Be Well Partners in Health Achieving Accountable Care in the Safety Net Addiction and Chronic Illness
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1 Be Well Partners in Health Achieving Accountable Care in the Safety Net Addiction and Chronic Illness Mark Loafman MD, MPH Assistant Professor Family Medicine, Northwestern Feinberg School of Medicine Chief Clinical Integration Officer, Norwegian American Hospital National Faculty Co-Chair, HRSA Patient Safety Collaborative Chair, Board of Certification in Family Medicine Obstetrics
2 Case Studies, orwhy We Are Here 46 yoman with advanced heart failure, on kidney dialysis for diabetic nephropathy. Addiction interfered with Rx chronic conditions Unfunded until disability 29 yowoman in preterm labor, no prenatal care, acute withdrawal from heroin. EtOH/weed in HS, EtOH/Coke in College Several arrests, 2 kids w/dcfs, no Rx 8years later her little boy is repeating 2 nd grade, now expelled for aggressive behavior. Born at 26 wks, left NICU intact Foster care shuffle, lead poisoning, etc. Theme: Amazingly Accountable Rescue Rx, but
3 If health care were an Olympic sport, how would the U.S. do in the medal count? #1 in Rescue care #37 in Population Health, Especially? -Minorities, poor and social barriers -Chronic illness, mental health, addiction
4 Determinants of Variation in Outcome Expected Difference Individual Choice: Clinical Appropriateness and Need, Patient Preferences Structural: The Health Care System Operations and The Regulatory and Legal Climate Disparities Discrimination: Biases and Prejudice, Stereotyping and Uncertainty
5 Allocation of Health Care Resources and Workforce Allocation of Healthcare Resources and Workforce what does it take to get our Gold medal care? - HTN, Diabetes, Lipids - Obesity, Tobacco, couch tatos - Mental Health/Addiction
6 Allocation of Health Care Resources and Workforce Allocation of Healthcare Resources and Workforce what does it take to get our Gold medal care? -Uncontrolled Conditions - Persistent Obesity, Tobacco - Addiction not Managed - Mental Illness not Treated
7 Be Well Partners in Health Enrollee (patient/client) Centered, Coordinated A Team based, multi institutional Collaborative Bridge care gaps, promote self management Evidence based and comprehensive scope Risk Stratification, Intensive education/training Care managed w/standardized processes Electronic Information Management
8 Be Well Partners in Health Main Partners: Norwegian American Hospital, MADO Healthcare, Methodist Hospital of Chicago, Neumann Family Services Target population: Adult and senior Medicaid recipients with serious mental illness Co-morbid substance abuse problem, a chronic health condition or developmental disability, and/or History of medical or psychiatric hospitalizations and excessive emergency room utilization
9 Outcomes Improve self-management skills and abilities Ensure timely preventative health practices Improve quality of care and satisfaction Achieve cost efficiency, including a focus on avoidable hospitalizations/re-admissions.
10 Anticipated Barriers System we have (now) is designed perfectly to get the results we are getting (now). Systems change = Outcomes change Services, resources, staff, capacity, culture Rescue focused silos built to churn fee for service Olympian level resistance to change Independent providers (doc, organizations) OMG!
11 System Change: Build a Clinically Integrated Network My patient -wherever they are, all the time States role: Help! Clinical scope: Comprehensive Integrated Primary Care Community and Hospital, aligned and integrated
12 PATIENT CENTERED CARE:GEOGRAPHICALLY BASED REGISTRY Affiliated Hospital Network Northwestern Memorial Hospital Norwegian American Hospital Local Community Hospitals NAH Behavioral Health and Detox
13 Community Outpatient Addiction Rx Addiction Rehabilitation Support Services, NA/AA programs Northwestern Memorial Hospital Long term Outpatient Rehab Norwegian American Hospital Intensive Outpatient Rehab Local Community Hospitals Acute Detoxification NAH Behavioral Health and Detox Residential Programs
14 Primary Care FQHC Medical Home Integrated Behavioral Health Northwestern Memorial Hospital Community Outpatient Addiction Rx Addiction Rehabilitation Support Services, NA/AA programs Long term Outpatient Rehab PCMH Support Norwegian American Hospital Intensive Outpatient Rehab Local Community Hospitals NAH Behavioral Health and Detox Residential Programs Acute Detoxification
15 GED Education Respite Care Job Prep Housing Primary Care FQHC Medical Home Integrated Behavioral Health PCMH Support Northwestern Memorial Hospital Norwegian American Hospital Community Outpatient Addiction Rx Addiction Rehabilitation Support Services, NA/AA programs Long term Outpatient Rehab Intensive Outpatient Rehab Ex Offender Services Local Community Hospitals Acute Detoxification NAH Behavioral Health and Detox Residential Programs
16 Be Well Partners in Health Achieving Accountable Care in the Safety Net Addiction and Chronic Illness Mark Loafman MD, MPH
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