it's completely possible Mass General Brigham for example is going for 200 plus. I hope to get to 50 to 75 by end of year but we've still got to decompress our hospitals. They're still full not of COVID but of chronic conditions that didn't get enough attention through COVID. So these patients are sicker than they might have been 3-4 years ago.

So again, being in a growing market is the blessing and a curse. People are still moving here to North Carolina, we've got to make room and building brick and mortar beds is costly and time-consuming and a waste. So if you're talking about value based care that's not value added to build beds at anywhere from a million to five million a pop just to create room, when we know this model works.

Agreed. That's some great insight. When you presented at the move to value summit recently you were talking a lot about holistic patient centered care. Why is providing care in the home, in your opinion, better than in a clinical setting and would there not be risks involved?

Well there's risk everywhere. But I'll talk to that in a minute. I learned about holistic person-centered care and nursing school nearly four decades ago. And I was so excited about it I thought wow this is so cool and we wrote nursing care plans that considered the whole person. And when I became a nurse in a real hospital it was pretty evident that that's not how we actually practice. Because we're built around professions and payment not patients. And I know that's a provocative statement, but in truth how we get paid is how we build health systems. So they're clunky and there's a lot of waste in them and they're expensive. We also know through value-based models and population health that only about 20% of a patients well-being is the medical care that they receive, and even of that 20% of medical care only a small part of that is the physician or provider orders that are written. The rest of the story is where I think our opportunity is in healthcare. What else is preventing that patient from living their best life even with chronic disease that they inherited, can't do anything about that, but how do we help them live their best life to decrease the need for these high cost complex medical interventions? And unfortunately, that's the stuff that most payers still don't cover in America. All the things that we know health coaches and care managers and what nursing does. The domain of nursing is mostly not a line item on a bill. So we've got our priorities kind of messed up in this country. I may not live to see it different, but I'm going to keep pushing because I think it could be done so much better. Other countries in the world spend far less on healthcare and have better outcomes at a lower cost.

Now about the risk thing. About 30% of Medicare patients have a harm event, some severe, when they enter a hospital, about 30%, that's coming straight out of CMS. So, it's true, hospitals are dangerous places. Patients fall, they get infection, they have delirium or sundowner syndrome, they don't sleep well, they don't eat well, and they don't move well in a brick-and-mortar facility. If you've ever been there you know it to be true. Hospitals, they're dangerous places but we'll always need them. Why would we not develop care models where patients can be cared for in the familiarity and comfort of their home. Yes patients fall at home they got rugs that are in the wrong place and they slip, but I guarantee they find their way to the bathroom a whole lot easier and safer in a familiar environment. So we know that some homes are not safe, they've got no air conditioning, or the roof leaks, there are there are stairs to navigate. But in most cases, if you do a good evaluation of appropriateness, the home is a safer place for most patients so they also tell us that's where they want to be that's holistic patient centered care.

Colleen Hole, thank you for joining us today on the Move to Value Podcast!

Thank you for having me.

I want to talk about the new ACO REACH model. Before we dig into the nuts and bolts of how it works, can you tell us briefly what has been happening at CMS and how we got here?

Yeah, that's a great question. So, you know, historically beginning with the Affordable Care Act, really CMS has been focusing a lot on how do we fix the healthcare system, what can we do. We know the Medicare Trust Fund is going to run out of money eventually. So, you know, how are we going to fix this? And over the course of the past 10 to 12 years, have been looking at so many different models of what's going to work and most of those models are coming out of the Innovation Center at CMS. So, what's going to work and how do we fix these different problems? And then that, you know, kind of birthed the value movement as we know it today. And then you see kind of the models that we know that have been kind of tried and true, which is the Medicare Shared Savings Program model which has you know multiple tracks and different levels of participation for different health care systems. Again, all focused on traditional Medicare patients.

And then in I think it was 2016, 2017 I can't remember exactly they started the Next Generation ACO model, which was kind of the precursor to ACO REACH. So, Next Gen was really kind of a way for healthcare systems to take on 100% shared savings, upside, downside shared savings. And what that means is that they're completely accountable for the care that they provide for these patients. And that's slowly morphed into, we'll probably talk about this later, but direct contracting is morphed into this direct contracting which then was renamed and revamped into ACO REACH.

Can you tell me why did they sunset NextGen? Was it not working or was it just not fulfilling the need?

Yeah, that's a good question too. So, I think part of the issue was that you know these models have to go through the process of being certified if they're going to be put into regulation. So, all the models that the Innovation Center does are kind of like testing grounds. Let's see what's going to work and are we actually going to save money with this model. And then, after they've run their course, they go through a process where they are looked at under scrutiny trying to determine “hey did this model actually save us money or is the money that we paid out to the health system, did we really not save a whole lot of money for the for the Medicare trust fund?” And so there was, you know, they have like the OMB and different arms of the government that are looking specifically at the model to figure out did we save money or did we not.

So, that certification process came back saying we did not save as much money in this model as we thought we would. Now I will say that there are a lot of people that say that there are some issues with the underlying methodology of how they went through the process of determining whether savings were there or not. And a lot would say there is savings, you're measuring the savings in an incorrect manner or there's intangible ways to measure value being created in these health systems that you can't really put a price tag on. So, there was a lot of back and forth in that arena, but it kind of came down to CMS as a whole does not believe that this model saved as much as it should have. So we need to go ahead and sunset it and come up with another model that is going to advance care and value and really kind of do a little bit more to save the Medicare Trust Fund money.

Is ACO REACH an acronym?

It is an acronym. So ACO, obviously accountable care...]]>Today we have the first in a series of conversations about ACO REACH with Melissa Pollock, Director of ACO Compliance and Regulatory Affairs at CHESS Health Solutions, who was instrumental in navigating all of the processes for acceptance into the newest CMS payment model.

I want to talk about the new ACO REACH model. Before we dig into the nuts and bolts of how it works, can you tell us briefly what has been happening at CMS and how we got here?

Yeah, that's a great question. So, you know, historically beginning with the Affordable Care Act, really CMS has been focusing a lot on how do we fix the healthcare system, what can we do. We know the Medicare Trust Fund is going to run out of money eventually. So, you know, how are we going to fix this? And over the course of the past 10 to 12 years, have been looking at so many different models of what's going to work and most of those models are coming out of the Innovation Center at CMS. So, what's going to work and how do we fix these different problems? And then that, you know, kind of birthed the value movement as we know it today. And then you see kind of the models that we know that have been kind of tried and true, which is the Medicare Shared Savings Program model which has you know multiple tracks and different levels of participation for different health care systems. Again, all focused on traditional Medicare patients.

And then in I think it was 2016, 2017 I can't remember exactly they started the Next Generation ACO model, which was kind of the precursor to ACO REACH. So, Next Gen was really kind of a way for healthcare systems to take on 100% shared savings, upside, downside shared savings. And what that means is that they're completely accountable for the care that they provide for these patients. And that's slowly morphed into, we'll probably talk about this later, but direct contracting is morphed into this direct contracting which then was renamed and revamped into ACO REACH.

Can you tell me why did they sunset NextGen? Was it not working or was it just not fulfilling the need?

Yeah, that's a good question too. So, I think part of the issue was that you know these models have to go through the process of being certified if they're going to be put into regulation. So, all the models that the Innovation Center does are kind of like testing grounds. Let's see what's going to work and are we actually going to save money with this model. And then, after they've run their course, they go through a process where they are looked at under scrutiny trying to determine “hey did this model actually save us money or is the money that we paid out to the health system, did we really not save a whole lot of money for the for the Medicare trust fund?” And so there was, you know, they have like the OMB and different arms of the government that are looking specifically at the model to figure out did we save money or did we not.

So, that certification process came back saying we did not save as much money in this model as we thought we would. Now I will say that there are a lot of people that say that there are some issues with the underlying methodology of how they went through the process of determining whether savings were there or not. And a lot would say there is savings, you're measuring the savings in an incorrect manner or there's intangible ways to measure value being created in these health systems that you can't really put a price tag on. So, there was a lot of back and forth in that arena, but it kind of came down to CMS as a whole does not believe that this model saved as much as it should have. So we need to go ahead and sunset it and come up with another model that is going to advance care and value and really kind of do a little bit more to save the Medicare Trust Fund money.

Is ACO REACH an acronym?

It is an acronym. So ACO, obviously accountable care organization. REACH standing for realizing equity, access, and community health. So really kind of a turn towards let's look at the communities, let's look at health equity with a greater lens, let's look at you know accessibility of care for populations of traditional Medicare patients.

So then, what is this new payment model trying to achieve? Can you tell us why they feel there is a need for a new model?

It's kind of interesting what happened. So, with the sunset of Next Gen, everybody was like ok what do we do next? What’s the next round of innovative, cutting-edge models from the Innovation Center? And they stood up this direct contracting model, and then eventually kind of steered it towards more of a health equity lens and renamed it ACO REACH.

What’s really different in this model is that it has, kind of, a quasi-capitated payment model. And that's really something that CMS has never done. So, when we talk about capitation in an insurance plan or program, you think per cap. Right? It's per head. So, you're getting paid kind of a, you know, a specific amount of money per patient. That's the money that you get, the money goes into your bank account. This is obviously way oversimplified, but the money goes into your bank account once a month. Here's the amount of money we're going to pay for you to take care of these patients. You can pull from this money, but when you run out of money, there's no more money. We're not going to give you any more money for these patients. So, it's a capped amount of money that they're giving you.

I think what's interesting is that really ACO REACH is disrupting the payment flow for the provider directly from Medicare. And so, the provider submits the claims to Medicare and then depending on the structure of Medicare can return either a percentage of that money directly to the provider or none of it if you decide to take 100% capitation. And then instead, that money will come to the ACO as a payment directly from Medicare and then we downstream pay the providers based on these contracts that we put in place. So, that really drives incentive for us, as an ACO how can we take the money that we're getting from CMS and become really innovative and creative to come up with different ways to incentivize providers. You know, what are the levers that we can use to pay them in different ways than maybe traditional Medicare would have ever paid them. And drive value through that payment process rather than a fee-for-service structure, which we know is just you're getting paid per, you know, widget and widget out type thing you're just getting paid whatever you bill.

How did we get the autonomy to do that? That seems like there’s, I don’t know, an accreditation or a lot of trust that’s involved that there’s not waste, fraud, or abuse of some sort because we’re getting big checks and then it’s up to us. I mean I’m sure that there’s a bad apple there, how do they determine who’s worthy or who’s respectable?

So, I mean first of all we had to apply for being in the model and the application process was not a small feat. They're going to look at ok, historically, CMS is going to look at have we participated in these models before? Did we perform well in these models before? You know, what kind of integrity is there? There's a lot of checks and balances in place for that. And then at the same time, you know, we as the ACO are contracted with Medicare to do this process. We then contract with all the different value partners or health systems that are in the model to say, “hey this is exactly how we're going to reimburse you, and this is exactly what you're agreeing to,” and make sure that contractually that's all tight. So that, you know, when we start getting money as CHESS, we know exactly how we're going to reimburse it downstream so that everybody is getting what they thought they would be getting.

Recap what’s been happening and explain some of the main differences between the MSSP, NextGen model and the new ACO REACH model?

Sure yeah. So, I think I mentioned this earlier, but Medicare Shared Savings Program (MSSP) is still fee-for-service. It’s kind of fee-for-service with a shared savings portion layered on top. You know, at a very high level, it’s a benchmark. You get paid. CMS is expecting that you will spend this amount of money on the patients in the performance year. If you go over that amount of money that they thought you were going to spend, that target benchmark, then depending on which track you are in, you have to pay it back. But all the while, fee-for-service is still underlying everything. Right? So, the provider is still seeing the patient, submitting claims to Medicare, Medicare’s still reimbursing them normally. And this is kind of like a second layer on top of fee-for-service. Ok, let’s see if you actually saved money compared to what we thought you were going to save, etc. The thing with MSSP is that it only goes up to 75% shared savings on the upside. Meaning that whatever savings you generate, you only get to keep 75% of it.

Next Gen was 100% risk, and that meant that whatever you saved, you get to keep all that you saved. So, you know, if you saved $3 on your entire patient population for the whole year, you get to keep those $3. Right? But, if you lost $3, you have to pay $3 back. So, that’s what they call first dollar savings and first dollar losses. But, you know, same with if you were able to generate $14 million in savings, you didn't have to pay a cut of that back to CMS. You got to keep the full amount of savings that you generated. So, that was kind of what Next Gen was. Next Gen also provided some really, kind of, interesting waivers that hadn't been tested before. So, they were trying to test some of the new waivers with Next Gen, so Skilled Nursing Facility Waiver (SNF) kind of started the Next Gen program before it moved to MSSP.

So, with the ACO REACH model, you still have providers that are submitting claims to CMS as you would in fee-for-service, but they have the ability to take out that reimbursement on fee-for-service. So, MSSP and Next Gen, they were still getting paid fee-for-service under everything. There is the ability, based on how you structure your ACO REACH model, to say, “Hey. You're not going to get, the provider's not going to get any money from Medicare at all.” And instead, that payment's going to come through come through the ACO, the ACO will get that money, and they're going to reimburse you based on how they decide to do it. It’s almost like putting a small, mini contract inside of a larger contract. Right? So, you almost like a Medicare Advantage, not in its entirety, but you're putting a smaller contract within this larger ACO REACH process. And, you're saying, “OK. We're going to make you accountable for these quality measures, or for annual Wellness visits, and you can earn some of this money back based on how you perform on these metrics.” Or some just say, “hey we're just going to pay you a straight PMPM, a per member per month. You have 10,000 patients in the model, we're going to pay, you know, whatever PMPM, and that's your pot of money that you get. We're not going to process claims at all. We're just going to know that you're doing what you should be doing to send that claims data to Medicare.” Because, you know, I mean, I think they're thinking that these the providers that are in these have been doing value-based care for a long time. And so, the quality measures that are required in MSSP that we're so used to, the web interface quality measures, you know, your colonoscopy screenings, your mammogram, all those things, we should be doing that for all patients. So, by the time you get to something as sophisticated as ACO REACH, they're saying “OK now you guys come up with the quality measures. What do you think is going to drive care and lower cost of care?”

Would it be typical for, in this new model, is it an upfront payment where the entity would receive the $14 million and then, oops you’re out, now you have to absorb the cost of care for if you go over? Or at the end of the of the year, do they make the accounting decisions and then send you a check of what the savings would be?

So, it kind of depends on how they structure, how you decide to structure your ACO REACH. So, we as the ACO, are getting weekly payments from Medicare based on the claims that were submitted the week before. So, we get a weekly claims file from Medicare that says, “hey in the last week, here's the claims that were processed, and here's the pot of money you can use to pay that.” But, at the end of the year, it's all going to be reconciled. Right? As you were saying, they're going to look at that benchmark that they've set, that target amount, at the end of the year and they're going to look at all the payments they gave us throughout the year, and they're going to determine was there any savings generated based on those payments that we gave you. And if so, you know, what do we need to claw back from you guys or what do what do what do you actually get in payment.

So, it just depends on how the ACO decides that they want to downstream pay their providers. I think one of the benefits of ACO REACH is that there is a lot of upfront money. Right? With MSSP, you had to wait you know a year, eight months after the performance year was over to actually see did we save anything, did we not, are we going to get a big payment. And I think REACH provides that kind of comfort in the days of COVID, when people are very low on cash, and you know scrambling for money for some of these places to stay open, REACH was very attractive because the ACOs could provide that upfront cash during each month or even on a weekly basis depending on how they wanted to structure things. And that, you know, gives them a little bit of a peace of mind. Now again, it'll all be reconciled on the back end, but that was a little bit of the of the upside to ACO REACH was that upfront cash flow for a lot of these smaller practices that were struggling.

I think that would be a huge benefit because then you could invest in the equipment, you could invest in the staffing, rather than trying to make do with you know everybody working three times as hard to make it happen. You could go ahead and get different things that you need.

Well, there was conversation in 2021/2022 about direct contracting. Where does that or where did direct contracting fit into this transition?

Yeah, so direct contracting was kind of the next iteration of what Next Gen was supposed to be. So, when Next Gen started sunsetting, they said OK the next thing is going to be direct contracting. And basically, that idea of the ACO is directly contracting with the providers. Which is what we see in REACH. This kind of idea of like setting a smaller plan, so to speak, inside of a larger framework. But what they noticed was, when they put out applicants for direct contracting, there were a lot of private equity firms that decided, “Hey. We’ve been in the MA market for a very long time. We’ve been able to, you know, approach or have a lot of patients via Medicare Advantage Plans. We’ve never really had a crack at traditional Medicare patients. The only way we get to the accountable for the patients cost of care is if they convert to an MA plan. And so, a lot of private equity firms spun up organizations in order to enter direct contracting. Because this was a new piece of the pie that they hadn't previously had access to, because it was just CMS, and the patient, right, and the provider. And there was no, you know, commercialization so to speak. I don't know if that's the best term to use, but it's a way to think about it.

So, there's a lot of private equity that entered the space, and then there was a lot of pushback on the hill from different senators who had heard that direct contracting was taking the rights of the traditional Medicare patient. You know, one of a patients’ rights is to be able to go anywhere. They can see whoever they want to see. There's no restriction like there is in other plans, where you have narrow network and things like that. A traditional Medicare patient should be able to see whatever provider they wanted to see. And there were some groups that were very vocal in their disagreement with the direct contracting plan, and really thought that this was kind of the death to traditional Medicare, is that it was you know bringing in this these new elements. Which is not true. There's a lot of misinformation out there, but it was heard at higher levels. And so, in an effort to make sure that the program, direct contracting, wasn’t scrapped altogether, CMS really put together some efforts to try to put protections around the patient, put a lot of transparency in the companies that were trying to come in and be in direct contracting. They wanted to look at governing bodies, who owns what company in this scenario, and they wanted that transparency in governance structure. And then, they also set up this kind of health equity lens, which is kind of one of their main goals for the next 10 years for the Innovation Center is to start to put health equity components in all of their models.

So, there was a really big focus on OK, lets make sure first of all we have transparency, second of all we're protecting the rights of the patients, but third we need to make sure that the patients are being treated equitably. And if anything, COVID really exposed the inequity in healthcare, right? It really did. And so, I think they realized this. We all realized that as well. And so, this is the first foray into really, OK, how do we how do we address this? And I don't think anybody has the right answer. You know, we hear the adage, if you see one ACO, you’ve seen one ACO. And so, all the populations are going to be different. So, how do we do this? I don't think anybody has the magic golden ticket of what to do, but we’ve got to start somewhere.

Well as, I'm going to put a spotlight on you for a moment, as someone who has been doing this for quite some time and who I consider you know one of the leading experts in this in the nation. What's your take on direct contracting?

That’s a really great question. Personally, I really felt like, it did, you did see some very odd companies trying to come into the traditional Medicare space. And then, kind of use the population of patients to convert them to their traditional MA plans. So, they were using direct contracting, and I will say this is what I’ve heard, but they were using some of those patients lists to do some things that they should not be doing with patient lists, like marketing them for MA plans or getting them to convert to MA plans, those types of things. So, you saw some kind of nefarious things happening that we heard whispers about. I think it's an interesting concept to allow this to happen, and I think if it's going to actually drive change in health populations, then let’s do it. But if it’s going to drive everyone to the all-mighty dollar, then I don’t know if I’m a fan of it. Personally, I want to see what’s best for the patient. I want to see, if this is going to help a patient population, OK then let’s help a patient population. But what are the motives behind that? So, I don’t know. We’ll see what happens. It was a little, I think there was a little bit of both sides. There was some misinformation at the congressional level, the senate level, of really the understand of what direct contracting was. And so there was a large effort from advocacy groups to try to combat that misinformation and help them understand how the patient is being protected. But at the same time, you have others coming in who just see, my...]]>e0da64cb-4381-4681-9f24-113ad9badfe0Thu, 23 Feb 2023 00:00:00 -050024:34falsefull2525Laneita Williamson, RN, BSN - How Adverse Childhood Experiences Impact OutcomesToday we continue our conversation with CareNet’s Laneita Williamson to dig deeper into the effect of trauma on well-being and the impact of adverse childhood experiences on a patient's health. Laneita Williamson welcome back to the move to value podcast

Thank you so much I'm glad to be here

Last time we talked quite a bit about trauma and trauma informed car. Can you share how health care providers can help patients address their trauma?

Yes, so healthcare providers can learn about trauma-informed care and they can use that at the individual level, the organizational level and even advocate at the system level through legislation. But at the individual level once you learn about trauma-informed care, there are four Rs that we kind of want everybody to be utilizing with every person they come into contact with. Those four Rs are realizes, recognizes, responds, and resist.

So realizes means that we realize the widespread impact of trauma on patients. That there are adverse childhood experiences that changes the architecture of the brain when it's pervasive and toxic and then those changes create a latency period to adulthood. And then there's around 40 plus diagnosis that have a correlation to those childhood adversities and just knowing how many people, nationally and globally, have childhood adversities is the first step. We want to realize that the people we are treating today we are seeing the symptoms of what occurred decades ago in their childhood.

So when we realize that, our next step is going to be to recognize what those signs and symptoms are. How they show up in a clinic setting. Is it showing up through their social status? Is it showing up through their behaviors? Is it showing up through their inability to be part of the treatment plan, leaving against medical advice? Is it showing up with diagnosis that we know are correlated to that adversity or that trauma in childhood?

And then once we recognize those signs and symptoms, the our logical next step is, well how do we respond? You know, what do we do? Well we respond by fully integrating our knowledge about trauma with that individual you know asking them you know how are things in your life impacting you? What in your life has impacted you that may be working against you with your health right now? That can open up a discussion with the patient. Another way that they can, physicians or providers, can respond is to look at the hospital policies, procedures, and practices. What are we doing that may be hurting our patients instead of actually helping them?

Which that leads us into our last and final R which is resist. We want to seek to actively resist retraumatization and that may look different from one patient to the next. But once we become trauma informed, we learn very quickly to ask what makes you feel safe. We want to make sure that we're helping you in the space that you're in, and we do things from a lens of curiosity. Is what I'm about to do possibly a trigger for a person? And if it is, how can I work with this patient to help them know what may be part of their treatment plan and how we can navigate through it so that they are not traumatized.

So although there are four R's that will know of in trauma informed care, there are two more Rs that have been used in a recent book that I'm familiar with, and the first is repair and the second is resilience. Repair means it's important for us to acknowledge the ways in which our systems and our communities have been harmed through judgment, rejection of abuse, and how we have impacted those trauma survivors. And then resilience it's important that we recognize individuals may not have resilience. Resilience comes from having tools provided to an individual family or community that allows them to build resilience. So as we're working with our patients, what can we offer them to help any repair that may need to happen and to build...]]>Today we continue our conversation with CareNet’s Laneita Williamson to dig deeper into the effect of trauma on well-being and the impact of adverse childhood experiences on a patient's health. Laneita Williamson welcome back to the move to value podcast

Thank you so much I'm glad to be here

Last time we talked quite a bit about trauma and trauma informed car. Can you share how health care providers can help patients address their trauma?

Yes, so healthcare providers can learn about trauma-informed care and they can use that at the individual level, the organizational level and even advocate at the system level through legislation. But at the individual level once you learn about trauma-informed care, there are four Rs that we kind of want everybody to be utilizing with every person they come into contact with. Those four Rs are realizes, recognizes, responds, and resist.

So realizes means that we realize the widespread impact of trauma on patients. That there are adverse childhood experiences that changes the architecture of the brain when it's pervasive and toxic and then those changes create a latency period to adulthood. And then there's around 40 plus diagnosis that have a correlation to those childhood adversities and just knowing how many people, nationally and globally, have childhood adversities is the first step. We want to realize that the people we are treating today we are seeing the symptoms of what occurred decades ago in their childhood.

So when we realize that, our next step is going to be to recognize what those signs and symptoms are. How they show up in a clinic setting. Is it showing up through their social status? Is it showing up through their behaviors? Is it showing up through their inability to be part of the treatment plan, leaving against medical advice? Is it showing up with diagnosis that we know are correlated to that adversity or that trauma in childhood?

And then once we recognize those signs and symptoms, the our logical next step is, well how do we respond? You know, what do we do? Well we respond by fully integrating our knowledge about trauma with that individual you know asking them you know how are things in your life impacting you? What in your life has impacted you that may be working against you with your health right now? That can open up a discussion with the patient. Another way that they can, physicians or providers, can respond is to look at the hospital policies, procedures, and practices. What are we doing that may be hurting our patients instead of actually helping them?

Which that leads us into our last and final R which is resist. We want to seek to actively resist retraumatization and that may look different from one patient to the next. But once we become trauma informed, we learn very quickly to ask what makes you feel safe. We want to make sure that we're helping you in the space that you're in, and we do things from a lens of curiosity. Is what I'm about to do possibly a trigger for a person? And if it is, how can I work with this patient to help them know what may be part of their treatment plan and how we can navigate through it so that they are not traumatized.

So although there are four R's that will know of in trauma informed care, there are two more Rs that have been used in a recent book that I'm familiar with, and the first is repair and the second is resilience. Repair means it's important for us to acknowledge the ways in which our systems and our communities have been harmed through judgment, rejection of abuse, and how we have impacted those trauma survivors. And then resilience it's important that we recognize individuals may not have resilience. Resilience comes from having tools provided to an individual family or community that allows them to build resilience. So as we're working with our patients, what can we offer them to help any repair that may need to happen and to build their resilience to help take care of their health?

Our next Move to Value Summit is about community health workers and community resources and we talked a little bit about this leading up to our Nursing event that we held in December of 2022. I'm curious as to what community resources might be available to support trauma outside of the practice that a provider might be able to say “hey between our visits here somewhere you can go and talk to someone” - or if that resource isn't there, do you see a need for one?

So community resources is a challenge and the reason it a challenge is that nationally and globally we have not recognized the impact of trauma until we’re already behind the curve. So we don’t have enough centers or organizations to handle the influx of the trauma outcomes that we are seeing but what I want to, you know, encourage, is that communities can help heal from within. So part of trauma-informed care and being a provider is giving education. Just like we give education to new parents about covering up their outlets or using a car seat, you know, how to feed their babies sitting up and in ways to sleep, or if you're an adult your risk factors for smoking and what that does to you. As clinicians, we provide ongoing education every single day. So one of the things that's so good about trauma informed care is that we can provide education to our patients to take back into their communities and communities can utilize this information to heal in the way that they need to heal because every community has different historical trauma. different adversities. They know what they need. They also have the wisdom to heal from the inside out once they get the knowledge. Once they understand how they've been impacted and have been validated. Now that's not to say we don't need to continue to advocate for our nation to help our healthcare systems have more resources in the community, such as CareNet or Parenting Path, which is here in Winston-Salem, or Forsyth Family Services, there's so many good organizations going on, Smart Start. But we need more of those. So our social workers do have relationships with the agencies within our area that we can send people to, but we also want to encourage community self-healing and give that education to them.

Very well said. So what are adverse childhood experiences, also called ACEs, and how do they impact adult health?

Adverse childhood experiences or ACEs are potentially traumatic events that occur in childhood before the age of 18. So from that zero to 17 years. They include some main categories like abuse, neglect, and pervasive household dysfunction, Now underneath those categories you're going to have subcategories such as in abuse you may have sexual abuse, or physical abuse. In neglect it may be physical neglect, or emotional neglect. Then in household dysfunction, it can be examples such as a parent who has an unmanaged mental illness, substance misuse, interpersonal violence within the home, incarceration. All of these things can be impacting that child's brain development. So that's why we're calling them adverse childhood experiences.

These traumatic events again create this latency period to the onset of poor health outcomes later in life. These adversities, we now know that by the time there are six or more of those categories that I just spoke to, in the original adverse childhood experience study those patients that had six or more of those, their life expectancy was 20 years less than children who had none of those adversities. So we really want to understand that these patients had this 20 year reduction in life expectancy. But even before that, they were already having chronic illnesses, health issues, behavioral challenges, substance misuse, social issues, and these are things that again we want to be able to repair and help each patient build their own resilience. And as we've learned about adversities, there were those 10 original adversities from the adverse childhood experience study, but we know those are not the only things that impact children or they're developing brain.

So for example North Carolina has developed the North Carolina resilience community, has developed a tree that has four dimensions of adversities. The first one is going to be your adverse childhood experiences that I just discussed. The second will be the adverse community experiences. This is what's impacting our population – poverty, structural racism, community disinvestment, police violence, lack of affordable housing, lack of opportunity and economic mobility, discrimination, disconnected relationships, unemployment, and deteriorating built environments.

The third area of the tree is adverse climate experiences. These include examples such as climate change, wildfires, droughts, hurricanes, earthquakes, environmental injustice, pollution, floods, and COVID-19, which is very critical for our healthcare system. We were addressing the pandemic as it was occurring, but while it was occurring all of these adversities were impacting these children, which means there's a latency period that we're going to see in our future, whether that's 10-20 years, of an influx of these children who were experiencing these traumas in their homes when they were not at school, when no one was watching, or when their parent had to go to work and leave them there, maybe without food. So there's all of these challenges that's coming from the pandemic which is under the adverse climate experiences.

Then there's also atrocious cultural experiences. There's impact with macro and sociohistorical conditions, like slavery, genocide, colonization, segregation, forced family separation, removal of property, and then just a political and social mistrust. So our children who have gone through atrocious cultural experiences, they are impacted through their environment and their community and then that carries over into the next generation.

For the provider, how can adverse trauma experiences be identified in their patients, and how should this information impact a treatment plan?

As clinicians or providers we don't necessarily aim to identify specific adversities but we do walk into every situation, again, utilizing that universal precaution. The vast majority of people have experienced adversities and this is a very different understanding than what we once believed. We historically believe that adversities were rare or children were resilient with no lasting impacts, but now since we know differently, we just walk into every situation wondering what's happened to them instead of what's wrong with them. So a provider should always have trauma at the forefront of how they engage. They should consider how trauma has impacted this patient neurologically, psychologically, socially, and biologically, and again going back to looking at what's happened to them instead of what's wrong with them.

Having this knowledge and this approach alters every action in our treatment. It changes how we engage to minimize triggers. It helps us resist that retraumatization. It changes the questions we create in order to obtain our differential diagnosis. It changes what labs or treatments are to be considered. How we respond to the patient's beliefs, fears, and behaviors. Then we also begin to collaborate differently with other providers and just be cognizant of reporting to each other in a trauma informed approach. Helping a patient, again, can be very simple. Is walking in with this lens of what trauma has done to us and then just making sure that we are not retraumatizating them, that we're working with that patient. And then that approach and that lens impacts every step of the journey through a patient’s health process, whether it is maintaining, improving, or in some cases, even in Hospice care, we want to make sure that we're giving them a trauma informed care approach at every point in time.

Laneita, how can health systems prepare to care for the next generation of patients with adverse childhood experiences?

Make sure that you have a road map or a toolkit in place and different milestones. So you may, for example, have five milestones. The first would be conduct a readiness assessment. Is your organization ready to shift to that trauma-informed care lens. Do you have the leadership buy in or are the leaders actually helping you move trauma-informed care through the organization. You want to define your clinical roles and tasks, who's responsible for what. You want to gather your resources, get to know your network of care. Who around you is also working on the same types of approaches but may not be falling completely under trauma-informed care, but once they learn about it, it brings everybody together to have a better framework. Consider that financing and technology needs. What is needed? Is it that you have financing for trainers in every division or every department, or that you have enough technology to have an Intranet build in your system where your employees and staff can go and look for resources you know who to contact to schedule trainings. And again, you want to monitor, evaluate, and continue to improve you know your processes as you move forward.

Healthcare systems absolutely do need to listen and learn from their communities though, that is first and foremost. We need to discover our communities specific history, take those steps to repair any historical trauma through a trauma-informed care lens so that our healthcare systems will be utilized by those patients who have had mistrust, for very valid reasons. That will help break the cycle of that intergenerational transmission of ACEs into the next generation.

Well what can a provider do starting today to begin to address these behavioral health needs for their patients?

So oftentimes one of the questions that I get from providers is that I love this information you know it makes sense but what do I do with it? And what I tell the providers is that it's important to learn how to respond to someone that either shares that they have a history of trauma or that has been triggered. So the first thing that you can do is say we now know adversities in childhood can impact our adult health, how are body works, and how we cope. How do you feel any adversities in your past may be impacting you now? Often times that allows the patient to open up to share or to express a concern. Typically, they don't because it's such a private moment, they're not going to share a lot, and that's another thing that providers are worried about is the time. Most of the time they will just share something small. But when they do you thank the patient for sharing, validate their strength by stating I'm amazed at how you came through your trauma and are trying to take care of yourself, and then you know once you've asked how they're impacted and you’ve validated them by sharing that you’re amazed how they came through it, you can usually move forth in your treatment plan. They’ve shared something, you validated it, and it gives you the knowledge that you need for that next step of where to go in your treatment plan.

Outstanding! Laneita Williamson, thank you for joining us today on the move to value podcast

Thank you so much it was truly a delight to be here.

Thank you so much I am so glad to be with you today and to talk with you.

Well we certainly are glad that you could join us. So my first question for you Laneita is what is trauma?

Sure, so if we're thinking about trauma we want to think about it as an event a series of events or a set of circumstances experienced as physically or emotionally harmful or life threatening and then has a lasting adverse effect on you, as the individual, or an organization, or communities, functioning. And this could be your functioning mentally, physically, socially, emotionally, and even your spiritual well-being.

So now I want to ask you - what is trauma informed care and what are the benefits?

When we are thinking about trauma informed care we want to recognize that it is an approach. It's an approach that a program organization or system takes when they become informed about trauma and the impacts from trauma. It is the approaches taken by those that realize the widespread impact of trauma and then understands the potential paths for recovery. And then also recognize the signs and symptoms of trauma in your clients, families, staff and the others. They would integrate knowledge about trauma into the policies procedures and practices. And then of course we want to seek to actively resist retraumatization in those clients, family, staff, or each other. And in regards to the benefits of a trauma informed care approach, what it ends up doing is it allows us to listen to our patients more. We begin to practice more patience and then that creates more empathy. We learn to get along better as a team. When a patient or a client or someone does something harmful, we actually began to look at the reason why or understand what is the cause of that action instead of judging that person. We also talk about how our work actually impacts us or affects us and then when we're having that connection and that peer connection with each other, we began to develop tools that help us understand what we need in our work day in order to continue forward. We begin to have new ideas, new creations of treatment plans, you know, recognize how we're to work together as a team or you know to address system issues and just create that connectedness to each other. This all of this allows us to feel more valued and be human and to recognize it's OK to have our human feelings to take care of ourselves and then to come back reenergized and hopeful so that our resilience is increased. The trauma informed care really does have a lot of benefits.

Well can you share an example or two from your own experience of how trauma informed care has been used to improve a patient outcome?

So there's so many examples we can use when working with patients in a hospital system where trauma informed care actually impacts that patient in such a way that it creates a better outcome. And I have so many stories, but it can be something as simple as you as a clinician or provider identify that it's not necessary to get a lab draw in the middle of the night. And the reason for that is that when we are going into a person's private space which is there you know hospital bed, their hospital room, to wake them up, then that can actually trigger them and they will want to leave the hospital. They may go back into a time where that being awakened during the middle of the night was something that was a trauma. So as we begin to think through how we work with our patients we've recognized something as simple as lab draws, we do it...]]>Today we talk with Laneita Williamson the trauma informed care manager at CareNet, who shares with us the effect of trauma on a patient, and also ways it can impact their care, and techniques for managing this potential barrier to positive outcomes. Laneita Williamson welcome to the move to value podcast.

