LIVE WELL SAN DIEGO. Creating an Accountable Care Community

Transcription

1 LIVE WELL SAN DIEGO Creating an Accountable Care Community Nick Macchione, MS, MPH, FACHE Agency Director Health & Human Services Agency County of San Diego, CA June 6, 2014

2 San Diego County 4,261 square miles - urban and rural regions, from coast to mountains to desert Larger than 21 U.S. States; same size as CT 5 th largest U.S. County, 2 nd largest in CA 18 municipalities; 17 unincorporated cities 18 Indian Sovereign nations 2012 Estimates million population o 48% White o 32% Latino o 11% Asian/PI o 5% African American o 1% American Indian o 3% Other Region is very diverse Over 100 languages Large military presence Largest refugee resettlement site in CA Busiest international border crossing in the world (San Ysidro/MX)

3 SAN DIEGO COUNTY GOVERNMENT Board of Supervisors publicly elected by District 5 Major Departments Health and Human Services Agency Created in 1998, Integrated Delivery System Public-private partnership emphasis $2+ billion annual budget 6,000 FTEs, 185 advisory boards 850,000 clients from Womb to Tomb Land Use and Environment Group Public Safety Group Community Services Group Finance and General Government 3

4 OUR PURPOSE Vision Safe, Healthy, and Thriving Communities Mission Make people s lives safer, healthier and self sufficient by managing essential services 4

5 WHAT THE HEALTH IS GOING ON IN SAN DIEGO? 5

6 PROBLEM Lack of Exercise Poor Diet Smoking 6

7 Lead to Result in OVER RESULT BEHAVIORS DISEASES PERCENT No Physical Activity Poor Diet Tobacco Use Cancer Heart Disease & Stroke Type 2 Diabetes Lung Disease of deaths in San Diego

8 COST IMPACT ECONOMIC IMPACT IN 2007: $4.6 BILLION IN SAN DIEGO

9 NATIONAL ECONOMIC PARADOXIC

10 HEALTHCARE SERVICES VS. SOCIAL SERVICES Healthcare Service Expenditures as % of GDP, 2005* Social Service Expenditures as % of GDP, 2005* Average life expectancy, 2007 Infant Mortality (deaths per 1,000 live births) USA Sweden France Canada Japan UK USA Sweden France Canada Japan UK *Bradley EH, et al. Health and Social Services Expenditures: Associations with Health Outcomes. BMJ Qual Saf (2011). *McGinnis JM, Russo PG, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21(2):78 93

11 TRADITIONAL BUDGET BALANCING APPROACH Cut people from care Cut provider rates Cut services Meanwhile

12 THE FOURTH PATH Change how care is delivered to improve health and wellness: Optimize existing healthcare, public health and social service resources to innovate new service delivery, reduce waste and improve health and cost outcomes Create local accountability by all, not some Health (and Safety) In-All-Policies Promote individual responsibility Achieve fiscal sustainability thru new payment reforms Connect the Unconnected thru modernized IT Knowledge Advance evidence-based policy making and planning Make some tough decisions Dealing with change Bring the focus back to individual and community wellness

13 Well-being is more than just physical health. Emotional Well-Being Financial Stability Social Connectivity Career Viability 13

14 Ecological Approach to Population Wellness Admin Patient-Centered Health Home Neighborhood

15 SOLUTION Building Better Health Living Safely Thriving

16 COMPREHENSIVE APPROACH SHARED STRATEGIES Building a Better Service Delivery System APPROACH Supporting Positive Choices Pursuing Policy and Environmental Change Changing the Culture from Within County Government

17 BUILDING BETTER HEALTH 1 Access to quality care 2 Increased physical activity 3 Healthy eating 4 Stop tobacco use 17

18 LIVING SAFELY Residents are protected from crime and abuse Neighborhoods are safe for working, living and playing Communities are resilient to disasters and emergencies

19 THRIVING Thriving

20 EVOLVING HEALTH AND HUMAN SERVICES SYSTEM WELLNESS TRANSFORMATION 20 Acute Health Care System 1.0 High quality acute care Coordinated Seamless Health Care System 2.0 Accountable care systems Shared financial risk Case management and preventive care systems Population-based quality and cost performance High quality acute care Community Integrated Health Care System 3.0* Population-based health outcomes Care system integration with community health resources Accountable care systems Shared financial risk Case management and preventive care systems Population-based quality and cost performance High quality acute care * Based on The Evolving Health Care System 3.0 by Neal Halfon, M.D., Director, UCLA Center for Healthier Children, Families, and Communities. Community Wellness System Population-based health outcomes Care system integration with community health resources Accountable care systems Shared financial risk Case management and preventive care systems Population-based quality and cost performance High quality acute care Accountable Care Community Person-centric, Community-led with open source data/transparency HIE Knowledge Network Exchange Integration of physical health, behavioral health & public health Integrated delivery of health and social services toward shared outcomes Indicators of community wellness shared across private and public sectors, including military/va Health (and safety) in all policies Intergenerational caring communities Economic development across region Eliminating health and social inequities

