Expansive Innovation: We Are All in This Together. Dr. Sheila Riggs 2013 Senior Trusted Leader University of Minnesota

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1 Expansive Innovation: We Are All in This Together Dr. Sheila Riggs 2013 Senior Trusted Leader University of Minnesota

2 Tonight s Agenda State Innovation Model (SIM) Grant Seven Nodes of Innovation Out of Body Experience!

3 State Innovation Model Grant Description* A comprehensive, statewide initiative to: Close current gaps in health information technology and analytics Exchange health information Build quality improvement infrastructure More providers in new payment methods Build workforce capacity Team-based, coordinated, patient-centered care for all *National Academy for State Health Policy

4 State Innovation Model Grant Payment Models Shared savings for Virtual ACO Health Care Delivery Systems (HCDS) Two-way risk sharing for Integrated ACO HCDSs

5 State Innovation Model Grant Overall Targets/Goals in Grant 200,000 Medicaid enrollees in ACO (HCDS) Model 60% of fully insured population in ACO/TCOC Model 1.72 M people (current is 1.26 M) Savings: $111 million $90.3 M in Medicaid savings $13.3 M in savings to private payers $7.5 M in Medicare savings

6 State Innovation Model Grant Data Analytics/HIT/HIE Expansion of provider data feedback and analytics capacity and reporting for HCDS, including possible integration of other data sources and other payers Provider electronic health record (EHR) adoption and health information exchange (HIE) grants Inventory needs assessment and roadmap for HIE in/with behavioral health and social services RFI responses due Oct. 15 th Secure, bidirectional gateway development for exchange of data between providers and the state

7 State Innovation Model Grant Accountable Community for Health $3.5 M portion of $45 M grant Fund 15 Accountable Communities for Health Stay tuned as details emerge over the next several months

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9 Seven Nodes of Innovation

10 HealthEast Care System Examples of Innovation HealthEast Medical Home Program community health workers in primary care clinics. 2. More than 1200 patients enrolled. 3. Foster patient engagement & develop patient-centered care plan. Community Paramedics Training of paramedics in a new role - Community Paramedics to provide first line care in the community. Diabetes Prevention as a Community Health Imperative 1. HealthEast,YMCA and CDC developed a Community Diabetes Prevention Program. 2. Programs at Passport Community Center, local churches and for HealthEast employees.. 3. Strong results! 30 people completed the program with over 400 pounds lost!

11 Courage Kenny Earlier this year, Allina Health s Sister Kenny Rehabilitation Institute merged with Courage Center to form Courage Kenny Rehabilitation Institute. Creates seamlessly integrated care continuum for people in need of rehabilitation services. Combining complementary strengths in breadth and depth of services. Service line will be unique in its comprehensiveness, holistic approach and commitment to innovation.

12 BluePrint Allina Health and Blue Cross have come together to create a new kind of insurance product. Designed with the input of doctors and patients, BluePrint will change the way providers and insurers work together to optimize health. Guided care approach helps provide better care at a lower cost. Will be available on MNsure.

13 Overview first 18 months An Integrated care model (medical/social services/health plan partnership) Accomplishments- Launched over 30 system improvement initiatives in year 1 Reinvested >$1mil into new system improvements for 2013 based on savings from <1% of population Reinvestments: >30% return on investment projections to further reduce costs in yr 2 Health Disparities- baseline for low income populations is dramatically below the general population, with focused preventive care (primary care, behavioral health) those gaps are incrementally lessening Lessons- tremendous opportunities exist when systems leverage each others strengths (versus competing) towards better care 13

14 Federally Qualified Health Center Urban Health Network FUHN is a formal collaborative network of 10 federally funded community health centers with 40 plus clinical sites in the Twin Cities metro area. FUHN is involved in several ACA and MN driven health care reform initiatives including a contract with MN DHS as a Health Care Delivery System (HCDS) Demonstration Project. Primary Goal of FUHN s HCDS project: Triple Aim Plus One Functionally FUHN emphasizes increased access to primary care services (the plus one) to (1) improve clinical quality; (2) improve patient engagement/satisfaction service; (3) reduce the Total Cost of Care (TCOC) Primary Strategy: Engage attributable patients to better partner with FUHN health centers in seeking the Right care at the Right Time at the Right Place whenever possible. Tactics: FUHN is deploying Population Health Management tools & data analytic technology to inform its efforts FUHN has deploying Performance Improvement Advisors to support actionable data integration into clinic workflows and to support data use to inform clinical practice transformation FUHN is deploying increased care coordination activities including increased patient engagement, care transition collaboration & health care home initiatives FUHN is continually exploring new ways of working with community partners & providers Current Status & Successes: Over 24,500 Medicaid patients are attributed to the 10 FUHN Health Centers with enhanced outreach to patients following ED or In-Patient care already occurring Focused care coordination to patients identified as high risk, with high utilization or comorbidity Current Needs: Improved and more timely notifications of hospital/ed utilization, continual (re)evaluation of efforts 14

15 Southern Prairie Community Care A collaboration of 12 counties in Southwest Minnesota. A joint powers entity was created in July of 2012 for the purpose of building a community based service coordination model-based upon the concepts of an Accountable Care Organization (ACO) or, more accurately, an accountable community. Currently in the process of becoming an HCDS demonstration project. The first to expand beyond the boundaries of an integrated health system. The SPCC community is comprised of all entities providing service to their Medicaid and MN Care populations (medical, public health, mental health, human services and community based service organizations). The SPCC network will begin serving its citizens on January 1, 2014.

16 Lutheran Social Service (LSS) Community Services ACO Partnership of Community Service Providers Integrating their services with healthcare services for people with disabilities Neighbors not patients Support not serve Proposal Submitted to Round 2 of the CMMI Innovation Fund

17 Mindshift Change. People who live in the community and occasionally go to the doctor

18 Interactive Exercise by Table Envisioning an Accountable Community of Health. Thinking beyond the current mindset of what an ACH should/could look like Each table will look at an ACH model from a different stakeholder perspective: Next door neighbor with no health care background City Council member (budgetary responsibility) Principal of school or school board member Local chamber of commerce or small business owner City Planner Administrator of local food shelf