Thank you so much I am so glad to be with you today and to talk with you.

Well we certainly are glad that you could join us. So my first question for you Laneita is what is trauma?

Sure, so if we're thinking about trauma we want to think about it as an event a series of events or a set of circumstances experienced as physically or emotionally harmful or life threatening and then has a lasting adverse effect on you, as the individual, or an organization, or communities, functioning. And this could be your functioning mentally, physically, socially, emotionally, and even your spiritual well-being.

So now I want to ask you - what is trauma informed care and what are the benefits?

When we are thinking about trauma informed care we want to recognize that it is an approach. It's an approach that a program organization or system takes when they become informed about trauma and the impacts from trauma. It is the approaches taken by those that realize the widespread impact of trauma and then understands the potential paths for recovery. And then also recognize the signs and symptoms of trauma in your clients, families, staff and the others. They would integrate knowledge about trauma into the policies procedures and practices. And then of course we want to seek to actively resist retraumatization in those clients, family, staff, or each other. And in regards to the benefits of a trauma informed care approach, what it ends up doing is it allows us to listen to our patients more. We begin to practice more patience and then that creates more empathy. We learn to get along better as a team. When a patient or a client or someone does something harmful, we actually began to look at the reason why or understand what is the cause of that action instead of judging that person. We also talk about how our work actually impacts us or affects us and then when we're having that connection and that peer connection with each other, we began to develop tools that help us understand what we need in our work day in order to continue forward. We begin to have new ideas, new creations of treatment plans, you know, recognize how we're to work together as a team or you know to address system issues and just create that connectedness to each other. This all of this allows us to feel more valued and be human and to recognize it's OK to have our human feelings to take care of ourselves and then to come back reenergized and hopeful so that our resilience is increased. The trauma informed care really does have a lot of benefits.

Well can you share an example or two from your own experience of how trauma informed care has been used to improve a patient outcome?

So there's so many examples we can use when working with patients in a hospital system where trauma informed care actually impacts that patient in such a way that it creates a better outcome. And I have so many stories, but it can be something as simple as you as a clinician or provider identify that it's not necessary to get a lab draw in the middle of the night. And the reason for that is that when we are going into a person's private space which is there you know hospital bed, their hospital room, to wake them up, then that can actually trigger them and they will want to leave the hospital. They may go back into a time where that being awakened during the middle of the night was something that was a trauma. So as we begin to think through how we work with our patients we've recognized something as simple as lab draws, we do it at a later time in the morning when they're awake. Or if we have someone who is struggling with addiction and they're in our suboxone clinic, we recognize that getting a lab stick may be a trigger and can actually send them back into injecting again. So we try to minimize those lab visits or have peer support with them so that they've got somebody there to actually help them through the process. So, again, there's so many benefits to trauma informed care but that is one simple you know example that we can use in our everyday practice. Of course there are many more stories that I could share that revolve around things like workplace violence and patients that have shared their stories that wanted to leave the hospital because they were being triggered by maybe a bath and maybe their trauma in childhood was around a bath and we found ways to work with that patient to create a new treatment plan so that they felt safe they had a choice and they were able to stay in the hospital setting.

Laneita, how do we go about discovering what past traumas may be present for our patients?

When we're thinking about our patients coming into any setting, no matter where you may work, we begin with a universal precaution. And that means that we assume all patients have had trauma and then we approach that patient just like we know they're coming in for an acute traumatic violent event. We use some of the same strategies and tools and we may not identify if this patient has had physical abuse, sexual abuse, emotional abuse, or neglect, but we're using the same approaches to that patient so that they already feel safe. They already know that there's someone that is allowing them to be in a space where they have a voice and they can actually feel safe and be a part of the treatment plan. We don't have to necessarily get into specifics of a trauma or ask specific information, like were you physically abused or sexually abused because we're going to be using the same approach no matter what.

It's funny that you mentioned the approach because that leads into my next question. Will you explain to us the six guiding principles of trauma informed care?

When we are approaching our patients through a trauma informed care lens, we do want to use the six guiding principles and the very first one of those is safety.

And of course you know most people in medicine is going to say well we already provide safety. And yes we do have a framework for safety - are they not falling, you know, are they getting the right medicines, the right treatment plans. But what I mean by this is does that person feel psychologically emotionally safe not retraumatized, not triggered. And one of the ways that we can do that is by asking questions. By asking that patient, What makes you feel safe today? How can I help you feel safe? Would you like the door open? The door closed? How would you like me to address you? What are the best ways that you can have this procedure? Is it with a friend? Is it someone there for you? Is there anything you need us to know before we begin this treatment plan? So just identifying safety is the first principle.

The second principle kind of has two components. It is trustworthiness and transparency. Trustworthiness means that we are utilizing concrete information, we are not making promises that we cannot meet, we are being open, we are talking with that patient, we are keeping things factual so that everybody is on the same page hearing the same information and again that transparency, if something has occurred then we talked to that patient. Or if we think there is something that's going to be happening in the near future maybe we want to get an X-ray or we want to do certain treatments or labs, we go in and we say these are the things that we are thinking about, we wanted to share this with you and see what your thoughts are to these treatment plans.

The other thing or the third principle is peer support. Who do you want with you? If they don't have a family member, which they often may not, that they feel is trustworthy, can we offer chaplains. Is there someone that can come visit you? Is there a friend in the community? And if this is a person that has had an injury that's going to be a life changing event, such as an amputation, there are peer support groups for those. Would you like a peer support advocate to come in and be with you.

The fourth is collaboration and mutuality, we're always wanting to collaborate with the patient. Have that mutual decision-making process. Yes we are looking at all of the symptoms and then we are coming up with our differential diagnosis. However, all of that information needs to be shared with that patient and that patient needs to be part of that decision making process of how their health is going to be managed.

We want to empower them so no matter what it may be, if they're coming in and they are just really at a place that they can't cope but we can find one thing that they are doing well, empower that empower that moment with them so that they know that they've got that skill set and then help build them to the next skill set to make it through that journey of their health. Because healthcare journeys can be short or can go on for years. So we want to empower everything that they do that is helping them move forward for themselves at the rate that they can move forward.

We want to give them a voice and a choice. You know, what are their thoughts about their health? Maybe our goals are not their goals so we need to hear what their voice is and we want to give them the choice. You're maybe is something as simple as your A1C is too high we would like to change, which is your blood sugar, we would like to change your meal plans and your diet and your exercise so that we can lower that and actually help you stay healthy for longer. But that may be their meals may be the best that they can do or coping mechanism, so it may not be something that they're ready to do. So we have to give them that choice. We have to think about their culture where are they coming from you know which area or region.

There are historical trauma into any gender challenges that may be coming up while they're in a healthcare setting, which oftentimes may feel like a very unsafe space for LGBTQ community. So we want to actually support them any way that we can. So just to recap the six principles are safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment voice and choice, and then cultural historical and gender issues.

That was a very comprehensive answer. Can you take it a step further and share what a trauma informed care approach would look like in a clinical setting?

Trauma informed care in a clinical setting is going to be literally embedded in everything from governance and leadership to finances. There are 10 organizational domains that is applicable for trauma informed care. And the first is governance and leadership. You have those leaders that understand what trauma informed care means and they are backing it they are finding ways to make trauma informed care education, knowledge, cultural changes take place and they help you lead that mission throughout the entire enterprise.

You're looking at policies. Are your policies trauma informed? Maybe they are maybe they are already as good as they can be or maybe they're missing a component to where we're not helping the employees or the staff feel safe in certain situations. Maybe when it's their annual review or when there is a challenge that comes up. So we're looking at those policies from the same guiding principles that we use with patients.

We look at our physical environment. Is it welcoming? Is it using the correct colors to help calm people? Are there the correct smells? Lighting? Is there lighting in the parking lot? Is there security that's available for urgent needs? You know that physical environment is extremely important. For example when we walk into a spa it's all quiet it smells good and we immediately relax. But when we walk into a clinical setting that is chaos and we don't have an environment set up for either the number of people or the sound and the noise or what we see or what we hear, that actually triggers people in trauma. So we would want to look at those physical environments and actually make it a place that would down regulate those emotional stressors for those sick patients that are coming in with a history of trauma.

We want to have engagement and involvement, not only with each other, but with our community. What is our community saying that they need from our organization. Do they need something that we've never thought about?

We want to look at cross sector collaboration. How do our departments work together utilizing the six guiding principles with each other and thinking about how we can come together and be a team that helps the patient, helps the system and the organization move forward with the safety lens of trauma informed care. When indicated in certain environments in clinic settings or in the hospital and when the organization has reached the point that they are trauma informed.

We can think about screening, assessment, and then referrals or treatment if needed for those trauma survivors.

There is ongoing training and workforce development it can be around safety it can be through workplace violence incidents it can be through annual training modules but we want to make sure that that training of trauma informed care and just continues to help the workforce, especially in hospital settings because there's so much turnover in staff, that trauma informed care is not a one and done is a continual journey. It's not an end goal.

We want to look at progress and monitor what we've been doing. Look at some data see how it's working.

You know think about that quality assurance making sure that we are reflecting upon all of the process changes that we've implemented through a trauma informed care lens and continue to improve upon that or maintain it if we've reached the goal that we want.

We want to think about financing. How does this work? How do we have enough people on board that can help teach others that can provide material and how do we allow enough financing that we can have our clinicians come out of their space for just enough time to get their training and to do some of their research and then practice it and then go back into their specific specialty in space and continue forward with trauma informed care?

And of course, then evaluate all of that. So those ten organizational domains again just to recap those this governance and leadership policy physical environment engagement and involvement cross sector collaboration screening assessment and treatment when indicated training and workforce development progress monitoring and quality assurance financing and evaluation.

Outstanding! Laneita Williamson thank you for joining us today on the Move to Value Podcast.

Thank you so much! I have really enjoyed being with you today and just going through these questions, thank you.

Dr. Rawat, welcome to the Move to Value podcast. Can you give us an overview about the current state of behavioral health in rural communities?

Sure I, you know, I think that it's important, first off, to know that the rural United States consists of 97% of the land area and is home to about 20% of the population with 50% of the population living in the South. When it comes to mental health conditions in rural versus urban areas, the prevalence of mental health conditions is the same overall. But the nature of the conditions, as well as the driving factors, are very different in rural areas. We see higher rates of suicide and depression with the rate of suicides unfortunately increasing overtime and the unique driving factors include economic ones like intergenerational poverty and higher rates of unemployment. Social ones like isolation, loneliness, and more stigma associated with such conditions. And finally environmental factors like climate change and natural disasters, which aren't exactly top of mind for those of us that that live in urban areas

When it comes to barriers to optimal behavioral health, can you tell me what differences exist between rural and urban communities?

Again the prevalence of mental health and substance use disorder conditions is relatively similar, but again, the nature and the driving factors are different in terms of access to care, especially access to Affordable Care, that remains - it's a significant issue in both urban and rural areas. But it's particularly problematic, if that's even possible, in rural areas. 75% of US counties are known as mental health practice shortage areas. That means that they don't have enough psychiatrists, psychologists, social workers, counselors, school counselors, and that shortage is correlated to two main factors. Number one, rurality, and number two, per capita income so that the lower the per capita income the higher the likelihood of having a shortage of mental health practitioners.

Now with respect to differences in affordability we know that affordability is the single most important factor correlated to using care. Increased cost sharing is associated with not seeking out the necessary behavioral health treatment that you need. And in the higher cost of services can result in a lower likelihood of going out and accessing behavioral health services. So rural residents are actually they're more likely to be uninsured and underinsured as you know. They're also more likely to receive Medicaid than urban residents. Now Medicaid is a good thing because that's actually correlated with easier time accessing behavioral health care but the problem is that 2/3 of the rural uninsured population live in states that did not expand Medicaid. And then finally those who are covered by private insurance or among those who are covered by private insurance, rural residents are far more likely than urban residents to have a high deductible health plan. So a couple of whammies there for rural residents generally when it comes to affordable access to care or access to Affordable Care rather.

Do you see any perceived stigma of having a behavioral health issue factoring into patients not utilizing resources that are available to them? Are these folks afraid of being seen as broken?

Yeah, absolutely that's one of the again important drivers or differences between urban and rural populations is again the stigma associated with mental health and substance use disorder conditions generally just]]>In this episode we talk about population behavioral health with Dr. Nishi Rawat, founder of OpenBeds, a behavioral health treatment availability platform, who now serves as chief clinical officer at Bamboo Health.

Dr. Rawat, welcome to the Move to Value podcast. Can you give us an overview about the current state of behavioral health in rural communities?

Sure I, you know, I think that it's important, first off, to know that the rural United States consists of 97% of the land area and is home to about 20% of the population with 50% of the population living in the South. When it comes to mental health conditions in rural versus urban areas, the prevalence of mental health conditions is the same overall. But the nature of the conditions, as well as the driving factors, are very different in rural areas. We see higher rates of suicide and depression with the rate of suicides unfortunately increasing overtime and the unique driving factors include economic ones like intergenerational poverty and higher rates of unemployment. Social ones like isolation, loneliness, and more stigma associated with such conditions. And finally environmental factors like climate change and natural disasters, which aren't exactly top of mind for those of us that that live in urban areas

When it comes to barriers to optimal behavioral health, can you tell me what differences exist between rural and urban communities?

Again the prevalence of mental health and substance use disorder conditions is relatively similar, but again, the nature and the driving factors are different in terms of access to care, especially access to Affordable Care, that remains - it's a significant issue in both urban and rural areas. But it's particularly problematic, if that's even possible, in rural areas. 75% of US counties are known as mental health practice shortage areas. That means that they don't have enough psychiatrists, psychologists, social workers, counselors, school counselors, and that shortage is correlated to two main factors. Number one, rurality, and number two, per capita income so that the lower the per capita income the higher the likelihood of having a shortage of mental health practitioners.

Now with respect to differences in affordability we know that affordability is the single most important factor correlated to using care. Increased cost sharing is associated with not seeking out the necessary behavioral health treatment that you need. And in the higher cost of services can result in a lower likelihood of going out and accessing behavioral health services. So rural residents are actually they're more likely to be uninsured and underinsured as you know. They're also more likely to receive Medicaid than urban residents. Now Medicaid is a good thing because that's actually correlated with easier time accessing behavioral health care but the problem is that 2/3 of the rural uninsured population live in states that did not expand Medicaid. And then finally those who are covered by private insurance or among those who are covered by private insurance, rural residents are far more likely than urban residents to have a high deductible health plan. So a couple of whammies there for rural residents generally when it comes to affordable access to care or access to Affordable Care rather.

Do you see any perceived stigma of having a behavioral health issue factoring into patients not utilizing resources that are available to them? Are these folks afraid of being seen as broken?

Yeah, absolutely that's one of the again important drivers or differences between urban and rural populations is again the stigma associated with mental health and substance use disorder conditions generally just as as you've described. In addition to that, that stigma plays out because you're not anonymous in a rural community, right? There may or may not be a practitioner, but there may be someone that people see and you'll be seen. And there's fear associated with being seen seeking help. So that that's a significant barrier, absolutely.

The good news is that with the pandemic, care delivery systems that were at the periphery, like telehealth, they're now mainstream and actually during the pandemic 50% of telehealth use was for behavioral health conditions. And people continue to seek behavioral healthcare in a telehealth way, whereas for medical care a lot of people have gone back to brick and mortar services. But where I'm going with this is that for rural communities in particular rural populations this is a mechanism. Getting care via the telehealth medium is a mechanism by which to bypass the stigma.

Outstanding. Dr. Rawat, will you share with us some of the findings from your work around substance use disorder?

Absolutely. So at Bamboo Health we work with 15 States and counting to improve access to both mental health and substance use disorder care. What we do is we work with state governments to establish a behavioral health network that's connected digitally to give those organizations who refer into mental health and substance use disorder services to give them that situational awareness and the ability to connect to providers digitally to find evidence-based care for their patients. We also support state 988 and in-crisis line initiatives. I don't know if your audience - if they're familiar with 988, but what we do is we thread together the crisis care services within that crisis care continuum to ensure that callers in crisis get access to definitive behavioral health assessment and treatment.

Can you share with us more information about the 988 initiative?

Absolutely, it's a very important initiative instigated by the federal government. Again, it was launched in in mid-July of this year not with a lot of fanfare. I do believe that the government and states are holding off on marketing for a little bit to ensure that the call centers aren't overwhelmed, but again, for those of you who are not familiar with 988, it's akin to 911 but for behavioral health crises. So just like if you were having a heart attack or perhaps your house was on fire, you call 911 and the appropriate folks, whether it's an ambulance or the fire people would come to your house, put out the fire or take you to an emergency department to get assessment for your chest pain.

Now you can call 988 if you're having a mental health or substance use disorder crisis, you or a loved one, you can be patched through to a clinician who will do a validated assessment and then will get you to the right level of care. So perhaps that's connecting you to an outpatient assessment or treatment episode, if necessary. If you are in need of more urgent care, in some markets or regions, they can dispatch a mobile crisis team to do an on-premise assessment. And then in other regions that mobile crisis team can take you to what's known as a crisis stabilization facility where you can be observed get care and then transition to appropriate outpatient or inpatient care.

Dr. Rawat, how can we create more collaborative care between behavioral health and physical health?

You know, look, we've been talking about this for too long and I think that there are few organizations that are, unfortunately, walking that talk. What we do know, or what I feel strongly about, is that this type of integration between behavioral health and physical health it happens at the point of care. And I can't stress that enough. That said, the appropriate incentives need to be in place for people, individuals and providers for the integration to happen at the point of care.

A good example of incentivized care is the certified community behavioral health clinic model, which is currently a Medicaid demonstration project. It was initiated by the federal government by Medicaid back in 2016 when they selected 10 demonstration states for this project. The participating demonstration States and behavioral health providers need to provide certain core services, which includes crisis care, access to crisis care, for their patients 24/7. They can't turn anyone away. They need to do care coordination collaboration across behavioral health and medical settings and they need to have the appropriate technology in place to be able to do that kind of care coordination. And then finally they're held accountable. They need to meet quality metrics associated with offering these core services.

Do you see a role in this collaborative continuum for the community health worker and community organizations?

yeah sure, so look it's important to meet people where they're at. And given that it's near impossible to travel five hours every week, right, for a treatment, appointment. We need to provide care in the community setting, out-of-the-box places like our schools, grocery stores, libraries, and so I do believe that these community settings are particularly important for rural populations given that the distances involved.

Now I know we just talked about telehealth and how that's made it easier but not everyone has access to telehealth or telebehavioral health, so there's that I also think that it's even more important for people to be served by people who look like them, talk like them, who have similar lived experiences and we see that in urban communities as well as rural ones alike. And so ensuring that the clinical population looks like those who are seeking care that's really important and that's something that I do believe is best achieved by community health workers.

What can a provider do starting today to begin to address some of these issues?

Sure so number one, institute screening for all your patience as recommended by the federal government. So, for example, substance use screening should be integrated into primary care community settings and the emergency department. We've known this for a very long time and others that SBIRT program the screening brief intervention and referral to treatment program that everyone should be aware of. We should also incorporate screening from a mental health perspective.

Recently the US preventive services task force recommended screening all adults for depression and those under the age of 65 for anxiety and then they also more recently recommended that all adolescents be screened for depression and anxiety, I can't remember the exact age group, but this makes a lot of sense because 50% of lifetime mental health conditions begin by the age of 14 and 75% begin by the age of 24. So people need to be screened and assessed early on in life.

And then second, care is inherently local right, we just talked about that. So that's what makes this question so difficult to answer but I would refer people to the American Medical Association's website. They have a behavioral health collaborative there that has compiled a detailed behavioral health integration compendium for providers. It has very very practical advice for providers including a spectrum of 6 levels of collaboration, how to go about picking a level of collaboration for your organization, assessing your organization's readiness, making the pitch to leadership, workflow design, measuring outcomes, it also includes billing codes. So there's a wealth of information there at that website and within this compendium and I do believe that you can very easily tailor that to your local setting and community.

Dr. Nishi Rawat, thank you for joining us today on the move to value podcast

Thank you for having me, Thomas

I want to pick your brain about clinical documentation improvement also known as CDI. So tell me amber what is CDI all about?

Well Thomas, I think the main message about CDI is around quality initiatives. Most people who ask providers why good clinical documentation is necessary, many of them are going to say that it's important for the communication to other providers about the continuity of care. Physicians generally understand the need to make documentation legible, timely, complete, and clear and you know with electronic medical records a lot of that is resolved. They also understand that documentation is a legal health record. They understand the common phrase - if you didn't document it, it didn't get done. CDI programs have increased significantly over the past ten years and are predominantly used in the inpatient hospital setting. But now this is expanding into the ambulatory and provider office setting due you value-based care and contract changes. The key is to really just engage providers to correlate how clinical documentation provides an opportunity to demonstrate the quality of care that was provided during an office visit. The American Health Information Management Association or AHIMA really says it best. They say the message to physicians should be: simple good clinical documentation will improve communication, increase recognition of comorbid conditions that are responsive to treatment, and validate the care that was provided, and show compliance with quality and safety guidelines.

Why should a provider change their documentation?

So physicians are taught to ask why as part of a diagnostic training that they went through and the need to understand the reason for a change in clinical documentation in order to fully embrace the concept. So if a provider challenges a CDI recommendation, it's an opportunity to explain why CDI is necessary. Explain the concept around whether it's MSDRG for inpatient or value-based care contracts and how they're designed to increase reimbursement for care of complex patients. It's also important to explain the severity or the illness or risk or mortality score that's derived from the codable diagnosis codes. It's also important that providers understand the process of audits and denials and financial impact. Not only for hospitals but the outpatient office visits as well. Documenting all of the chronic conditions that are known for the patients that affect the care and treatment for that patient impact the medical decision making by the provider and can also impact the level of evaluation and management services.

Amber, tell me how a provider can implement CDI into their workflow?

Electronic medical record technology has really improved the ability for medical records to be legible and timely. Physicians generally use structured templates to input documentation or they can dictate in a standard progress note format. But sometimes, the benefits of the electronic documentation are not always great. Sometimes there are significant challenges with electronic documentation, such as copy and pasting documentation, which can increase the risk of audits including outdated problem lists and then the inability for providers to find the correct diagnosis code in a drop-down selection. It's important to remember that providers are not trained in coding, yet many providers now know the codes that are important for their billing. If the provider chooses a nonspecific diagnosis code to include in the medical record, it could potentially make it more difficult for someone to code the case with a more specific diagnosis code. The EHR creates the opportunity to...]]>This episode is the second installment about Clinical Documentation and Coding. Today, we have a conversation about Clinical Documentation Improvement with Amber Malone-Wright, Director of Clinical Documentation Integrity at CHESS Health Solutions.

I want to pick your brain about clinical documentation improvement also known as CDI. So tell me amber what is CDI all about?

Well Thomas, I think the main message about CDI is around quality initiatives. Most people who ask providers why good clinical documentation is necessary, many of them are going to say that it's important for the communication to other providers about the continuity of care. Physicians generally understand the need to make documentation legible, timely, complete, and clear and you know with electronic medical records a lot of that is resolved. They also understand that documentation is a legal health record. They understand the common phrase - if you didn't document it, it didn't get done. CDI programs have increased significantly over the past ten years and are predominantly used in the inpatient hospital setting. But now this is expanding into the ambulatory and provider office setting due you value-based care and contract changes. The key is to really just engage providers to correlate how clinical documentation provides an opportunity to demonstrate the quality of care that was provided during an office visit. The American Health Information Management Association or AHIMA really says it best. They say the message to physicians should be: simple good clinical documentation will improve communication, increase recognition of comorbid conditions that are responsive to treatment, and validate the care that was provided, and show compliance with quality and safety guidelines.

Why should a provider change their documentation?

So physicians are taught to ask why as part of a diagnostic training that they went through and the need to understand the reason for a change in clinical documentation in order to fully embrace the concept. So if a provider challenges a CDI recommendation, it's an opportunity to explain why CDI is necessary. Explain the concept around whether it's MSDRG for inpatient or value-based care contracts and how they're designed to increase reimbursement for care of complex patients. It's also important to explain the severity or the illness or risk or mortality score that's derived from the codable diagnosis codes. It's also important that providers understand the process of audits and denials and financial impact. Not only for hospitals but the outpatient office visits as well. Documenting all of the chronic conditions that are known for the patients that affect the care and treatment for that patient impact the medical decision making by the provider and can also impact the level of evaluation and management services.

Amber, tell me how a provider can implement CDI into their workflow?

Electronic medical record technology has really improved the ability for medical records to be legible and timely. Physicians generally use structured templates to input documentation or they can dictate in a standard progress note format. But sometimes, the benefits of the electronic documentation are not always great. Sometimes there are significant challenges with electronic documentation, such as copy and pasting documentation, which can increase the risk of audits including outdated problem lists and then the inability for providers to find the correct diagnosis code in a drop-down selection. It's important to remember that providers are not trained in coding, yet many providers now know the codes that are important for their billing. If the provider chooses a nonspecific diagnosis code to include in the medical record, it could potentially make it more difficult for someone to code the case with a more specific diagnosis code. The EHR creates the opportunity to really assist the providers with clinical documentation and often provide a means of great communication between a CDI specialist or a coder and the physician. Whenever possible, building clinical documentation systems that make it easy for providers to select a codable diagnosis is best practice. For example, the diagnosis of chronic kidney disease is common when providers document and code this condition, but it's oftentimes unspecified. However oftentimes there are other indicators in the medical records such as an abnormal lab or a note from a specialist or hospital visit that may indicate a specific stage of chronic kidney disease. This can easily be queried back to the provider utilizing the electronic medical record and clinical other references to specify the stage in the documentation. CDI should also be vetted through a compliance department to ensure integrity without leading the provider to a specific diagnosis. It's also important to educate providers on how to choose the appropriate diagnosis from the electronic medical record drop down selections.

And what's the best way to query a provider?

So, the ideal solution would be electronic queries from the electronic medical record as this is easily accessible to the provider and often links the patients health record. When querying a provider it's really important to make sure the query is not leaning but that the communication is clear. Queries can be verbal they can be paper or electronic and should be monitored and tracked for responses and engagement. Physicians will have a greater response to queries when they’re evidence based and clinically evident in the medical record. Queries should be presented to the provider in the context to actually clarify the documentation to ensure compliance. CDI programs can also use clinical guidelines to assist with identifying diagnoses that are not documented but are clinically indicated in the documentation. So for example, you might see a patient whose documented as diabetes uncontrolled and they have an A1C of 9.0 in the medical record which could indicate that possibly this patient has uncontrolled diabetes. Queries should be clear and concise. They should contain the clinical indicators, present only facts to the physicians, and also be compliant. The Association of Clinical Documentation Integrity Specialist or ACDIS is a great resource that is available to review with when starting a CDI or query workflow program. Written queries can be formatted as open-ended multiple choice or yes or no but again it can never be leading for a physician to a specific diagnosis code. Organizations are free to determine the specifics around their query process and compliant practice requires that all queries either be a permanent part of the medical record or be retrievable in a business record for tracking and monitoring purposes.

So Amber, tell me, how can an organization get started successfully with a good CDI program.

Well Thomas, I think the first thing is really conducting a documentation and coding review process of what is documented in the medical record. Identifying documentation discrepancies or deficiencies can help identify opportunities for education and improvement. I think it's important to take into consideration with the ACDIS and AHIMA must have already established around query guidelines and rules and regulations to make sure that they're compliant. And then also working with their compliance or legal department to make sure that they're not leading their physicians and that they have good policies and procedures in place.

Outstanding stuff! Amber Malone-Wright, thank you for joining us today on the Move to Value Podcast!

Thank you

Jennifer what are some of the rural focused value-based strategies that you're currently employing?

That is actually been a focus for us many years. So working with CHESS evolving our Medicare Shared Savings, Medicare Advantage, scaling that now to our Medicaid population, we have been building what I would say is a foundation of value based capabilities that almost from day one we also scaled immediately in our rural communities. So some of those include working closely with our providers and to promote Annual Wellness Visits and that's such an important piece of the work that we do to close care gaps, address those social drivers of health and really proactively identify the patients that we need to care manage, So working with our rural providers to build out a process that works well for their clinics and making sure the patients, through those e-consult virtual visits and proactively scheduling them in, are able to get to their medical home in a timely manner to do that. So that that's something we've really focused on with our rural providers and that's where some of the wrap around transportation and other services come into play. Access is such a critical piece of that. Transitions of care would be another one. We have put RN resources in the ED; we work very closely with our hospitalist program, and part of that is development of the hospitalist to home program so that that allows patients to be maybe be discharged early home but putting in additional supports with our care management team; our community health worker team; social work; as well as some remote patient monitoring to help them be successful and hopefully not get readmitted. And then other supports that kind of play more of a behind the scenes role include some of our robust analytics. So doing some risk stratification work, which again, just really helps us understand the population from who has high social needs? Where is there polypharmacy? Do we have patients who have multiple chronic conditions? Allowing us to understand who's seeing their primary care provider, who needs to be scheduled in and create a more proactive approach and I do think that's very important in rural because again we might have more scarcity of resources. So really trying to be proactive and sort of leverage some of these other access ways to provide a medical home support becomes even more key. And the analytics also allows us to know our patients, know all of the care gaps that we need to address, but then also evaluate whether what we're doing is working and sort of shift that around. And so knowing where we may have provider gaps working with our family medicine internal medicine departments, making sure we can scale resources where we can from that perspective also is something we've worked on.

Jennifer is it sometimes difficult to think in entire population segments concerning outcomes? You're looking at vast groups. Do you find that to be a challenge in terms of moving the needle in public health?

In our region we have about 250,000 unique patients and it is a lot of data. We're getting data from the EMR on multiple clinical indicators with our payer partners. We're collecting now social driver information. I think that's where having such a strong analytics platform is so important. Risk segmentation becomes really important, so if we know patients are well, they're seeing their physician every year, they're taking their medications, they're controlled within their chronic disease, then there's a pathway for that. But if there are patients that we know are at risk for a readmission or are not adherent to their medication and seem to not be managing well then that's where we think...]]>In this episode, we continue our conversation with Jennifer Houlihan, Vice President of Value-based Care and Population Health for Atrium Health Wake Forest Baptist, about the need for value-based care in rural population health.

Jennifer what are some of the rural focused value-based strategies that you're currently employing?

That is actually been a focus for us many years. So working with CHESS evolving our Medicare Shared Savings, Medicare Advantage, scaling that now to our Medicaid population, we have been building what I would say is a foundation of value based capabilities that almost from day one we also scaled immediately in our rural communities. So some of those include working closely with our providers and to promote Annual Wellness Visits and that's such an important piece of the work that we do to close care gaps, address those social drivers of health and really proactively identify the patients that we need to care manage, So working with our rural providers to build out a process that works well for their clinics and making sure the patients, through those e-consult virtual visits and proactively scheduling them in, are able to get to their medical home in a timely manner to do that. So that that's something we've really focused on with our rural providers and that's where some of the wrap around transportation and other services come into play. Access is such a critical piece of that. Transitions of care would be another one. We have put RN resources in the ED; we work very closely with our hospitalist program, and part of that is development of the hospitalist to home program so that that allows patients to be maybe be discharged early home but putting in additional supports with our care management team; our community health worker team; social work; as well as some remote patient monitoring to help them be successful and hopefully not get readmitted. And then other supports that kind of play more of a behind the scenes role include some of our robust analytics. So doing some risk stratification work, which again, just really helps us understand the population from who has high social needs? Where is there polypharmacy? Do we have patients who have multiple chronic conditions? Allowing us to understand who's seeing their primary care provider, who needs to be scheduled in and create a more proactive approach and I do think that's very important in rural because again we might have more scarcity of resources. So really trying to be proactive and sort of leverage some of these other access ways to provide a medical home support becomes even more key. And the analytics also allows us to know our patients, know all of the care gaps that we need to address, but then also evaluate whether what we're doing is working and sort of shift that around. And so knowing where we may have provider gaps working with our family medicine internal medicine departments, making sure we can scale resources where we can from that perspective also is something we've worked on.

Jennifer is it sometimes difficult to think in entire population segments concerning outcomes? You're looking at vast groups. Do you find that to be a challenge in terms of moving the needle in public health?

In our region we have about 250,000 unique patients and it is a lot of data. We're getting data from the EMR on multiple clinical indicators with our payer partners. We're collecting now social driver information. I think that's where having such a strong analytics platform is so important. Risk segmentation becomes really important, so if we know patients are well, they're seeing their physician every year, they're taking their medications, they're controlled within their chronic disease, then there's a pathway for that. But if there are patients that we know are at risk for a readmission or are not adherent to their medication and seem to not be managing well then that's where we think about our ambulatory care management and then deploying some of the other resources, like again, a community health worker, which has been incredibly helpful especially when we need to make visits to patients’ home. But I think that's really where segmentation comes into play, because you're right, otherwise it becomes very overwhelming. But then it is sort of having a level of sophistication where you can sort of say, we've arrayed the population, we understand the risk segments, we know which provider groups they're working with, who may not be working or seeing a provider that we need to get them in with, but then deploying this whole array of pharmacy, care management teams, maybe our community partner teams, to sort of hopefully engage with patients at the right time at the right place. Because otherwise you're right it it's sort of how do you get your hands around this. And I have found it's usually not about one disease condition, it's really looking at more of that whole population. You know we say we want to do everything for everyone all the time and we I think we I think we want to do everything for people at the right time when they need it and I think being proactive is usually what I think sets apart like how is pop health different? Because we're using this information to really be proactive and reach out and not wait for somebody who's not managing because we have things like the frailty index and other risk scores so our goal is to also try to sort of anticipate what might happen in and intervene before it happens.

Well how can healthcare leverage community based organizations to improve those outcomes?

I think that's a double edged question because I think we often need to be engaging our health care organizations more intentionally about asking them what they need. I think thinking about what does it mean - you certainly we have the data - but what does it mean to improve health in this community? What would that look like? What would tell you what outcomes would tell you that we were improving health? So I think our community partners are incredibly important and if we think about you know what's driving someone's health, I think 20% of a patients overall health is what's derived from the medical services that are rendered to them. So the rest of that is social and physical environment, behavioral, and a little bit of genetics but really that kind of behavioral social emotional health, and then the physical environment is so key to that. And we can't solve all of the health care issues that are so broad based alone. So they are an incredibly important partner. I think it's everything from thinking about what we make investments in and sometimes they may not be directly healthcare related. They might be supporting a new housing development, like we've done here in Winston. It might be we're promoting the opening of a Federally Qualified Health Center which we have in and supported through our Wilkes Foundation, which means we're opening up another primary care access point for the community. It also might be investing of course with our local food bank partners, investing in school based programs, and then other partners that may focus certainly on social substance abuse and behavioral health, really helping support our partners there, because we also know we don't have the capacity or the workforce to also provide all of that care. So it they having that as whether it's part of a foundation, local Community Board, having our teams be present in their meetings or on their boards. But I think it is sort of rethinking what community investments mean and then using things like the CHNA and a needs assessment as a guideline of really determining this is what the health of the community, this is what it's saying is the highest and prioritized needs and making sure we're aligning with that.

