CWHAT SYSTEMS-BASED PRACTICE MEANS TO PROVIDERS – Class 1

Individuals measure quality of care by their access to the right caregiver at the right place at the right time

Social Determinants of Health

Today, health care providers and system leaders understand that the health of patients is driven in large part by the conditions in which they are born, grow, live, work, and age — what is called the social determinants of health.  A growing body of research shows that integrating social services into health care delivery can improve health and reduce spending. 

However, much remains unknown. How do we determine what social services patients might need? How can we leverage care teams to improve patients’ social circumstances? How can we address the social determinants of health without adding to an administrative and measurement burden that is already unacceptably high for health providers?  A group of health system leaders from across the county in 2015 examined how health care organizations address social determinants of health as a standard part of quality care. 

Six “drivers” that are key to successful social needs strategies in clinical settings:

  1. Patient Identification and Screening
  2. Navigation and Resource Connections
  3. Social Health Team and Workflow
  4. Data and Evaluation
  5. Community Partnerships
  6. Leadership and Change Management

According to an article by Damon Francis, M.D., “An Evolving Roadmap to Address Social Determinants of Health,” To the Point – Quick Takes of Health Care Policy and Practice (January 16, 2019), this group developed a framework called the Essential Needs Roadmap organized into six “drivers” that are key to successful social needs strategies in clinical settings:

  1. Patient Identification and Screening: Which patient population will you target and how will you assess their social needs?
  2. Navigation and Resource Connections: For which specific social needs will you offer support? What level and type of support?
  3. Social Health Team and Workflow: Who will provide resource support for patients? How will this integrate with broader clinical processes?
  4. Data and Evaluation: How will you know how much to invest in social supports in the long run? How will you know how to maximize the impact of this investment?
  5. Community Partnerships: What community-based organizations are critical to the health of your members? How will you partner with them to continually improve access to resources?
  6. Leadership and Change Management: Have you identified a social needs champion with the ability to allocate resources? Do you have the necessary buy-in from key stakeholders?

Some examples that evolved from this process include: clinical microsystems, or small groups of professionals who work together on a regular basis to provide care to discrete populations of patients, are key to spreading a given innovation from one care team to another. The collaboration also has helped us identify and share new tools, such as Empathic Inquiry, a screening approach, and the Partnership Assessment Tool for Health for those working on developing community partnerships.  Per article

According to HVPAA to effectively refine medicine, performance improvement efforts must be implemented across 5 pillars:

  • Diagnostic and therapeutic efficiency
  • Quality-driven care pathways
  • Care transitions including hospital discharge
  • Optimizing patient care setting
  • Preventive medicine and healthy lifestyle

The High Value Practice Academic Alliance (HVPAA), a national information exchange network, created in 2016 focused on care redesign.  This organization consists of more than 90 institutions and participants include practicing physicians from large and small teaching hospitals in the US, Canada, Japan, and Norway, representing 30 different medical specialties. 

According to the article “Diffusion Of Innovation To Improve Health Care Value: Physician-Led Care Redesign,” by Pamela T. Johnson, M.D. and others in Health Affairs (March 14, 2019) HVPAA defined a roadmap for value improvement, or the “architecture of high value health care,” which includes performance improvement across five pillars of care delivery:

  • Optimizing diagnostic and therapeutic efficacy and efficiency, in keeping with the Lown Institute’s Right Care paradigm, by guiding appropriate use of resources including lab and imaging tests, medications, treatments, and procedures.
  • Ensuring consistency in care delivery to decrease unwarranted variability in practice that increases cost without improving outcomes, in both inpatient and outpatient settings. Quality-driven care pathways reduce hospital length-of-stay, decrease infections, decrease the rate of hospital readmission, and improve outcomes.
  • Improving care transitions and, in particular, discharge transitions to reduce avoidable post-discharge emergency department (ED) visits and hospital readmissions.
  • Optimizing patient care setting to increase health care access and effectiveness in the outpatient setting and reduce avoidable hospital and ED use. Patient education and empowerment are important components of these efforts.
  • Enhancing access to preventive medicine and evidence-based screening tests in an effort to protect patients from preventable disease, hospital-acquired conditions, and late-stage cancer diagnoses. 

One way to think about how capitation can affect providers is to consider the following example:  Eight millennia ago, Chinese healers traveling a circuit of remote villages spent a day or two in each place, dispensing medicine to hundreds of people. If villagers were healthy, they paid the healers a small sum. If they were sick, they paid nothing, until they got well.

Patients and customers are more willing to shop for medical and health care services. Twenty years ago, this was virtually unheard of. Businesses that purchase health insurance for their employees want the best quality, the lowest cost, the greatest access, the most extensive coverage and least administrative hassle for each dollar expended.

Consider:

Eight millennia ago, Chinese healers traveling a circuit of remote villages spent a day or two in each place, dispensing medicine to hundreds of people. If villagers were healthy, they paid the healers a small sum. If they were sick, they paid nothing, until they got well.

As the need to prove quality increases, managed care organizations will have to juggle the competing demands of individuals and purchasing health care groups (like companies, employers, government). Individuals measure quality by their access to the right caregivers at the right place at the right time. Groups want a return on their investment in health benefits. Providers are caught in the middle between cost-conscious major purchasers and service-conscious individual customers.

Systems-based practice is moving towards:

  • Care coordination – to avoid waste, duplication of services and inefficient or inappropriate uses of services
  • Case management – also referred to as episodic care management, providing a process and protocols for managing medical needs of a patient during a specific illness, usually in acute inpatient care setting
  • Population health management – to assist physicians in cost-effectively managing chronic illness; and demand management – involves education of patients

Early attempts to control costs under managed care relied largely on the unpopular gatekeeper model, discussed later in this book, and “Mother-may-I?” utilization management techniques that basically focused on restricting services. This caused anger and resentment by providers and patients. Managed care is moving towards: Care coordination – to avoid waste, duplication of services and inefficient or inappropriate uses of services; Case management – also referred to as episodic care management, providing a process and protocols for managing the medical needs of a patient during a specific illness, usually in the acute inpatient care setting; Disease management – to assist physicians in cost-effectively managing chronic illness; and demand management – this involves education of patients.

It is important to note that one thing that consumers most need to know about a health plan is how it will perform if they become seriously ill

Many physicians have grown less confident about their financial and social stature with the growth of managed care. Many medical groups and physicians are at a crossroads of an uncertain future. They are examining how can they position themselves to win in the long run. Informed physicians and medical group managers are better positioned to capitalize on the opportunities that change brings. This includes reinventing what it means to deliver care for the 21st century. In reinventing medical group practices, medical groups must figure out how they will remain ahead of other groups in customer service. One answer for medical groups is to capitalize on what they do best. Become recognized as the best, the exemplar, in the delivery of services. Medical groups must strengthen their revenue flows by maintaining traditional revenue streams and adding new streams. Medical groups require managerial skills that formerly were less important in their operations. Information management is critical for effective overall management of group practice performance.