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HEALTHY PEOPLE. HEALTHY COMMUNITIES. MAKING IT SO:
PUTTING THE ME INTO MESOSYSTEMS
Eugene C. Nelson, DSc, MPH
The Dartmouth Institute
The Health Assessment Lab
Maine Primary Care Association
Annual Meeting
October 4, 2018
FLOW
1. Back Story
2. Keyhole or Panoramic View
3. Health Determinants
4. Cases: Success Stories
5. Call to Action
2
1. BACK STORY
“Gene why don’t you
draw up a model for our
brainstorming session
tomorrow?”
3
COLLABORATORIES & COPRODUCTION: A NEW MODEL
4October 16, 2013
Social Systems:
Patients + Providers
Technological
Innovations:
Registries + Networks
COPRODUCTION MODEL: PATIENT-CENTEREDLEARNING HEALTH SYSTEM
5
Feed ForwardPRO Data
Feed Forward Clinical Data
Shared Information Environment
Partnership forCo-production
Electronic Health RecordsCollaborative Improvement Networks
Personal Health RecordsPatient Facilitated Networks
Registry &Research
Collaboratory
Patient & Family
Provider & Care Team
Optimal Health and High Value Care for Patients and Populations
© 2014 Trustees of Dartmouth
College and Karolinska Institutet
See BMJ July 2016, Nelson et. al.October 23, 2013
Aim: optimal health for patients & populations & highest value healthcare services
Feed Forward
Patient-Reported
Outcome Data
Feed Forward
Clinical Data
Shared Information Environment
Partnership for
Coproduction
Electronic Health Records
Collaborative Improvement Networks
Personal Health Records
Patient Facilitated Networks Research
Registries
Patient
& Family
Clinician &
Care Team
Subsystem 2 –
Registry-Based
Research
Collaboratory
Subsystem 1 –
Clinical Microsystem
Dashboards
Subsystem 3 –
Collaborative
Improvement
Network
Subsystem 4 –
Facilitated
Support
Network
6
4 Sub-Systems
7Lind Family
Mesosystem
Transportation
School
Info &
Advocacy
Community
Legal & FinanceSupport
Health
BIG IDEA #1. COPRODUCTION
8
All services, at some level, are coproduced.
CORE OF THE MODEL
9
Co-Assess
Co-Decide
Co-Design
Co-Deliver
Co-assess the patient’s health status and how
the treatment plan has been working to
improve patient’s health and well-being
Co-decide
on what the
next steps
in the
patient’s
treatment
plan should
be based on
relevant
evidence
and past
experiences
to MINIMIZE
the BURDEN
OF DISEASE
Co-design the treatment plan for daily care
and professional interventions to attempt to
minimize the BURDEN of TREATMENT
Co-deliver
the
treatment
plan that
usually
involves
daily self-
management
and
adherence
to plan and
occasional
treatments
by a
professional
clinician or
clinical team
BIG IDEA #2.