As we're making investments in the community through food banks or school-based initiatives, are we able to quantify that investment to see the impact to the overall health of the population we're investing in?

That's a good question. I think sometimes you know when we look at some of the indicator data, the American Community Survey CDC data, I would say yes. But it's not always immediate. It sometimes can take two, three, five years to see an impact. And some of the challenges are so large and systemic, it could take decades. So that I think is always the balance of what are we making investments in and what is the return? Is it we're managing diabetes and we can show that we lowered A1C four 500 patients or is it we're working on childhood obesity and it's going to take decades before we see the rate of child obesity go down in a community? So that's so the answer is yes, but I also think that it sort of depends on the scope and scale, but also you know maybe defining early indicators. Knowing that some of those longer-term outcomes may take much longer. And I think that's a challenge for health systems, for funders and general, because we typically like to see those wins pretty quickly. We want to see results and some of these challenges are deep, have been in place for a very long time and will take a very long time before we can see real movement in that. But I think there are what I'd say leading indicators that yes we would definitely be looking for that.

Well Jennifer, one final question. What can a provider do right now to begin to address some of the needs of their rural patient population?

That's that is a good question. I think providers probably know there's you know they're seeing patients and families; they probably know across their practice what they're seeing. Whether maybe it's maybe it's something that's more straightforward like I have a lot of missed appointments and I need more support for transportation. I think connecting in, our goal I think for all of our practices, including rural is to have a care team connected to them, whether that's an RN navigator, social worker, community health worker. So making sure they're tapping into that and if there are resources that they're not aware of, taking advantage of that, but at the same time also sharing being part of some of these more think community social impact committees of helping prioritize where we're resourcing and making investments to support that. So I think that you know having a primary care medical home, you know, is such an important piece of what we're trying to do in general and pop health, that really being able to work with that team and take advantage of some of the things like we're doing with our find help resource hub, again, engaging with that care team, and then also telling us as pop health leaders we need more of X because this is actually what's really, these are the barriers for our patient to actually achieving optimal health is what I would say as well.

Well Jennifer Houlihan, thank you for that insight and thank you for joining us today on the move to value podcast

Thank you for having me

Can you tell me about the correlation between rural communities, rural hospitals, and poor health

Rural Americans really face numerous health disparities compared with their urban counterparts. 15% of all Americans live in rural areas with higher risk of death. And so, thinking about rural communities, rural hospitals, rural healthcare, there are five leading causes are heart disease, cancer, uh respiratory diseases, stroke. And all of those are impacting how we think about health care delivery, what we need from our rural hospitals, and also what the community focuses on. So, rural hospitals are at risk for closure. There are quite a few that have closed over the last several years and yet there's a greater need as the population ages, the prevalence and incidence of disease grows, uh and we're at risk for access challenges in this community. And so, our rural providers really become that, especially in primary care, that critical piece to provide that medical home support, to manage these healthcare conditions. And then, hospitals often are an anchor in the rural community and, really important part, they're often the largest employer and have a long-standing history of pride in those communities. So, when you think about the ability to seek care close to home, to be able to have providers in your backyard, and be able to care for your population, not only with the chronic disease piece, but again significant disparities and some of the social drivers I know we'll talk about. So, really all of that is connected and real challenges being faced by our rural hospitals and communities.

I see. So, what are the socioeconomic factors that are in play here?

Yeah, so specifically I'll talk about North Carolina, but really this would be applicable much more broadly. But typically, in North Carolina, what we're seeing is about 16,000 year lower median household income. 26.7% more likely to have children living in poverty, which is a significant socioeconomic factor and often a leading indicator from any other social drivers. 21% fewer adults with post-secondary education and approximately 13 to 14% more uninsured residents under the age of 65. So, all of those, in addition to you know some of the higher percentages of chronic disease, that all presents significant challenges for rural communities and the providers and being able to care for them.

Can you tell us about some of the health issues that rural communities are facing?

Sure. Yeah. There's a couple. So, part of rural hospitals, and we have a several rural hospitals within the Atrium Health system, with our health department partners every three years we do a robust community health needs assessment. So, looking across all of our rural communities, we actually kind of ranked through all of them. Obesity is actually the most prominent issue, uh closely followed by substance misuse, mental health, chronic disease, educational attainment, and teen pregnancy. But when we looked across all of them, obesity and chronic disease is typically the number one. With, I would say substance abuse and mental health continuing to grow, and certainly post COVID, that's actually, that has actually grown and sort of needs and identified stats in the community as well.

Well Jennifer, are there new strategies in play for rural health that will hopefully improve outcomes?

There are quite a few strategies. And so, I think some of that is, again, what we're, every, really every year, we're looking at what strategies are working and what aren't. So, a couple different...]]>Today we talk with Jennifer Houlihan, Vice President of Value-based Care and Population Health for Atrium Health Wake Forest Baptist, about some of the pressing issues and health care concerns facing rural communities and how they are assessed. Jennifer, Welcome to the Move to Value Podcast.

Can you tell me about the correlation between rural communities, rural hospitals, and poor health

Rural Americans really face numerous health disparities compared with their urban counterparts. 15% of all Americans live in rural areas with higher risk of death. And so, thinking about rural communities, rural hospitals, rural healthcare, there are five leading causes are heart disease, cancer, uh respiratory diseases, stroke. And all of those are impacting how we think about health care delivery, what we need from our rural hospitals, and also what the community focuses on. So, rural hospitals are at risk for closure. There are quite a few that have closed over the last several years and yet there's a greater need as the population ages, the prevalence and incidence of disease grows, uh and we're at risk for access challenges in this community. And so, our rural providers really become that, especially in primary care, that critical piece to provide that medical home support, to manage these healthcare conditions. And then, hospitals often are an anchor in the rural community and, really important part, they're often the largest employer and have a long-standing history of pride in those communities. So, when you think about the ability to seek care close to home, to be able to have providers in your backyard, and be able to care for your population, not only with the chronic disease piece, but again significant disparities and some of the social drivers I know we'll talk about. So, really all of that is connected and real challenges being faced by our rural hospitals and communities.

I see. So, what are the socioeconomic factors that are in play here?

Yeah, so specifically I'll talk about North Carolina, but really this would be applicable much more broadly. But typically, in North Carolina, what we're seeing is about 16,000 year lower median household income. 26.7% more likely to have children living in poverty, which is a significant socioeconomic factor and often a leading indicator from any other social drivers. 21% fewer adults with post-secondary education and approximately 13 to 14% more uninsured residents under the age of 65. So, all of those, in addition to you know some of the higher percentages of chronic disease, that all presents significant challenges for rural communities and the providers and being able to care for them.

Can you tell us about some of the health issues that rural communities are facing?

Sure. Yeah. There's a couple. So, part of rural hospitals, and we have a several rural hospitals within the Atrium Health system, with our health department partners every three years we do a robust community health needs assessment. So, looking across all of our rural communities, we actually kind of ranked through all of them. Obesity is actually the most prominent issue, uh closely followed by substance misuse, mental health, chronic disease, educational attainment, and teen pregnancy. But when we looked across all of them, obesity and chronic disease is typically the number one. With, I would say substance abuse and mental health continuing to grow, and certainly post COVID, that's actually, that has actually grown and sort of needs and identified stats in the community as well.

Well Jennifer, are there new strategies in play for rural health that will hopefully improve outcomes?

There are quite a few strategies. And so, I think some of that is, again, what we're, every, really every year, we're looking at what strategies are working and what aren't. So, a couple different ways we're looking at that, so I'll just talk about from a health system perspective some of the strategies that we have focused on are really making sure we're improving access. And so, whether that's actually hiring more OBGYN or primary care into the community, as well as training more residents in the community to hopefully increase that pipeline. So residents, providers, will want to stay and start their practice there. But other ways we're thinking about access are virtual. So obviously COVID expanded our use of virtual but continuing to provide virtual primary care as well as e-consults. So, that's really a way to supplement primary care and close the specialty care gap. So, we have kind of created a very robust program within the enterprise that all of our primary care would have access to all the specialties across. So, that can certainly cut down on driving time and also timeliness to be able to get some of that specialty support.

The other piece is really thinking about more creative ways to partner with our ED, our hospitalists. Really partnering some of our transitions of care team, or our care management team, to be more aligned. So, when patients are either transitioning out, or even before they're in, knowing that there’s sort of this continue approach. Also, looking at things like remote patient monitoring. Allowing us to do more management in patients homes. And really, we've done that with COVID, but now expanding to congestive heart failure, etc. And then, again, kind of making sure that we're using data where we can to really understand maybe who some of our highest risk patients are that we need to proactively reach out to. Whether that's through some of our social work, community health worker initiatives, to be able to manage them.

From a CHNA standpoint, that again, that is another way we're thinking about. And that's usually done more in partnership. So, with our, that could be, of course, our local public health departments. We have supported the development and implementation of federally qualified health centers to expand access points. Certainly, funding for farmers market transportation initiatives. Partnering with our schools on, could be, healthy meals, physical activity programs. Brenner FIT is a great example. There's a Brenner FIT component, but really that focuses on healthy eating for patients and their families. And then, certainly our faith health NC has done a lot of work with local congregations, and we actually have one of our faith health leads, many in our rural hospitals. So, really supporting that linkage back to the faith health community and developing transportation supports or maybe where congregations are driving patients. But also making different investments in some of those more social drivers.

Outstanding. So, you touched on this a bit, and I’d like to hear more about the community health needs assessments that you are involved with?

Yeah. So, those are, you know. Post the Affordable Health Care Act, all nonprofit hospitals were required now to conduct a community health needs assessment every three years. And health departments also have usually an accreditation requirement associated with that. I think for our system, we were always doing assessments, working closely with our local health department and nonprofit and foundation partners, but this really is, now under post ACA, there is a little bit more, I guess, guidelines on what to include in that.

So, that includes everything from understanding our own data, so really taking a look at ED and hospitalization, but understanding certainly for our self-pay and underserved populations, looking at our own EMR data of chronic disease prevalence and seeing, you know, what are patients coming in for, are we seeing increases decreases in certain conditions. But then it's also really supplementing with secondary data, so Center for Disease Control data, CMS data, census data, American Community Survey data, which is looking a lot of what's happening with income and poverty and more of a holistic look. And then, we use a lot of the county health rankings data, which does a great job sort of summarizing that. But more importantly, it's also collecting primary care data, so actually holding focus groups, and doing surveys with our residents and community members to find out what they feel is working well, what are barriers to health, what are gaps still in the community. And then, usually the process, once you sort of integrate all of this rich primary and secondary data, really coming together with your community partners to sort of prioritize where do we need to focus. And that really is then developing. And all of these reports are available publicly online. You can go to our Atrium Health website. You can go to our specific hospital websites. And then, in addition to that, and they're approved by our board, so there's higher visibility there. They actually, these findings and assessments, actually get reviewed at the at the leadership level. And then, the result of that is to develop a plan of how we are going to tackle that, and it's called an implementation strategy. So, that's also publicly available. And there you would find what are we proposing to do to tackle obesity in this county or these are the investments that we've made, this is how we'll evaluate success. And so, all of that would be captured in that strategy.

I would say health systems have been doing this work for years, it's just provides a little bit more of a structure. And then our health department, and oftentimes our competitor hospitals, are partners in this work too because it's really about sort of coming together to address these social needs regardless of whether there's competition or not.

Well Jenifer, where do we go from here?

One of the things we're working to address to is educating the next generation overall care providers. So, I think maybe even the last question. I think just even how does value-based care and pop health get infused or integrated into medical school curriculums today. But certainly, knowing that some of the rural population challenges are going to be more heightened or more prevalent than maybe in some other non-rural practices. So, I think that the educational pipeline is critical. And so, we're just add that, that again, that's certainly not my area of expertise, but that is one way. Because access at the end of the day, we're trying to ensure adequate access. That's one of the other pieces that we want to continue to support and emphasize as well.

Thank you. It’s an honor to be here.

Dr. Yang, what is comprehensive Dementia Care and why is it more important now than ever?

Absolutely. So, as many of us already know, the baby boomers are getting older and as people age there are more people who have cognitive impairment and dementia is where people whose cognitive impairment is making them have impairments in their daily function. So, as we get into the next couple of decades, we're going to see a tremendous increase in the millions of Americans who have some sort of cognitive impairment. And comprehensive dementia care means that it's not just talking about the medical aspect of treating dementia, we're not talking about just prescribing pills, which there are very few, but a very holistic treatment including caregiver support, education, discussing legal and other related topics that our patients go through, as well as kind of a wraparound service that helps these patients who are living with dementia and their families go through this journey.

Dementia obviously has a pretty negative connotation when people hear about it. They think they're crazy or you know that you're going to go live in a rest home or something like that. But it really just means that someone’s memory problems is affecting their daily function. It is an umbrella term, and the word dementia is used oftentimes interchangeably with Alzheimer's disease or Alzheimer's dementia, but there are many different types of dementia and Alzheimer's is the most common type but it's not the only type. And there are pre-dementia conditions called mild cognitive impairment where the person might notice some subjective signs of memory loss and objectively a memory testing, we don't think this is just what happens as you get older. Compared to other people of similar age and education, this person scores very poorly and those people are called mild cognitive impairment because they're still able to function independently, they're just noticing some subtle issues that are perhaps to beginning of dementia.

Well tell me how a cognitive impairment or dementia diagnosis impacts the overall health of the patient and care team?

So, dementia or cognitive impairment is not just one of the many chronic medical issues our patients deal with it. It really affects the self-management of all chronic illnesses. So, if you think of someone who has diabetes and they have memory problems, how are they going to remember to take their medicines accurately? Are they going to be able to draw up their insulin? Are they forgetting how to cook so they eat poorly or maybe they have forgotten that they have not eaten and are losing a lot of weight or gaining a lot of weight from forgetting that they have already eaten. So, that's just an example of how our cognition is really central to the overall health of the person.

What is the current landscape like in cognitive impairment AKA dementia care?

I think that research in Alzheimer's disease and related dementias, which we can call the general term dementia or ADRD is what the National Institute of health used to call all the related dementias to Alzheimer's. A lot of the research have been very focused on the biological pathways of the disease and of course in ways to prevent the development of cognitive impairment, but there hasn't been as much funding until recently in the care of patients who already have the disease. Most of the drug trials have moved earlier and earlier on in the disease course,...]]>In this episode we talk with Dr Mia Yang, a practicing physician involved in clinical care, teaching, and clinical research. She is Director of the Wake Forest House Call program and the co-Investigator for the D-CARE study, comparing health system-based dementia care versus community-based dementia care. Mia Yang, Welcome to the Move to Value Podcast.

Thank you. It’s an honor to be here.

Dr. Yang, what is comprehensive Dementia Care and why is it more important now than ever?

Absolutely. So, as many of us already know, the baby boomers are getting older and as people age there are more people who have cognitive impairment and dementia is where people whose cognitive impairment is making them have impairments in their daily function. So, as we get into the next couple of decades, we're going to see a tremendous increase in the millions of Americans who have some sort of cognitive impairment. And comprehensive dementia care means that it's not just talking about the medical aspect of treating dementia, we're not talking about just prescribing pills, which there are very few, but a very holistic treatment including caregiver support, education, discussing legal and other related topics that our patients go through, as well as kind of a wraparound service that helps these patients who are living with dementia and their families go through this journey.

Dementia obviously has a pretty negative connotation when people hear about it. They think they're crazy or you know that you're going to go live in a rest home or something like that. But it really just means that someone’s memory problems is affecting their daily function. It is an umbrella term, and the word dementia is used oftentimes interchangeably with Alzheimer's disease or Alzheimer's dementia, but there are many different types of dementia and Alzheimer's is the most common type but it's not the only type. And there are pre-dementia conditions called mild cognitive impairment where the person might notice some subjective signs of memory loss and objectively a memory testing, we don't think this is just what happens as you get older. Compared to other people of similar age and education, this person scores very poorly and those people are called mild cognitive impairment because they're still able to function independently, they're just noticing some subtle issues that are perhaps to beginning of dementia.

Well tell me how a cognitive impairment or dementia diagnosis impacts the overall health of the patient and care team?

So, dementia or cognitive impairment is not just one of the many chronic medical issues our patients deal with it. It really affects the self-management of all chronic illnesses. So, if you think of someone who has diabetes and they have memory problems, how are they going to remember to take their medicines accurately? Are they going to be able to draw up their insulin? Are they forgetting how to cook so they eat poorly or maybe they have forgotten that they have not eaten and are losing a lot of weight or gaining a lot of weight from forgetting that they have already eaten. So, that's just an example of how our cognition is really central to the overall health of the person.

What is the current landscape like in cognitive impairment AKA dementia care?

I think that research in Alzheimer's disease and related dementias, which we can call the general term dementia or ADRD is what the National Institute of health used to call all the related dementias to Alzheimer's. A lot of the research have been very focused on the biological pathways of the disease and of course in ways to prevent the development of cognitive impairment, but there hasn't been as much funding until recently in the care of patients who already have the disease. Most of the drug trials have moved earlier and earlier on in the disease course, where there might be treating people who have perfectly normal memory but are having biomarkers that suggest that they are perhaps on the path of developing dementia. While all of that research is very important, it really doesn't address the people who have the problem now and there aren't that many clinical trials looking at the group who have the disease now and particularly in the later stages of the disease. Usually in a moderate stage of dementia is when all the challenging behaviors that are commonly associated with dementia come about and most of the clinical trials are not looking at that. Although I do think there is a change in the landscape to really help the caregivers take care of the person with dementia better. A lot of the trials that we have that have been published are relatively small, so a couple hundred people at most oftentimes in only one institution. But the dementia study, or the D-CARE study, the dementia care study, is the largest dementia care clinical trial going on so far. This is where we recruited over 2100 dyads, so they're person living with the disease plus a family or friend caregiver.

Wow. Can you tell us more about the D-care study and the outcomes you have been seeing?

So, the D-CARE study is funded by PCORI and NIA. It's a comparative effectiveness study and it's what's called a pragmatic study, meaning it's right in the intersection between what we traditionally think of clinical trials versus clinical care. So, there are aspects of the study where we bill Medicare for using a billing code for cognitive evaluation and care planning and there are aspects of the trial that are paid for by the grants. And that is a very interesting type of clinical trial that not even many researchers know about because it's really at the intersection of comparing the effectiveness of two things that already have evidence that they have efficacy. And in this trial, we know that the two arms are being compared are already shown in their separate studies that have been published over the past 10 years that they are beneficial at helping caregivers at relieving their burden plus possibly other healthcare outcomes for the person living with the disease. But D-CARE is really comparing a health system-based dementia care model with the community-based dementia care model to see which one is better at reducing caregiver burden and the behaviors that are associated with dementia and the person living with the disease.

There is going to be a comparison of cost as well because this is going to relate to Medicare policy. On the health system-based arm, the intervention is delivered mainly by advanced practice practitioners, so nurse practitioners, or physician assistants, who have gone through specific training related to dementia care and they're supervised by a clinician, like me, partnering with their primary care physician. It’s a model that borrows from psychiatry and the collaborative care model where you bring in the mental healthcare and collaborate with primary care. In this case, we bring in the dementia care to collaborate with their primary care. The community-based arm it's much more separate from the healthcare system. These are usually nonprofit organizations in the specific communities that are doing aging related work. So, for example, Alzheimer's Association chapters or area agencies on aging. These are federally funded nonprofits or in our community, senior services was one of our partners where a social worker, who is embedded and an employee of that nonprofit, helps these dyads go through the journey of dementia for the 18 month period of the trial and provide telephonic support over that period of time.

Can you tell me how this work has impacted the Value-based Care triple aim of improved patient experience, better quality of care, and lower cost?

Absolutely. I think we're going to talk more specifically about the health system-based model because we are talking within the health system of value-based care. So, putting aside the community-based model for now. The health system-based model, I think, really does achieve the triple aim of improve patient experience. We have a life person who understands the comprehensive reach and needs of people going through the dementia journey and are proactively reaching out to them and proactively trying to prevent hospitalizations or other deterioration of their behaviors. And this is much more than again going to see a neurologist and getting two prescriptions. Nothing against neurologists but oftentimes we just don't have the time or the skills in our current healthcare system to really fully address all of the needs that these people have. And things for example like driving. Oftentimes primary care doctors don't know what to do about that. You don't want to tell someone they can't drive anymore because they'll never come back and see you. And I think we have seen through this particular trial and through previous research that overwhelmingly patients and their care partners really like this program. They feel like people are listening to them, that they're not just aimlessly wandering through the healthcare system trying to find what they need. They have a person that they could call when something comes up. This person happens to be able to prescribe medications if necessary. But that's really a relatively small part of the intervention. A lot of it is education for the care partner, connecting to community resources.

In terms of better health care outcomes because the study is still ongoing, I don't have those results. But looking at the original papers that were published from this model, which was developed at UCLA, they called it the Alzheimer's disease care model, and they have seen that people who are in getting this intervention have fewer hospitalizations and emergency room visits compared to people who are just waiting to be enrolled on a wait list control. This program is very significantly reducing the chance of long-term care. Enrollment, meaning that you know the family are just overwhelmed and they say we can't take care of this person anymore at home they need to move into a long term care a nursing home permanently, the studies have shown that this model can reduce that long term care enrollment by 40%. Which is significant when you have a value-based model that perhaps gets Medicaid funding, because Medicaid is really what funds long-term care services in our country.

And in terms of the lower cost, I think a lot of that relates to the fewer hospitalizations and emergency room visits. That people are able to access someone who can address their needs rather than taking this person who has challenging behaviors to the emergency room. Oftentimes that's really the worst place for these patients to go to. It’s a very disorienting place and people actually get worse oftentimes by going into the hospital rather than get better because there are very susceptible to get delirium on top of dementia, which is a condition where they get acutely agitated. They may be hallucinating, could be from a multitude of factors whether it's infection or just from sensory deprivation, you know, not being in their natural environment, not getting any sleep because the hospital is a terrible place to rest, and getting more and more confused. And sometimes, even though we learned that delirium is a temporary condition, oftentimes in people who already have underlying cognitive impairment it becomes a permanent decrease in their cognitive function.

So, I think through what I have mentioned so far, this model is really able to help the person who's living with the disease, help their family members get them the care that they need, help them stay in their home longer, and reducing the cost. Now the study, the D-CARE study, will wrap up in the summer of 2023 and then data will start coming out after that. So, probably by the summer of 2024 we will have a much more definitive answer as to how much money saves. But we do know that Center for Medicare and Medicaid Innovation is very interested in this model because even some back of the envelope calculations has shown that it could potentially save billions for the healthcare system, for Medicare and Medicaid.

What can a provider do right now to provide the support and best care for a patient, and their family, or care team, to improve outcomes?

I think that's a great question because we know that there are very few memory specialists like myself in our healthcare system even though we have a great geriatrics department, and we have great collaborators with the neurology. It is still taking months to get in to see us. We are working on the patient flow aspect of this to try to improve the access perhaps even through telemedicine to do some of these evaluations remotely for people who are too far away to come to Winston Salem. But I think outside of the realm of memory specialist, from a primary care perspective, and I'm also a primary care doctor, I understand the challenges. I think setting up the visit before the visit is very important for these particular situations. What usually happens is that the person with dementia or the person with memory loss may not know or acknowledge that they have a problem and it's someone else who is sending you report, or message, or calling your office saying, “I really need to talk to you about my husband ,or my dad, or my mom, and can we talk you know without that person there.” So that adds a lot of additional time that primary care providers don't have because, you know, you just don't have the time to be on the phone with the family member for 40 minutes after having a 40-minute encounter with the person.

So, I think as much as like using your team in the clinic to gather information ahead of time would be ideal. There are some validated measures that we give to our caregivers to answer when they come to clinic that's available and can be given out either through the patient portal or just on paper and pen. One is kind of asking the caregiver to rate the person's level function. So, their instrumental activities of daily living and their activities of daily living. Some of these questions are already in the Medicare Wellness Visit and are already populated in your flow sheet. There are two other measures where I think can give you a lot of very helpful information and you don't necessarily to have to ask all of these questions verbally. You can hand the caregiver, or someone on your team, can hand the caregiver the neuropsychiatric inventory questionnaire or NPIQ. It's a two-page sheet basically for the caregiver to rate the severity of behaviors related to the person who has cognitive impairment. And these behaviors are things like delusions, or false thinking like someone's stealing from me even though they just misplaced their bag, hallucinations, depression and anxiety, apathy, problems with sleeping problems with appetite, sleeping too much, sleeping too little, eating too much, eating too little. So, the caregiver can rate how bad these symptoms are and they can also rate how distressing it is for them. So, there may be some dissonance between the severity of the behavior and the distress it causes for the person who is trying to care for them. So, for example, sleep is a really big issue. If the person with dementia is not sleeping and the caregiver is not sleeping either, and that can very quickly transition someone out of the home because the caregiver has to get up the next morning and go to work and do all the things. And that is one thing that primary care doctors, even just by asking that one question, “how are you sleeping?” You know can we, you know, try to give some medications to help you sleep at night so that you're not sleeping during the day and having that day night reversal.

Dr. Yang, I understand you have additional resources that are publicly available to anyone who would like to learn more about cognitive impairment?

So, I am going to shamelessly plug my own podcast, which is not affiliated with Atrium Health Wake Forest Baptist, but my own personal views, that could be helpful for those who are interested in listening and finding out more about memory diagnoses and some of the new Alzheimer's drugs that might be coming out on the market and just general geriatric cases that are you know deidentified and could be helpful and in your clinical practice. So, my podcast is called Ask Doctor Mia and it is available on all the major podcast platforms or you can check it out on my website which is just my name miayangmd.com.

Outstanding! We’ll be listening. Dr. Mia Yang, thank you for joining us today on the move to value podcast.

Thank you. It’s been fun!

Ask Dr. Mia: Conversations on Aging Well

What is risk adjustment and why is it so important?

So risk adjustment is really a way to describe funding for resources and care to manage patients chronic or serious illnesses. It really helps to identify the risk that the patient is going to incur when medical costs that are above or below average for the year. It's really a financial forecasting that the health plans use to predict the future medical needs for the patients. So for example, a health plan receives payment from the government to help pay for the services that that patient is going to seek, whether that's an outpatient visit for chronic condition or an inpatient visit for a serious or acute illness, such as sepsis or a serious infection. And the funding to the health plan that they receive from the government pays those services at the hospital and office visit or primary care level. Risk adjustment matters because it's a way for the providers to report how sick their patients are and to ensure that there are resources available to those patients are there at their fingertips. So when a provider is able to manage their patients chronic conditions and prevent the hospitalizations the health plan actually ends up in a surplus and is able to share those funds with the provider, who is controlling the costs, and those patient chronic conditions. Health plans generally are going to use the funding to offer patients better premiums and other resources as well, such as Meals on Wheels or transportation and ways to lower prescription costs and many other different programs.

And how does risk adjustment work?

So in risk adjustment, value is assigned to each diagnosis code that falls into this payment model that's used by the government for the health plans. The ICD-10 codes are grouped in what we call HCC's or hierarchical condition categories. And these HCC categories are related to both clinical and financial resources available for those patients. Each diagnosis code that's mapped to one of these categories provides a risk adjustment factor score to identify the acuity or the sickness of that patient. Those risk scores are then calculated and converted into our financial resource for the health plan to cover those services for those patients.

How are providers impacted by risk adjustment?

So many providers are not directly impacted by risk adjustment because it's a way for the health plan to receive funding. A majority of providers are still part of what we call the fee-for-service reimbursement model, where they're reimbursed for a service they provide to the patient using a procedure code or an office visit code, for example. Most hospitals are reimbursed based on what we know is the MSDRG system when a patient is admitted to the hospital. It's a similar reimbursement methodology to risk adjustment in that the hospitals are paid a lump sum based on the diagnosis to cover the cost of care provided for those chronic or acute conditions that are being treated in the inpatient setting. Value-based care is really shifting the providers to be more responsible with managing the patients more effectively and coding more accurately. This means that providers need to be aware of what specialists are they are referring to how, often the patients are seeing their specialists, if they're going to the ED for unnecessary illnesses, such as urinary tract infections, and how many times they've been admitted to the hospital. All of those are you know primary care gatekeeper responsibilities. This also means that providers need to document and code all of the chronic conditions to the highest level of specificity and this is to...]]>This episode is first in a two-part series about Clinical Documentation and Coding. In part one, we talk about the importance of Risk Adjustment with Amber Malone-Wright, Director of Clinical Documentation Integrity at CHESS Health Solutions.

What is risk adjustment and why is it so important?

So risk adjustment is really a way to describe funding for resources and care to manage patients chronic or serious illnesses. It really helps to identify the risk that the patient is going to incur when medical costs that are above or below average for the year. It's really a financial forecasting that the health plans use to predict the future medical needs for the patients. So for example, a health plan receives payment from the government to help pay for the services that that patient is going to seek, whether that's an outpatient visit for chronic condition or an inpatient visit for a serious or acute illness, such as sepsis or a serious infection. And the funding to the health plan that they receive from the government pays those services at the hospital and office visit or primary care level. Risk adjustment matters because it's a way for the providers to report how sick their patients are and to ensure that there are resources available to those patients are there at their fingertips. So when a provider is able to manage their patients chronic conditions and prevent the hospitalizations the health plan actually ends up in a surplus and is able to share those funds with the provider, who is controlling the costs, and those patient chronic conditions. Health plans generally are going to use the funding to offer patients better premiums and other resources as well, such as Meals on Wheels or transportation and ways to lower prescription costs and many other different programs.

And how does risk adjustment work?

So in risk adjustment, value is assigned to each diagnosis code that falls into this payment model that's used by the government for the health plans. The ICD-10 codes are grouped in what we call HCC's or hierarchical condition categories. And these HCC categories are related to both clinical and financial resources available for those patients. Each diagnosis code that's mapped to one of these categories provides a risk adjustment factor score to identify the acuity or the sickness of that patient. Those risk scores are then calculated and converted into our financial resource for the health plan to cover those services for those patients.

How are providers impacted by risk adjustment?

So many providers are not directly impacted by risk adjustment because it's a way for the health plan to receive funding. A majority of providers are still part of what we call the fee-for-service reimbursement model, where they're reimbursed for a service they provide to the patient using a procedure code or an office visit code, for example. Most hospitals are reimbursed based on what we know is the MSDRG system when a patient is admitted to the hospital. It's a similar reimbursement methodology to risk adjustment in that the hospitals are paid a lump sum based on the diagnosis to cover the cost of care provided for those chronic or acute conditions that are being treated in the inpatient setting. Value-based care is really shifting the providers to be more responsible with managing the patients more effectively and coding more accurately. This means that providers need to be aware of what specialists are they are referring to how, often the patients are seeing their specialists, if they're going to the ED for unnecessary illnesses, such as urinary tract infections, and how many times they've been admitted to the hospital. All of those are you know primary care gatekeeper responsibilities. This also means that providers need to document and code all of the chronic conditions to the highest level of specificity and this is to help ensure that those resources and funding is available to the patients when they utilize the health care system. So when providers manage utilization and they code to the highest level of specificity, in value based care, there's often incentives and bonuses to reimburse those providers for the additional work that they're doing to manage those patients. Health plans are held at risk for diagnosis that are submitted via claims and if those diagnosis codes that are submitted or not supported in the medical record documentation, then the health plan is ultimately penalized financially. So not only that but health plans run the risk of being underfunded if all of the chronic conditions are underreported. So providers documentation and coding directly impacts the funding for the health plan. Improved documentation and coding leads to better patient care. This is the primary way of communicating the patient record for specialty care and also to the health plans and CMS. So accurate documentation also improves quality reporting and efficiencies when responding to regulatory requirements such as a HEDIS or MIPS or quality reviews and risk adjustment data validations known as RADV audits that are conducted annually by CMS.

Would you tell me about the impact that unspecified diagnosis coding may have on both providers and patients?

So that's a great question. If medical documentation lacks the accuracy and specificity needed to assign the most appropriate diagnosis codes, providers face the possibility of reduced payment if they're part of a performance-based payment model and they won't be compliant with CMS standards. There's also a missed opportunities for patients to be identified for care management programs or even disease interventions programs. So as healthcare continues to change, high quality documentation continues to be a cornerstone of accurately reflecting the work of the provider and the condition for each patient. Risk adjustment takes a close look at how ICD documentation and coding can also contribute to the complexity of care for the visit, the medical decision making, and the time spent with that patient. Good documentation around coding will paint the true clinical picture of the patient and is reflective of the thought process of the provider. Many providers have oftentimes heard if it wasn't written it wasn't done. This helps also to control the cost of care and stabilize patient premium increases.

What recommendations do you have to help providers in value-based care contracts?

Providers should have their documentation audited to ensure that the patient's clinical conditions are being fully described in clinical documentation. It's important to work with coders or clinical documentation improvement specialists and consider their feedback around their documentation. It's also important to monitor and decrease their use of unspecified diagnosis codes, as unspecified diagnosis codes did not fully describe the patient's clinical conditions. Oftentimes, electronic medical records or practice management systems can have errors in mapping of ICD 10 codes, so it's important to make sure that the diagnostic description matches the ICD 10 code. Education and training should be conducted based on the results of the audit. Providers did not go to school to learn medical coding and it is like learning a new language. There's a lot of rules and guidelines and regulations that are not available in an EMR for provider education. So it's important really to just conduct an annual audit to ensure documentation and coding accuracies are sustained and when errors are identified to reeducate and monitor those audits and programs in place.

What can a provider do right now to begin to move the needle in risk adjustment?

So one major component that providers can do is really understand who their population is by managing their appointments. So bringing all of their patients in for routine Annual Wellness Visits, chronic care management disease programs, or identifying the transitional care management opportunities for patients who have been at the hospital and identifying and addressing all of their chronic conditions and managing them appropriately so that we can decrease utilization that's unnecessary and make sure that those patients chronic conditions are stable and well managed.

Dr Vass-Eudy, as a provider with a rural patient population what are some of the unique challenges about practicing medicine in a rural community?

I think the first thing is that the space there's a lot of space in a rural health community. Patients are driving many miles to get to restaurants or grocery stores or to their doctor, so it really does create an issue for some patients especially in a in an economy where there's issues with paying for gas or food. So for a provider in a community like that, they have to be really aware of that distance. It creates community though because a lot of people families will stay in the same area together.

So when I was working in a rural health community facility, I would take care of everybody from great grandma all the way down to you know the tiniest infant because they all live nearby they all kind of stayed together and created a community. There's a lot of people in my practice that knew each other which was nice because they would take care of each other and look out for each other and so it was a different concept to me than maybe working in a bigger city where people don't always know each other

And what factors are driving poor health in rural communities?

