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Social Needs Interventionsfrom
Pilot to Scale
December 6, 2016
Christina Lundquist, MHS
VP Operations, University Hospitals
Kati Traunweiser, MBA
VP, Quality and Regulatory Services, Kaiser Permanente
Anna Roth, RN, MPH
CEO, Contra Costa Health Systems
Today’s discussion
• Share key lessons and strategies to address social needs
• Identify challenges and opportunities in moving from pilot to scale
• Identify actions to take in your system
@AnnaMRoth
“Here is what we seek: a compassion that can stand in awe at what the poor have to carry rather than stand in judgment at how they carryit.”
~ Boyle
UNIVERSITY HOSPITALS:
BUILDING YOUR CASE
6
Christina Lundquist, MHS
VP Operations, University Hospitals
7
• Vision 2010 Principles: Hire Local, Buy Local, Live Local
– Invest in our communities
• Used our buy and spend locally
• 5,200 jobs
• $500 million in salaries
– Revitalize our neighborhoods
– Create jobs and develop skills
– Design and develop multi-institution, city and regional partnerships
UH Anchor Mission and Strategy
Next Phase in the Evolution of the Anchor Strategy
UH Rainbow Center for Women & Children: Leveraging the power of community-centered work to create a culture of community health
• The UH Rainbow Center for Women & Children, a newly constructed facility of UH Rainbow Babies & Children’s Hospital and UH MacDonald Women’s Hospital, will serve a federally designated medical/dental underserved area. The center will be built where patients live, becoming a highly accessible medical home for the existing patient base for Rainbow and MacDonald.
• Utilizing strategic philanthropic funding to support new programs such as Health Leads.
Transitioning the Model of Care
• Multi-sector collaboration• Anchor that supports community well being—hire
local, buy local, live local• Integrating social, behavioral, and environmental
health determinants• Leverage opportunities for upstream intervention
• Isolated from the community• Come-to-us mentality
10
• How would you rate your organization’s readiness to start
integrating social needs into care delivery?
Rate the following on a scale of 1 (not at all) to 5 (ready):
– Leadership is committed to making an investment in social needs interventions
(includes finances and infrastructure)
– The organization’s strategy reflects social needs as a priority
– Change management practices are incorporated in the organization’s operations
– The organization’s culture encourages continuous learning, new ideas, and learning
from experience and experiments
Discussion
Kaiser Permanente:
Implementation Journey to Address
Social Determinants of Health
Kati Traunweiser, MBA
VP, Quality and Regulatory Services, Kaiser Permanente
11
Project Description - Overview Goals
– Understand, address social needs of high utilizers
– Define the human and business case(s) based on evidence
– Learn to scale system- and sector–wide
Intervention
– Integrate KP/HL operations to screen, refer, and close social gaps
Population
– Main: patients with highest 1% of predicted costs using highly accurate clinical predictive analytics (target n = ~5000)
– Others: defined locally by opportunities at each medical center
Outcomes: Costs, Clinical (Structure/Process/Outcome), Social
Time Frame: Pilot (1-2 years) with hopes for permanent integration
Location: Pilot at three medical centers – West LA, Fontana, Kern
12
Who are the Predicted 1 Percent?
13
Care Across the Continuum: A scaled approach matching resource intensity to patient need
Implementation Strategy: Region Level
Pilot at 3 Diverse Centers
West LA, Fontana, Kern
Regional Resource Hub
Remote desk or call center
Outreach and screening of predicted high utilizers
Allows for automation, higher volume, and randomized evaluation
EHR-based workflow and assessment integration
15
16
Cold Call Screen Identify Needs Enroll
11/15/15 to 7/30/2016
N=2,330 members
called
81% agree to take
screen 52% have 1+ need
49% enroll
72% answer call
N=1687answer call
N=1373took
screen
N=712screen
positive
N=352enrolled
What happens when you cold call?
The screening funnel above shows that a majority of predicted high utilizers screen positive for a social need; additionally, our current cold call engagement shows that Kaiser Permanente have a unique opportunity to engage with members around social needs.