LEARNING HEALTH SYSTEM
“a learning health system… generates and appliesthe best evidence for thecollaborative health carechoices of each patientand provider … (and)drives the process ofdiscovery as a naturaloutgrowth of patient care”
- IOM Roundtable on Value & Science-Driven Health Care
10
11
Coproducing learning health systems now starting
in CF, IBD, Rheumatology, MS & Palliative Care
in US Sweden, Scotland, Canada, Netherlands
PATIENT MODULE
12
Patient’s overview
Earlier Later
<<Previous part Print the whole summary
Your disease activity
High
Medium
Low
CLINICIAN MODULE
13
2015 2016
RxPrescribed
Patient ReportedOutcomes
ClinicalOutcomes
SUMMARY OVERVIEW OF A RHEUMATOLOGY
PATIENT
14
Case in point:
Swedish National
Quality Registry …
This patient is
doing better …
N of 1 experiment…
responded to biologics
January - March
June - December
Patient Registering Data on Swollen
and Tender Joints on her Touch Screen
https://www.youtube.com/watch?v=Kmqzy1hqcOw
The SRQ Approach
RA DISEASE BURDEN IN SWEDEN DECREASING
Starting Feed Forward &Open Care vs Tight Care
2002 2012
RED Sweden
BLUE Gavle
2. LOOKING THROUGH THE
KEYHOLE OR TAKING THE
PANORAMIC VIEW
16
LOOKING THROUGH THE KEYHOLE
Keyhole View: Pathophysiology
aka Clinician’s View
• Chief complaint
• History
• Review of systems
• Physical exam
• Diagnostic tests
• Differential diagnosis
• The diagnosis
• Treatment prescribed
18
TAKING THE PANORAMIC VIEW
Panoramic View: Ecosystem aka Patient’s World
• Family & friends
• School & work
• Wealth & assets
• Physical environment
• Technical environment
• Health resources
• Social resources
• Community resources19
KEYHOLE PEEK OR PANORAMIC VIEW
Keyhole: pathophysiology aka
clinician’s view
• Chief complaint
• History
• Review of systems
• Physical exam
• Diagnostic tests
• Differential diagnosis
• The diagnosis
• Treatment prescribed
Panoramic: ecosystem aka patient’s
world
• Family & friends
• School & work
• Wealth & assets
• Physical environment
• Technical environment
• Health resources
• Social resources
• Community resources
20
Wrap Around: What are assets & needs?
Treat using health, social & patient resources
Limited service: What is clinically actionable?
Treat using formal health care resources
BRIAN’S INSIGHT: SRU
210
23
24
Person’s self-care system
ClinicalMicrosystem
Mesosystem
Macrosystem
Ecosystem
HEALTHCARE SYSTEM LEVELS: “CLASSIC VIEW”
MICROSYSTEMS &
MESOSYSTEMS
Aim: to coproduce high
performing clinical
microsystems that recognize
they are part of a health and
social and community
ecosystem that has the
challenge of assembling an
effective and efficient
mesoystem that meets the
needs of the patients and
families that they serve
25
Let’s put the Me into Mesosystems!
CHALLENGE
To develop attractive, affordable, personalized
mesosystems that actually coproduce high value care –
best outcomes, best experience, lowest costs to the
community – to individual patients, families &
communities
Note: Mesosystems include patients, families, health,
social and community resources relevant to the
individual and offer opportunity to leverage effective
coproduction of health, well-being and healthcare
26
MEET THE CHALLENGE BY LEVERAGING...
1. The assets, talents and capabilities of patients, families and friends to coproduce
2. Learning health system principles & methods
3. Coproduction of healthcare principles & methods
4. Information technology to track patient’s goals and needs and treatments and outcomes over time and to facilitate peer-to-peer and professional support and services
5. Artificial intelligence and other methods to answer a key question: what treatments work best for this particular type of patient under what conditions
27
28
3. HEALTH DETERMINANTS:
WHAT CONTRIBUTES TO GOOD HEALTH?
229
29
MOLLIE
CASE
• 50 years old, moved to Upper Valley to help take care of mom
• Found dishwashing job at Dartmouth
• Initial contact with Iora Health: severe back pain, depressed, occasional alcohol abuse
• Back surgery indicated
• Transportation to specialist provided
• Became homeless … found place for her dog while Mollie spent time in shelter
• Found permanent housing
• Coach helped Mollie on her resume for job hunting
• Now “holding her own”, better job, helping mom, stable housing 31
(not actual photo)
HEALTH DETERMINANTS
32
Healthcare
Genetics
Physical Environment Social Environment
Economic ResourcesLifestyle & Habits
Chance
Geography & family & community are destiny
HEALTH DETERMINANTS
33
Healthcare
Genetics
Physical Environment Social Environment
Economic ResourcesLifestyle & Habits
Chance
Iora: Dartmouth Health Connect & Orthopedics
Jobs at Dartmouth
Mother & new friends
Alcohol Abuse +/-
Upper Valley & Housing
Mollie’s Story
4. PANORAMICVIEW CASES:
MIXING CLINICAL, SOCIAL
AND COMMUNITY SERVICES
• Iora Primary Care
• Camden Hot Spotting
• TIPS Wrap Around
• Cincinnati Children’s
33
1. IORA PRIMARY CARE
“Putting humanity back into health care.”