So one of the biggest issues with the rural health community is just learned behaviors. Maybe this is a rural area where there was farming in earlier generations and so eating biscuits and gravy and putting lard in everything is acceptable because you're going to burn off those calories working in the farm from sunup to sundown. But in a more in a in a time when that is not the issue, when they're not working in the in the fields they're working in a factory job and they're coming home and sitting on the couch, those same patterns of eating behaviors not exercising you know veging out on the couch is something that kind of perpetuates bad outcomes or bad health.

So I've seen that a lot just - well that's how grandma cooks so that's how I cook and really having a hard time not putting a meat with every meal or you know meat and potatoes with every meal putting gravy on everything. That's something I've had to really try to work with patients on. I think diet and having that education for patients in a rural health community is something that's really lacking and just that learned behavior trying to unlearn it for healthier at lifestyle

And how are these challenges uniquely suited for practicing value-based care?

I think what I've learned especially now that I'm part of CHESS is that we really look at the data. We're not making a blanket statement about a group of patients. We're really looking at what those needs of those patients are in their setting. So, what is necessary for rural health practice may not be the same as for an urban practice. I like the idea that we really look at what the needs are and then try to come up with solutions to solve those problems. So, for instance in a rural health community, there's an increased risk of hypertension, diabetes, tobacco use, so we would tailor projects and pilots and processes that would help patients in those settings and for those diseases that may not be the same as in an urban area.

And you really can't bludgeon them you know you can't beat them over the head about it it's a process they have to come to the realization that this is something that they want to do for themselves. I just recall a patient of mine. She always this always makes me laugh because she was a diehard smoker, she said you know Dr. Vass-Eudy, when I die my hand is going to be sticking up out of the grave with a cigarette in it. I'm]]>In this episode we learn about what it is like driving value in rural communities with CHESS Health Solutions senior director of clinical operations and practicing physician Dr. Kimberly Vass-Eudy

Dr Vass-Eudy, as a provider with a rural patient population what are some of the unique challenges about practicing medicine in a rural community?

I think the first thing is that the space there's a lot of space in a rural health community. Patients are driving many miles to get to restaurants or grocery stores or to their doctor, so it really does create an issue for some patients especially in a in an economy where there's issues with paying for gas or food. So for a provider in a community like that, they have to be really aware of that distance. It creates community though because a lot of people families will stay in the same area together.

So when I was working in a rural health community facility, I would take care of everybody from great grandma all the way down to you know the tiniest infant because they all live nearby they all kind of stayed together and created a community. There's a lot of people in my practice that knew each other which was nice because they would take care of each other and look out for each other and so it was a different concept to me than maybe working in a bigger city where people don't always know each other

And what factors are driving poor health in rural communities?

So one of the biggest issues with the rural health community is just learned behaviors. Maybe this is a rural area where there was farming in earlier generations and so eating biscuits and gravy and putting lard in everything is acceptable because you're going to burn off those calories working in the farm from sunup to sundown. But in a more in a in a time when that is not the issue, when they're not working in the in the fields they're working in a factory job and they're coming home and sitting on the couch, those same patterns of eating behaviors not exercising you know veging out on the couch is something that kind of perpetuates bad outcomes or bad health.

So I've seen that a lot just - well that's how grandma cooks so that's how I cook and really having a hard time not putting a meat with every meal or you know meat and potatoes with every meal putting gravy on everything. That's something I've had to really try to work with patients on. I think diet and having that education for patients in a rural health community is something that's really lacking and just that learned behavior trying to unlearn it for healthier at lifestyle

And how are these challenges uniquely suited for practicing value-based care?

I think what I've learned especially now that I'm part of CHESS is that we really look at the data. We're not making a blanket statement about a group of patients. We're really looking at what those needs of those patients are in their setting. So, what is necessary for rural health practice may not be the same as for an urban practice. I like the idea that we really look at what the needs are and then try to come up with solutions to solve those problems. So, for instance in a rural health community, there's an increased risk of hypertension, diabetes, tobacco use, so we would tailor projects and pilots and processes that would help patients in those settings and for those diseases that may not be the same as in an urban area.

And you really can't bludgeon them you know you can't beat them over the head about it it's a process they have to come to the realization that this is something that they want to do for themselves. I just recall a patient of mine. She always this always makes me laugh because she was a diehard smoker, she said you know Dr. Vass-Eudy, when I die my hand is going to be sticking up out of the grave with a cigarette in it. I'm never quitting. And I said OK well lets you know we just talk about it every time - hey are you ready are you thinking about it and finally she quit. It was her decision though and it was just being supportive of her in that process. But she did quit and she's not you know with her hands sticking up out of the grave with this cigarette in it.

Well thank goodness! Dr. Vass-Eudy, how do rural providers increase patient engagement to be more invested in their own health?

Honestly you just have to meet the patient where they are. You have to care have to care about where the patient is coming from what their specific needs are. I think if you are in a real health community have to be part of it in a lot of ways even if maybe you don't necessarily live there. But you have to take part in the community like community outreach. I remember going to senior centers and having lectures to the seniors in the rural health area. I remember churches and bazaars and just doing different things to educate patients, bringing medicine to them, bringing the blood pressure cuff to them, talking about diabetes screening at these different functions to try to get them to understand that I care about their health.

I think if a provider in a community shows that they're going to get engagement from their patients, their patients are going to know that they care about them. It's a little bit easier to do this sort of outreach when you have a smaller not busy practice and kind of a newer provider in a community, but I really hope that any provider in any community will take part in the area and what's going on with their patients.

What are the advantages for the patient, care team, and clinicians for providing value-based care?

It gives a road map to success for the patients’ health outcomes. If you are practicing value-based care, you're looking at what is most affecting your patients and you're coming up with solutions to benefit them, and if I'm benefiting my patients, that's my whole the goal of my job. That's what I'm trying to do. It's all about them. So, with value-based care, because we're always looking at the numbers and watching and seeing and what's happening to the patient, how well are we caring about them, we can find where there's holes where there's places that we can plug in care team members nursing staff, home health education, diabetes education, dietitians. Like we can see where those places are and really meet the patient where they are.

We spend too much money in healthcare for really bad outcomes, so the goal is to flip it pay less and get better outcomes. That's the whole point of this. I don't like to think about the payment part of it because I've never liked that even as a healthcare provider. I'm the worst at this. I never know what my paycheck is. It just goes in the bank like I don't pay attention to that. But I know that we're spending too much money. I know that we have the greatest country in the world with the greatest health care in the world, but we're spending so much money and we're getting very little for it. Patients are no better off. So we have to do something and if it means we look at the bottom line at the same time as looking at quality as well. If I'm spending all this money, why am I not getting anywhere with patients? I need to figure out how to take better care of them and not spend as much money.

In our country there's been an ongoing debate about rural telecommunications, and when COVID hit it became more imperative that we become more interconnected through the web. How have you seen technology be a barrier in these communities within the healthcare space?

Oh yeah. I mean you hit the nail on the head. They just don't have access. They don't have the I guess the high speed Internet that maybe I can get in a bigger city. And I've had patients who live off, you know, a dirt road and to have that kind of access is going to cost them tens of thousands of dollars that they don’t have, because no one's paying for it. They want better access; they're going to have to pay for it. So I think that is truly an issue.

There is definitely and there's definitely a difference between a wealthier community and a poorer community and what kind of access they have. I would hope that we could find other ways around that because it doesn't mean that they don't need or deserve the kind of care that other people are getting. Virtually, I do a lot of phone visits. I mean, I may not see the patient. I've even done some face times on my cellphone, whether or not that's approved by you know corporate or not. I'm like, that's one way I can see but let me see your wound we're on FaceTime with my phone because they cannot access the computer Internet. So I think that we can work around it. It's got to happen. I think people need to put pressure on their leadership, the government leadership in their rural communities, to get that sort of access that we all deserve because that's where we're heading. You know I would love to see more medicine done at home. Why do you need to drive 45 minutes to my office when I could have done this over the telephone? So I'd like to see more of that and I think we can do that.

Have you also seen a technology barrier within the practices itself that have caused it to struggle with patient care?

I think so I mean I think a lot of people - everyone's a little resistant to change and we had to change really fast during COVID. I've never had to do a pivot in my life like that. As far as my practice, it definitely changed how I perceive things and how I do things. I was dead set against doing anything on the telephone because in my mind I thought I have to listen to the heart and I have to listen to the lungs and I need to put my hands on the patient and I learned really quick that I can do a lot without having my hands on the patient. I had an attending once who told me think about it as if you're - this was many many years ago getting older - think about it as if you're if you're practicing in the jungle. Like what are the basics that you need to take care of a patient and I've always kept that in my mind because we do get really reliant on technology, X-rays and images, and things like that. And I remember him saying that and I would think about it a lot during COVID. Like what if I'm in the jungle? What do I need and so I could do a lot without a lot you know taking care of patients? So I think people are resistant to change. So maybe some people are not willing to do things differently than they've always done them.

We're always researching and trying to figure out do I we need to do pap smears every year? No we don't do I need to do certain tests every single year. No I don't because we've studied that and it's just historical and we've always done it that way so we always will. So I think it's nice to think outside the box a little bit and see if we can do something different.

So tell me Dr. Vass-Eudy, how can clinicians leverage partnerships with community based organizations to improve patient care?

Great question. I've definitely have learned a lot just working with CHESS on how I can partner collaborate work with others. When you're a doctor, especially a rural health doctor, you really learn how to do everything yourself because I have no one else to rely on. The patient walks in with a wound you know fingers hanging off or some kind of wound from a farm equipment. I'm the one who's going to handle it because there's nowhere else for them to go. So I've had to unlearn that I have to understand that I'm not the only one and then I can leverage other people's knowledge and experience and expertise and gifts that I can bring all of that to the patient not just me. There's so much more that can be brought so I had to unlearn that myself and I find that utilizing dieticians, diabetes educators, nurses that will call the patient and talk to them on the phone, um pharmacist my gosh they're so underutilized on what they can offer patients, their doctors as well. So getting a team together relying on your team not thinking you're the only one who can take care of the patient but there's so many people that can help and the patients appreciate that. They love it they want that team approach. They've often, you know, over the years people would say well you know they were disappointed in something their doctor did, but when you have a team, it's a whole group of people deciding and helping and throwing, in you know, their two cents. So it's not just relying on one person to do it. There's an effort from everyone.

So now with a greater awareness of social determinants and the big push to alleviate those barriers, do you see opportunities outside of the clinical space for partnerships that can support hunger, job training, or Family Services all to create a better collaborative effort for patient health and wellness?

Absolutely. There is such a lack of connection with resources in the community. I have often, especially in a rural health area, have been disappointed or frustrated with trying to get help for people. I've had patients who didn't have electricity because some wiring on the outside the house. Something was wrong. So then we're trying to leverage all these different people in the community to help. Churches, organizations, but I don't know who they are. I had to start from zero. I don't know who to ask. So my staff and I and just getting on the phone and calling people to try to get help. So I definitely wish there was more of a concerted effort to partner with groups in the community that can help patients with things like, you know, electricity issue or a, you know, broken window or something that that is kind of not exactly healthcare but it does impact a patient health.

What opportunities do you see on the horizon for improving pop health in these rural communities?

Partnerships definitely. Outreach is another one. Getting patients comfortable with having other people than their doctor calling them on the telephone. So, but coming at it as a group my nurse my pharmacist this is I'm representing Dr Vass-Eudy because patients are going to be reluctant, especially our older community. They're always thinking somebody is trying to scam them. So I really would love to see that grow where the patients understand that it's not just me, it's an outreach from my office and it's there for them.

I'd like to see more monitoring devices at patients home so blood pressure cuffs, glucometers um, you know, congestive heart failure devices where we're measuring fluid overload, so things like that to help the patient at home. I want to see more things done at home for the patient. I'd like to see, you know, more education. Whether it's groups at a Senior Center. I brought a dietitian to the Senior Center and had everybody come over there, the community as well as my patients, so that the dietitian can give them some education about what to eat what not to eat as a diabetic. So I'd like to see more of that. Definitely groups collaboration and outreach and coming at it from the perspective of helping your doctor help you.

Well Dr Vass-Eudy, what can a provider do right now to start seeing better outcomes for their rural patient population?

A provider needs to care about the patient, especially in a rural health community. They're a special group that requires a doctor or provider that really understands that group. They're loving and wonderful and sometimes they're sassy and sometimes they don't want to follow your advice and sometimes they're going to come with their own things that they've done because mom told them back in the day this is what you do. So there's so many interesting parts to that patient-provider relationship that I really could. If someone would just care about that and really meet the patient where they are, I think that that would make all the difference in the world.

Over the years I have had patients that if I could if I just show them I cared, they were dug in their heels were dug in they or going to do something that I asked them to do that was in their best interest, but I just kept staying with them and just kept hearing them out and over time they came around. You know, they really said I appreciate what you've done. I appreciate that you cared, appreciate that you showed up and that you're here for me. And I think that's what's important. Baseline basics for any provider. Just be there for your patient. Care about them.

Bethany, Welcome to the Move to Value Podcast! Let’s talk a bit about Medicare Advantage. Can tell us what it is and how it works?

Sure. So, before I get into specifically Medicare Advantage, I did want to just give an overview that Medicare consists of four parts being Part A, Part B, Part C, and Part D. Medicare Advantage is Part C of Medicare. And what that is, is it's not necessarily a supplement to Parts A and Parts B but rather a placement. So, if someone is in Medicare Advantage, they're going to be on Medicare Part C. And then some Medicare Advantage plans also have what's called Part D, which is your drug spend. So, you will see a lot of plans that have both Part C and Part D.

The difference between Medicare Advantage and traditional Medicare in a nutshell is that the government, instead of the government managing the Medicare Part A and Part B, private sectors are actually taking on the Medicare Advantage population. So, the government is literally shifting those patients within to the private sector or publicly traded organizations. And what the government is doing is they're basically giving those organizations an allotted amount of money that is risk adjusted to take care of those patients.

What's interesting about Medicare Advantage, or commonly referred to as MA, is now in today's age, nearly half of Medicare eligible patients are actually on a Medicare Advantage plan. So, we've seen explosive growth since its inception.

How did Medicare Advantage get its start? What's the catalyst for that?

So, before there was Medicare Advantage, there was Parts A and Part B, which would be coined as traditional Medicare or original Medicare. And in 1965, President Lyndon B Johnson signed this into law. It um, for traditional Medicare. So fast forward several decades, Medicare Advantage was signed into law in 1997 by President Bill Clinton under the name Medicare Plus Choice. However, the base of Medicare Advantage actually goes back into the 70s. But that was kind of a breaking point in terms of that. It was truly becoming Medicare Advantage in 1997. But the goal of MA was really to give beneficiaries a choice for purposes of their health insurance and cost savings derived from managed care efficiencies that ultimately would save the government money that the government wasn't necessarily putting into place by themselves. The name actually shifted to Medicare Advantage in 2003 and this was also when Part D, which is drug spend, was created. And that is the Medicare prescription benefit and that officially went into effect in 2006.

Bethany, would you explain to us the differences between traditional Medicare and Medicare Advantage?

Sure. So, traditional Medicare includes Part A, which is considered institutional coverage, and Part B, which is medical coverage; or think really outpatient coverage. As a Medicare eligible patient, you're covered at 80% in respects to Part B. So, for many, they do, that are on traditional Medicare, they'll typically select a supplemental plan that covers that additional 20%. Which again is different than Medicare Advantage, which is a replacement plan compared to a supplemental plan. And traditional Medicare is funded entirely by the government. Typically, when someone becomes Medicare eligible, Social Security will actually enroll them in Parts A and Parts B. So, we look at that as those, generally speaking, those over 65 will receive Parts A based off of the amount of time they or their spouse have paid into Medicare taxes. And then for Part B, they'll be paying a monthly premium that's really income dependent. But just to give...]]>In this episode, we learn about the commercial side of value-based care contracting and Medicare Advantage from Bethany Palmer, Senior Director of Contract Strategy and Clinically Integrated Network Management for CHESS Health Solutions.

Bethany, Welcome to the Move to Value Podcast! Let’s talk a bit about Medicare Advantage. Can tell us what it is and how it works?

Sure. So, before I get into specifically Medicare Advantage, I did want to just give an overview that Medicare consists of four parts being Part A, Part B, Part C, and Part D. Medicare Advantage is Part C of Medicare. And what that is, is it's not necessarily a supplement to Parts A and Parts B but rather a placement. So, if someone is in Medicare Advantage, they're going to be on Medicare Part C. And then some Medicare Advantage plans also have what's called Part D, which is your drug spend. So, you will see a lot of plans that have both Part C and Part D.

The difference between Medicare Advantage and traditional Medicare in a nutshell is that the government, instead of the government managing the Medicare Part A and Part B, private sectors are actually taking on the Medicare Advantage population. So, the government is literally shifting those patients within to the private sector or publicly traded organizations. And what the government is doing is they're basically giving those organizations an allotted amount of money that is risk adjusted to take care of those patients.

What's interesting about Medicare Advantage, or commonly referred to as MA, is now in today's age, nearly half of Medicare eligible patients are actually on a Medicare Advantage plan. So, we've seen explosive growth since its inception.

How did Medicare Advantage get its start? What's the catalyst for that?

So, before there was Medicare Advantage, there was Parts A and Part B, which would be coined as traditional Medicare or original Medicare. And in 1965, President Lyndon B Johnson signed this into law. It um, for traditional Medicare. So fast forward several decades, Medicare Advantage was signed into law in 1997 by President Bill Clinton under the name Medicare Plus Choice. However, the base of Medicare Advantage actually goes back into the 70s. But that was kind of a breaking point in terms of that. It was truly becoming Medicare Advantage in 1997. But the goal of MA was really to give beneficiaries a choice for purposes of their health insurance and cost savings derived from managed care efficiencies that ultimately would save the government money that the government wasn't necessarily putting into place by themselves. The name actually shifted to Medicare Advantage in 2003 and this was also when Part D, which is drug spend, was created. And that is the Medicare prescription benefit and that officially went into effect in 2006.

Bethany, would you explain to us the differences between traditional Medicare and Medicare Advantage?

Sure. So, traditional Medicare includes Part A, which is considered institutional coverage, and Part B, which is medical coverage; or think really outpatient coverage. As a Medicare eligible patient, you're covered at 80% in respects to Part B. So, for many, they do, that are on traditional Medicare, they'll typically select a supplemental plan that covers that additional 20%. Which again is different than Medicare Advantage, which is a replacement plan compared to a supplemental plan. And traditional Medicare is funded entirely by the government. Typically, when someone becomes Medicare eligible, Social Security will actually enroll them in Parts A and Parts B. So, we look at that as those, generally speaking, those over 65 will receive Parts A based off of the amount of time they or their spouse have paid into Medicare taxes. And then for Part B, they'll be paying a monthly premium that's really income dependent. But just to give you an example, so in 2022, the monthly premium for Part B services was $170.10 at the base. But again, that can be adjusted based off of your modified adjusted gross income. So, if a person elects to stay on traditional Medicare, it is recommended to get a supplemental plan because it does help cover that 20%. And keep in mind, for traditional Parts A and Parts B, there is not necessarily a maximum out of pocket. The supplemental plan will help with that. So, that's where you have your Parts A and Parts B.

Now shifting to Part C, which is Medicare Advantage, that is where you have your replacement. So, instead of being on Parts A or Parts B, you can elect to be on Part C. So, with Medicare Advantage plans you do have a max out of pocket compared to original Medicare. Medicare Advantage plans are also required to offer extra benefits that original Medicare do not include. So, examples of that would be vision, hearing, and dental services. Part D is also included in most Medicare Advantage plans, opposed to if you're on just Parts A and Parts B, you typically have to buy a separate dental plan.

With Medicare Advantage there will sometimes be a case where you do pay a premium. So, think about going back to the Social Security you're still paying. When you're in Medicare Advantage, you're still paying that Part B premium that was roughly $170.10. But then you might have another separate premium with Medicare Advantage. Typically, you will have a less premium within Medicare Advantage than you will in a supplemental plan. One of the things that I think people they see with Medicare Advantage is they typically will have a defined network, um, opposed to just having the open market and being able to go wherever. Now there are different plan options and I think we've seen throughout the years that there's been a lot more concerted effort to have plans that have more of what you would considered an open network. But there are still large portion of Medicare Advantage organizations that will have defined network for those plans.

So, I know a lot of people wonder kind of what is the cycle for enrollment for Medicare Advantage plans. And sometimes you'll see certain things within the year when more marketing seems to be prevalent with Medicare Advantage than others. So, for someone that becomes Medicare eligible, initial enrollment, or better known as age-ins, you can enroll 3 months prior to your birth date or three months after your birth date. Then there's something what's called annual enrollment period for Medicare Advantage and that, or better known as AEP, and that typically runs from the middle of October every year through the beginning of December. And so, within that time period, someone can elect to be on a Medicare Advantage plan. There's also another season, not to be confused with annual enrollment, but open enrollment and that runs from January 1st through the end of March, where a patient can actually switch once during that time to either another Medicare Advantage plan or back to original Medicare. So, there's really a layered approach of how patients are able to elect a Medicare Advantage plan. And then there's also something called a special election period, and there's several different areas where, or patient populations, that fall into that space as well.

I would like to know how provider groups partner with Medicare Advantage with in value based care?

So, great question. So, at the beginning, it starts with providers coming into the picture once those MA patients are attributed to them. So, in order for a provider to really work with an MA plan, they have to have some type of patient attribution. The Medicare Advantage organization and provider group can then work together to help take the best care of the patient as possible. So how does that work? So, think about it in both the MA organization and the provider have an aligned goal to really produce value for the patient population by decreasing any type of unnecessary medical costs, reducing producing inpatient and ER admissions, ensuring that that population is completing preventative visits and screenings. And those really are all foundational to an MA organization working together with a provider group.

And a lot of those things can be done through some type of contractual value-based agreement. So. it's really important for the provider group to really understand what the MA plan is being measured. And then for the MA plan to really understand the provider group in terms of what resources they have. Because I think by being able to understand one another, you can really align incentives and then also reduce any type of duplication within those resources and being able to maximize benefits that are mutually beneficial for both parties. So, really, collaboration is key when working together, but keeping the same goal in mind of taking better care of the patient population and improving that patient population is vital to the success of that provider and MA organization working together.

We would like to know about the STARS program. Can you tell us about this?

Sure. So, what's also known as the stars quality measures program is basically what CMS has come out with in terms of the MA quality program. So, it's a star rating of one through five that an MA organization can receive. The stars program is really twofold in terms of goals. So, one being for the consumer to be able to see how their health plan is rated. So, when they're going into select a health plan, they're able to see every single health plan and what their star rating is and some of the components that are included in that. Secondly, the stars program is really help, it's helping to incentivize MA organizations to take good care of the patients within quality, and then also incentivizing them to be able to put money back into their benefits for a future year to be able to increase the their robust benefits.

So, the stars, I will say that the stars program, how health plan is rated, is fairly complex and it does change annually. But some examples of categories that a plan is rated on is member or patient experience, both at the provider level and the plan level. Management of chronic conditions including measures that may focus on diabetic measures as an example of diabetic patients. Then there's preventative screening, so such as breast cancer and colorectal cancer screening. And then finally, a lot of, there's some metrics that are really focused on MA plan internal metrics. So, plan customer service and how customer service is being measured is another example. So, you can see that the actual star rating itself is fairly comprehensive and a portion of that is directly impacted by the provider and the care they provide to the patient.

So, that's something to keep in mind. That plans are really incentivized to work with providers to be able to maintain or increase their star rating year over year. Plans really do need to, they're incentivized to stay competitive within their benefits and how the quality program works is if they do to a certain threshold, they may receive a quality bonus payment. And they also could receive a percentage of rebate dollars that are allocated to their benefits for future performance years. And as you do better in stars, your rebate percentage that goes directly back into your benefits actually increases. So, again, the quality program really is built to be consumer facing but it's also a way for MA organizations to build their benefits and ultimately grow their population. And I think we've seen that in the industry, in the past several years, that MA plans that are successful in creating, maintaining, and improving their star rating are able to capture a larger population by increasing how well their benefits are structured.

So as we're talking about ma and value based care which is really important to our organization tell us one way that total cost of care is looked at?

Yeah. So, a major component in Medicare Advantage is cost management, which is something that's important to Medicare Advantage organizations for several reasons. But one of the main ones is to have some type of margin and then also to be able to adequately take care of the patient population from that managed care perspective. But really it can be boiled down into one foundational concept known as the medical loss ratio. Which at its fundamental definition is going to equal your total cost of care of the population divided by your total revenue of the population. So, that MLR ratios really looked at at the holistic population, which again can be broken down into different layers but as a whole they're looking at what that ratio is and how it continues to look and track.

So, this concept is used really to ensure plans are using a certain amount of premium to actually take care of the patient through their benefit structure. So, they're actually guardrails in place between CMS and the health plan to ensure a certain proportion of money is being derived directly to the patient care. But what happens is that medical loss ratio can actually trickle down into provider contracting. So, it's really used as a method of measuring that total cost of care when aligning financial incentives. So, it does come from that CMS to Medicare management plan relationship, but it will, you'll see it at times directly within a contract that a provider is aligning on.

So, keep in mind that there are really two parts of the equation. So, you have your total cost and then your total revenue. So, total cost can really be made-up of all medical spend that may include pharmacy. So, what does that look like? Again, going back to managing unnecessary spend, unnecessary inpatient or ER visits, readmissions are just examples of managing that spend. But then there's the revenue side, which is what CMS is paying the plan at a per member per month basis. That revenue is actually risk adjusted and the benchmark is actually at the county level. So, it's geographically stratified as well. So, there are ways to play into the equation on both the numerator and the denominator and it's really important as the provider that you're, when you're looking at managing cost, you're keeping in mind both sides of the equation as well.

If you had a crystal ball that you could gaze into what do you see the future holding for us in this space

Well, I hope it would hold me winning $1,000,000, but outside of that, I think Medicare Advantage will has been growing and will continue to grow its popularity and the amount of patients that serving. So, roughly right now about 50% of Medicare eligible patients are within Medicare Advantage. I don't necessarily see that going away. Medicare Advantage is very much here to stay.

What's really interesting though is within the quality realm, CMS is really starting to shift away from measuring and waiting heavily clinical measures through HEDIS and PQA in the stars formula. And they're shifting more towards, those are still well so important within the stars formula of how the health plan is rated, they're really shifting the focus more to patient experience. And so, this is really important for providers to understand around how they're, how patient experience is being measured directly correlating to the providers. Because patient experience for health plan is being measured as how their experiences is with the health plan but also how their experience is with the care delivery. And so, it's really important for providers to understand what that measurement looks like and what types of questions are being asked so they can align better with the health plan on strategies to increase their ratings here.

I think we're also going to see a ton of, continue to see a lot of focus on health equity in several components across MA plans. Not just necessarily in quality. And finally risk adjustment, which is always a compliance favorite; I think will continue to be a debate within the industry of whether or not, um, HCC RAF, risk adjustment factor, is the right methodology and is being used appropriately.

What can a care provider do right now to be most effective within the Medicare Advantage world?

I think providers really, I think foundationally they really need to understand at the core what they're being measured upon. Because it can vary between MA plans. But also making, ensuring that whatever they're being a measured on is really aligning to how the health plan is being measured at the CMS level. Fairly. Um, so again, I think there's things that provider groups can do collectively with MA organizations to just understand and educate themselves.

I think they can also collaborate together to understand and maximize the resources because MA plans will produce a ton of resources for these patients. But sometimes the provider organization or the provider group does not know that those resources exist. So, I think being able to communicate and educate one another on what is being, what is available to your patient population is really key to working together to ensure success of taking the best care of the patient population as possible.

Outstanding. Bethany Palmer, thank you for joining us today on the Move to Value Podcast.

Thank you so much for having me. It was a pleasure talking with you, Thomas.

About Jeff Williamson

About Center for Healthcare Innovation

Transcript:

Can you talk to me about Center for Healthcare Innovation and the Center for Aging? What is the mission of each?

Yep. Well, the Center for Healthcare Innovation was really founded, uh, on the concept that we needed a vehicle for more rapid communication and translation of our discovery into the patient’s environment. Whether that's wellness or actually the delivery of care, for example, in the hospital. So, Wake Forest is known around the world for its research. It's a research institution. But many of the things we discover are implemented 20 years after the discovery or they're implemented in some health system halfway across the nation. So, that was really the purpose for the Center for Healthcare Innovations.

We've had for many years a sister center, so to speak, Wake Forest Innovations, which is about commercializing discovery. You know, a new kind of hip replacement or a new enzyme. But our Center is specifically tasked with taking a lot of that discovery that's not commercial allowable but has tremendous value to patients, their families, and to the health care system. And getting that more rapidly to the front lines.

You also asked me about geriatric medicine. Wake Forest really has a clinical entity, it’s called the Section on Geriatric Medicine and Gerontology, which I’m head of. Then there’s a Center for Healthy Aging and Alzheimer’s Prevention. I’m a clinical leader of that. The Center is actually led by doctors Stephen Kritchevsky and Suzanne Craft. They’re research faculty. But our mission of all of that together is to find more ways to help prevent disability with aging. So, when I mean disability, a simple way to put it is how can we prevent the two most common reasons that someone moves from their home and into an assisted living or nursing home facility. And either they have difficulty walking or difficulty remembering. So, our main thrust of our research is understanding how to delay or prevent loss of particularly leg strength and walking and loss of brain health. The most common form of which is Alzheimer's disease. That's really the purpose of Geriatrics in the Center for Health Care Innovation.

And even all of our clinical care, uh, when I take care of patients, I'm thinking of them holistically. How can I help you preserve your ability to walk and think? Even if you have 10 diseases at 90, the successful patient to me might have 10 diseases, but they're still interacting with their family, they're remembering those interactions, and they're still able to physically contribute to family life. You know, we all want to be that patient that at 95, just doesn't wake up one morning and the night before we were, you know, hugging our honey or reading to our grandchildren, tucking great grandchildren taking the bed. That's the goal. So, that's what we do, and we really try to marry those two goals between the Center for Healthcare Innovation, that I’ll talk about a little bit later, and Geriatric Medicine and the Sticht Center for Healthy Aging and Alzheimer's prevention.

Well you touched on this a moment ago, but I would like you to elaborate on how you see this work impacting patients’ quality of life?

Yes. Uh, I see a lot of patients, you know, journey through the health care system and at the end of that journey they're not really sure are they better off or not. Um, and has the...]]>In this episode we talk to Jeff Williamson, MD, MHS, Director of the Center for Healthcare innovation, about what is on the horizon for patient care and how it impacts value.

About Jeff Williamson

About Center for Healthcare Innovation

Transcript:

Can you talk to me about Center for Healthcare Innovation and the Center for Aging? What is the mission of each?

Yep. Well, the Center for Healthcare Innovation was really founded, uh, on the concept that we needed a vehicle for more rapid communication and translation of our discovery into the patient’s environment. Whether that's wellness or actually the delivery of care, for example, in the hospital. So, Wake Forest is known around the world for its research. It's a research institution. But many of the things we discover are implemented 20 years after the discovery or they're implemented in some health system halfway across the nation. So, that was really the purpose for the Center for Healthcare Innovations.

We've had for many years a sister center, so to speak, Wake Forest Innovations, which is about commercializing discovery. You know, a new kind of hip replacement or a new enzyme. But our Center is specifically tasked with taking a lot of that discovery that's not commercial allowable but has tremendous value to patients, their families, and to the health care system. And getting that more rapidly to the front lines.

You also asked me about geriatric medicine. Wake Forest really has a clinical entity, it’s called the Section on Geriatric Medicine and Gerontology, which I’m head of. Then there’s a Center for Healthy Aging and Alzheimer’s Prevention. I’m a clinical leader of that. The Center is actually led by doctors Stephen Kritchevsky and Suzanne Craft. They’re research faculty. But our mission of all of that together is to find more ways to help prevent disability with aging. So, when I mean disability, a simple way to put it is how can we prevent the two most common reasons that someone moves from their home and into an assisted living or nursing home facility. And either they have difficulty walking or difficulty remembering. So, our main thrust of our research is understanding how to delay or prevent loss of particularly leg strength and walking and loss of brain health. The most common form of which is Alzheimer's disease. That's really the purpose of Geriatrics in the Center for Health Care Innovation.

And even all of our clinical care, uh, when I take care of patients, I'm thinking of them holistically. How can I help you preserve your ability to walk and think? Even if you have 10 diseases at 90, the successful patient to me might have 10 diseases, but they're still interacting with their family, they're remembering those interactions, and they're still able to physically contribute to family life. You know, we all want to be that patient that at 95, just doesn't wake up one morning and the night before we were, you know, hugging our honey or reading to our grandchildren, tucking great grandchildren taking the bed. That's the goal. So, that's what we do, and we really try to marry those two goals between the Center for Healthcare Innovation, that I’ll talk about a little bit later, and Geriatric Medicine and the Sticht Center for Healthy Aging and Alzheimer's prevention.

Well you touched on this a moment ago, but I would like you to elaborate on how you see this work impacting patients’ quality of life?

Yes. Uh, I see a lot of patients, you know, journey through the health care system and at the end of that journey they're not really sure are they better off or not. Um, and has the healthcare system addressed what's the most important thing to them. And usually what I find is that patients, especially this Center for Healthcare Innovation, is unique in the nation, even in the world, there is no other one that's focused on wellness and health care delivery for the senior population. That's a major focus of ours. And for that population, we want to make it so that the people caring for them have the tools at their disposal to increase the joy that they have of working with older people. And we want to make it so that the patients, the citizens, the participants at the end of that experience say, “I know more about myself. This was a much easier experience than the complicated healthcare system that we've had to navigate before.” And finally, that “the care that I received was tailored to where I am in my functional health and not just my numeric health.”

CHESS has done a lot of work with social determinants around removing barriers in the home that impact the elderly population. Can you tell me about the work your team is doing in this space that exists beyond clinical care?

So, there's been, over the last decade and a half, a lot of talk about personalized medicine and a lot of that generated from genetic research. Can I match a person’s genes to their treatment plan? But for me, and for many of my colleagues in the Center for Health Care Innovation, personalized health is matching the care plan to where someone is in terms of their the social factors and social determinants headwinds that they might face. It might be factors related to where they are in terms of their functional help, their cognitive health, their family structure. And so, personalized medicine goes well beyond genes and that is in many ways the core of the mission of the Center for Healthcare Innovation. To help health care providers, doctors, nurses, therapists, and their patients to personalize the health care based on whether they're frail or not, whether they're highly functioning, are they playing tennis. And I have I have a lot of patients here in their late 80s and early 90s who play tennis 2 or 3 times a week. And I have some who the biggest challenge for them is getting out of bed and going to the mailbox every day. So, I want to personalize that care to each one of those.

As we’re talking about ideation, development, and innovation, I’d like to know what your recommendation would be for how we can all work together to expedite research from the bench to the bedside?

One of the, uh, both banes and blessings of the last decade or so has been the development of the electronic health record. And because of that, and the times that we live in, which are amazing, well there's tremendous computing power. We can combine those now to actually rapidly understand a person’s health status. We can understand their social determinants of health status. We can understand their cognitive and their physical health. And we can put all that into an equation that helps a doctor, or a nurse, or a therapist standing in front of them know exactly where this person is. So, they can start the therapy where the patient is and not just a generic start. So, the answer to your question is the way we can do that is to combine the electronic health record technology we have with the desires of the patient and that the health care system. Are we there? We are nowhere near there yet. We're still, in many cases, practicing as if it's as if it was 2000 or 1980. Uh, but slowly, we're beginning to make changes in that regard.