21 LIVE WELL SAN DIEGO IS LINKING THE PUBLIC, PRIVATE, AND NON-PROFIT SECTORS TO PROMOTE WELLNESS AT THE CLIENT AND NEIGHBORHOOD LEVELS 21

22 ACCOUNTABLE CARE COMMUNITY Convening and Framing with Stakeholders Infrastructure to improve Health Outcomes ACC Infrastructure to Integrate Quality & Cost Data Managing Population Health Budgets 22

23 PREVENTION/PUBLIC HEALTH INITIATIVES CPPW CTG CPPW : Communities Putting Prevention to Work CTG: Community Transformation Grant Healthy Food Systems Workplace Breastfeeding Policy Farm-to-Institution Urban/Rural Agriculture Planning Policies Improving School Meals Moderate-to-Vigorous Physical Activity Regional Safe Routes to School Plan Health/Wellness Policies for Regional Land Use & Transportation Planning Regional Monitoring & Evaluation Complete Streets Policy & Implementation Health Benefits & Impact Analysis Program Healthy Foods Healthy Schools Healthy Places 23

24 CHULA VISTA ELEMENTARY SCHOOL DISTRICT LAUNCHED A MULTI-FACETED APPROACH Revamped and enhanced school wellness policies and practices: More nutritious school lunches Increased physical activity Replaced unhealthy birthday celebrations with games and activities Reached out to parents and community with cooking classes, healthy food budgeting and family fun To assess impact, measuring Body Mass Index of students over time

25 COLLECTIVE IMPACT HOW MANY ARE HELPED TO LIVE WELL? BEST PRACTICE SHARED WITH OTHER SCHOOLS 28,500 students 45 schools in Chula Vista Elementary School District Families too!

26 2010 Chula Vista Elementary School District 2010 & 2012 School of Attendance Student Obesity K-6 th grade 2012 Legend % Obese Children % % % % %

27 LOVE YOUR HEART CAMPAIGN Population-Based Strategies to Combat Heart Disease and Stroke 2014 Event 200 Community Partners Blood Pressure Screening 27

28 OUR PARTNERS Acted as public-facing or internallyfocused Love Your Heart sites Actively promoted the Love Your Heart event to the public Collected and submitted data on all BP s performed Sites represented by red dots submitted blood pressure range data Sites represented by white dots submitted total blood pressures taken

29 COLLECTIVE IMPACT 17,700 Blood Pressure Screenings conducted at over 200 sites across 60 organizations One out of two individuals screened identified as having elevated blood pressure 57 individuals identified as having urgent or emergent hypertension requiring immediate medical referral

30 INTEGRATED SERVICES ACROSS THE LIFESPAN Drivers: Vision/Strategy Service Delivery Financing Workforce P3 in Action Children / Youth We Can t Wait Positive Parenting Program Kickstart Adults Behavioral Health / Primary Care Integration Summit Bridges to Recovery In-Home Outreach Team Older Adults Aging Summit Community Care Transition Program Passport to Healthy Aging Behavioral Health Services Primary Care Community Based Social Services 30

31 LOW INCOME HEALTH PROGRAM (LIHP) Created under California s Bridge to Reform Medicaid Section 1115 Waiver to prepare for Medi-Cal expansion Enrolled uninsured adult county residents with incomes <133% FPL to provide medical care and limited mental health services Used a network of local service providers 22 hospital sites (13 hospital organizations) 58 community health clinic sites (16 parent organizations) 20 mental health clinics 122 specialty groups, including more than 345 individual providers Enrollment grew from 14,000 in July 2011 to more than 45,000 in December 2013 All LIHP enrollees transitioned to Medi-Cal January 1, 2014

32 LIHP HEDIS PERFORMANCE LIHP HEDIS Quality Indicators: Q2 Compared to Q8 80.0% GOAL: 71% 70.0% 60.0% 72.9% 63.1% GOAL: 60% 74.5% 73.9% 50.0% 52.1% 57.2% 40.0% 30.0% 50.0% GOAL: 35% 31.0% 42.8% 42.2% 35.0% 47.0% 20.0% 10.0% 0.0% DM HbA1c Control DM LDL Control DM BP Control Highest SD-MCMC Level Q2 Percent Compliant Q8 Percent Compliant Lowest SD-MCMC Level 32

33 CARE COORDINATION Meals Service Primary Care Medical Specialty In-Home Services PATIENT Skilled Nursing Facility Acute Hospital Transit Day Health Care Patients/caregivers provided social support services, by referral or direct provision, to reduce the risk of avoidable readmission.