35
Rushika Fernandopulle
Care Support Tools and Mechanisms:
• Daily Huddle and Review of Worry List Patients
• Custom Built Electronic Health Record for Longitudinal Care
• Systematic and Repeated Health Assessments Using Patient
Reported Measures
• Post-visit Patient Experience Survey
• Patient advisory Group Quarterly Meetings
Person and Family
• Mollie
• Mental Health
• Orthopedics
• Homeless Shelter
• Employment
• Resources
• Pet Shelter
Community Resources
Primary Care Team
• Physician
• Coach• Behavioral Health Specialist
• Office Staff
• Drive to specialist• Dog sitter • Home health for frail
mother• Job skills counseling• Better job• People who really cared
... a team
MOLLIE’S STORY: A COACH & A TEAM & PANORAMIC VIEW
36
IORA HEALTH: REDESIGNING PRIMARY CARE TO
DO WHAT EVER NEEDS TO BE DONE
37
IORA HEALTH 2018
35 Practices
450 employees
27K patients
US$100m
revenue
37
USING INNOVATIVE
PATIENT-CENTERED
DESIGN TO ...
• Improve Outcomes for Themselves
• Improve Outcomes for Other Patients
• Improve the Design of the Microsystem
• Tap into the Mesosystem
38
PATIENTS IMPROVING OUTCOMES
FOR THEMSELVES
Coproduction promoted by:
• Shared Care Plans
• Personal Health Coach
• Right Setting
• Open Medical Records
40
IMPROVING OUTCOMES FOR OTHER PATIENTS
41Support groups, health promotion events (massage & Paps), yoga ...
IMPROVING THE DESIGN
OF THE MICROSYSTEM
• Continuous short-loop feedback
• Net Promoter Score
• What did we do well?
• What can we do better?
• Close monitoring of Social Media
• Patient and Family Advisory Boards 42
EARLY RESULTS
• Better Experience
• Net Promoter Scores > 91% (vs. < 60% for US primary care practices)
• Better Outcomes
• Control of hypertension improved from 50% to 81%
• Lower costs
• 33% decrease in hospital stays, 24% fewer ED visits, and 5% lower per capita costs
43
IORA DESIGNED TO
• Coproduce primary care (including patients, coaches, mental health, education, social support)
• Coordinate social and community services to provide humane care
• Identify patient’s goals, to improve outcomes and to reduce total costs
• Use a novel longitudinal EHR that both patients and clinicians use for coproduction
44Special Sauce: Coproducing primary care and coordinating Mesosystem
2. CAMDEN PROJECT: HOT SPOTTING & WHOLE PERSON CARE
44
AIM: TO DESIGN A
NEW SYSTEM TO CUT
COSTS OF HEALTH CARE
FOR SUPER UTILIZERS
ORIGINS
• Jeff Brenner: MD working in Camden primary care center
• Discovery: large % of dollars spent on small number of Medicaid patients
• Failed system: primary care designed for average patient & failed the super utilizers – indigent, complex chronic, homeless, mental illness, addiction, jail …
• Data: Used data for hot spotting super utilizers
• Whole Person: Developed wrap around system: housing first, primary & social care, coordinated care & health coach, motivational interviewing, all done “on site”
46
CONTEXT: CAMDEN COALITION OF HEALTH CARE PROVIDERS
MECHANISMS: HOW IT WORKS
• Data: Use data to discover the outliers: super utilizers
• Design: Understand the problem, dedicate resources, and design effective interventions
• Deliver Whole Person Care: Start new system of multi-disciplinary, coordinated care that treats the whole patient, and
• Deliver Social Care: Meet the non-medical needs that affect health: housing, mental health, substance abuse, emotional support
47Source: https://hotspotting.camdenhealth.org/
OUTCOMES
EVIDENCE OF IMPACT