The electronic frailty index, which we haven't talked about in this interview, but you and I have talked about it personally, is an example of that. We can now start treatment based on how healthy or how frail a person is. Actually, we have someone working with us now who wants to rename that the electronic healthy index, um, because it actually measures all spectrums of people, not just frail, it measures health. And, so, um, but that's an example of how we begin to personalize health care. And that opens up a ton of innovation for personalizing healthcare. We're just on the very beginning of what I could see is a wonderful and beautiful journey to try and do that. You know, when you go to Walmart or you go to any department store or even you go fishing, you have a specific interaction in mind. Still the healthcare system is very generic. I mean, you don't, it doesn't match the consumer with the consumers desires with our services very well yet. And so, we want to help that. That's a very important piece of the innovation that we have.

What problems or pain points can the CHI team solve for Health systems, for providers, for patients, for family members?

Well, one of the important, um, events in the past 48 months or longer, has been the combination of healthcare systems into, you know, the Wake Forest for example healthcare system combining with Atrium. At least in parts. So, this then increases our ability to work with providers in many locations. Whether that's inner city or rural areas to bring some of the kind of care that we've been talking about, even in this podcast, to more people, in a more efficient way. Many people, for example, in this nation, maybe even the majority of people, live you know hundreds of miles or 100 miles from a geriatric specialist. But now, with our work in the Innovation Center, we can take their electronic health data, understand that they might need a geriatrician, and actually do at least a virtual visit. Which isn't as good as an in-person visit still with a geriatrician, but it's better than nothing. And so, we can begin to help people understand how can I prevent or preserve my cognitive function who live in far-flung places of the world or who just don't have, they might live very close to this microphone, but traveling to the physician to take their mom to the physician is too hard. But maybe they can do that from their living room or from a doctor's office in their neighborhood. So that's how we can begin to bring innovation into the neighborhoods and the communities where people are living without them having to come to some ivory tower. That's our goal.

And how do you see the role of the geriatric emergency department fitting into that

Yes. Uh, you and I just were talking about the, you know, concept of the fact that emergency rooms are packed around the country. And I think one of the one of the reasons for that is we have not begun to rethink, uh, emergency care. You know, we we're still practicing it as if it's like 1975 in some ways. Not technologically practicing it, but in terms of customer service. Practicing it that way. So, for many years we've had pediatric emergency rooms. But now the fastest growing part of our population, and really one of the largest parts, are older people. And emergency rooms, uh, are often not a friendly place for older people.

So, there is a movement in the country, there are some places already that are developing, just like we have pediatric emergency departments, that are developing geriatric emergency departments. Where we can then implement, um, electronic health record metrics that tell us already this person was frail before they ever got here. Or they had cognitive impairment or dementia before they ever got here. And we can then adjust our protocols according to that. So, I think this is going to be an increasing demand but also an increasing implementation of geriatric emergency rooms and geriatric protocols more for emergency rooms.

So, Doctor Williamson, tell me what are some of the cool ideas that your team is investigating now?

Well, what you and I've already talked about, the frailty index. Which again might be renamed the healthy aging index as well. But that has tremendous, um, applicability to many areas of medicine. For example, our cardiology teams or cardiovascular medicine teams are trying to identify people who are in that sort of middle ground. They're not frail, but they're not healthy. But those are the people who often get a procedure and it and they actually never recovered. Their function is worse rather than better. You know, they spend you know many days in intensive care unit or in a nursing home and actually don't ever return home. So, one of the projects that we're really working now is how can that electronic health index help refine, especially people in the middle. We're doing pretty good already with someone who's very frail. We don't we don't put them through chemotherapy or operations. But can we identify people in that middle group, who this means everything to restoring their function or it means actually the worst possible thing to reducing their function if we operate on them or replace their aortic valve etc.? That's a big project.

We're doing exactly the same thing; we're beginning to do this with cancer therapy. What people in that middle will chemotherapy actually help restore them like a younger person or give them a longer functional life. But what people, who if we give them chemotherapy, we're actually shortening their life by doing that. So, that's a big product project for us and that will use data. We'll begin to look and see what are the factors that we didn't really realize were factors, uh, in this. Such as, maybe, these people have what we call subclinical cognitive impairment. They're beginning to have an unhealthy brain and so the chemotherapy actually makes that even more unhealthy. Uh and so that's just one example. Or there's some people that their social determinants of health headwinds were so high that we need to address all that before we started replacing their heart valve. That kind of thing.

We have another very important project. One of the “holy grails” of dementia research, is can we begin to identify people early, much earlier, than what I often say is that the next-door neighbor can diagnose to that someone has Alzheimer's disease or not. That doesn't take a professional physician. But understanding very early in the course the disease when you could do something about it. Right now, there's not any tests that we do for that. But we believe there are signals in the electronic health record, in some of the billing and prescription refill records, that will begin to help us identify people who may be having some memory difficulty and we can start working with them when their families early.

We're also working a lot on remote patient monitoring. So, small devices that could be used in communities that are not very close to the hospital, but they could tell us a lot more about what's going with the patient. Are they walking more slowly today than they did last year? Just by testing them for a week; putting a little dot on them. Can we gather some of the information without them having to travel take a day off of work with their family member to get information? Can we start getting some of that information at home? That's a really big one. We just actually published a paper also working with Verily health, which is sort of, it's a division that's in the same company that Google is in, measuring people's temperature with a little patch about the size of quarter. That just where it tells the temperature or your day. But that's really important in retirement homes because temperature changes were often undetected and then COVID breaks out in the facility and infected a lot of people before they ever knew. So, those are the kind of things we're really working on now.

Wow. So much potential and opportunity! How can CHESS and CHI work together to change the world?

CHESS is in many ways the best laboratory for the CHI. All kinds of research need congenial and convenient laboratories to test new ideas, especially an Innovation Center. So, we've been partnering with CHESS, as you know, to implement the electronic frailty or the electronic healthy index so that we can help primary practitioners identify patients who are more prone to miss a visit, for example. Can identify people who they need to prioritize for vaccinations or can identify people who really maybe the last thing they need is a dermatologic surgery but instead they need advanced care planning or a colonoscopy. It might be less important for them to get a colonoscopy than advanced care plan.

So, CHESS is the laboratory in which we're looking for early adopters of, uh, of innovation to help them improve the personalized care they want to deliver to patients. CHESS has a group of clinicians, be they nurses, nurse practitioners, physicians, etc. who are willing to think about, you know, the old Wayne Gretzky thing about where the pucks going, not just where it is. They're willing to think about where the healthcare system going, where does it need to go to be a better citizen. You know, we're talking about corporate citizenship, well there's healthcare citizenship. And so, I think CHESS seems to attract people who are wanting to especially improve the citizenship of the health care system. And that's how we can really partner. What we also need in that partnership from CHESS are the frontline clinical providers coming to us through the CHESS leadership and saying, “Well here's something you could really help us with.” We may or may not be able to help, but until we know what the pain points for providing better care are, we might be working on something that has no relevance to the frontline. So, that's also part of this partnership.

What is the next frontier?

I like to use the analogy of Amazon, and probably others are using it now, but I always think I did it first. But people purchase consumer goods from their living room now, and I think there's a huge hunger to produce healthcare services from your living room. And to me, I think, that's part of the, uh, that's part of the mission, that's part of the frontier, that will expand better health. Actually, people want to purchase wellness from their living room. You can't purchase an ICU in your living room, but you can purchase wellness and information to help you age successfully like we talked about at the very beginning, to preserve physical and cognitive function for as long as possible. That's the frontier that I think is going to be really important over the next 5 to 10 years. Giving people from all walks of life, all socioeconomic status, access, equitable access to information that can help them live productive lives in their families and their communities.

Well, Doctor Jeff Williamson, thank you for joining us today on the Move to Value Podcast.

Tom, it's been a pleasure for me to do this and I just really enjoyed talking with you. And even as I'm talking and listening, I'm thinking about the exciting opportunities we have in the future.

Transcript:

What are the different staffing components that comprise the integrated care of a GED and what if any special training is preferred or required for physicians and APPs working in GEDs?

Kevin: Awesome. So, there are 3 levels of accreditation for geriatric EDs. Level one is the highest level, like a trauma center, it's how we think; level 2 is silver; level 3 is bronze. All three of these levels have people at them that would be interested, and this is the theme I want to come back to, perhaps even eager to connect with ACO leaders in their neighborhood. They don't, probably I'll come back but, they probably don't know who you are, or they might not even be able to tell you what an ACO stands for, but these are friends you just haven't met yet. All three of them have that. All three of these levels have champion nurses and champion physicians, and those are the friends you haven't met yet. People that are like, yes this is important to us, they've had some additional education in geriatrics, depending on what level is how many hours of geriatric emergency medicine. We're talking about care transitions, polypharmacy, falls as a syndrome, etc. The two higher levels, silver and gold, two and one, also have all their staff has some training in geriatric emergency care, so that they are more, the different language, there's a different culture. The things that are being talked about after an older person has a fall are a little different than a traditional ED, and everyone is acquainted with that language and that culture even if it's not their specific expertise. Level 2 and level 1’s have requirements for either all or some of, depending on whether they're a level one or level two, of physical therapy, occupational therapy, pharmacists, and care management, or social work, within that emergency department able to be turned towards the needs of older adults.

So, what you'll find to varying degrees is a more interdisciplinary team with additional training in geriatric emergency medicine. And again, how much is contingent upon what level they got accredited at. But I can't say this loudly enough, a Level 3 is meant to be in the zone of proximal development at all 5,000 EDs in the country. It's not that hard to become a Level 3. However, you are doing a quality improvement project for older adults, and you have a champion nursing, a champion physician, which means that there are people there that would want to hear from people like you and you can work together to figure out. They've tilled the soil. They may not have grown the orchard yet, but the soil is tilled for collaborative efforts, such as you would be interested in pursuing if you’re listening to this podcast. Like huh, a whole bunch of beneficiaries go to Saint elsewhere emergency department. Oh, look there are Level 3 geriatric ED. Shouldn't we connect these dots somehow. Answer yes. Champion nurse, champion physician is who you want to connect them with.

What is the role of a transitional care nurse in the GED and how does this role impact value-based care?

Kevin: Um so, Megan was just kind enough to cite some of the stats that come with geriatric emergency department, which is decreased admissions, decreased readmissions, improved patient satisfaction, and not surprisingly, decreased cost associated with these interventions.

The care transitions nurse is what makes that possible. They're really the quarterback. Different geriatric EDs call that person by different names. Some of them call them the genie nurse, or the gem nurse, but essentially these geriatric EDs identify who]]>In this episode we continue our conversation with Doctor Kevin Biese and Megan Donovan about the role that Geriatric Emergency Department have in the move to value and how it touches all aspects of the quadruple aim.

Transcript:

What are the different staffing components that comprise the integrated care of a GED and what if any special training is preferred or required for physicians and APPs working in GEDs?

Kevin: Awesome. So, there are 3 levels of accreditation for geriatric EDs. Level one is the highest level, like a trauma center, it's how we think; level 2 is silver; level 3 is bronze. All three of these levels have people at them that would be interested, and this is the theme I want to come back to, perhaps even eager to connect with ACO leaders in their neighborhood. They don't, probably I'll come back but, they probably don't know who you are, or they might not even be able to tell you what an ACO stands for, but these are friends you just haven't met yet. All three of them have that. All three of these levels have champion nurses and champion physicians, and those are the friends you haven't met yet. People that are like, yes this is important to us, they've had some additional education in geriatrics, depending on what level is how many hours of geriatric emergency medicine. We're talking about care transitions, polypharmacy, falls as a syndrome, etc. The two higher levels, silver and gold, two and one, also have all their staff has some training in geriatric emergency care, so that they are more, the different language, there's a different culture. The things that are being talked about after an older person has a fall are a little different than a traditional ED, and everyone is acquainted with that language and that culture even if it's not their specific expertise. Level 2 and level 1’s have requirements for either all or some of, depending on whether they're a level one or level two, of physical therapy, occupational therapy, pharmacists, and care management, or social work, within that emergency department able to be turned towards the needs of older adults.

So, what you'll find to varying degrees is a more interdisciplinary team with additional training in geriatric emergency medicine. And again, how much is contingent upon what level they got accredited at. But I can't say this loudly enough, a Level 3 is meant to be in the zone of proximal development at all 5,000 EDs in the country. It's not that hard to become a Level 3. However, you are doing a quality improvement project for older adults, and you have a champion nursing, a champion physician, which means that there are people there that would want to hear from people like you and you can work together to figure out. They've tilled the soil. They may not have grown the orchard yet, but the soil is tilled for collaborative efforts, such as you would be interested in pursuing if you’re listening to this podcast. Like huh, a whole bunch of beneficiaries go to Saint elsewhere emergency department. Oh, look there are Level 3 geriatric ED. Shouldn't we connect these dots somehow. Answer yes. Champion nurse, champion physician is who you want to connect them with.

What is the role of a transitional care nurse in the GED and how does this role impact value-based care?

Kevin: Um so, Megan was just kind enough to cite some of the stats that come with geriatric emergency department, which is decreased admissions, decreased readmissions, improved patient satisfaction, and not surprisingly, decreased cost associated with these interventions.

The care transitions nurse is what makes that possible. They're really the quarterback. Different geriatric EDs call that person by different names. Some of them call them the genie nurse, or the gem nurse, but essentially these geriatric EDs identify who are high risk patients, who are patients that maybe have suffered falls, have cognitive impairment, have social vulnerabilities, like they don't have enough food, etc. caregiver burnout, and then send them the care transitions nurse. And that individual kind of quarterbacks some of the care. Like oh look at this bag of medication, someone get the pharmacist down here because like this is a mess. Or like you know, my goodness you look like you haven't eaten a little while, I'm going to call the social worker and see what we can figure out. Right. Because it's complicated, like what insurance do you have, where do you live, what county, and there's all this stuff that like I, as a doc, I have no, I don't know all that stuff. But the care transitions nurse is the quarterback of that additional care for high-risk patients. The majority of those stats about the admissions and readmissions rate, that research was done looking at if you had a care transitions nursing in a geriatric ED, how much less likely were you to be admitted? Answer, up to 16.5%. How much less likely were you to be re-admitted? Answer, up to 17.3%, etc. So, the care transitions nurse is the proven intervention that leads to these higher value care pathways.

Megan: And what I want to see happen eventually in my lifetime, hopefully in the not too distant future, is that these transitional care nurses in the GEDs also start to view value-based care plans, ACOs, other arrangements, as an additional tool for them to call to help the patients and the GED. And that's what Kevin and I have been working on these past few years and really working towards is how do we make that happen. How do we help to create these communications pathways between these transitional care nurses and the other staff of geriatric emergency departments and connect them to value-based care? Because the reality is is that a lot of these value-based care arrangements have additional tools at their disposal for their beneficiaries that that transitional care nurse could use. She could use them, or he, on the ground, in the in the GED, to help bring higher value care to the patient. And that also helps to get value-based care insight into the fact that their beneficiaries are actually in an ED, which we know is a huge pain point for them right now. So, I think this transitional care nurse role is really critical. It's really important. And if I was in, if I was an executive of value-based care plan, I would want to start talking to every single transitional care nurse in a GED in my geographic market. Because the reality is that they're probably seeing my beneficiaries, and they are probably the ones directing their care in the GED, and they are also probably the ones that have a lot of influence, and a lot of, influence is probably the best word, about what happens to that patient. Do they get admitted or are they able to be transitioned and supported with other resources to a higher value setting of care.

One of the things that Kevin and I did about a year ago is we wanted to understand if this was actually happening. If beneficiaries in MSSP ACOs were actually seeking care at GEDs. And thanks to the partnership of the West Health Institute, which is a research organization based in San Diego, as well as the Institute for Accountable Care, we were able to run an analysis that looked at the overlap. So, pulled claims data and looked at if MSSP ACO beneficiaries were receiving care in GEDs. And what we found is that it was, it’s happening you know. MSSP ACO beneficiaries are seeking care at over all three, you know, at all 320 and growing GEDs in the country. And not only that, but a lot of the times their beneficiaries are going to the GED multiple times. So, on average 1.6 times these beneficiaries are seeking care at GEDs. And what was even more surprising was the volume for certain MSSP ACOs. So, there were about 20 MSSP ACOs who had about 1,000 beneficiary visits to a GED in that given year, which is a lot. If you're thinking about 1,000 of your beneficiaries potentially not being admitted to a hospital, that's a tremendous cost savings. So, we know that this is happening. We know that beneficiaries in value-based care arrangements are seeking care and receiving care at geriatric emergency departments. And one of the things we wanted to know is we wanted to understand it more deeply, so we actually ended up conducting a focus group between some MSSP ACO executives and their GED counterparts, and actually got them to talk to one another. Talking about us, trying to facilitate and really create these connections. And the most fascinating thing and the most fascinating outcome from that conversation was that 2/3rds of the ACOs had no idea what a GED was and they had no idea that a GED even existed within their own health system or within their own geographic market. So, that to us was a huge area of opportunity. Right? We really need to start making sure that there is an awareness about what a GED is and the value that it provides because it's key. What happens inside the GED can create such value. So, that was that was really interesting. The results of that analysis and that focus group were really interesting.

How can an EHR and other resources be leveraged to integrate GEDs and ACO beneficiaries who may need additional social support?

Megan: One of the big things we heard in the focus groups we conducted was that one of the largest pain points for both ACOs and GED clinicians is a lack of awareness. ACOs don't know when their beneficiaries are in a GED and ED clinicians don't know when a patient they're treating is in a value-based care arrangements. So, creating this communication pathways to both alert an ACO to let them know that their beneficiaries in a GED, and to alert the clinician that the patient you're treating might have additional resources available to them is going to be absolutely imperative to move emergent geriatric emergency medicine towards value-based care. One of the ways that you could do this is through your EHR by creating some sort of an alert mechanism, you know, within the EHR. One of the things that we've also heard of that's happening is that some hospitals are using their states’ health information exchange data to facilitate that connection. And there's other industry solutions out there. There's software solutions out there that can help. So, there's a lot of ways that this can be done, and that people are kind of experimenting with. I don't know what Kevin thoughts would be on this, but I can't say with any certainty that there is one way that's working the best or that most people are using, but what we do know is that in order for this to ultimately be successful in the move to value that that ability to remove that communication barrier is going to be very key.

Kevin: I think that your patients, your members, your ACL partners, your value partners need the primary care team and the ACO team leaning in as soon as possible when that patient hits the emergency department. And actually, the ER docs often want that too. An 80-year-old comes in saying they have chest pain. What am I going to do? I'm going to admit that patient unless you call me and say, “Miss Smith has had chest pain for 20 years Kevin. Like and I can see her in clinic tomorrow. That EKG looks like the last EKG. We can figure this out.” And what you just did for me, to be very frank, is now Miss Smith doesn't have to wait for a bed. Every hospital is overcrowded. Many hospitals are overcrowded. And you've actually helped me with like throughput and different ways of making sure that I'm not sustaining moral injury putting Miss Smith in the hallway to wait 20 hours for a bed for something that's not really going to help her. I think that there is a real opportunity here for ACO and value partners to lean in to when their beneficiaries are hitting the doors of an ED and have a conversation both about a little bit more medical perspective and also just the resources. I don't know that you have a system in your ACO that's going to help this patient have care in two days. I don't know that. I don't know what home health options you have. But all of those things are going to be meaningful to me about what option, what I can then do to help this patient and get her to the highest value care setting. So, Megan and I are both very eager to deploy this more aggressively, in a more embedded way, and demonstrate the improved value of care that can be created through this. It's kind of happening in different places, including in my own spot at the University of North Carolina, but only kind of. There's a lot more work that can be done on this front.

Are CMS or the MA payers taking notice and creating any additional financial incentives for standing up GEDs?

Kevin: The conversations are there, but I think we're just now getting enough of evidence to really have a meaningful conversation about setting up alternative payment models based around some of what we're saying. And I guess I’d make one other comment on that, I don't know. I can't look into the future. But especially if you look at Liz Fowler and others are doing at CMMI right now, having separate APMs for emergency departments alternative payment models is probably not the way to go. And instead, what we really need to do is crosswalk some of the value that can be created in a GED with an ACO and just think about how we work together to drive this forward. So, early conversations, interest, and awareness, but more to be done to really develop that data and think together about how we can really drive higher value care. And prove it, continue to prove it, and then facilitate it.

What can a health system do right now to begin the process of having their older population of patients start receiving the right care in the right place at the right time?

Kevin: I think, so, a health care system can do, can basically go down the pathway of helping create the infrastructure of a geriatric ED within their system. If you Google geriatric emergency department accreditation; if you Google equally good, the geriatric emergency department collaborative, you'll find lots of toolkits, resources. Your EDs that you work with do not have to figure this out on their own. There's podcasts, they’re journals around this, there's every-other-month webinars with over 100 doctors from around the world. There's lots of resources. We've been fortunate with Johnny Hartford and West Health to create infrastructure. Lean into that infrastructure. Do that in collaboration with your healthcare system leadership so that you can really play to what their strategic priorities are so you can get the resources you need to do this well. Equally important, if you're listening because you're part of an ACO or you’re a provider wondering, “well this isn't what happens when my patients go to the ER. What are they talking about? Like they just get admitted and like 6 MRIs or I don't know whatever.” So, like if that's what you're thinking right now, then I would suggest that what you need to do is look at the directory and see if there are geriatric EDs in your neighborhood. Reach out to the American College of Emergency Physicians; it's on the website. If you can’t find it, we can help you. Reach out to Nicole and others there and find out who the nurse and physician champion is. And reach out to them. Share a lotte. Separate lattes. Sit down and just begin to figure out where you're overlapping interests lie. What are they struggling with with their patients, and what resources do you have that might help? And what are you struggling with and how can they lean into that. One really important point here is you're probably only going to be able to offer additional services to your ACO beneficiaries and they're going to have other patients in their ED that aren't yours, but you know what, that's normal. Some patients come with their daughter or son at bedside, some don't. Some have a robust social network they can lean into, and some don't. When I'm making a disposition decision on a patient, I want to know what resources are available for that patient. You're not going to tell the ED what to do. You’re not going to tell them whether to admit them. You're just going to say, “Hey listen team. Before you admit Miss Smith, know that this is what we could do for her.” So, if you're an ACO leader, go find your geriatric ED. There may be one in your neighborhood. These are friends you have yet to meet, and they're going to help you take that next step and your benchmarks and driving your care forward because how can you improve the value to your whole population if you lose visibility, if you lose any control or influence, once they hit the ER. I know we're all trying them to not have them hit the ER, but they're going to. You need to have that connection if you're going to continue to rise in the value stream.

Kevin Biese, MD serves as an Associate Professor of Emergency Medicine (EM) and Internal Medicine, Vice-Chair of Academic Affairs, and Director of the Division of Geriatrics Emergency Medicine at the University of North Carolina (UNC) at Chapel Hill School of Medicine as well as a Vice-Chair of the Board of the UNC Health Care Senior Alliance.  He also serves as a consultant with West Health, a San Diego based philanthropic organization dedicated to improving care for older adults. With the support of the John A. Hartford and West Health Foundations, he is the co-leader alongside Dr. Ula Hwang of the national Geriatric Emergency Department Collaborative, serving as PI of the implementation arm. He is grateful to chair the first Board of Governors for the ACEP Geriatric Emergency Department Accreditation Program which has now improved the quality of care in over 300 emergency departments in 40 states and 4 countries. 

Megan Donovan is an Atlanta-based independent management consultant. She helps executives turn their ideas into reality and works closely with entrepreneurs, academic medicine and healthcare policy leaders to shape business strategy and operational implementation. Megan has a BA in psychology from Wake Forest University and an MBA from the University of North Carolina at Chapel Hill where she graduated in the top 10% of her class.

Transcript:

I’d like to start off by asking what is a Geriatric Emergency Department, also known as a GED, and how is it different from a standard ED?

Kevin: Thank you so much Thomas. And I'll go ahead and just give a little bit of background history on that. So, anything that I say that suggests about how emergency departments can do better comes from an understanding or perspective that there's a number of wonderful people that work in emergency departments, but that the system isn't really quite designed right for the needs of older adults. And when I say older adults, I really mean vulnerable older adults. Not 66-year-olds who sprain their ankles playing tennis. I mean it can always be better, but I'm really thinking about people with cognitive deficits, perhaps with needing caregiver assistance, with complicated medical history, with multisystem issues like you know like heart failure or lung disease. A lot of complicated issues. The system of emergency medicine isn't optimally designed for this specific, complex, multilayered needs of older adults by that definition.

And so, an geriatric ED, just a brief story if I can. I was a third-year resident on a four-year emergency medicine program at really good program in Boston. So, it doesn't matter, at Mass General. And it’s Mass General, they’re supposed to be really good. Like they're really, but we didn't learn anything about the care of older adults, specifically. Like when I was at residency, we knew that a 2-year-old wasn't a 40- year-old and we knew that 80-year-olds got sick more than 40-year-olds. I mean you could kind of tell by looking around. But there wasn't like a month of like, well what's different about older adults, or what is polypharmacy mean, or what about hyper, what is the difference between delirium, dementia, and depression, and why would that matter. That wasn't part of what we learned. So, one day I'm leaving the end of a 12-hour shift at Mass General in the trauma section, and there is this older woman on a cot in the corner. And I didn't think anything of it. We were really busy. We were full, heart attack, stroke, gunshot. There was always an older person like kind of waiting to go upstairs or something. And I just, I was tired, stinky, exhausted. Well, I came back 12 hours later, because we were you know in 12-hour shifts, same woman, same corner, same cot. And I got mad. I didn't know that she had hypoactive delirium. I couldn't even have told you exactly what that was. I didn't know that we'd probably given her a urinary tract infection through prolonged foley use. I did know that that cot looked really uncomfortable, and she probably needed something to eat. And I knew that like my grandma helped raised me and this didn't seem OK. You didn't have to go to geriatrics training for this to seem like, “wait a second. You were here 12 hours ago and here you are now, same place. This can't be good.”

And so, we started to do some stuff around emergency medicine in residency and then when I came here to the University of North Carolina, Jan Busby-Whitehead, who's the chief of geriatrics, sort of adopted me. And a lot of the work that we have done in the decades since come from that initial awareness of how can we do better for older adults in the emergency department. In about 2013, a group of us in emergency medicine, and my colleagues actually wrote some geriatric ED guidelines about how to do best practices in geriatric emergency medicine. That was really important. We were fortunate to get that like signed off by the big nursing and physician organizations in geriatrics and emergency medicine. And we established best practices. And then about three...]]>Today we talk to Dr. Kevin Biese, from the UNC Chapel Hill School of Medicine and Megan Donovan, an Atlanta-based independent management consultant, about Geriatric Emergency Departments and the role they play in value-based care.

Transcript:

I’d like to start off by asking what is a Geriatric Emergency Department, also known as a GED, and how is it different from a standard ED?

Kevin: Thank you so much Thomas. And I'll go ahead and just give a little bit of background history on that. So, anything that I say that suggests about how emergency departments can do better comes from an understanding or perspective that there's a number of wonderful people that work in emergency departments, but that the system isn't really quite designed right for the needs of older adults. And when I say older adults, I really mean vulnerable older adults. Not 66-year-olds who sprain their ankles playing tennis. I mean it can always be better, but I'm really thinking about people with cognitive deficits, perhaps with needing caregiver assistance, with complicated medical history, with multisystem issues like you know like heart failure or lung disease. A lot of complicated issues. The system of emergency medicine isn't optimally designed for this specific, complex, multilayered needs of older adults by that definition.

And so, an geriatric ED, just a brief story if I can. I was a third-year resident on a four-year emergency medicine program at really good program in Boston. So, it doesn't matter, at Mass General. And it’s Mass General, they’re supposed to be really good. Like they're really, but we didn't learn anything about the care of older adults, specifically. Like when I was at residency, we knew that a 2-year-old wasn't a 40- year-old and we knew that 80-year-olds got sick more than 40-year-olds. I mean you could kind of tell by looking around. But there wasn't like a month of like, well what's different about older adults, or what is polypharmacy mean, or what about hyper, what is the difference between delirium, dementia, and depression, and why would that matter. That wasn't part of what we learned. So, one day I'm leaving the end of a 12-hour shift at Mass General in the trauma section, and there is this older woman on a cot in the corner. And I didn't think anything of it. We were really busy. We were full, heart attack, stroke, gunshot. There was always an older person like kind of waiting to go upstairs or something. And I just, I was tired, stinky, exhausted. Well, I came back 12 hours later, because we were you know in 12-hour shifts, same woman, same corner, same cot. And I got mad. I didn't know that she had hypoactive delirium. I couldn't even have told you exactly what that was. I didn't know that we'd probably given her a urinary tract infection through prolonged foley use. I did know that that cot looked really uncomfortable, and she probably needed something to eat. And I knew that like my grandma helped raised me and this didn't seem OK. You didn't have to go to geriatrics training for this to seem like, “wait a second. You were here 12 hours ago and here you are now, same place. This can't be good.”

And so, we started to do some stuff around emergency medicine in residency and then when I came here to the University of North Carolina, Jan Busby-Whitehead, who's the chief of geriatrics, sort of adopted me. And a lot of the work that we have done in the decades since come from that initial awareness of how can we do better for older adults in the emergency department. In about 2013, a group of us in emergency medicine, and my colleagues actually wrote some geriatric ED guidelines about how to do best practices in geriatric emergency medicine. That was really important. We were fortunate to get that like signed off by the big nursing and physician organizations in geriatrics and emergency medicine. And we established best practices. And then about three years ago, we started to create an accreditation system for emergency departments to recognize when they're doing better jobs for older adults. Hospitals speak accreditation systems. They understand that like, OK if I need this, this, this, and this, and this, and then I get recognized as being a stroke center of excellence. A cardiac center of excellence; a trauma center; a geriatric emergency department. It’s a currency in hospital language that they can use to drive towards certain quality improvement goals. And so, the American College of Emergency Physicians started that effort in 2018, and there's now about 320 or so geriatric EDs mostly in the United States, but in about 4 countries overall. But like 315 of those are in the United States or 314 or something like that.

So, a lot of work has gone into this space, but as our demographics have continued, there's more older folks, their medical needs are increasing, there is a tremendous imbalance between social support and medical support on a financial level across this country, which means that people come to healthcare systems for a myriad of reasons, not all of which are clearly medical in nature. For all these reasons together, along with the move to value, the fact that we are now in at some sort of stumble towards value-based healthcare on a national basis. All of those confluent factors have led for the opportunity for systematic evolution in how we take care of older adults in a geriatric ED, or in any emergency department.

So, to get to your question, sorry. How is it different? Why? What's a geriatric ED? Like what the heck does that mean? A geriatric emergency department changes the way we do 4 elements of care to better meet the needs of complex older adults. One, we change the structure at least a little bit. There are some EDs that have been specifically built for older adults. But most hospitals don't have $20 million or whatever it is to like build a new emergency department because it seems like a good idea. And even, most ACOs don't have $20 million to give them. So, like, we you know, that's not. So, I'd say out of the 320, like 315 are in not separate EDs. Like not like some new ED. But even in those EDs, the structure, you're not shining bright lights on people’s faces all night. It's quieter where older adults are. There is space for caregivers; don't lock the caregivers out, it does not help you. There is an interdisciplinary, there's space for interdisciplinary team like pharmacy, social work, etc. The beds are more functioning for older adults. Chairs even better when appropriate. So, there are some structural modifications. Light dimmers cost $12. You don't need to rebuild your ED.

Two, education. As I just alluded to a minute ago, we didn't learn about geriatric emergency medicine. We are now. There's a lot more education in geriatrics for emergency medicine training than there was before, but still not enough. And what we're really doing on an educational front in a geriatric ED is two things. One, you've got a champion nurse and a champion physician that have specific education and geriatric care. Which also means if you're in an ACO, you've got friends. There's somebody on the other side of the isle that's interested in what you're doing. However, the rest of the ED has its some additional training in geriatric ED so that you move geriatrics from the unknown unknown, like of course I know how to take care of older adults, I do it all the time, to the known unknown of oh there's different things about this I need to look a little deeper before I make that disposition decision or that medication choice.

So, structure, education, staffing. I've already said, you know, it's interdisciplinary. In many of these EDs, were bringing physical therapists down to the ED and making sure you're safe to ambulate before you go. We're connecting you with physical therapy on the way out. We're doing medication reconciliation before we discharge you to make sure your medications aren't contributing to problems, and we've got them straightened out etc. Social work connecting you with community resources. Connecting you with ACO resources that they may bring to the table.

And finally, as I just alluded to, community connections. Structure, education, community connections, and policies and protocols all work together to identify underlying challenges that older adults have and connect them with resources within the ED in the hospital, and within the community, like their ACO, that can help them get better care.

So, last thing I'll say about this, promise. What's a geriatric ED? A traditional ED, in contrast, tries to be a wonderful place. Sometimes it is, sometimes it isn't. Wonderful people work in there. If you fall, if you're 82-years-old and you fall, and they take you to that emergency department, a traditional emergency department will fix you up from the fall you had. They'll make sure you didn’t have a big heart attack or something, and they'll put a splint on your wrist, and they'll fix you up, and they’ll send you home. And they've done their job, sort of. A geriatric emergency department says what an unfortunate opportunity to take a deeper look and see what's going on. A geriatric emergency department recognizes that falls are a syndrome in older adults, not an event. That if you fell today, you might have fallen before, and you might be at risk for falling next week. And how can we decrease that risk. How can we make sure you're not on 3 different beta blockers from three different doctors and no wonder you're getting dizzy every time you stand up. That your house doesn't have cord stretching back and forth and we can't work with community paramedics to go home go with you and do a health about a house safety eval. That we don't bring down physical therapy, make sure you've got the right mobility assist devices, or plug you into physical therapy as an outpatient. But traditionally, the ED fixes yet from what happened. A geriatric ED knows that in that immediate time after an ED visit, you are very high risk for further adverse outcome, and plugs you in with services to help decrease that risk and best of all, in close coordination with your primary care physician.

What role does a GED play in administering value-based care? How should GED’s interact with Primary Care?

I'll throw out a story to begin that answer with, and then let Megan talk specifically to those interaction and the value-based care in the rubrics. But just a story. From couple years back, I had the opportunity to meet Eric Harden, who's the Deputy Secretary of Health and Human Services from the last administration. I had a half hour meeting, and eight minutes into the meeting, Deputy Secretary looked at me and said “Kevin. Haven't you gotten the memo. We don't want anyone to go to the emergency department,” and I said, “Yes Sir. How's that working for you?” Like so, he laughed, and we went on for 45 minutes until his staff dragged him out of the room. Because the reality is that in a really perfect healthcare system, the need for complex older adults to utilize the emergency department would be substantially decreased. All of us want to care to be quarterbacked by the primary care physicians as much as possible. What a geriatric ED does is identify the underlying geriatrics syndromes that are going on, the social vulnerabilities, and get that patient back to the care of the primary care physician as soon as possible. That's what geriatric EDs do, and that's why they're so important to value. You cannot win at value, one of my roles is to help, I'm the vice chair of our ACO at the UNC Health Care System, vice chair of the board, and I help oversee our clinically integrated network. You cannot win long-term in the area of increasing benchmarks, everybody putting down the screws harder and harder. How do you win long- term if you don't have your hand on the steering wheel when your members are at greatest risk of admission and deleterious effects afterwards? You can't afford to give up on ED care and still win in the ACO world. We make it possible for you to lean in, connect, and coordinate the care of your patients.

