Cheryl Bartlett, RN Former MA Commissioner of Public Health

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1 Cheryl Bartlett, RN Former MA Commissioner of Public Health

2 } C.58 Expands access to health insurance (98%) } C.305 Cost containment, transparency, access & quality (primary care workforce development) } C.305 Part II Cost containment & quality in the provision of health insurance } 2012 C.224 Payment reform and creation of the Health Policy Commission, CHIA & the Prevention & Wellness Trust

3 } Reduction in prevalence of the most preventable chronic diseases } Reduction in health care costs and/or growth in cost trends } Increase focus on wellness and prevention } Reduction in health disparities } Develop stronger evidence-base for prevention } Reduction in costs

4 } $60M Trust Fund over four years } No annual restrictions on funding allocations } 75% required to be spent on grantee awards } 10% to be targeted for worksite wellness } Not more than 15% for DPH admin expenses

5 } Financed through a one time assessment on health plans and acute hospitals with more than $1B in net assets ($195M) } $60M Funds used for Prevention & Wellness grants } $135M used for health information technology and struggling community hospitals

6 } Repeated cuts to DPH budget (40%) } Innovative precedent, Pediatric Immunization Trust } Ensure sustainable funding in future recessions } Recognition that new approaches are needed to control costs } Promising new practices for population health management of chronic diseases (PSE, MiM, CTG) } Broad-based coalition that supported C.58 passage } Unusual collection of leaders from diverse fields

7 } The Massachusetts Public Health Association } The Massachusetts Health Council } American Heart Association } Tobacco Free Massachusetts } Health Care for All } Massachusetts Association of Health Boards } Boston Public Health Commission

8 } 21 member board (14 gubernatorial appointments) } Board makes recommendations to the Commissioner (Chair) 1. Administration and allocation of funds 2. Establishment of criteria 3. Performance evaluation (initially separate commission) 4. Annual report to legislature } Met 3 times to guide development of RFR and priorities } Quarterly meetings ongoing for updates and to give feedback

9 Applicants were required to have three types of partners: Clinical: healthcare providers, clinics, hospitals (at least one clinical partner must be able to share electronic medical records Community: schools, fitness centers, nonprofits, multiservice organizations Municipalities: health/human services departments Other: insurers, worksites, regional planning departments

10 } Examined cost trends by health conditions } Examined the prevalence of preventable conditions } Examined co-morbidities by condition and cost } Developed a model for optimum population size based on costs of interventions and relative effectiveness } Selected 13 chronic health conditions with strong evidence for delivering ROI (short intervention timeline)

11 } Research identified 13 diseases, risk factors, and health events where cost savings could be achieved } Data briefs were prepared for each condition on: prevalence, incidence, hospitalization(ed/inpt), cost estimates, geographic distribution, racial/ethnic disparities, meaningful use or other clinical quality measures Health Conditions 1. Asthma 2. Cancer 3. Cholesterol Control 4. Congestive Heart Failure 5. Diabetes (Type II) 6. Falls Prevention 7. Hypertension 8. Mental Health/depression 9. Obesity 10. Oral Health 11. Stroke 12. Substance Use 13. Tobacco

12 Priority Conditions (2 of 4 required) } Tobacco Use } Asthma (pediatric) } Hypertension } Falls (older adults) Optional Conditions (not required) } Diabetes } Obesity } Oral Health } Substance use disorders All grantees need to address vulnerable populations to reduce disparities and co-morbid mental health conditions such as depression.

13 } Health disparities a priority } Value of historical relationships } Suggestions for other health conditions } Promote innovation balanced with evidence-based interventions } Evaluation, data collection and outcomes need clear expectations } Insure geographic distribution across state } Build sustainability planning early } Process, communications and infrastructure ongoing development and refinement

14 } Use evidence based interventions with some opportunity for innovation (tiered approach) } Target areas with high disease incidence and/or high healthcare costs } Strong linkages between clinical settings and community resources } Maximize ROI } Promote sustainable systems change } Fund fewer communities with larger grants } Limit conditions to two of the priorities selected } Limit populations size and service areas } Integrate use of Community Health Workers } Use of e-referral system designed for SIM grant (at least one clinical partner) } Two phase approach: Capacity Building & Implementation

15 After meeting with subject matter experts interventions were separated into 3 tiers: 1. Strong evidence for clinical impacts and likelihood of positive ROI 2. Evidence base exists, emerging best practices however data not as strong as tier 1 3. Little evidence available that demonstrates impact and little likelihood of ROI in 3.5 years of funding Grantees required to select at least Tier 1 intervention in each domain. No more than 5% of funding can be used on a Tier 3 intervention.

16 Electronic linkages- MA SIM e-referral program } Bi-directional between clinical and community sites } Integrated into EMR for at least one partner Community Health Workers } Core curriculum developed } Consistent training } Consistent supervision } Certification (inaugural Board of CHW s) Limit service area and populations size } Population size K } No overlap in service area

17 } Bidder s conference September 12, 2013 } Letter of intent required September 27, 2013 } Application submission November } Review process November/December 2013 } Award notices February 2014 } Award negotiations February/March 2014 } Start date April 2014

18 } 20 applications submitted } Two levels of review: Technical and Programmatic } Internal and external review teams } External participants: AHA, MPHA, MMA, PWAB

19 Urban Areas: } Boston Public Health Commission } Holyoke Health Center (southwest) } City of Lynn (north) } Manet Community Health Center (south) } New Bedford Health Department (southeast) } City of Worcester (central) Suburban: } Town of Hudson (central) Rural: } Berkshire Medical Center (western) } Barnstable County Department of Human Services (eastern)

20 } Total population within funded communities is 987,422 (approximately 15% of state population) } Some of the most racially and ethnically diverse communities in the state } Many communities with large percentage of people living below the poverty level } Significantly higher than state averages for prevalence of priority health conditions (Asthma, hypertension, falls, tobacco use)

21 Capacity Building Phase: Each award up to $250,000 for partnership development, governance structures, work plans, budget planning, communications strategies, intervention selection, e-referral development Implementation Phase: Between $1.3M-$1.7M on annual basis

22 Outcome measures defined by C.224 } Reduction in prevalence of preventable chronic diseases } Reduction in health care costs/growth trends } Which populations benefit most from interventions } Increase workplace-based health and wellness programs Two primary goals } Using evaluation to promote change (QI) } Using evaluation to demonstrate change Recommendations to legislature } Should program continue as is or be amended } Is there a better/different approach to achieving goals

23 } Complicated model with 3 domains and interventions in each } Developing collaborative partnerships takes a lot of time and effort } EHR s not always compatible with each other and technical acumen variable at sites } Practice variability a challenge with commitment & acceptance } Extraordinary staff time required for TA & training } Three-year ROI a challenge to demonstrate health outcome changes } Some early indicators of success with decreased utilization of costly healthcare services } Relationship building is beginning to blossom } Enthusiasm of partners is significant

24 } Leadership from top critical (Commissioner et al) } Research & epidemiology staff to prepare the data sheets } Health economists to develop cost analysis and projections } Subject matter experts for chronic disease prevention & control } CHW workforce development experts } Coalition building skills } IT team } Evaluation gurus } Communications staff } Administrative and coordination staff } Government relations and policy team

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