• Camden hot spotting method “exported” to Arizona by Jeff Brenner & United HealthCare
• Worked with state Medicaid & affordable housing owners
• Started new system: housing first & integrated wrap around services & in home delivery
• Results for first n=41 patients
• Hospital admissions down 71%
• Hospital days down 81%
• ER visits down 55%
48
Source: United HealthCare Community & State Services. Used with permission.49
WHOLE PERSON WRAP AROUND
50
Patient & Coach
Housing
Health Services Social Services
Better Health & Value
Hot Spotting
Needs Assessment
CAMDEN PROJECT DESIGNED TO
• Find hotspots
• identify high need, high cost people
• Work Maslow’s hierarchy
• Safety, food and shelter first
• Assess needs
• provide wrap around health and social services including skills training
• Deliver value
• Track use of healthcare and delivery costs to show positive ROI
51Special Sauce: Hot spotting > Wrap around housing, health and social services
TIPS
Overview
“High Tech Meets
High Touch”
3. TIPSTELEHEALTH INTERVENTION PROGRAM
FOR SENIORS
52
TELEHEALTH VITAL SIGNS MONITORING & COACHES
We provide the TIPS service for the sickest and neediest in our community, targeting
• Over 65
• Medicaid/Medicare
• 2 or more chronic conditions
• Living at or below the poverty line
53
“High Touch”: Wraparound Social Services
Benefits Check Care Circles for Seniors
Caregiver Coaches Chronic Disease Self Mgt
Speakers Bureau Exercise
FitBit tracking Information & Referral
Elder Abuse Screen Falls Prevention, etc. 54
TIPS INTEGRATED SERVICES
55
Mesosystem
Entry Points
Workplace
*Public
Housing
*Senior
Housing Health Care,
Hospitals,
Home Care
Houses
of Worship
*Homebound
TIPS Locations and Partners
Continuing
Care
*Senior Centers
& Nutrition Sites
*Libraries* “Villages”
RFD Volunteer
Fire/Ambulance
* Currently operational 56
> Metrics collection at TIPS site> Wrap-around services assessment
> Triage (if necessary)> Information & referral
Start
• Blood pressure• Weight• Heart rate• Blood oxygenation• Five questions about
subjective wellness
TIPS PROCESS
57
> Metrics collection at TIPS site> Wrap-around services assessment
Remote evaluation by RN
Secure data transfer to server
> Triage (if necessary)> Information & referral
Start
• Blood pressure• Weight• Heart rate• Blood oxygenation• Five questions about
subjective wellness
TIPS PROCESSOvertimeOver time
58
Increased quality of care
Expanded healthcare access
Reduced system and individual healthcare costs
Benefits
MAJOR OUTCOMES
AT FIRST-GLANCE
• Tracked N=735 participants over an average of 300 days
• 88% participation rate in weekly coaching visit
• Average 30% reduction in pre-/post- ER visits
• In Medicare cohort:
• 60% reduction in hospitalizations
• 75% reduction in under-30 day readmissions
59
TIPS DESIGNED TO
• Use Telehealth and volunteer graduate student coaches to coproduce wrap around health and social services
• Offer longitudinal care coordination and foster a bond between the client and the coach to coproduce personalized service plan
• Improve health and well-being and to reduce costs
61Special Sauce: coaches coordinating the Mesosystem
Contact
John Migliaccio, PhD: [email protected]
David Sachs, PhD: [email protected]
David Putrino, PhD: [email protected]
www.seniorcitizens.westchestergov.com/telehealth-tips
WANT TO LEARN MORE???
62
4. CINCINNATI CHILDREN’S:IMPROVING COMMUNITY HEALTH
“Focusing on the first 9 years of life.”