Megan, I don’t know if you want to add some stuff to how we create high value care and some of the data around what's been created.

Megan: Absolutely, I think you did a really great job Kevin of summarizing what a GED is, how it's different. I think the important thing to really call out about GED's role in administering value-based care, is that much like value-based care arrangements, GEDs want to transition patients to the lowest setting of care possible. They want to help avoid that hospital admission or that hospital re-admission. How do they do that? That's what Kevin really just described. Right? They have this specially trained staff that understands and knows what these underlying kind of geriatrics syndromes and symptoms are. They have standardized care protocols that they deploy across the GED for this incredibly complex patient. And they’re more focused on the continuity of care. And they're more focused on addressing social needs after a patient leaves the GED. One of the things that I find really fascinating about some GEDs is that one of the screening tools that they use is for food insecurity. And so, when that screening tool comes back positive that this particular complex older adult is food insecure, that GED is able to connect that individual with their local Meals on Wheels program. Right? So, I think this is where the intersections between GEDs and value-based care really come alive, is when we start to see and understand how GEDs have some of the same goals that value-based care does. They don't want to admit the patients to the hospital. They want instead to address some of those underlying social determinants to make sure that you know they don't get admitted, they don't get re-admitted, and instead push them to the lowest you know and transition them to the lowest setting of care possible. And like Kevin said, you know, connect them back to their primary care provider. GEDs really want that primary care provider to be the quarterback for that patient’s care. So, I think some of the I think those are the really the highlights around how GEDs play a role in administering value-based care.

Kevin: You know, Megan, it's so true. And yet, I think as a doctor that works in a GED, we're really trying to push folks to the highest value setting of care possible. There are patients that it is consistent with their care wishes; with what matters to them. Care wishes aren't just end of life care wishes. It's their priorities. To have what we might call really aggressive medical care. And I know you mean this, but I just want our audience to know it too, then that is absolutely where that patient should be. But we are trying to push them to the highest value setting. Where is the highest quality going to happen for that patient? With an eye towards sustainability of the health care system. But the great, we're not making a choice here between cost and quality. Many of our unneeded medical admissions today are also deleterious medical admissions. The patient comes out weaker than they were before. The patient comes out less able to do their daily activities of living. The patient gets delirious from their hospital stay. So, we are always trying to do the thing that gets the care to the highest value setting and lines up with the patient's values. And yet, even when we do that or because we do that, we're actually substantially driving down the cost of care.

Megan, I don't know if you want to share just a little bit of some of the data that you're so familiar with as far as like decreased admissions, readmissions, cost of care.

Megan: No absolutely, there's really a growing body of evidence to suggest that GEDs really help to address that quadruple aim of value-based care. So, with the intervention of a transitional care nurse, which Kevin can talk about a little bit more, there's been a huge reduction in risk for hospital admissions. So, a 16.5% reduced risk of hospital admission and a 17.3% reduced risk of readmission. And that holds true over a period of time in addition to it, we've seen a $3,000 savings for Medicare beneficiaries after 30 days. So, one of the really impressive things that we know is happening is that this works, and not only that, not only are GEDs and some of the that the interventions that occur within them able to lower costs, they're also able to improve quality. So, one of the things Kevin talked about was how there's an interdisciplinary team that oftentimes treats patients in GEDs and one member of that team is oftentimes a physical therapist. And there was a study done that showed when a physical therapist came and addressed a patient’s fall or other underlying issue that there was a decreased odd of a 30 and a 60 day repeat ED visit with that PT consult. So, it's just great because we know that this is helping to improve quality as well and to improve the patient and the caregiver experience. There was a big retroactive study done that showed an 87.3% satisfaction with the clarity of discharge information received in a GED. And we know that creating communication pathways and helping to clarify discharge recommendations and connecting that patient back to their primary caregiver is such an important part in adding value. And that's something that GEDs do as well. And I know too, and I'll ask Kevin to talk about this, that GEDs really help to improve the care team experience as well. Just knowing that these physicians and advanced practice providers and nurse champions and interdisciplinary clinicians. When they work in a GED, they know that they're doing better by their older adult patients. And I know that Kevin sees that every day.

Kevin: Absolutely, I'll lean in there and then Thomas, we will give you a chance to ask questions, I promise. But the, you know, there's a risk of moral injury. I heard this summarized nicely by one of the healthcare systems leaders I work with. There's a risk, a real risk, of moral injury when you work in healthcare today. And what I mean by that is, sometimes it can feel like you're trying to like keep a tidal wave away, a tsunami, from landing on the beach by sticking your hands up in the air and you know it's going to stay. And there are days when we look out in the waiting room and there's 40 patients in the waiting room, and you know, the older adult is in the same corner, same cot, and you're fighting all of these systems that you know, I mean most of us who practice healthcare went in here to try and help people, and we know some days the system is just not succeeding. You know, when a daughter of an older adult comes up and says how come my mom is still in the ED 20 hours later. I can say whatever I want to say in response to that, but I know she's the daughter is right. The mom shouldn't be there. And I want to fix that. And I can feel defeated when I can't. We have a healthcare system worker crisis in this country right now. Go interview any healthcare system leader and ask do you have all the nurses you need, you have all the physicians you need, you got your whole team all set? I'm going to guess that the vast majority are going to say “No, we're in deep doo doo.” We can't afford to run a system that continues to inflict repeated moral injury on the workers we’re depending upon.

So, the fourth part of the quadruple aim is a GED helps you feel better. You get those systems in place. You know you help people. The best GED systems in the country actually send monthly newsletters to all their parties, like all the hospitals, and workers, like, “hey here's a couple stories about patients...]]>572e5f7e-9f08-4e8d-82ec-d12b563579feThu, 11 Aug 2022 00:00:00 -050023:33falsefull1212Melissa Pollock, M.Div., CHC - The Story of Federal Payment Models in Value-based CareIn this episode we talk to Melissa Pollock, M.Div., CHC, director of ACO Compliance and Regulatory Affairs for CHESS Health Solutions. She shares with us her expertise on the current CMS payment models, as well as the history and what she sees in the future.

Transcript:

Melissa would you provide some background on their precursors leading up to what we now know as value based care?

Sure! as most people probably know in the 1960s Congress you know began passing legislation to create the Centers for Medicare and Medicaid Services which you know provided Medicare for older populations, provided Medicaid for you know lower income populations, but we all know that that's all based on a fee model right? So you go and see your provider your provider sees you they bill based on the services that they provided you and then you're reimbursed they're reimbursed based on those services. So that's you know kind of the initiation of CMS as we know it Centers for Medicare and Medicaid Services.

In the 1970s and 80s we saw the proliferation of the health maintenance organizations preferred provider organizations where people were trying to better control cost and quality through narrow networks. So in the 1980s to 2000s you really saw capitation become more popular. Capitation models being a perspective amount of money given to providers to take care of a population of patients and then this kind of led to the idea the advent of value based care through the idea of the triple aim the triple aim being better care for individuals better health for populations but at a lower cost for the for the patient and for this health care system. And so that became the foundation of value based care, this idea of the triple aim.

And so in 2010 Congress passed the Affordable Care Act and allotted $10 billion to give to CMS and they created the Innovation Center. And the Innovation Center is basically there how are we going to fix the healthcare system? What can we do to try to stem the tide of rising costs and how can we create better care and better equity of care for patient populations? And that's really what the Innovation Center was poised to do and that kind of started value based care.

CHESS has been in value for quite some time. Can you explain the timeline of the different CMS payment models using the CHESS journey as a guide?

Yes, happy to do that. So CHESS really was founded out of the organization of Cornerstone Healthcare back in 2012 I think is when we started. And we realized, cornerstone healthcare at that time in in high point NC was making the move to value. The leadership of the organization saw that you know value based care is going to be the wave of the future and we need to go ahead and make that transition, align up our insurance contracts in a way that we know we can be successful in value based care. So in 2012 CMMI which is the Center for Medicare and Medicaid Services their Innovation Center created the Pioneer ACO or accountable care organization and this was the beginning of a total cost of care model for value based care.

We joined actually in I think it was midway through the year of 2012 when they created the Medicare Shared Savings Program and so we participated as Cornerstone Healthcare in 2012 in the Medicare Shared Savings Program and I believe did see savings within the first year or two. So that was kind of the first foray for CHESS. And we realized we're really good at doing this we've been able to generate savings with this group of providers, what if we became an organization that was able to provide this to other healthcare systems in the state of North Carolina? You know could we use what we've learned in these years leading up to our transition to value based care to implement this at other places at other hospitals and would this...]]>In this episode we talk to Melissa Pollock, M.Div., CHC, director of ACO Compliance and Regulatory Affairs for CHESS Health Solutions. She shares with us her expertise on the current CMS payment models, as well as the history and what she sees in the future.

Transcript:

Melissa would you provide some background on their precursors leading up to what we now know as value based care?

Sure! as most people probably know in the 1960s Congress you know began passing legislation to create the Centers for Medicare and Medicaid Services which you know provided Medicare for older populations, provided Medicaid for you know lower income populations, but we all know that that's all based on a fee model right? So you go and see your provider your provider sees you they bill based on the services that they provided you and then you're reimbursed they're reimbursed based on those services. So that's you know kind of the initiation of CMS as we know it Centers for Medicare and Medicaid Services.

In the 1970s and 80s we saw the proliferation of the health maintenance organizations preferred provider organizations where people were trying to better control cost and quality through narrow networks. So in the 1980s to 2000s you really saw capitation become more popular. Capitation models being a perspective amount of money given to providers to take care of a population of patients and then this kind of led to the idea the advent of value based care through the idea of the triple aim the triple aim being better care for individuals better health for populations but at a lower cost for the for the patient and for this health care system. And so that became the foundation of value based care, this idea of the triple aim.

And so in 2010 Congress passed the Affordable Care Act and allotted $10 billion to give to CMS and they created the Innovation Center. And the Innovation Center is basically there how are we going to fix the healthcare system? What can we do to try to stem the tide of rising costs and how can we create better care and better equity of care for patient populations? And that's really what the Innovation Center was poised to do and that kind of started value based care.

CHESS has been in value for quite some time. Can you explain the timeline of the different CMS payment models using the CHESS journey as a guide?

Yes, happy to do that. So CHESS really was founded out of the organization of Cornerstone Healthcare back in 2012 I think is when we started. And we realized, cornerstone healthcare at that time in in high point NC was making the move to value. The leadership of the organization saw that you know value based care is going to be the wave of the future and we need to go ahead and make that transition, align up our insurance contracts in a way that we know we can be successful in value based care. So in 2012 CMMI which is the Center for Medicare and Medicaid Services their Innovation Center created the Pioneer ACO or accountable care organization and this was the beginning of a total cost of care model for value based care.

We joined actually in I think it was midway through the year of 2012 when they created the Medicare Shared Savings Program and so we participated as Cornerstone Healthcare in 2012 in the Medicare Shared Savings Program and I believe did see savings within the first year or two. So that was kind of the first foray for CHESS. And we realized we're really good at doing this we've been able to generate savings with this group of providers, what if we became an organization that was able to provide this to other healthcare systems in the state of North Carolina? You know could we use what we've learned in these years leading up to our transition to value based care to implement this at other places at other hospitals and would this be something that people would be interested in other healthcare systems would be interested in? And so CHESS was created kind of as a consulting organization, another arm of really driving value based care for other healthcare systems that didn't have a way to do it and needed help in that journey.

So that was kind of 2012 and we were in the Medicare Shared Savings Program for I think 3-4 years three and a half four years and then in 2016 CMMI or the Innovation Center created a brand new model called the Next Generation ACO or the Next Generation accountable care organization and this was again another total cost of care model and CHESS joined in 2016 we were one of I think it was 18 maybe total organizations in the US that took on this new model and started and have been with or was in the next generation ACO from 2016 to 2021. So really kind of start getting our feet wet in the MSSP program and then moving to NextGen and taking on full risk for populations for the past six years.

Well that's a great segue into my next question can you talk about the MSSP model and the basics of benchmarking along with the levels and tracks.

Yes. So the MSSP model kind of has two main tracks. There's the basic track and then there's an enhanced track. Basic has five levels within that track - A through E. So level A new starting at the very you know onset of the program it's your first year in value based care and then each year CMS progresses you to a higher level within the system until you are five years in you're at level E and you're going A through E and walking through those levels. And then after that those five levels are completed you would go into the enhanced track which would be the highest level of risk for that population of patients. And when I say risk I kind of want to explain a little bit of what I mean by risk.

So within the CMS MSSP model, they are looking for providers to be accountable for the care that they're providing for a population of patients. And so for a provider it's not every traditional Medicare patient that walks through your doors, they're going to look at a specific group of the Medicare patients that you've seen for the past two years and they want to see if that patient has seen these providers for their primary care services more than they've seen anybody else in United States. So they're looking at historical claims data and they're saying OK patient X has seen a provider at this hospital for primary care than they've seen anybody else so we're going to make you accountable for their care. Because it's obvious to us from the historical claims data that these patients are being seen at by this provider at this organization. So we're going to make you accountable for their care.

On average it's usually 40 to 50% of the patients that are coming through the doors of a health care system that are traditional Medicare are actually in the ACO if the health system signs up for the ACO. Right? So you're not taking on health for the entire population of patients of traditional Medicare patients. You're only really taking it on 40 to 50%, and of those are the ones who really see you more than they see body else. So once you have that population of patients, CMS looks at the historical claims that have been filed and they say OK based on how they've you know what their cost of care looks like we're going to set a benchmark for you. And that benchmark is going to be based on this historical costs, and I'm just going to ballpark a figure here, we're going to say that the benchmark is $1000 per patient per month. So CMS is going to come up with this benchmark and they're going to say we think it's going to cost you $1000 per patient per month to take care of these patients. If you can do really great lower that cost of care but still do really great on quality right, we're not just cutting costs of care we're not stinting on care, but if you can lower the cost of care but really have amazing quality then you're going to generate a savings between what was expected of you to spend and what you actually ended up spending. But on the other side you might go over that cost right you might have to spend over that because the patient had extra things that happened and there's more need there. So CMS takes that benchmark and then measures you against that benchmark. And then depending on whether or not you're able to lower the cost of care or if you overspend, then that generates a savings or could generate losses.

So once you're in the MSSP model they give you your benchmark you try to perform throughout the year providing great quality for patients you know lowering the cost of care in places that make sense and then at the end of the year they're going to true it up and for those that are in level A and in level B you're not taking on downside or risk for these patients. So what do I mean by downside risk? If you are able to lower the cost of care and create that differential between what they thought you were going to spend and what you actually spent, then you get to share in some of that savings and the split of that of what you've generated is 40%. So using my model that I came up with $1000 per patient per month you lowered the cost of care to $800 per patient per month you generated $200.00 you keep 40% of that the other savings kind of goes into the pocket of CMS. On the other hand if you overspend in levels A and B you're not paying anything back you're not taking on risk for this population. Oh you overspent let's do better next time. That's kind of level A and B once you get into C D and E is when you start taking on risk and you'd have to pay back a portion of what those losses that you generated if you went over the benchmark. And then enhanced would be the highest level where you get to keep 75% of the savings that you generated but you're also having to pay back more losses. So greater risk greater reward as you go up the different levels of the MMSP model

Melissa can you share with us an overview of the NextGen model, how it differs from MSSP, and why it was initiated?

Sure. So the MSP model had been around for a while but there was no way in Medicare for the providers to take on 100% risk. Right? So instead of having only 75% of the savings split or 50% or 40%, if providers knew that they were doing really well with taking care of these population of patients with really under you know lowering the cost of care providing great quality, they wanted more cut of that pie of that general of the savings that they were generating. And so this was a way for providers to choose between taking on 80% of the risk or taking on 100%, meaning first dollar savings and first dollar losses. And really what that means you'll hear that a lot I have first dollar savings or losses, you know if you generate a dollar savings you keep a dollar if you lose a dollar of savings you pay back a dollar that's kind of what it means around that that benchmark that's CMS has set. so very similar to the MSSP model but a little bit more you know you're taking on greater risk for the population.

They also introduced a lot of new waivers to the Medicare program through the NextGen model so they kind of beta tested the skilled nursing facility three day waiver through that model and a lot telehealth waiver through that model as well. So there are a lot of you know ways that they tested different waivers that have then gone on to become regulation at a later time.

The CMMI models, specifically NextGen, are way more nimble and I don't know a lot of people probably don't care about this as much as I do I'm kind of like a policy wonk, so I think it's very interesting that MSSP is codified through regulation so annually they put out exactly what's going to happen with MSSP and that's we you know have to adjust accordingly. Whereas the model with CMMI is more nimble. It's a contract and we can you know have conversations with CMMI. We kind of have access to the staff, we can talk them through hey this doesn't make sense and we wanted these are different things that we want to do, or this isn't working for us or here's data that we really need to in order to make this model work and it's more of a collaborative effort with the Innovation Center rather than the MSSP program that's just here's the regulation the regulation is what the regulation is.

So now NextGen actually has been sunsetted as of the end of 2021. So that model has come to a close and the determination for most out there that were in that model was do you go into this new model called direct contracting, which was very controversial at the time and still somewhat remains to be controversial. But direct contracting was CMMI's first foray into a somewhat capitated payment model for traditional Medicare beneficiaries or traditional Medicare patients. So historically they had never really offered any type of capitation model where they would provide you you know with an amount of money up front here's your money for to take care of this patients, this is the money that you get and you know you you can still send us claims, we're not really going to reimburse you anything for those claims, but it has to go through some type of you know claims processor. So this was a very innovative and new model which also allowed for entrance of a lot of different companies into the space of traditional Medicare. Some private equity companies that have entered the space of traditional Medicare patients where historically they had kind of been limited to MA plans.

So it's been very interesting so direct contracting is going on right now and they have recently announced the new ACO REACH program which is on the chassis of direct contracting but some added elements to make it more equitable. So those are kind of the those are the choices that you have out there you can go to MSSP or you can kind of dip your foot in the water of very limited capitation through currently direct contracting, soon to be called ACO REACH

Is there a recommendation about what types of entities should participate in each of these models?

Yes that's a great question. I think that really no health care system should jump into value based care blindly. There's a there's a big shift in mentality and a big shift in culture that has to take place. When you start saying that you're going to reimburse providers differently than they've been used to for the past many many years um there has to be kind of that top down trickle effect of this is a different culture of how we're going to address patient care. It's not going to be about seeing 35 patients in a day in 10 minute time slots, but it's going to be about spending the time with the patient that needs to be spent and addressing more than just symptoms and problems. Maybe we need to talk about you know multiple things related to social determinants. Maybe we need to talk about just wholeness wellness in general.

And I think 2. they would have to be prepared to invest in value based care. I mean there is a cost to doing value based care as far as infrastructure for the services that value based care provides that wraps around the provider so you'll hear that a lot that services are wrapped around the provider. So it's not just a provider trying to do this. There are health navigators on the back end, there are pharmacists that are looking at medications there are, you know, data analytics teams that are reviewing the claims information that we get from the insurers to get a better holistic care or picture of care for these patients. So there is there is a cost to doing value based care. But are we striving for better care for the patient. 100%. That's what we're looking for. We want to make sure that each patient is treated as a patient and not another number of a 10 minute time slot office visit let's work through to the next patient. So for a lot of systems I think value based care automatically is hands off and cost prohibitive. It's risky and a lot of health systems don't want to go that route. and I think that's really where CHESS comes into help. Right? We want to help you make that transition. We've done it successfully so let us help you use what we already know since we're down that road farther than you are to set you up for success and like in your value based care journey.

This is great information. I just wonder from your lens in the work that you do what is the benefit of moving to value?

That's a great question. So I think part of the benefit is that specifically I personally think we're going to see this being mandated from the government or from CMS specifically in years to come and it behooves you to start now. You know to look from those perspectives, but I think, too, it really puts the focus on a patient. I think we really want to make sure that a patient is heard and seen, they are understood, they're being reached out to on a regular basis if they need help for things that are outside the normal scope of an office visit. So they need help for you know they they don't have access to food They have COPD and need an air conditioning unit. Like these are the types of things that value based care is geared towards helping that is different than coming into a provider’s office, seeing that patient, addressing the symptoms, addressing medication, addressing the problems, and then they're on their way and you don't see them again for another year. Because we know that there are so many things outside of just medication and you know what's going on in that 10 minute 15 minute office visit that affect a patient’s care and a lot of times providers don't have insight into that. So I think value based care provides that lens to help see the holistic picture

That's powerful. So Melissa, what's next? what's in the immediate future and what do you see on the horizon?

So, I did mention a little bit about this but I do think you're going to see more and more health systems addressing social determinants of health. You know what are those outside influencers that are affecting care for patients that aren't always what can be seen in an office visit. I heard one of our providers say you know before the pandemic I didn't know what this patient's house looked like. I didn't know what kind of living conditions they were in and then all of a sudden everyone switching to telehealth really quickly and the pandemic provided me a lens into their house. And all of a sudden I could see, oh my goodness, these are the conditions they are living in, how can I help this patient outside of just the medicine they need and the care that I usually provide. And I thought it was insightful that, you know, yes, we went through a pandemic. It’s been awful. It’s continuing, but there have been some really interesting and insightful things that have happened that have come out of it, you know, specifically like he was saying, I get to see where my patients are. So I think we’re going to see a lot more of these models addressing social determinants of health and trying to collect that type of data too. I think they're going to want to collect the social determinants of health data and data related to Health Equity.

I think health equity is a buzzword that you're hearing a lot around the circles and I don't think anybody really knows what it means right now. I think everybody is a little bit like we realize that the pandemic exacerbated the issues with Health Equity that we didn't know we had, so in how do we address them? What do we do about that? And I think CMS’s first foray into that is through the ACO REACH program and they're going to start trying to collect data on health equity and then try to use that data to further develop models to kind of help in that]]>44bd8e89-95c4-4583-ba25-386f2e90ff36Thu, 28 Jul 2022 00:00:00 -050024:28falsefull1111Matt Zavadsky, MS-HSA, EMT - The Role of EMS in Value-based Care Pt 2In this episode, we continue our conversation with Matt Zavadsky of MedStar Mobile Healthcare about the role that Emergency Medical Services has in value-based care and how the economics come together to provide value.

Transcript:

How has CMS come to realize the value of the role EMS has in health care through models such as Emergency Triage, Treat, and Transport or ET3?

Yeah, and Medicare for most EMS agencies is our largest payer, right. Whether it's regular fee for service or Managed Medicare. And they've been one of our audiences for a decade with us telling them, you know, if you keep paying us to transport, again, you're just incentivizing us to spend your money. So, they finally, through the CMI, the Center for Medicare and Medicaid innovation, put together a model, that we actually helped work on with them, that changes the economic model for EMS. And it now reimburses EMS agencies not just for transport anymore, but for things like nurse triage in the 911 center. If you can mitigate that 911 call and not have to even send a resource, and you can get them connected with their doctor, and you've triaged them over the phone, that's reimbursable now for select agencies that are a part of this program. If you get on scene, and you do an assessment, and you do a telemedicine connection with a physician, and that physician agrees that this patient does not need to go to the emergency department, they can be treated at home, and go see their own doctor, we're now reimbursed for that. And so, by the way, is the doctor that’s doing the telemedicine.

Similarly, if we transport a patient to an alternate destination. So, yep, you know what, you twisted your ankle. You might need an x-ray, but you don't need to go to an ER for that. Let's take you to an urgent care that has x-ray. It's a third of the cost and certainly much more patient-centric perhaps than going to a busy emergency department. And we transport them to an urgent care. That model revolutionizes how EMS is delivered. We've often said that, you know, Medicare does not set health care policy, but they do set payment policy. And as they change payment policy, they change the practice of health care. So now we, and about you know 40 other agencies around the country that have been approved by Medicare to test this model, are not transporting every Medicare patient to the ER anymore. We're offering them an opportunity to stay home.

I did this myself with a patient a couple weeks ago and he loved it. His wife was thrilled. He was in a lot of sciatic pain. We gave him some pain medication, talked to the doc, we had an urgent care, mobile urgent care, come out to the house later in the afternoon, and we didn't have to put him on a stretcher, and take him down a bumpy road, and take him to a busy ER where he's going to languish for 2-3 hours because you know he doesn't have a high priority medical complaint. And the patients love it and it's much less expensive and everybody benefits. So those are the types of models that we're continuing to test with now other payers

We just signed a in-network agreement with one of our largest commercial payers where they're paying us the same way. “Hey. We'll pay you the same whether you take somebody to the hospital or not. We prefer that you not, if you don't have to, because it's going to save us you know $5,000 cost of care at the end of the day.” So those are the types of things that Medicare, and other payers, and a lot of Medicaid offices across the country are starting to say, “Yeah. This is a much better economic model for EMS. Let's pay them for patient navigation, not just for patient transport.”

How have telemedicine waivers allowed EMS to do on-scene patient navigation?

The telemedicine waivers that were, that have been and they're still in place, because of the public health emergency, has really stepped]]>In this episode, we continue our conversation with Matt Zavadsky of MedStar Mobile Healthcare about the role that Emergency Medical Services has in value-based care and how the economics come together to provide value.

Transcript:

How has CMS come to realize the value of the role EMS has in health care through models such as Emergency Triage, Treat, and Transport or ET3?

Yeah, and Medicare for most EMS agencies is our largest payer, right. Whether it's regular fee for service or Managed Medicare. And they've been one of our audiences for a decade with us telling them, you know, if you keep paying us to transport, again, you're just incentivizing us to spend your money. So, they finally, through the CMI, the Center for Medicare and Medicaid innovation, put together a model, that we actually helped work on with them, that changes the economic model for EMS. And it now reimburses EMS agencies not just for transport anymore, but for things like nurse triage in the 911 center. If you can mitigate that 911 call and not have to even send a resource, and you can get them connected with their doctor, and you've triaged them over the phone, that's reimbursable now for select agencies that are a part of this program. If you get on scene, and you do an assessment, and you do a telemedicine connection with a physician, and that physician agrees that this patient does not need to go to the emergency department, they can be treated at home, and go see their own doctor, we're now reimbursed for that. And so, by the way, is the doctor that’s doing the telemedicine.

Similarly, if we transport a patient to an alternate destination. So, yep, you know what, you twisted your ankle. You might need an x-ray, but you don't need to go to an ER for that. Let's take you to an urgent care that has x-ray. It's a third of the cost and certainly much more patient-centric perhaps than going to a busy emergency department. And we transport them to an urgent care. That model revolutionizes how EMS is delivered. We've often said that, you know, Medicare does not set health care policy, but they do set payment policy. And as they change payment policy, they change the practice of health care. So now we, and about you know 40 other agencies around the country that have been approved by Medicare to test this model, are not transporting every Medicare patient to the ER anymore. We're offering them an opportunity to stay home.

I did this myself with a patient a couple weeks ago and he loved it. His wife was thrilled. He was in a lot of sciatic pain. We gave him some pain medication, talked to the doc, we had an urgent care, mobile urgent care, come out to the house later in the afternoon, and we didn't have to put him on a stretcher, and take him down a bumpy road, and take him to a busy ER where he's going to languish for 2-3 hours because you know he doesn't have a high priority medical complaint. And the patients love it and it's much less expensive and everybody benefits. So those are the types of models that we're continuing to test with now other payers

We just signed a in-network agreement with one of our largest commercial payers where they're paying us the same way. “Hey. We'll pay you the same whether you take somebody to the hospital or not. We prefer that you not, if you don't have to, because it's going to save us you know $5,000 cost of care at the end of the day.” So those are the types of things that Medicare, and other payers, and a lot of Medicaid offices across the country are starting to say, “Yeah. This is a much better economic model for EMS. Let's pay them for patient navigation, not just for patient transport.”

How have telemedicine waivers allowed EMS to do on-scene patient navigation?

The telemedicine waivers that were, that have been and they're still in place, because of the public health emergency, has really stepped up the ability for EMS to use telemedicine in the patient’s home. And again, specifically because of the change in the payment authorization. So, forever, telehealth would only be provided reimbursement if it was from one health care facility to another health care facility, for the most part. A physician providing telehealth services to a patient in the patient’s residence was not a covered benefit. So, there were not a lot of physicians that were doing it for obvious reasons and there were not a lot of patients taking advantage of that because if they did, it typically came out of their pocket. So, when the telehealth waivers were put into place back in April of 2020, seems so long ago, suddenly that now included patient’s residence as a covered origin. Suddenly, there are a whole host of groups that were willing to do telemedicine and EMS leveraged that. We did, a number of agencies did, and we contracted with all of the you know a bunch of different telehealth providers to help us navigate patients. And now the physicians are able to get reimbursed. So, we respond to a 911 call, we engage telemedicine from the patient’s bedroom, living room, whatever, and the we get reimbursed because that's part of you know the waiver. It’s also reimbursable to the physician.

What we're all focusing on now is yes this is a waiver. It has worked exceptionally well on the EMS side. Very little fraud and abuse because it's almost always in response to a 911 activation. So, there's not the marketing that's going on for example that OAG might get concerned about you know inflating the encounters. And we're not bringing a whole bunch of people to the hospital. So, we're hoping and working with OAG, and with CMS, and MedPAC, to say look, even if you're going to change the waiver and allow it to expire. Let the EMS component of it remain in place because it is saving healthcare dollars, it's improving the patient experience of care, and leading to better outcomes. Because instead of someone going to an ER, again seeing a doc they've never seen before, having a battery of tests that they need just because the ER doc has to practice defensive medicine, they get referred to their primary care physician, it's a better continuum of care and that telehealth waiver should remain in place for EMS. And we're hopeful that that will continue because it has really revolutionized our ability to navigate patients from the scene of a 911 call because we've got physicians willing to be a telehealth provider for us in that patient’s living room. And Thomas, the reality is that the ERs are so busy now and you know people with low acuity medical complaints end up waiting for quite a while in a lot of emergency departments across the country. And if we can help decompress the ERs, then everybody even wins further, because the patients who are going to the ER don't have to wait as long because there aren't 110 borders in a 110-bed emergency room.

Talk about the need for transforming the EMS economic model and what is the vision moving forward in the value-based care space?

Yeah. It's really everything we've talked about so far. It's reimbursing EMS for the response, not for the transport. And finding, as we've been able to do here in Fort Worth, finding alliances with value-based partners. So, one of our newest partnerships is with a care management organization who has taken on full risk for the care utilization of an ACO population. And they were going to be using CNAs, and RNs, and NPs, and PAs, going out to see these, you know, high utilizers or the problem children if you will, in that population and trying to schedule someone when they call 10 digits to the care management organization that says “Hey. You know, my feet are getting swollen. I'm not sure what's going on and I'm sleeping with three pillows now instead of one because I can't breathe when I lie down.” So, instead of having to send an NP, or PA, or other provider out to try and schedule, they just call us and say “Hey. Will you go see Thomas? Listen to his lungs, take a 12-lead, let me know what his edema looks like.” And we’re doing that for them. And it's much less expensive because of paramedic, quite frankly, is less expensive per hour than the other type of provider. And they are very good at assessments, and protocols, and starting IVs, and giving D50, or giving Lasix, or Zofran, or doing pain management with some medications that they have on board, to really do that good care coordination.

So, finding more of those alliances and likeminded people. We've got a couple of Medicaid Managed care organizations that are doing the same thing with their problem populations and using us to help manage those populations. Hospitals have been paying us for readmission prevention for years because the economic model for them is if they have lower readmissions, they get lower penalties from Medicare and obviously the high utilizers. So, the real transformation for EMS is really finding those partners and again it could be commercial payers, Medicare, Medicaid, or IPAs. One of our very first agreements for mobile integrated healthcare was with a very large independent practice association who's in a full risk contract with United Healthcare to prevent observation admissions. Because observation admissions were being billed at Part B every band aid, every IV catheter, every test was being credited to that IPA in the risk arrangement and they said listen we're going to send these patients home, will you guys follow up with them for 48 hours to make sure they go see their PCP. And that's the perfect alignment. We did that back in 2013 and we're still doing it today because there's value to the IPA for that. But again, it's finding its educating people about what the real value of your local EMS agency is, and that value really has nothing to do with the transportation that they provide.

How well equipped are EMS staff to perform more complex triage to determine the appropriate site of care for a patient?

That's a great question, Thomas. And, you know, paramedics and EMTs see patients all day long just like other healthcare providers do, and we become experts at triage. Really who's sick, who's not sick. You know, I haven't been full-time in the field for a long time, I'm still certified, but I can still tell you. I worked a shift two weeks ago in the streets and 7 calls in 12 hours, and I can look at a patient from across the room and say “Yep. You're sick,” or I can look at and say “Nope. You're not.” And now, you take that really good patient assessment process that EMTs and paramedics do multiple times a day and you augment it, for example, with a telehealth program.

Where, you know, OK, I think this patient’s got low acuity medical complaint, but don't take my word for it. Let's spend 4 minutes on a video chat with, you know, our contracted IES physician group just to get confirmation. To get a doc on the line. Yep. They do a couple of additional things. We ask some questions. Ask us to do one or two additional assessments, whatever. And now you get a second opinion that, yeah, this patient does not need to go to the emergency room. They can go see their primary care physician. They need to do it in the next day or two. Or not, depending on whatever it is. I'm going to call in a prescription in the meantime, etc, etc. But the ability for EMTs and Paramedics to do that. They do it multiple times a day. They can get additional training if the medical director, or the IPA, or the group that you’re working with, wants some specific training on a specific disease process, or cohort of patients that they want you to help manage or to navigate. But again, telehealth whether it's video, audio, telepsych we're doing in a number of cases to help with assessments of behavioral health patients. Just get that second opinion. Very, very safe. We've been an ET3 model participant for a little over a year. We have put almost 600 patients who called 911, Medicare patients, who called 911, and some would say that Medicare patients tend to be a little bit more medically fragile than other patients, and you know 600 of those patients have gone through this secondary triage with our EMTs and paramedics on scene. No bad outcomes. Over 500 of them have stayed home and not had to go anywhere, and it's very safe. And just work with your local EMS agency, they do this all the time. Help them with some secondary triage through telemedicine program and it's very, very safe.

If an ACO or health system is interested in exploring this model further, where would they begin the implementation of a program such as this?