34 CARE COORDINATION 34 COMMUNITY-BASED CARE TRANSITIONS PROGRAM (CCTP) Section 3026 of the ACA Goal: reduce all-cause 30-day readmissions for fee-for-service (FFS) Medicare patients by 20% in 2 years. $500 million over 5 years to test models for improving care transitions from inpatient hospital to home or other settings. Link Community-Based Organizations to hospitals. San Diego Care Transition Partnership (SDCTP) Partnership between HHSA and San Diego Health System 11 hospitals/13 sites. Goal: serve ~21K FFS Medicare patients per year for 2 years, starting January Activate patients and caregivers to better manage chronic conditions.

35 CARE COORDINATION 35 DUAL ELIGIBLES Beneficiaries dually eligible for Medicare and Medicaid are a high priority for CMS. Most expensive and complex. Medicare-Medicaid Coordination Office established by ACA to create patient-centered coordinated care for dual eligibles. California Coordinated Care Initiative (CCI) Two Parts: Cal MediConnect: combine Medicare, Medi-Cal, and Medi-Cal Managed Long-Term Services and Supports (MLTSS) into one managed care health plan. Medi-Cal MLTSS: manage Medi-Cal medical benefits and long-term social services through a managed care health plan. Enrollment began April 1, ,000 beneficiaries in 8 participating counties. San Diego is one of 8 counties participating.

36 Children in Foster Care System Assessments and Trauma Treatment for Children Enhanced Parent Development Services Enhanced visitation and therapy for families Increase system capacity and collaboration Pre and post developmental assessments Developmentally appropriate, evidence-based parenting classes Enhanced quantity and quality of visitations Incredible Years staff trainings and Cross-system training workshops Trauma and behavioral assessments Evidence based and informed trauma and/or behavioral treatment Incredible Years and Infant Massage curricula Service integration between the FIT partners Multi-disciplinary and System level Steering Committee team meetings Cross System Outcome Measurement Team Prepared by Harder+Company Community Research for San Diego County Child Welfare Services (CWS) and Alcohol and Drug Services (ADS) September 2013

37 MAJOR SAFETY ADVANCES - Trauma Informed Agency - Neighborhoods for Kids - Project Shine for Refugee Families - Intergenerational Mentoring - Exceptional Families Initiative

38 Technology + Interoperability Support Health + Social Services 38

39 San Diego Knowledge Exchange Community Information Exchange San Diego Regional Wellness County of San Diego Knowledge Integration Program San Diego Health Connect Information Exchange 39

40 MEASURING COLLECTIVE IMPACT 40

41 TRIPLE AIM 2.0 Improved Health and Social Well Being for the Entire Population Better Services for Individuals Lower Cost per Capita 41

42 Influences Reporting and Performance Metrics: Influences

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44 COLLECTIVE ACTION FOR MEASURABLE IMPACT Actions We Take Collectively Across Sectors Results We Seek for Community Impact County Government Health Providers Community & Faith-Based Organizations Business Schools Law Enforcement and Courts Military Behavior Changes in Population Short Term: w/in 3 years Risk Factor Changes in Population Mid-Term: w/in 7 years Outcome Changes in Population Long Term: w/in 10 years I N D I C A T O R Other Local Jurisdictions 44

45 MEASURING RESULTS Areas of Influence Definition Top 10 Indicators Enjoying good health and expecting to live a full life - Life Expectancy - Quality of Life Learning throughout the lifespan - Knowledge Having enough resources for a quality life - Unemployment Rate - Income Living in a clean and safe neighborhood - Security - Physical Environment - Built Environment Helping each other to live well - Vulnerable Population - Community Involvement

46 Live Well Roadmap 46

47 WHAT THE FUTURE HOLDS The biggest scale that you can get requires the simplest idea... And you achieve this by connecting with people. - Bono, U2

48 COMMUNITY PARTNERS More than 50 Recognized Partners (and growing) including The largest city in the County - City of San Diego The largest elementary school district in the State (K through grade 6) - Chula Vista Elementary School District The largest public health district in the State - Palomar Health The largest Chamber of Commerce on the west coast - San Diego Regional Chamber of Commerce

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51 From Field to Fed

52 TO LEARN MORE Learn how you can participate in Live Well San Diego Visit the Join Us page at LiveWellSD.org Or us at

53 LIVE WELL PERSPECTIVE MATURES Past/Present Present/Future Transactional Transformative Volume-Based Value-Based Competitive Advantage Co-opetition Silos and Categorical Integrated System Connecting the Unconnected/Trapped Data InterOptimability/Open Source Data 53 Sick Care and Social Welfare Wellness

54 QUIET OPTIMISM Policy makers, providers, customers, advocates are becoming more aligned and committed on achieving regional wellness Relationships are expanding and being built on trust Shifting from collaboration to more integration/generation Data sharing and Technology have become effective enablers for improving knowledge, innovation and better outcomes Winnable battles on chronic health and safety conditions are showing improvements with meaningful results Realistic approach with implementation marathon, not a sprint Public is beginning to believe and engage

55 Live Well San Diego! 55