63Uma Kotagal
“EXECUTION”
Cincinnati Children’s
Hospital Medical Center
64
MISSION
For patients from our community, the nation and the world, the care we provide will achieve the best:
• medical and quality of life outcomes
• patient and family experience and
• value
• today and in the future
65
CONTEXT: STARK CONTRASTS
• CCHMC had become national leader in
healthcare quality
• Winner of AHA’s best hospital award
• Trendsetter in quality and safety and learning
health systems
• But based in a neighborhood with high infant
mortality rates, high crime rates, high
poverty rates
66
START WITH AIM & DATA: WORLD CLASS MEDICAL CENTER IN POOR HEALTH
NEIGHBORHOOD
67
AIM: TO IMPROVE THE HEALTH OF CHILDREN AGE 0 TO 9 LIVING IN CINCINNATI
68
PATH FORWARD
• Strategic commitment by CCHMC leadership: live the mission
• Strong senior leader champion: Uma Kotagal
• Focus on ages 0 to 9
• Asthma 2011
• Preterm births 2013
• 3rd grade reading proficiency levels 2015
• Networking with community leaders to form health coalition: mayor’s office, school officials, police officers, housing authorities, local leaders
• QI methods fit to context: driver diagrams, key success measures, control charts, PDSAs, action learning
69
GETTING ORGANIZED
70
HOT SPOTTING IN COMMUNITY: BUILDING CODE VIOLATIONS, ASTHMA ADMITS, ED VISITS
71
PRETERM BIRTHS IN CCHMC NEIGHBORHOOD
72
Zero preterm
Births since 2015
ACT DESIGNED TO
• Focus on a good start in life: ages 0-9
• Form community coalition (complex adaptive system) to improve health of children
• Use community organizing, collective impact, coproduction, learning system & QI methods to rapidly improve outcomes
73
Special Sauce: Adapting improvement strategy &
techniques mastered at CCHMC to work for local
Population health improvement
74
5. WHAT’S TO BE DONE? A CALL TO ACTION
75
WE ARE IN A PICKLE
76We need to coproduce better outcomes, better care, lower costs
“OH BY THE WAY”
78
OH BY THE WAY ... GOOD HEALTH PAYS OFF:UPSHIFT IF HEALTHCARE USES VALUE PAYMENTS
Old Cost Stream:
Illness Pays
Patient exits home when sick
Primary Care
Specialty Care
Hospital Care
Quaternary Care
New Value Stream:
Health Pays
Person healthy doing self-care
Primary Care
Specialty Care
Hospital Care
Quaternary Care
79
$$$$$$
$$$$$$
THE FUTURE .. . MOVING FROM
OPTIMIZING CLINICAL
MICROSYSTEMS TO BUILDING
EFFECTIVE, AFFORDABLE,
PERSONALIZED MESOSYSTEMS THAT
“COPRODUCE THE GOODS” .. . WEAVING TOGETHER HEALTH, SOCIAL, LAY CARE
AND PEOPLE’S PERSONAL ASSETS,
TALENTS & MOTIVATIONS
These Mesosystems will ...
• Leverage effective coproduction
• Be authentic learning systems
• Be assisted by IT and AI
• Promote effective self-careand home-care
• Be judged on their measured ability to deliver value: outcomes, convenience, accessibility, costs
80
HOME RUN: HIT A FOUR
BAGGER
• 1st Base
• Whole person: master the mesosystem
• 2nd Base
• Coproduction: co-assess, co-decide, co-design, co-deliver
• 3rd Base
• Learning Health System: learn what works for patients & populations
• Home Plate
• Measurably improve value81
WHAT’S TO BE DONE? A CALL TO ACTION FOR MAINE’S FQHCS
1. Whole Person Services: Make foundation of your system whole person assessment and comprehensive health & social service delivery over time
2. Coproduction of Services: Leverage local assets – patients & families, health & social services, payers & policy makers – to implement coproduction of health and social services. Make competent self-care the new principal care -- convenient, attractive, supported, facilitated
3. Learning Health System: Develop a learning health system that supports learning and value measurement -- using feed forward and feedback data -- at the level of patients & families, clinical and social service programs, and the region’s health and social service ecosystem
4. Value Improvement: Redesign programs and processes to actually measure, improve and pay for value for people, patients and families
82
THANKS TO ...