First, find out who the largest EMS provider is in your region and that's going to depend on your medical trade area. So, we've done a lot of work with a very large ACO in upstate Wisconsin, and they are working with Green Bay fire, Milwaukee fire, a number of fire departments up there to do mobile integrated healthcare, community paramedicine, patient navigation across their medical trade area. Here, we're doing it along with Dallas fire and some others. So, if you're in North Carolina or you’re in wherever and you think, “Hey. I'd really like to start working with my EMS agency to not bring every patient to the emergency room.” Who's the biggest provider? Is it Wake County EMS? Is it Greensboro EMS? Is it whomever? Reach out to their service director, reach out to their medical director, have a quick meeting with them and say “Hey. I got this harebrained idea. I listened to this crazy podcast and this knucklehead was talking about, you know, EMS doing other things. Typically, you're going to find very willing partners. Because I can tell you that almost every EMS director, every Fire Chief, all the national associations are really promoting this new model for EMS because of what we learned, not only over the last decade, but certainly during the coronavirus pandemic, that this is really the best value that we can bring is partnerships and navigations.

And here's the example. We're working now with one of our partners that “Hey. We take a 911 call. It meets a triage criteria for a very low-level medical complaint and trust me it happens multiple times a day. People call for ingrown toenails, blisters on the feet, nausea, vomiting for 3 weeks and now it's 2 o'clock in the morning, and now we link them up from the 911 center with a telehealth provider. And we stay on the line, but we send them a link, and the caller you know clicks on their smart device, and now they're talking to a doc by video chat. And we mitigate that “response” without even sending a fire truck, without even sending an ambulance, because the patient got what they wanted, to your point earlier, they got triaged by a telehealth provider. They had a prescription called in that will be delivered to their house within, you know, the next 3 to 4 hours, and a recommendation to call their doctor. There are agencies all over the country that are willing to do that. They just don't know who you are. So, if you're listening and you want to be that innovative agency, just reach out and find that that provider.

If you're having a hard time with that, you can literally call me. We'll give you my e-mail address. We know almost all the providers in the country, and we are more than happy to hook people up because this really is the right thing for the patient, and the right thing for the system.

Matt, do you feel that there's anything we've neglected to discuss today that would be an important part of this conversation?

I think one of the things that people don't realize is how nimble EMS agencies can be. We are often now referred to as the Swiss army knife of the health care system. And if you want a program that does, as we said earlier, contact tracing, vaccines, monoclonal antibody infusions, testing, you name it, fall risk prevention, your EMS agency can literally develop a protocol with your medical director, do some training, figure out the data exchange, figure out the metrics that you want to use to measure the effectiveness of the program, and literally do pretty much anything. So, don't be afraid to ask them.

We had a, during the pandemic, one of the big ACOs here that we partner with said “Hey. We're going to get a little bit of HEDIS of trouble if we don't get eye exams for our Medicare population. And nobodies coming into the doctor's offices because the offices are closed. And we've got about 125 patients who haven't had their annual eye exam. Can you go out with your community paramedics, and you know bring this camera, and take a picture, and send us the image so the doctor can look at it and say that checked the box?” And we did. We stood that program up, Thomas, literally in three days and it was done within a month because I had to get it done by September 30th and they didn't contact us until the beginning of September. And we did it for them. Those are the types of things that you don't think about that “Hey. This is a, you know, another Swiss army knife thing that we need, and you know EMS can probably do it.” And we did. So, that would be I think the last message that we want to send. If there's a gap, your EMS agency, a trusted local provider, if you work on it with them and tell him what protocols you need, and what the economic model, is they can do pretty much anything.

Transcript:

Tell us a little bit about MedStar, what your organization does, and how it has impacted the communities in which it operates.

Thanks for asking. MedStar is the trade name for a public authority called the Metropolitan Area EMS Authority. We are a regional, governmental administrative agency that is created by 15 member jurisdictions to provide emergency medical services across all 15 of those cities, irrespective of city boundaries. It's a, again a regional public authority. The challenge was that the Metropolitan Area EMS Authority was way too many letters to try and put on the side of an ambulance. So, we when the, when the Authority was formed the community had a naming contest back in 1986 and MedStar was the name that was chosen. So we are that public authority. We provide 911 and non-emergency medical services, emergency medical services, to about 430 square miles with 1.1 million population. Fort Worth is our largest member jurisdiction. There are 14 others. And we do so without any tax subsidy which is a little bit unusual being a public authority much like you might think about a transportation authority or an airport authority, but we receive no tax dollars. So, it's a very high-performance EMS system.

What is mobile integrated healthcare and how does it reduce utilization? What are some of the proactive measures being done?

Mobile integrated healthcare is a term that has been used by the EMS profession to categorize services that we are able to provide that may or may not be the result of a 911 response. Most people think of an EMS agency as you know group of experts who hang around a station, wait for a 911 call to occur, and then we respond, mitigate the emergency, and then shlep people off to an emergency department. What we've learned over time is that there's a certain portion of our population who could benefit from some proactive education, medication management, connection with other resources in the community, maybe re-connection with their primary care network, to actually prevent a 911 call. So, the term mobile integrated healthcare is really that umbrella term that refers to all of the things that EMS agencies can really do to improve the health of populations, to reduce the expenditures of the health care system, and to most importantly improve the patients experience of medical care.

What are some of the healthcare roles that EMS has transformed?

So that's a great question. And if you think about it, one of the major transitions and transformations has been that prevention of the 911 call. We have always been reactive as a profession. EMS agencies, sort of by nature, react to a 911 call. But what we're doing now, and at MedStar and a number of other agencies across the country, is working with partners, payers, hospital systems, home health agencies, hospice agencies, ACOs, to fill a gap that still exists in our health care system and those gaps are different depending on the population and the partner that we're working with. So for example, a hospital system has a bunch of frequent flyers that come to the emergency department for ambulatory care sensitive conditions. Those things that really had they seen their PCP or their primary care system, that ER visit would have been avoided. They identify those patients, refer those patients to us, we go visit them with specially trained community paramedics who are trained in things like motivational interviewing and social determinants of health, in addition to doing the typical things that paramedics do, 12-lead EKGs, medication...]]>In this episode, we pay a visit with Matt Zavadsky, EMT and Chief Transformation Officer at MedStar Mobile Healthcare, a high value Emergency Medical Services system that provides advanced clinical care with high economic efficiency.

Transcript:

Tell us a little bit about MedStar, what your organization does, and how it has impacted the communities in which it operates.

Thanks for asking. MedStar is the trade name for a public authority called the Metropolitan Area EMS Authority. We are a regional, governmental administrative agency that is created by 15 member jurisdictions to provide emergency medical services across all 15 of those cities, irrespective of city boundaries. It's a, again a regional public authority. The challenge was that the Metropolitan Area EMS Authority was way too many letters to try and put on the side of an ambulance. So, we when the, when the Authority was formed the community had a naming contest back in 1986 and MedStar was the name that was chosen. So we are that public authority. We provide 911 and non-emergency medical services, emergency medical services, to about 430 square miles with 1.1 million population. Fort Worth is our largest member jurisdiction. There are 14 others. And we do so without any tax subsidy which is a little bit unusual being a public authority much like you might think about a transportation authority or an airport authority, but we receive no tax dollars. So, it's a very high-performance EMS system.

What is mobile integrated healthcare and how does it reduce utilization? What are some of the proactive measures being done?

Mobile integrated healthcare is a term that has been used by the EMS profession to categorize services that we are able to provide that may or may not be the result of a 911 response. Most people think of an EMS agency as you know group of experts who hang around a station, wait for a 911 call to occur, and then we respond, mitigate the emergency, and then shlep people off to an emergency department. What we've learned over time is that there's a certain portion of our population who could benefit from some proactive education, medication management, connection with other resources in the community, maybe re-connection with their primary care network, to actually prevent a 911 call. So, the term mobile integrated healthcare is really that umbrella term that refers to all of the things that EMS agencies can really do to improve the health of populations, to reduce the expenditures of the health care system, and to most importantly improve the patients experience of medical care.

What are some of the healthcare roles that EMS has transformed?

So that's a great question. And if you think about it, one of the major transitions and transformations has been that prevention of the 911 call. We have always been reactive as a profession. EMS agencies, sort of by nature, react to a 911 call. But what we're doing now, and at MedStar and a number of other agencies across the country, is working with partners, payers, hospital systems, home health agencies, hospice agencies, ACOs, to fill a gap that still exists in our health care system and those gaps are different depending on the population and the partner that we're working with. So for example, a hospital system has a bunch of frequent flyers that come to the emergency department for ambulatory care sensitive conditions. Those things that really had they seen their PCP or their primary care system, that ER visit would have been avoided. They identify those patients, refer those patients to us, we go visit them with specially trained community paramedics who are trained in things like motivational interviewing and social determinants of health, in addition to doing the typical things that paramedics do, 12-lead EKGs, medication administration, vital signs assessment, following protocols.

So now you've got these community paramedics who can reach out to the person who ends up in the emergency department three times last month with congestive heart failure, pulmonary edema, and the ER doc is befuddled as to why. The cardiologist just can't figure it out. But when the community paramedic goes into the home, finds out that it's family that eats pepperoni pizza three times a week, or that the patient lives on a second- or third-floor walkup in Texas where it's 110 degrees in the summertime and when the person gets to their third-floor apartment, they've decompensated and are now suffering from pulmonary edema, or their emphysema has flared up. And we work to get that patient, for example, moved to the first-floor apartment instead of a third-floor walkup. The PCP would never know that because they don't typically go to the patient’s home. The ER doctor certainly wouldn't know that. Same thing with the diet that we talked about earlier, that menu.

Many times patients get discharged from the hospital with a booklet of discharge instructions. And let's face it, when they're being discharged from the hospital and they're getting their discharge instructions, they are barely listening. But yet, when someone can sit down with them and their family in the kitchen and literally take an hour or two and go through every one of their discharge instructions, explain why it's important to take their Lasix, explain why it's important to not eat a high sodium diet, look in their refrigerator, look in their cabinets, help them with that process, we can change the behavior and then give that feedback to the primary care physician, to their primary care network, to say hey here's what's going on in the home. And they can change that patient’s whole education level to really keep them out of the hospital. And that high utilizer population is only one. We work with the hospitals on things like readmission prevention, observation discharge avoidance, so they don't have to be admitted to the hospital under observation status, and then again partnering with payers and ACOs and now a lot with hospital in the home providers, to really be that episodic care for the hospital and home patients as well.

One of the great things about EMS is that the communities that we are in, and we're in almost every community right because you've got your local EMS agency, is they are a trusted group of people. And even the most suspicious patient, who might be afraid that someone's going to come and take their kids away, or make them go into a nursing home or do something like that, when someone comes to their door in an EMS uniform, and knocks on the door, they let us in. Because we've been in their home at 2 o'clock in the morning when they can't breathe, or when they've crashed their car, or when their kid has fallen. So that trusted resource really lends itself well to patients listening to the recommendations and the instructions given by the paramedic.

Talk about the utilization outcomes for the home health partnerships you have in place?

One of the gaps that we help fill is with home health agencies. Patients want home health generally are relatively medically fragile, and they activate 911 quite a bit, they may have needs literally 24 hours a day, 7 days a week. And the goal of the home health agency is to prevent those patients from going to the emergency department. Because if their contracted with the payer, if they're contracted with the hospital, and they have a high ER utilization rate in their cohort, the payers is going to stop using them or the hospital going to stop using them. Because that's against what they're using home health for.

So, we have several partnerships with home health agencies that do two important things. The home health agency registers their patients on service with us. Every time they do an intake on a new patient, one of the intake process is they notify us that this patient, Patient A, is now on their service. We register that patient in our 911 computer aided dispatch system and if, and what we find more often than not, when that home health patient calls 911, they're flagged. And we take the call just like we would any other 911 call. But we also dispatch a community paramedic to co-respond with our ambulance. And then, simultaneously, our 911 center calls that home health agency and says “Hey ABC home health to MedStar listen. I want to let you know Patient A just called 911 for difficulty breathing. Tim, our on-duty community paramedic, is on the way to the scene. He'll call you in about 15 minutes once he does an assessment.”

So now the home health agency can contact their on-call nurse who brings up Patient A's medical records on their homecare homebase system, or Kinnser, or whatever they're using. So that when Tim calls the on-call nurse at 2 o'clock in the morning and says “Yeah. You know what. He's got you know 2 pillow orthopnea and he's got rales at the bases. You know, blah blah blah. 12-lead looks good, his vital signs are relatively stable. We're going to start IV. Give him so Lasix. Stay here for about half an hour with the ambulance or so, or however long we need to. Measure urine output and can you come see him tomorrow. And we don’t take him to the hospital. So, the home health agency benefits from avoiding an avoidable ER visit. Good care coordination I'm seeing and now they can follow up with that patient the next morning to make sure that they're stable. Maybe they need to adjust Lasix. Maybe there was some educational gap. Work with the cardiologist, whatever the case might be. So, that brings huge value to a home health agency, and they pay us for that type of on-scene care coordination from a 911 call.

But then there's a second service that's part of that expanded role and the home health agency can call us on a 10-digit hotline into our 24-hour 911 center and say “Hey Patient A just called here it's 2 o'clock in the morning. They’re complaining about a little bit of difficulty breathing. They didn’t call 911 but they called us because they didn’t know what to do. It’s going to take us 2 hours to get a nurse out to the house or quite frankly it's too expensive for us to pay a nurse overtime for 4 hours minimum pay to go out and assess this patient. Will you guys please send the on-duty community paramedic to do an assessment and call me?” And we do that. And to give an example of how often that is used so far, we've had about 3,700 home health patients registered in our system. 72% of those 3,700 patients have activated the 911 system, which is not surprising but when you start putting the numbers to it you can really say wow that’s a lot of activations and that makes a lot of sense. So, those are the calls that we're sending this community paramedic to along with the ambulance and doing the on-scene care coordination. And when we do that, only about 51% of the time are we actually transporting someone to the hospital. Because the rest of the time we're able to mitigate it on-scene, care coordinate with the home health agency, and not take him to the emergency room.

In addition to that, the home health agencies have asked us about 600 times to go see an episodic case. Middle of the night, weekends, even during the day if they’re super busy. And when we go to those calls, only about 6% of those patients end up needing to go to the emergency department. We mitigate in on-scene and really just become that service level extension of the home health agency.

So huge value to the home health agencies. We do the same thing with Hospice agencies for the same reason. We do it almost the exact same type of program for multiple Hospice agencies to prevent patients from going to an emergency department who were on Hospice, and it works really well. The patients benefit, the home health agency benefits, and certainly we benefit because we've changed our model and we're getting revenue by bringing more value to the rest of the health care system.

That sounds like a major shift in utilization reduction

Yeah absolutely, and we see that across all of our programs. You know, for years, EMS agencies were only reimbursed if we transported someone to the hospital from a 911 call. And what we've been able to do over the last decade is really, really explain to the payers, Medicare, Medicaid, commercial insurers, anybody who will listen, that all you're really doing is incentivizing us to spend your money. Because we know that only about 10% of the 911 calls that we respond to are truly life threatening. Another 20% probably need acute care right now at an emergency department. But 70% of the calls that we respond to can probably, and we're showing more and more, can be mitigated on scene, referred to another health care resource, whether it's urgent care, or primary care, self-care at home, follow up with your doctor, and that navigation as opposed to transportation is what is starting to be reimbursed. And really bringing more value to not only the payers but care management organizations, ACOs, IPAs who are in a shared risk arrangement with payers, and that's really the transformation that's occurring with EMS.

What do patients seem to want when they call 911?

What do patients seem to want when they call 911? That is the gold ring question, and it probably falls into two types of calls. The type of call where the patient truly feels or knows that there is a life-threatening medical emergency occurring. Dad is unconscious and nonresponsive. The kid is unconscious, unresponsive. Toddler fell out the window. Motor vehicle crash with a rollover and ejection. You know, those types of calls fall into that 10 to maybe 30 percent bucket where yep, this is a true emergency, we need somebody here to stop bleeding, start breathing, start pressing on the chest, you know, whatever it’s going to take to sustain life until they can get definitive care in the hospital. And that's great. Some patients really need that, they want that, that's why they call.

What we're finding, especially during the pandemic, it was really accented through that process, is a lot of patients called 911 to see if they needed to call 911. Because they don’t what's going on. So, you know, a little bit of difficulty breathing, or their vomiting, or they just don't feel well, or is it a kid with a fever, and you know they want someone to come to their house, who they trust, who wears a stethoscope around their neck, who has an EKG machine, who can check blood sugar, who can you know check oxygen level, to see do I really need to go to the emergency room or not. Or can you do something for me now that A, reassures me, B, maybe fixes the problem that I'm having so that I can go to my own doctor. The classic case in that is a diabetic, where you know somebody goes into insulin shock, and we get there, and they're stuporous, or they're unresponsive, and we check their blood sugar, and it's 30, and we start an IV, and we give them D50, the wonder drug, they wake up. We, you know, have the family make them a peanut butter and jelly sandwich with, you know, marshmallows or whatever, and that patient does not need to go to the emergency room. And we checked their blood sugar rates now, you know, 110. They need to see their endocrinologist because maybe they need to have some adjustments with their insulin or whatever the case might be, or their diet, but we don't need to bring those people to the ER. And they wanted to know that. But we fixed their problems. Same thing with asthmatic. Same thing with a number of things that we can correct in the field so that they can now go see their normal care provider.

We had a case recently that just typified this where we had a diabetic who the family called because his blood sugar was showing high, and we found that, in fact, his blood sugar was like you know 300 and normally we would take that person to the hospital. Hydrate him. There’s not a lot we can do. Where the hospital is going to see him. An ER doctor who doesn’t know that patients are going to run a while bunch of tests, and be concerned about DKA, and doing all sorts of stuff. But what we do instead, is now we call this endocrinologist and say “Hey. We’re here. We started IV and we’re hydrating them. His blood sugars 300. What do you want us to do? Do you want us ...” And he says “Oh. His blood sugar is only 300? Yesterday when he was in the office it was 450. So, he’s doing better.” It’s just when you connect the person with their PCP, who knows that patient, you get better decisions that are patient centric. So that, you know, patients want to know that they're going be OK and there you go. And I think that more and more that's the role that we're starting to fill.

Matt, this is very reminiscent of an era when Providers would make house call visits to their patients.

And we facilitate the doctor doing the house call. Especially today with telemedicine and all sorts of different things, we can be in the home, whether it's on a 911 call or an episodic request by the payer or by the physician practice or whomever, and telemedicine the doctor in. And say OK, here’s the vital signs, here’s the 12-lead, here’s the blood sugar, here’s the SA02. And we can be that extension of the physician where he or she can still be in their office, they can still be at home if it’s on the weekends, or whatever. They don’t have to go out, we can help facilitate that and just again bridge that gap between the patient and their physician.

Let’s talk about Emtiro Health. Tell us about what you've been doing and how it's been going lately

Great! So Emtiro Health is a population health management company based in Winston-Salem, NC with a specific focus in working with the Medicaid population there's a lot of companies and groups out there that focus on Medicare, Medicare Advantage, other commercial insurers and where we have really found our niche is supporting providers and patients in their move towards value in the Medicaid space which is something that’s a little bit new and a little bit different. Emtiro was born by two not for profit companies with a 20 year experience in working with the Medicaid population. North Carolina specifically has for 25 or more years had an enhanced primary care case management program that was really overseen by the Department of Health and Human Services and a number of years ago now, about nine years ago, there was an emphasis on moving the state's Medicaid Program towards managed care and after many pauses and delays and an even a suspension along the along the way, we finally have gone by with the Medicaid managed care program last July. And we are still in the fairly early phases I think everybody across the state has learned a tremendous amount including Emtiro and we are still rolling out new components of the Medicaid managed care program in North Carolina but with the change that we saw coming with what Medicaid managed care was going to bring to providers, the impact it could have on our local communities and the patients that we had served for a really long time, there was really a group that came together that said there's a different vision that needs to be had, This is an opportunity for us to partner with and just do Healthcare differently for this population specifically. And so that's why we decided to form Emtiro Health and really make the bridge across the bridge from the old Medicaid program to now the Medicaid managed care program.

The managed Medicaid program in North Carolina went live in July 2021. How has this start up then and how are things proceeding?

So I have to say that overall I think the program implementation has gone over incredibly well. I think, one our Department of Health and Human Services did a tremendous amount of work and looking around at other states to see kind of lessons learned. North Carolina was really the last big state to transition to Medicaid managed care so there were a lot of learnings that could have happened over the last 20 to 25 years that other states have gone through this type of transition. I think we've learned a tremendous amount. I think we learned the importance of data flow and that being accurate from the get-go. I think we learned some hard lessons potentially particularly around patient attribution which was it always going to be important in any value space regardless of the payer because that's how we collect quality data and have to report out on it and ultimately payments get tied to those types of things. And so overall I think generally it went smooth. Of course, we didn’t have as many patients self-enroll as maybe we would have initially liked but we’re still, again, kind of in the early phases so we rolled out the first phase which is the standard plan we are still looking ahead now towards December 1st of 2022 who were going to be rolling out tailored plans which is a specific program that is designed for the this more severe behavioral help mentally ill patient population that is going to be served by Medicaid going...]]>In this episode, we have a conversation with Kelly Garrison, President and CEO of Emtiro Health, about the leap into managed Medicaid care in North Carolina and how to support providers that participate in value-based payment arrangements for Medicaid populations.

Let’s talk about Emtiro Health. Tell us about what you've been doing and how it's been going lately

Great! So Emtiro Health is a population health management company based in Winston-Salem, NC with a specific focus in working with the Medicaid population there's a lot of companies and groups out there that focus on Medicare, Medicare Advantage, other commercial insurers and where we have really found our niche is supporting providers and patients in their move towards value in the Medicaid space which is something that’s a little bit new and a little bit different. Emtiro was born by two not for profit companies with a 20 year experience in working with the Medicaid population. North Carolina specifically has for 25 or more years had an enhanced primary care case management program that was really overseen by the Department of Health and Human Services and a number of years ago now, about nine years ago, there was an emphasis on moving the state's Medicaid Program towards managed care and after many pauses and delays and an even a suspension along the along the way, we finally have gone by with the Medicaid managed care program last July. And we are still in the fairly early phases I think everybody across the state has learned a tremendous amount including Emtiro and we are still rolling out new components of the Medicaid managed care program in North Carolina but with the change that we saw coming with what Medicaid managed care was going to bring to providers, the impact it could have on our local communities and the patients that we had served for a really long time, there was really a group that came together that said there's a different vision that needs to be had, This is an opportunity for us to partner with and just do Healthcare differently for this population specifically. And so that's why we decided to form Emtiro Health and really make the bridge across the bridge from the old Medicaid program to now the Medicaid managed care program.

The managed Medicaid program in North Carolina went live in July 2021. How has this start up then and how are things proceeding?

So I have to say that overall I think the program implementation has gone over incredibly well. I think, one our Department of Health and Human Services did a tremendous amount of work and looking around at other states to see kind of lessons learned. North Carolina was really the last big state to transition to Medicaid managed care so there were a lot of learnings that could have happened over the last 20 to 25 years that other states have gone through this type of transition. I think we've learned a tremendous amount. I think we learned the importance of data flow and that being accurate from the get-go. I think we learned some hard lessons potentially particularly around patient attribution which was it always going to be important in any value space regardless of the payer because that's how we collect quality data and have to report out on it and ultimately payments get tied to those types of things. And so overall I think generally it went smooth. Of course, we didn’t have as many patients self-enroll as maybe we would have initially liked but we’re still, again, kind of in the early phases so we rolled out the first phase which is the standard plan we are still looking ahead now towards December 1st of 2022 who were going to be rolling out tailored plans which is a specific program that is designed for the this more severe behavioral help mentally ill patient population that is going to be served by Medicaid going forward.

So it sounds like Emtiro Health is moving into the behavioral health space?

We are. So I think one of the big emphasis that the Department of Health and Human Services had was really whole person care. The kind of adage probably many have heard is that you can't separate the head from the body and we know that any patient that has any type of behavioral health issue even though it might be a mild to moderate depression or anxiety, that can still have a long-lasting impact on their physical health and vice versa. And so in the Medicaid managed care program the mild to moderate patients are largely incorporated into the standard plans so we’re actually holistically treating patients in the standard plans now and then after December we're going to have tailored plans which are going to be separate essentially health plans that are going to be responsible for the management of about 160,000 patients across the state that are the more severe, so it is the IDD population it’s the traumatic brain injury what most would just kind of lump into a broad category of SPMI or severe and persistently mentally ill. And so and then those providers and those plans are responsible for not just the behavioral health component, but also the physical help component for those patients. And each of those arrangements, both standard plans and tailored plans are under capitated payment arrangements for delivering whole patient care,

I'd like to know more about how Emtiro Health interacts with patients. Can you tell us more about that engagement?

Absolutely. So we have kind of an interesting business model. So the state actually put out this Clinically Integrated Network or other support provider and we really fall into that other support provider space and so we work directly with providers to help them in their negotiations with the pre-paid health plan. We don't actually negotiate the contract on their behalf. And we support the operationalizing of that contract in a number different way. So we have one model where we work directly with patients. We provide care management services from the prevention and wellness component all the way up through transitions of care to the most complex care management that can be provided that is NCQA recognized and that kind of thing. And then we work with providers who a lot of I think that we can see is that a lot of providers have had some experience delivering chronic care management or transitional care management especially for the Medicare population because those codes have been out there for a while. So they had a little bit of practice. And so we say you know care management that is delivered locally at the provider level is where care management is most effective. And so we support other providers in that realm where they're delivering that prevention and wellness, care gap closure, some care coordination functions but they're not quite ready for the true complex care management what we're talking about spending you know 45 minutes on a conference of health assessment and developing a patient-centered care plan. And so we have a hybrid model where we support them with those more complex and transitional care patients. And then the final kind of model that we and how we work with providers and patients is really supporting them through all of the data and technology requirements. So for the first time really in North Carolina, Medicaid providers are responsible for data that’s a very different space than they've been in. So if a provider were wanting to be Advanced Medical Home Tier 3 practice under this Medicaid managed care arrangement, they’re responsibility for data aggregation and claims processing or accepting claims files and beneficiary attribution files pharmacy lock in files and others from now potentially 5 different health plans. They’re responsible for risk stratifying their patient population and they’re responsible for all of the quality reporting, both in terms of hedis measures but also care management productivity. And they have to report that back to the plans. And so since that is such a new space and it's just incredibly complex, Emtiro works with providers to provide that technology solutions, so if they are ready and equipped to deliver all aspects of care management on their own, we can come alongside them to support them with the data and technology platform that they need in order to be able to ultimately manage their patient population and document all of the care management and care coordination activities and be able to report those back to the plans.

So how does the data flow? How would one visualize the movement of that patient data?

Absolutely! So this is where you know we should probably have a whiteboard and lots of different colors of markers, but so ultimately the plans house the data. Providers are billing the plans the they have a partnership with the state in which they get the beneficiary attribution files. And so patients self-select into a prepaid health plan or they are auto assigned to one of the pre-paid health plans here in North Carolina. Those files come to Emtiro and in some cases they are also mapped over to our provider partners. Ultimately we believe that the providers own the data, we are the housekeeper of the data and the ones that can help them make sense of it. And so ultimately our goal is to accept all of this data standardize it, normalize it into a digestible format which is populated in our information system ultimately we're doing all their quality reporting and care management documentation and then give that back to the payors in the formatting that they need it. But the probably the most complex part of it is being able to, one, pull all of that data in, standardize it, normalize it, marry it up with the real-time clinical information that we pull out of the provider's EHR so that care management can be done most effectively. I think a lot of times what we have seen is that we get claims files, which is great because it's a little bit of a map of where the patient has gone, but if a patient was seen, for example, in the emergency room and they had high blood pressure and we know that they followed up with their PCP it would be nice to know what the high blood pressure is. But because we are pulling that real-time clinical information directly from the providers EHR, we’re able to have all of that information in one spot for the care manager, for the provider, for anybody who is on that care team to see and ultimately be able to manage the patient.

So to provide so background, can you explain to us how a prepaid help plan works?

Absolutely. So it's funny the best thing that I know to do is to really talk about what were the goals. So obviously the Medicaid Program is kind of a dually funded program. They’re - part of the funding for Medicaid comes from the federal government and part of it comes from the state. But the state puts in about two-thirds of the total funding. So the states actually have a pretty good amount of discretion as to how the Medicaid Program operated in their state. And so I like to say that there used to be an old commercial here in the Triad and they would say you know I'm the Father of the Bride I write checks. And ultimately that is what our general assembly wanted they wanted budget predictability around the Medicaid Program and the way to do that was to ultimately roll it over to prepaid health plans. So is just kind of a North Carolina term for managed care company or an insurance provider. So we’ve seen organizations like Blue Cross Blue Shield and United and others that are very familiar to anybody in North Carolina that have rolled out now a Medicaid plan. And so the state provides funding to each plans based on what their population is and then they are responsible for paying providers, both for claims but then also a couple of additional payments that providers are eligible for. So one, just by seeing Medicaid patients, they have an enhanced per member per month for having attributed Medicaid patients on their panel. The second bucket of payment on top of their fee-for-service that providers are eligible for is that they can attest to and act as an advanced medical home tier 3 practice, which basically says that we have the capability or can partner with somebody to bring the capabilities to the table, like Emtiro, to provide the care management at the practice level, do all of the quality reporting and meet quality measures and they negotiate an additional per member per month payment for those for their patient population. And the final that we are moving into now, that we’re six months in is based on quality. So we’re seeing performance incentives based on kind of core standard hedis quality measures, trying to move the needle along. So North Carolina has four statewide health plans - United Healthcare, Blue Cross Blue Shield Healthy Blue, AmeriHealth Caritas and WellCare and then we have a local, what they call a provider-led entity or PLE, you often will hear it called and that is based on a couple of different regions so in North Carolina that is Carolina Complete Health and Carolina Complete Health is a provider-led entity with the backing of Centene, which is a nationally known Medicaid plan but it was actually a joint venture that was formed by providers and is led by providers here in North Carolina and their operating in three of the six North Carolina Medicaid regions.

So given your relationship with providers, how have you gone about fostering good working relationships with payors?

So I think, early on we realized just how important having good close relationships with the payors is for a number of different reasons. So the first reason being that the plans for practices that are not attesting to tier 3 that Emitro are supporting, the plans are actually taking on the responsibility of managing the Medicaid population. But the Medicaid population in particular is fairly transient. So they move and they may move providers and so all of a sudden we’re having to transition patients from their care management being provided by the health plan to now the care management needing to be provided Emtiro. And so facilitating warm handoffs at the patient level was going to be of utmost importance, The second way is really an understanding how Emtiro works with providers because I think at the end of the day, we're all trying to drive quality and value forward both the plan, the provider, Emtiro, and ultimately so that we're getting the best outcomes for patients and doing it in a way that is as easy and as seamless as possible for providers. And so, one, I think we have worked really hard and diligently to foster relationships with the plans, one so that we can align on quality. What we didn't want to do especially is to really chop up the population anymore. So just because now we've gone from the single Medicaid payor to five Medicaid payors, we wanted some standardization of quality across those. We've had to develop incredible strong relationships with the plans as it relates to data flow because they do own and house the data a lot of times and we needed to have good understanding of how the data was flowing, at the frequency at which it was going to be coming to us, any data quality management issues that we've had, we had to have really good close working relationships with them. And finally is understanding Emtiro’s role in this population health and Medicaid managed-care space, and really quite frankly, what our business model is because there are providers across the state and even broader than just North Carolina alone now that are trying to find how they move on the value continuum. And I think we often seen providers asking themselves the question of what does it take in order to move this value continuum? What does it take specifically in the Medicaid space and how do I do that? And really saying yes we can provide care management and then move along the continuum to where you're doing some of this work and ultimately driving care management delivery that is local and facilitating that and really teaching providers how to provide local community-based care management for the Medicaid population in particular where we're dealing with a lot of social determinants of health issues and other disparities that are just so local that it can be hard to provide it in another way. And so we've been able to work successfully with providers and understanding that model so as providers are willing to take on more risk for their Medicaid population, they now have resources that they can refer to to facilitate that because the state is trying to drive providers and plans toward risk and so they’re kind of pushing the plans to push it down to providers but the plans can't do that unless they're comfortable with the providers that are that are providing that support to these patients. And so a couple of key areas there where we work really closely and developing those relationships with the plans as a referral mechanism for providers that are seeking solutions.

Where does a provider begin the journey to be an effective giver of care who is not only going to have the best possible outcomes for the patient but also most effective in the system and for themselves so we can optimize healthcare in the US? What can a provider start doing right now?

That's a great question and there’s a couple of things that really jump out at me when you when you asked that. I would say the first thing it's commit to the move to value. This is not really a space where you can sit on the fence but for so long because the move towards value even in the Medicaid space is happening very quickly. Most states, if we look at Medicaid in particular have had 20 to 25 years of managed care experience before we're just starting to see states like Washington State and others move towards having providers owning some risk in the Medicaid space. In North Carolina we're not going to get a 20-to-25-year runway. We really are looking at just a couple of years before that expectation is going to come even so much North Carolina is one of four states that is participating in a state transformation collaborative that’s kind of under the umbrella of the HCP LAN or health care payment learning in action network. So I think we can expect that move towards risk is going to come really quickly and it takes a commitment on behalf of the providers and really anybody that is in their practice because I think that what we believe is that value is driven and you can begin to move toward accepting risk when everybody is involved in the process and has a clear vision of what the outcome should be. So having everybody from the front desk person onboard to the nurse that is responsible for rooming the patient all the way through the referral coordinator that might be the last person seeing the patient at the end of the door or out the door. I think the second thing is understanding the help her ecosystem that surrounds them so all of the people that are touching their patients. So whether that is providers in the inpatient and outpatient setting understanding the hospital-based transitions that take place and what's happening there. Building out community-based relationships that are specifically in the Medicaid space and I know there's a lot of conversation happening just globally around addressing social determinants of health, but specifically in Medicaid there are different resources a lot of times that are available to patients that are on Medicaid or even uninsured and so understanding that ecosystem and who is interfacing with your patients. Because again goal alignment, to the extent possible, I think is...]]>d92e1925-0bf2-4cdd-9778-c3f19fe6e3f1Thu, 16 Jun 2022 00:00:00 -050022:20falsefull88Derrick Stiller - How Quality Drives Success in Value-based CareIn this episode of the Move to Value Podcast we have a conversation about quality and its importance as a driver of success in value-based care with Derrick Stiller, Senior Director of Value Based Contract Operations at CHESS Health Solutions, where he leads the Contract Operations and Clinical Documentation Integrity departments as well as Quality Services.

Today we want to talk about quality and its importance as a driver of success in value-based care. Can you share with us what goes into Quality performance monitoring, data collection, and reporting?

Definitely. Quality is very important in value-based health care. It’s how you get started in the game. Organization can’t move to more advanced contracts without performing well in quality. And then you also won’t have dollars to reinvest in the infrastructure it takes to move on to the more advanced contracts that include more nurse positions that cost more, advanced data that’s required to bend the cost curve. So, it’s very important. You need the quality dollars. You need to perform well. And then of course quality is designed to have better care for the patient. So that’s ultimately what we’re in for. It’s also great because for the most part it is very easy to measure and track over time. Very objective. There are patients who qualify for a measure, that’s your denominator. Patients that are compliant for the measure, that’s your numerator. I went to public school but even I can figure out numerator divided by denominator equals performance. So that’s a very objective measure that people can kind of really grasp. You can see what levers make changes.