Project Description - Evaluation
Main Questions:
– What are the social needs of high utilizers in KP? Population and patient-level profiles.
– What is the impact of addressing social needs on clinical, cost, and social outcomes compared to controls among those high utilizers?
Nested Design:
– Overall: quasi-experimental design, ITS differences in differences comparing all 1% high utilizers who receive social need intervention to controls at other sites
– Sub-population: randomized trial amongst the patients enrolled through resource hub comparing those randomized to intervention vs. controls
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Screening Prevalence
18
Financial (30%)
Caregiver Support (31%)
Affording healthy meals (28%)
Food didn’t
last (28%)
High
Prevalence
Medium
Prevalence
Lower
Prevalence
Health literacy / numeracy (26%)
Social Isolation (23%)
Transportation (20%)
Utilities (19%)
Medical Care Costs (18%)
Homelessness (9%)
Housing conditions (9%)
Applying for public benefits (8%)
Financial Counseling (7%)
Child-related (4%)
Employment (3%)
What are members screening positive for?
19
Curation of social needs
10% of community resources = 80% benefit
27% of community resources cause harm
Many areas of need not met in the community
20
Discussion
On a scale of 1 (not at all) to 5 (ready), how prepared is your organization to measure program results and outcomes?
– Analysis / evaluation expertise
– Data
– IT Systems
How can you maintain the organization’s engagement and commitment as the project team pursues program outcomes?
Contra Costa County:
Moving to Scale
Anna M. Roth, RN, MPH Chief Executive Officer
Contra Costa Regional Medical Center, Health Centers & Detention Health
Today’s Landscape/Context
Stay ahead of the game or be left behind
How we work
Who we are
• Regional Medical Center &
11 Health Centers, 5 Jails
• County’s safety net
hospital and clinics
• 4200 staff, including
• $600m
Addressing Social Needs
Our Progress
Icons from FlatIcon
2067patients served
2270Resource
Connections
47%of clinic
screened
A Regional Issue“East Contra Costa County has transformed
from a blue-collarsuburban enclave into a new epicenter of
Bay Area poverty in just 15 short years.”
“We’re dispersing the low-income population into places where hard
infrastructure and social services are either nonexistent or inefficient.
“We are seeing the next chapter in the story of segregation: low
income people in the suburbs and more affluent people in the urban
core.”
“It’s kind of like this vortex — the community isn’t well organized
enough to understand, let alone demand, what they need, and for
funders and investors, there’s no there there to invest in.”
Our Vision
Contra Costa will be the first county in the nation to address
basic resource needs system-wide; This will be achieved by:• Screening: Screen patients for social needs county-wide
• Connecting: Connect every patient who wants assistance to social need support
where the resources exist
• Measuring Outcomes: Collecting data to improve programs, evaluate impact and
make the national case for addressing social needs
• Community and Policy Partnerships: Using the data, better understand where
resource gaps exist and partner with community and policy stakeholders to
strengthen the existing resources and address gaps
27
So where are we today? And how do we achieve these goals?
Intervention Models for Expansion
28
Enable self-care through targeted outreach, mobile apps, flyersIntervention: Self Serve Kiosk & Info Desk Staff
Blend of technology & human support to enable patient successIntervention: Equipping existing workforces with Reach & Health
Lead’s Desk
High touch & personal support, tightly integrated with care teamsIntervention: Social Work, Public Health Nursing, CCHP CM
Low Need and Low Patient Complexity
High Need and High Patient Complexity
It is not enough just to open the
gates of opportunity. All our
citizens must have the ability to
walk through those gates.
Lyndon B. Johnson
Consider• Rate your organization’s readiness to embark on a plan to scale social
needs system-wide?
Rate the following on a scale of 1 (not at all) to 5 (ready):
– Leadership is committed to making an investment to scale social needs (includes finances and infrastructure)
– The organization’s strategy incorporates social needs as a priority
– Change management practices are incorporated in the organization’s operations
– The organization’s culture encourages continuous learning, new ideas, and learning from experience and experiments
36
• Share your
challenges when
you think about
addressing social
needs
• What conversation
are you committed
to having when
you return to your
organization or
work?