83
Case Studies
• Rushika Fernandopulle
• Joel Lazar
• Staffan Lindblad
• Andreas Hager
• Kristin Lind
• Jeff Brenner
• John Migliaccio
• David Sachs
• Uma Kotagal
ICOHN @ Dartmouth Team
• Paul Batalden
• Amber Barnato
• Jake Casale
• Glyn Elwyn
• Alex Gifford
• Lisa Johnson
• Alice Kennedy
• David Leander
• Kathy Kirkland
• John Mecchella
• Brant Oliver
• Kathy Sabadosa
• Corey Siegel
REFERENCES
1. Getting more health from healthcare: quality improvement must acknowledge patient coproduction – an essay by Paul Batalden. BMJ 2018; 362:k 3617 doi: 10/11/36/bmj.k3617 (Published 6 September 2018)
2. Kamal AH, Kirkland KB, Meier DE, Nelson EC, Pantilat SZ. A Person-Centered, Registry-Based Learning Health System for Palliative Care: A Path to Coproducing Better Outcomes, Experience, Vale, and Science. Journal of Palliative Medicine, November 2017. doi:10.1089/jpm.2017.0354
3. Ovretveit J, Zubkoff L, Nelson EC, Frampton S, Knudesn JL, Zimlichman E. Using patient-reported outcome measurements to improve patient care. International Journal for Quality in Health Care, August 2017. doi:10.1093/intqhc/mzx108
4. Johnson LC, Melmed GY, Nelson, EC, Holthoff MM, et. al. Fostering Collaboration through Creation of an IBD Learning Health System. American Journal of Gastroenterology. February 2017; doi: 10.1038/ajg.2017.9
5. Nelson EC, Dixon-Woods M, Batalden PB, Homa K, et. al. Patient Focused Registries Can Improve Health, Care and Science. BMJ 2016; 354: i3319 doi:10.1136/bmj.i3319.
6. Ovretveit J, Nelson EC, James B. Building a Learning Health System Using Clinical Registers: a non-technical introduction. Journal of Health Organization and Management 2016; 30(7):1105-1118; doi:10.1108/jhom-06-2016-0110
7. Linblad S, Ernestam S, Van Citters AD, Lind C, Morgan TS, Nelson EC. Creating a Culture of Health: Evolving Healthcare Systems & Patient Engagement. QJM 2016; doi: 10.1093/qjmed/hcw188
8. Nelson EC, Eftimovska E, Lind C, Hager A, Wasson JH. Patient reported outcome measures in practice. BMJ 2015;350:g7818.
9. Nelson EC, Lazar JL. Mollie’s Story: A case and a place that exemplifies person-centered care. Journal of Ambulatory Care Management, January-March 2015 38 (1):87-90.
10. Weinstein JN, Tosteson AN, Tosteson TD, Lurie JD, Abdu WA, Mirza SK, Zhao W, Morgan TS, Nelson EC The SPORT value compass: do the extra costs of undergoing spine surgery produce better health benefits? Medical Care 2014 Dec. 52(12):1055-63
11. Nelson EC, Meyer G, Bohmer R. Self-care: The New Principal Care. Journal of Ambulatory Care Management, July-September 2014: 37(3):219-25
12. Nelson EC, Batalden PB, Godfrey MG, Lazar JS: Value by Design: Developing Clinical Microsystems to Achieve Organizational Excellence, Jossey-Bass, 2011.
13. Nelson EC, Batalden PB, Lazar J: Practice-Based Learning and Improvement: A Clinical Improvement Action Guide, Second Edition, Oak Brook Terrace, Illinois: Joint Commission Resources, 2007.
14. Nelson EC, Batalden PB, Godfrey M: Quality by Design: A Clinical Microsystems Approach. San Francisco: Jossey-Bass, 2007.
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