Payors are good about sending quality summaries that show current performance compared to target and patient level detail. This is important because you want to identify the non-compliant members. Then you need to come up with a strategy. One thing we’ve helped, found helpful, is adding gaps to target. Some payors provide that, some don’t. But it’s great and you can do a simple, VLOOKUP formula, or some formulas to provide information to figure out what that gaps to target is. And then, that allows you to really focus and find the patients that are going to move the needle for you. Traditional Medicare ACOs are a little different though. It’s definitely a different animal. You have to have the infrastructure to be able to produce these reports yourself. So, most of the time, when I’m talking today, a lot of, it’s going to rely on contracts that are in the MA space versus traditional Medicare ACOs. But of course, we do have traditional Medicare ACOs at CHESS, and we do produce quality data. But it is a little harder than just relying on the payors.

So then, you know, the question becomes what do we do with this information once we have it. So, you need to develop a process that will ensure non-compliant patients become compliant. This starts way upstream. You want to audit templates, such as the annual wellness visit template, that is used for patients. You want to standardize it across the board. You don’t want 30 providers having 10 different templates that they use. You want to make sure quality measures are presented to the provider at the point of care. You want to make sure that data is captured in discrete data fields. What is that, right? That’s some jargon. But that’s just the, think, yes no; integer 1 to 10. Not free text. So, it’s not a, when you’re filling out a form online, there’s text, there’s fields that you can just type in. They’re pretty rare these days because you want, the data folks want to be able to pull the information and compare it and not have, they don’t want to have to have a computer and AI to analyze what’s typed in the field. So discrete data is very important. So, this ensures great performance, and allows you to really take advantage of automated...]]>In this episode of the Move to Value Podcast we have a conversation about quality and its importance as a driver of success in value-based care with Derrick Stiller, Senior Director of Value Based Contract Operations at CHESS Health Solutions, where he leads the Contract Operations and Clinical Documentation Integrity departments as well as Quality Services.

Today we want to talk about quality and its importance as a driver of success in value-based care. Can you share with us what goes into Quality performance monitoring, data collection, and reporting?

Definitely. Quality is very important in value-based health care. It’s how you get started in the game. Organization can’t move to more advanced contracts without performing well in quality. And then you also won’t have dollars to reinvest in the infrastructure it takes to move on to the more advanced contracts that include more nurse positions that cost more, advanced data that’s required to bend the cost curve. So, it’s very important. You need the quality dollars. You need to perform well. And then of course quality is designed to have better care for the patient. So that’s ultimately what we’re in for. It’s also great because for the most part it is very easy to measure and track over time. Very objective. There are patients who qualify for a measure, that’s your denominator. Patients that are compliant for the measure, that’s your numerator. I went to public school but even I can figure out numerator divided by denominator equals performance. So that’s a very objective measure that people can kind of really grasp. You can see what levers make changes.

Payors are good about sending quality summaries that show current performance compared to target and patient level detail. This is important because you want to identify the non-compliant members. Then you need to come up with a strategy. One thing we’ve helped, found helpful, is adding gaps to target. Some payors provide that, some don’t. But it’s great and you can do a simple, VLOOKUP formula, or some formulas to provide information to figure out what that gaps to target is. And then, that allows you to really focus and find the patients that are going to move the needle for you. Traditional Medicare ACOs are a little different though. It’s definitely a different animal. You have to have the infrastructure to be able to produce these reports yourself. So, most of the time, when I’m talking today, a lot of, it’s going to rely on contracts that are in the MA space versus traditional Medicare ACOs. But of course, we do have traditional Medicare ACOs at CHESS, and we do produce quality data. But it is a little harder than just relying on the payors.

So then, you know, the question becomes what do we do with this information once we have it. So, you need to develop a process that will ensure non-compliant patients become compliant. This starts way upstream. You want to audit templates, such as the annual wellness visit template, that is used for patients. You want to standardize it across the board. You don’t want 30 providers having 10 different templates that they use. You want to make sure quality measures are presented to the provider at the point of care. You want to make sure that data is captured in discrete data fields. What is that, right? That’s some jargon. But that’s just the, think, yes no; integer 1 to 10. Not free text. So, it’s not a, when you’re filling out a form online, there’s text, there’s fields that you can just type in. They’re pretty rare these days because you want, the data folks want to be able to pull the information and compare it and not have, they don’t want to have to have a computer and AI to analyze what’s typed in the field. So discrete data is very important. So, this ensures great performance, and allows you to really take advantage of automated processes that are offered to reduce the manual work.

Then you have to design processes to capture proof that members are compliant where payors say they’re not. So, a lot of times, you’ll have a payor tell you that someone is missing a colonoscopy, and the patient tells you that they’ve had one of those five years ago. Well, it turns out they had it at a different health system, and they had it when they were on Humana and now they’re on Blue Cross. And Blue Cross is the one telling you that they don’t, that they don’t have evidence of the colonoscopy. So, there’s something that has to be trigger for you to know that information and then you also need to know how to go gather that information. And that’s not an automated process, that’s more of a manual process. So, we want to cut down that as much as possible. There are also automated process that are best practice but there’s always records that are going to fall in the manual category. Unfortunately, large health systems struggle with manual processes because it takes so much due to how many patients they have attributed to them. But, we feel like there’s always a place for that.

What is the importance of having a robust quality team in value-based care?

Yeah, this really speaks to my last point about manual efforts. You need folks to perform manual chart retrieval. You need folks to perform telephonic outreach to get ahold of patients to make sure they get in. You need EMR subject matter expert to develop automated processes. From a clinical perspective, you need quality measures subject matter experts who design processes and suggest things like standing orders to automate a process. So, if a patient hasn’t had a colonoscopy in 10 years, there’s a standing order there for the provider when the patient does come in. A quality department can help greatly with that. Of course, as you can imagine, there’s resistance to checking boxes. You’ve got to connect the fact that it’s good patient care is why there’s a box there to begin with. And if you can achieve that, check the box or make the patient compliant, many times that’s going to lead for great outcomes for the patient and better quality of life.

You need someone that can communicate performance. Right? So, you need somebody that can sit in the boardroom and tell executives, and CMOs, nurse leaders, how they’re doing and have a discussion on how to get better at what they do. Maybe talk about processes that are in place and why a health system does something that you don’t understand. Just, kind of, as I’ve talked, and I’m sure I’ve missed things, I’m sure you can see that it takes a lot of expertise, and it is a lot of work. So, a robust team is very important. And there is the fact that increased quality performance is going to help you pay for those positions. So, it’s not just the cost of doing business necessarily. You should be able to connect performance and ROI on those positions.

Tell me about the consequence of data in Quality. What types of data are important and how is it most effectively captured? Can you provide examples of good data and bad or missing data? What is the impact of bad or missing data?

Great question. Many times, when you get your first reports for quality performance, it’s a little bit of a shock factor because you know you’re doing better than these reports say. You know that 75% of your diabetics are not out of control and do not have A1Cs greater than 9. So, kind of back to our point about a robust quality team, you need to find out where the breakdown occurs. And so, what we call them are gaps in data versus gaps in care. Okay. The hard work’s already done. We want to capture that and make sure you get credit for it. Okay. So, it’s very important that that happens. We want to make sure that information is in the right place in the EMR. It’s a real shame when excellent quality patient care is provided, but the health system is not rewarded for their work. You want to set up templates that capture information and fields that can easily be reported. Back to my discrete data comment. Patient matching is a big problem. In my opinion, if we could make strides here, I think, patient care and patient identifying opportunities, it’s kind of out of the quality arena, but utilization and rising risk folks, there’s a lot of time a disconnect between what the payors are telling you versus what’s in your EMR. And one, the fundamental issue there is that the payor is operating off of a member ID that they provide. It’s unique to them. An EMR is working on an MRN, medical record number, that is unique to the EMR. And they don’t share. So of course, you could ingest patient member IDs from payors, but those change and folks come in and check in is entering a number. And it’s just a very cumbersome process if you will. That I think some type of creation of a unique ID for all of us. So obviously you aren’t going to put social security number on there, right. Now, it’s interesting, I’ve read a lot of folks are finding success using email addresses because the nature of an email address is unique. But anyways, I’m kind of digressing a little bit. But I think that’s a big problem.

So, what happens is with quality, in the quality space, missing data is very often caused by the matching problem. The consequences are frustration by patients and providers. They know the work’s been done but you keep bugging them about it, right. So, there’s patient abrasion, there’s provider abrasion, there’s also unnecessary spend due to duplication of services. Right. So, you’ve got to get a colonoscopy, you’ve just had one four years ago, but somehow you talk them into getting one because you can’t find evidence of it. Well now you’re spending more than you should. No cost to the patient, but it’s cost to the health system. So, there are unnecessary spend due to that. And then poor contract performance, you know. I can send in 10,000 lines of quality data to close quality measures back to the payor, but if they don’t know who that belongs to, you’re capped at who they find matches for. So big big problem. Sounds like of fundamental and easy, but it’s hard to change. It really is. It’s something that I’ve been kind of passionate in my six years with CHESS about and have not made the strides I’d like, but it’s an interesting space there.

What advice do you have for our listeners who have been struggling with their quality performance?

Yeah. It’s interesting. I think there’s quite a few things that can be done and they’re not super complex. So, I think it speaks to the folks out there who may find themselves in some early contracts that are quality only. But it’s also, can really help in the very advanced contracts. You know, CHESS has contracts all along that continuum. And so, we find a lot of these items that I’m going to admit, that come to mind, work across all of those contracts.

So, an AWV outreach strategy is crucial. We want to make sure that all patients get in to see the doctor in the calendar year. And the earlier, the better. So, some payors allow you to do it on a calendar year basis. Traditional Medicare is a little harder. They want it, you know, eleven months plus a day from the last one. And, you know, it’s not good practice to have an annual wellness visit in February if you just had one in November. You know, that’s not getting a true picture of an annual visit, right. But I think it’s very important to have the infrastructure set up where you can outreach every patient that’s on your attribution filing. And that can be done different ways. You know, CHESS hubs that. Right, so we have Patient Care Advocates who make those phone calls and do that outreach. But you could also push those lists to the patient, to the provider offices, right. So, you can work closely with them and send them only their patients and ask them to do the outreach. Even better, you can have the patient schedule the following year’s annual wellness visit when they’re in their doing theirs for this year. That’s really best practice. And we’ve seen offices that use that are by far the best performers.

So, make sure all data is captured in discrete data fields. Told you about that earlier. Want to make sure the templates are set up for that. That’s going to allow for you to have the automated processes and cut down on a lot of the manual work. Work on your patient matching, I’d say, is probably another one. You want to develop clinical extracts that, so that’s directly related to the patient matching because the payor needs to know who you’re sending data for and they need to be able to connect that and again kind of the fuzzy matching of name, date of birth, just doesn’t cut it. It takes some pretty sophisticated algorithms to figure that out. So, unique IDs are very important.

So, the clinical extracts will lighten the load for manual labor. See there’s a theme here, right? It’s setting yourself up for success to cut down on manual labor. And then train employees performing outreach on motivational interviewing, I think. That’s probably a must. Get folks to do the behavior that you want them and change their behaviors for the good. And then finally I’d say as the year winds down and your automated processes have taken place and you still find yourself with a area for improvement and you’ve done the things I’ve talked about, what you want to do is go in and say okay for breast cancer screening I need to close 10 gaps to get to a 4-star rating if that’s my goal, or if a five-star rating is my goal. And be able to identify the 18 people that you can get your 10 from and go after those folks. Make sure that you’ve called them, asked them have they done it elsewhere, where at. Google the phone number, call, ask if the facility will send you a copy of the screening. Get that put into the EMR in the right place so next year the automated process catches it.

So, there’s a lot of things that can be done there. But we’ve really found that this manual outreach at the end, this focused outreach, will get you over the hump. It really, it’ll take a 3.75 performance to a 4 or a 4.25. And many many times, there are patients out there that you can close. And a lot of times, like I said earlier, the work’s already been done. So, I think that’s where I’d end it. I think there are, those are some very practical steps that you can take, and you can take them in a small rural health system, or a single provider clinic, or everything to an academic medical center.

There’s a bit of an oversimplification when you talk about one portion of value-based care. Right, so we’re talking quality. A lot of times, some quality measures will add in utilization measures like an inpatient admission per thousand measure or plan all-cause readmission. So, I don’t want, everyone to think that I’m oversimplifying, but I think if we’re going to talk quality, that’s where we land. This is what we talked about today. There are many other parts and pieces. Maybe we can have a conversation at another time about another topic, but I would say that. I don’t want folks to think that it’s easier than, I’m making it sound easier than it is. It’s hard work. It really is. And you have to have buy in all over the place, from the top down, to get folks to do that. The stars align, you can have great performance, do amazing work for your patients, and also for your organization.

Dr Kaplan has additional Motivational Interviewing resources available here: https://www.guilford.com/author/Sebastian-G-Kaplan

If a provider would like to incorporate MI into daily practice, where would a good starting point be?

Well, a few places to start. I mean, if people like to read, obviously there’s a lot of books out there on motivational interviewing. The two main authors are the founders of MI are William Miller and Steven Rollnick, and they have written many of the texts out there. And its now, the main motivational interviewing text is now in its third edition. They’re in the process of writing the fourth edition currently. And so that’s, it’s a great book. It’s not overly jargonized or dense with all kinds of statistics. It’s a really approachable, easy read. Guilford Press is the one that is the publishing company that has the majority of MI books out there. Both in general and kind of a general sense, but also there’s, like there’s an MI in healthcare book that’s out there. There’s MI for all kinds of, you know, applied settings and problems. So, that would be one.

The other thing though, and is to find a MI trainer, you know, like myself. Or there’s a, we have a website, motivationalinterviewing.org. And on that website, there are, you know, hundreds and hundreds of trainers all over the world and you can reach out to somebody and we’re a very friendly, you know, friendly bunch and we’d be more than happy to steer people in the right direction.

A lot of people go to a workshop, you know, one-day or two-day workshop. You know, I think there’s a lot more flexibility in training now with Zoom kind of experiences and that sort of thing. But, and so, there’s some reading, a workshop would certainly be useful. But ultimately what we know about training, there’s been some studies done on the training of motivational interviewing specifically, is that for those people who really want to get it and really want to develop proficiency with MI, what’s most needed is somebody who listens to samples or examples of MI conversations that the learner is trying to do and giving that person feedback. You know, getting that coached feedback is really the key.

What is the righting reflex and how can we avoid that trap as a provider?

Yeah, so the righting reflex, this is something that Miller and Rollnick came up with, you know, as far as a term. And righting it’s helpful to know is r-i-g-h-t, so like the word right, to get it right, or to do right. So, the righting reflex. And it is, it comes from a very well-intentioned place. Any healthcare provider, or not any, I would imagine the vast majority of healthcare providers went into whatever field of specialty that they’re in at some level because they wanted to be helpful to other people. And over the course of our training and our experience, we probably know a lot about what is helpful for humans to be healthy. And so, what the righting reflex is, is when is the potential for any healthcare provider to jump in really quickly in a conversation with all the reasons why a person should make a change. And really kind of focusing solely on that information giving, or the sort of encouraging and cheerleading and all those types of things, that are, that still kind of maintain that traditional hierarchy of expert, patient, you should change because I’m giving you this information or because I’m telling you slash encouraging you. So that’s really what the righting reflex is. It’s not a, you know, a bad quality or characterological flaw. It is...]]>In this episode of the Move to Value Podcast, we continue the conversation about Motivational Interviewing with Sebastian Kaplan, PhD, who talks in greater detail about Motivational Interviewing, touching on empathy, provider burnout, and optimal patient care.

Dr Kaplan has additional Motivational Interviewing resources available here: https://www.guilford.com/author/Sebastian-G-Kaplan

If a provider would like to incorporate MI into daily practice, where would a good starting point be?

Well, a few places to start. I mean, if people like to read, obviously there’s a lot of books out there on motivational interviewing. The two main authors are the founders of MI are William Miller and Steven Rollnick, and they have written many of the texts out there. And its now, the main motivational interviewing text is now in its third edition. They’re in the process of writing the fourth edition currently. And so that’s, it’s a great book. It’s not overly jargonized or dense with all kinds of statistics. It’s a really approachable, easy read. Guilford Press is the one that is the publishing company that has the majority of MI books out there. Both in general and kind of a general sense, but also there’s, like there’s an MI in healthcare book that’s out there. There’s MI for all kinds of, you know, applied settings and problems. So, that would be one.

The other thing though, and is to find a MI trainer, you know, like myself. Or there’s a, we have a website, motivationalinterviewing.org. And on that website, there are, you know, hundreds and hundreds of trainers all over the world and you can reach out to somebody and we’re a very friendly, you know, friendly bunch and we’d be more than happy to steer people in the right direction.

A lot of people go to a workshop, you know, one-day or two-day workshop. You know, I think there’s a lot more flexibility in training now with Zoom kind of experiences and that sort of thing. But, and so, there’s some reading, a workshop would certainly be useful. But ultimately what we know about training, there’s been some studies done on the training of motivational interviewing specifically, is that for those people who really want to get it and really want to develop proficiency with MI, what’s most needed is somebody who listens to samples or examples of MI conversations that the learner is trying to do and giving that person feedback. You know, getting that coached feedback is really the key.

What is the righting reflex and how can we avoid that trap as a provider?

Yeah, so the righting reflex, this is something that Miller and Rollnick came up with, you know, as far as a term. And righting it’s helpful to know is r-i-g-h-t, so like the word right, to get it right, or to do right. So, the righting reflex. And it is, it comes from a very well-intentioned place. Any healthcare provider, or not any, I would imagine the vast majority of healthcare providers went into whatever field of specialty that they’re in at some level because they wanted to be helpful to other people. And over the course of our training and our experience, we probably know a lot about what is helpful for humans to be healthy. And so, what the righting reflex is, is when is the potential for any healthcare provider to jump in really quickly in a conversation with all the reasons why a person should make a change. And really kind of focusing solely on that information giving, or the sort of encouraging and cheerleading and all those types of things, that are, that still kind of maintain that traditional hierarchy of expert, patient, you should change because I’m giving you this information or because I’m telling you slash encouraging you. So that’s really what the righting reflex is. It’s not a, you know, a bad quality or characterological flaw. It is the tendency for us to want to be helpful and sometimes to kind of rush into that without really checking in first where the patient is in terms of their change process.

What are some roadblocks to watch out for when getting started with MI?

Well, so some roadblocks to get started. One roadblock would be, and this might be a situation where its actually harder for someone whose more experienced because they have had a lot more time to really like dedicate themselves to asking questions. And so that shift from question-centric conversation to reflection-centric conversation, that’s a real challenge. You know, Nurses, physicians, in particular that I’ve found just have a hard time making that shift because their so well trained to ask all these excellent questions. So that would be one.

I would say, you know, another trap is, you know, sometimes people will, even if they get the kind of change in style when using reflections initially, they, when it comes time to like talk about change itself and what “needs to happen for the patient to get better” it’s really easy to slip back into that here’s what you need to do kind of mindset. Now a provider might do it in a friendlier way, you know, a much more gentler, compassionate style. They might do it in that way. But, you know, it can be so easy to slide back into the ok and you know we know what you need to do now, right, so you need to do x, y, or z, and kind of leaving out the evoking style, drawing out from the patient what their ideas are about it.

Another thing that could be challenging is if you are working with patients and you’ve started to change your style, they may not be used to that. And so, it would be something where you kind of need to be patient with yourself, patient with the patients, as you’re adapting and adjusting your style because they might be more used to you being more of that expert in the room.

Is MI considered a best practice for optimal patient care?

Yeah. I’m glad you brought that up actually. You know, so yeah, that, as far, I was thinking more kind of barriers within the provider in a way, and you know that kind of sort of environmental or systemic barrier for sure would exist. You know whether it’s feeling like you don’t have enough time because you have, your primary care doc has, what, average of 7-9 minutes per patient. And so that’s another thing that, you know, we feel like if we don’t have that much time, well we don’t have time to sit and reflect on somebody’s story even for 1-2 minutes. Or maybe feeling like, you know, that they would need to have a lot more time to use that reflective listening style. And what we find, more so anecdotally certainly, is that there can be a lot of efficiency that comes with using motivational interviewing.

You know, if I spend 3 minutes telling a patient how they should change without finding out what their experiences are with change, or where they’re at with change, or what their thinking about change, I perhaps have wasted 3 minutes because maybe they know exactly what I’m already saying. Maybe they have tried these things and it hasn’t worked. And I should know that before lecturing them on it. And maybe they’re just not ready for change, and the conversation would be more helpful to be focused on that kind of exploring what would help them get ready to change as opposed to how to change. And so, we sometimes under the time crunch that many healthcare providers are in, we kind of you know unwittingly waste time actually. Because we want to, you know, get the job done, get the patient in and out. So that would certainly be another barrier is the time pressure, for sure.

You mentioned empathy in healthcare in your Move to Value presentation. Can you speak more on how empathy and motivational interviewing play a role in providing effective care?

Right, so the word empathy is you know, it’s one of these words everyone kind of knows what it means. Although it’s also easily confused with other words that are similar, you know, sympathy and compassion and things like that. So empathy, the way I think about empathy, the way I teach you know students and residents about empathy, is that it is a non-judgmental understanding of another person’s experience. It’s as if you are putting yourselves in another person’s shoes or seeing the world through another person's eyes. And that’s a, I’m quoting Carl Rogers there, a famous psychologist from previous century.

So, that is, the experience of empathy internally for the provider, the key thing with MI though is what we are trying to do is express it, express that empathy verbally. And that’s where the reflection comes in. So, a reflection, again, it invites a person to move on in the conversation, but it’s also a way, it is the way to express empathy. Questions are great but they don’t express empathy. And we know from a lot of different research, not just research on MI but researchers have looked into the impact of empathy in health care. Not just in, you know, mental health settings but in primary care settings and you know all kinds of other settings. And the more that patients rate their providers as empathic, the better outcomes. Whether its health outcomes or patient satisfaction scores or increased comfort and confidence in talking about difficult topics.

So, empathy in healthcare, is it’s one of those things that its, across specialty, you know, it’s just something to seems to really enhance the healthcare experience. And empathy is a real central part of motivational interviewing. You know, again, like that reflective listening is a way to communicate that kind of human experience. And you know, human beings really appreciate being heard, and listened to, and not being judged. And by the way, it’s important to note we’re also not saying that we necessarily agree with everything that people choose to do. You know, so I can talk with a young, you know let’s say a teenager who harms themselves. Right. Really concerning behavior. Concerns a lot of adults. They’re usually quite upset about different things in their life. And I can express a non-judgmental understanding about this kid’s experience and even about the ways in which harming themselves is helpful at some level. That doesn’t mean I endorse it, or I approve it, or I encourage it. But I can express an understanding of how that’s something that they’ve resorted to at this point. And also, curiously explore with them what they think about change and what other ways they might consider taking care of themselves. It’s a bit about empathy there.

Anything to add to conversation?

I guess it’s maybe addressing what is the most common challenge or barrier to go back to that question. And that is the concern about time. Is there enough time? Probably not. It certainly doesn’t feel like there’s enough time. Burnout is, for better or for worse, is, you know, well it’s for better in terms of we have shined a light on the problem of burnout in these last few years and COVID only you know brightened that light. So, and one of the sources of burnout for healthcare providers is just being on the hamster wheel and the lack of time and the pressure to do all this other stuff that they don’t feel is related to actually sitting down with people and helping them. And so, a lot of people I train are concerned about not having enough time.

And I guess, first of all, I’m not here to say that that’s make believe. So, starting there. But I guess then the question is in the time that you do have, what are the ways that you can maximize it? And because what a lot of people think that they need to do in the short amount of time that they have is they need to get to the punch line where they deliver the answer. And I would imagine any healthcare provider that is listening to this would connect with or agree with the idea that if the patient doesn’t leave that office with an intention or any kind of enhanced motivation to follow through on the wonderful ideas that were likely shared, then you know did that period of time, however long it was, did that serve a purpose. And if you, it doesn’t require a 45-minute conversation. In many instances, it can all it can take in many instances, and there’s evidence to suggest that, you know, MI is a brief intervention that only really needs a few sessions or a few conversations to show greater change than maybe more traditional methods. To just act as if you have more time and to almost take a breath and slow down, listen for a little bit, draw out what the other person’s ideas are, and then there’s an opportunity to share ideas that you have provided that the patient is open to hearing them and doesn’t have ideas of their own. And that is something that can be done in a relatively brief period of time. And what you are also doing, especially for providers that see patients repeatedly over time, is you’re starting to establish that relationship where the person is going to be happy to come back, and likely more open to share, and you know building kind of that long-term relationship that can help with change as well.

Dr Kaplan has additional Motivational Interviewing resources available here: https://www.guilford.com/author/Sebastian-G-Kaplan

Can you give a broad overview on motivational interviewing and its role in healthcare?

Sure, well, motivational interviewing in its most simplest way of defining it, is it’s a conversation about change. Now there’s all kinds of ways to have conversations about change honestly. So, what makes MI unique? So, one of the things that separates it is the interpersonal style that we strive for in every MI conversation. And it’s a style that is predicated on collaboration, on a lack of judgment or minimal judgment, one of acceptance of a person’s choices and whether they are choices that seem to be consistent with health or not, we’re accepting of their autonomous decision-making. And it’s a style that’s rooted in compassion as well. So that’s the like style of the conversation.

There’s also an intentional, strategic part of the conversation, which really does separate MI. The interpersonal style, that’s pretty consistent, at least in theory, on what other approaches would be about. But the specific strategy about MI is one that listens for and explicitly invites the patient to talk about change. And so again, that might seem like, well ok, that’s what all conversations are about. But there’s a really set of specific strategies and techniques that are used on top of that style that serve to build a conversation about change. But, most importantly though, it’s the patient’s own reasons for change. Their own desires and motivations for change. Not our imposition of what they should or they shouldn’t do. It’s designed to kind of draw that out from the other person.

What is the benefit of MI versus traditional health behavior change methods?

So, I guess we could start with what would traditional behavior change methods be. Broadly speaking in healthcare, right? We’re not only talking about psychotherapy, you know, because MI is something that’s broadly applicable. I would say a traditional conversation follows a, and this is a generalization of course, but follows a path where the healthcare provider, who is viewed as the expert on whatever the topic at hand is, gathers information. With that information they develop the, they arrive at a diagnosis, and they develop a plan for the patient. And then informs the patient what the plan is, and, you know, go along on your way to implement this plan. And again, this is a gross generalization. But in general, it’s a very, it’s fairly hierarchical where there’s one expert, and that’s the provider, and then the patient is there to, you know, tell the provider information about themselves but the provider is the one who has the answers, you know.

And, you know, so what are the advantages? Well, I guess, we know both from empirical research but even just our own experience, human beings aren’t great at following through with things when they’re told what to do. Right? And not just, you know, lectured or you know if it’s done in a harsh way, not even that. It’s, you know, we’re more likely to follow through with behavior change, particularly really challenging behavior changes that are discussed all the time in health care. We’re more likely to follow through if the plan, and if the drive and reasons for change come from within us.

It’s obvious that there are major benefits of using MI, so why do you think it...]]>In this episode of the Move to Value Podcast, we have a conversation about Motivational Interviewing with Sebastian Kaplan, PhD, a clinical psychologist at Atrium Health Wake Forest Baptist and Associate Professor of Psychiatry and Behavioral Medicine at the Wake Forest School of Medicine.

Dr Kaplan has additional Motivational Interviewing resources available here: https://www.guilford.com/author/Sebastian-G-Kaplan

Can you give a broad overview on motivational interviewing and its role in healthcare?

Sure, well, motivational interviewing in its most simplest way of defining it, is it’s a conversation about change. Now there’s all kinds of ways to have conversations about change honestly. So, what makes MI unique? So, one of the things that separates it is the interpersonal style that we strive for in every MI conversation. And it’s a style that is predicated on collaboration, on a lack of judgment or minimal judgment, one of acceptance of a person’s choices and whether they are choices that seem to be consistent with health or not, we’re accepting of their autonomous decision-making. And it’s a style that’s rooted in compassion as well. So that’s the like style of the conversation.

There’s also an intentional, strategic part of the conversation, which really does separate MI. The interpersonal style, that’s pretty consistent, at least in theory, on what other approaches would be about. But the specific strategy about MI is one that listens for and explicitly invites the patient to talk about change. And so again, that might seem like, well ok, that’s what all conversations are about. But there’s a really set of specific strategies and techniques that are used on top of that style that serve to build a conversation about change. But, most importantly though, it’s the patient’s own reasons for change. Their own desires and motivations for change. Not our imposition of what they should or they shouldn’t do. It’s designed to kind of draw that out from the other person.

What is the benefit of MI versus traditional health behavior change methods?

So, I guess we could start with what would traditional behavior change methods be. Broadly speaking in healthcare, right? We’re not only talking about psychotherapy, you know, because MI is something that’s broadly applicable. I would say a traditional conversation follows a, and this is a generalization of course, but follows a path where the healthcare provider, who is viewed as the expert on whatever the topic at hand is, gathers information. With that information they develop the, they arrive at a diagnosis, and they develop a plan for the patient. And then informs the patient what the plan is, and, you know, go along on your way to implement this plan. And again, this is a gross generalization. But in general, it’s a very, it’s fairly hierarchical where there’s one expert, and that’s the provider, and then the patient is there to, you know, tell the provider information about themselves but the provider is the one who has the answers, you know.

And, you know, so what are the advantages? Well, I guess, we know both from empirical research but even just our own experience, human beings aren’t great at following through with things when they’re told what to do. Right? And not just, you know, lectured or you know if it’s done in a harsh way, not even that. It’s, you know, we’re more likely to follow through with behavior change, particularly really challenging behavior changes that are discussed all the time in health care. We’re more likely to follow through if the plan, and if the drive and reasons for change come from within us.

It’s obvious that there are major benefits of using MI, so why do you think it hasn’t been adopted by the entire health care industry?

Well, yeah, so it’s a good question. I think a few things. One, and I think a lot in the work that I do and a lot of the trainings that I’ve done, have been for professionals that are involved in pretty high stress or with problems of fairly high urgency. You know, so for instance, in psychiatry we talk a lot, and in my particular work, you know, at least part of my work, I work with teenagers that are suicidal, that harm themselves for various reasons. Who may use drugs and alcohol. And, you know, that and other, you know, kind of urgent, you know, health problems, I think elicit a lot of, you know, stress and concern on the part of the healthcare provider. And I think it’s just really, I think that higher level of urgency, kind of, evokes more of a you have to change kind of approach from the provider and it’s a lot harder to kind of settle into a more relaxed, collaborative, conversational style when someone is in that kind of high stress, high urgency kind of situation. So, I think that’s one.

But, you know, I think it’s just been, it’s also a method that’s just been passed down over the years. Where the healthcare provider is viewed as the expert, and that, the expertise of the healthcare provider is what will ultimately lead the patient towards health. And it just takes a while in healthcare for things to change. You know, healthcare, the literature certainly doesn’t support a lecturing, paternalistic style of communication. But, because that’s what has been, you know, in place for, you know, decades and centuries perhaps. You know, those that teach the younger generations continue to do that and I think we’re seeing shifts, we’re seeing changes. There’s certainly a lot of like patient-centered language that’s in our medical education curriculum here. I think it feels a lot more natural for Med students now than maybe fifteen years ago when I first started in this position to really get and understand why lecturing somebody to change is probably not going to be all that helpful.

What would a conversation using MI techniques look like?

Well, it would, I think a key element to an MI conversation that would lead one to sniff it out pretty quickly is the use of a particular counselling skill or conversational skill called a reflection, or broader than that, reflective listening. And so, what reflective listening is is a, it’s sort of, I guess a way to start describing it is to contrast it with what’s typically seen and that is a series of questions followed by answers. A reflection isn’t a question. You can think of it as a brief summary about or of what somebody just said.

Now, the reflection though has a couple of purposes. One is it is an invitation to say more, to speak more. And in particular to say more about the thing that the provider has reflected. So, in that sense, it functions kind of like a question because people kind of know if you ask me a question, I’m going to answer your question. Well, most people kind of get, if you hear a reflection, they’re going to likely say more about that thing. The other thing though about a reflection is that it does something that a question doesn’t, which is it has, in an unspoken way, it delivers the message I’m listening and what you say matters, I’m accepting of what you say. And, you know, of course, the tone and intonation matters too in how you deliver a reflection.

But, so what is an MI conversation sound like? Well, you’re likely to hear way more reflections than questions. That’s the most obvious difference. And then, I guess another one is you’ll hear questions that are, you know, probably, I guess less frequent than you might find in other settings or in other kinds of styles. You might hear questions like, “What are your top three reasons to quit smoking?”, for instance. Right? That is a question that, again, if you’re going on the traditional role where the provider’s job is to tell the patient why they should quit smoking, there’s no need to ask the patient what their three reasons are because we have the reasons. We know and we’re going to tell the patient. So, it’s questions like that that serve to draw out from the patient their own ideas about change, the reasons why they would change, their impressions for any advice and feedback that the provider does have is really explicitly drawn out. So, I guess that would be another thing. You’d probably hear the patient talking a lot more than they otherwise would.

If I’m a provider and I want to start using motivational interviewing in my practice, where do I start?

Yep. So, one strategy for those that are, you know, a lot more comfortable with questions. We try to rely more on open questions versus closed questions. So, open questions are ones that typically start with the words what, or how, or why, or even the invitation of tell me more about, you know, x, y, or z. And not that we can’t ask closed questions or shouldn’t, but if we, if our default setting is ask closed questions, you are likely going to get really abbreviated answers. You are likely to get kind of narrow experiences from the patient. Whereas, if you ask open questions or at least start with open questions, it both invites more from the patient but also, you know, it, in terms of leveling the playing field and enhancing the patient’s active role in the healthcare encounter, open questions just invite that more so than closed questions. So, that would be one thing.

The use of reflections, obviously. That’s something that’s really critical in terms of a skill. And, you know, I also wouldn’t want to express the belief that unless you’re, you know, doing 2-3 times more reflections to questions, then don’t bother. Actually, there was a study that I cite sometimes, although I don’t have it, the exact citation in my mind, but it demonstrated that in primary care settings, any use of reflections, any use, by the physician, was a significant contributor to that healthcare experience on the part of the patient. I believe it was a study looking at, you know, obesity and weight management. And so, it facilitated a more open dialogue and more comfort on the part of the patient to convert. So, you know, even if you just sprinkle in a reflection or two in there, that’s a great place to start.

What would be another thing? I would, you know, kind of get comfortable with the question that is so often overlooked when talking about change. And that is, before you start delivering the message of how a person could change, stop, and find out what’s in it for them. Why would they change at all in the first place? And I would go even so far as to say it is perhaps even more important to ask that question for the higher urgency conversations. You know, so I, one of the things that I teach a lot of the psychiatry residents and Med students I work with is, you know, working with kids that are harming themselves, I mean that’s as high urgency as you might get. I always ask those kids, so what’s in it for you. What, how would, if you decided not to harm yourself, how would that make life better for you? And we so often skip that. And again, out of good intentions trying to get to the strategies that we know, or we think we know that will help, we miss that whole part of it, which is so important because they’re not going to change if they don’t have reasons to change. So, it can be really important to ask that kind of a question.