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Whole-Community Cooperation Health by Design
South King County
Care Transitions ConferenceMarc Pierson
June 4, 2015
From Prediction to Action
Who is “We”?
Anything smaller than community is too small.
Where is “Home”?
How long will you care?
TRIPLE AIM?
Population Health
Per Capita Cost
Experience
PARADIGM 1
BUSINESS
COMPETITION
HEALTHCARE
Perfect parts do not make a perfect whole.
May 6, 2015 Cambridge Management Group 6
It is the interactions of the parts that determine the effectiveness of the whole.
Russell Ackoff
A LATE INSIGHT
PARADIGM 2
• COMMUNITY – (BUSINESS)– Population Health
• Ultimately means whole community
• COOPERATION – (COMPETITION)– Align financial incentives for cooperation and enough
of it will happen?• We are not anti-cooperative.• We are economic optimizers and entrepreneurs.
• HEALTH – (HEALTHCARE)– Better Health (social determinants)
• Less healthcare needed, about half
CURRENT SITUATION
Demographics
Population Health
Workforce Designed for Parts
IN CRISIS
Inequitable
Unhealthy
Frustrated
Unsustainable Costs
Insolvent Parts
ALTERNATIVESAT EACH LEVEL
I. NationII. States
III. CommunitiesIV. InstitutionsV. Individuals
I. NATIONAL PURPOSEPOPULATION HEALTH
Triple Aim
ACA (Nation) Requires: Population HealthTakes More Than Medicine
Cambridge Management Group 12
Cambridge Management Group 13
22 State Innovation Plans“Multi-payer, System Transformation”
http://innovation.cms.gov/initiatives/state-innovations/
Cambridge Management Group 14
II. STATEENABLING POLICIES
INNOVATION PLAN
HEALTHIER WASHINGTON
5-10 YEARS
WA STATEHEALTHCARE INNOVATION PLAN
(HCA)
State as an INTEGRATIVE purchaser Integration of Insurers and Providers
Integrated Communities for Health & Social Services Integration of Community Health Workers
Integrative Design and Learning Centers for Population Health
WA State: Supports for the Triple Aim
Cambridge Management Group 18
Planning for Whole System Coordination
July 2014 Cambridge Management Group
19
WA Plan for
Integrating Medical Care
and Community
ACH
ARBE
Community
Regional
Design & Learning
Centers
“Regional Extension
Centers” Accountable
Community for
Health
(Integrator)
Government,
Private
Enterprises,
Foundations
Accountable
Risk Bearing
Entities
(ARBEs)
(Providers--
Insurer)
Planning for Whole System Coordination
July 2014 Cambridge Management Group
20
WA Plan for
Integrating Medical Care
and Community
ACH
ARBE
Community
Regional
Design & Learning
Centers
“Regional Extension
Centers” Accountable
Community for
Health
(Integrator)
Government,
Private
Enterprises,
Foundations
Accountable
Risk Bearing
Entities
(ARBEs)
(Providers--
Insurer)
Planning for Whole System Coordination
July 2014 Cambridge Management Group
21
ACH
ARBE
CommunityAccountable Communities of Health:
Integrating Medical Care and Community
Regional
Design & Learning
Center
“Regional Extension
Centers”
BH, A&R, PH
Integration
Accountable
Community for
Health
Self Care
Networks,
PAM
CHW Net,
PAM & Tech
Prevention
Wellness
Stress, ACEs
Jobs,
Economic
Development
Social
ServicesHousing
Education,
Training,
Development
Government,
Private
Enterprises,
Foundations
Medical
Community-
wide Service
Lines
IDCOP,
PCMH
EMR, HIE,
Analytics,
Metrics
Accountable
Risk Bearing
Entities
(ARBEs)
(Providers--
Insurer)
COMMUNITY HEALTH WORKERS
Curriculum
Work force
Grass roots
ACH / ARB role?
AAA role?
PHD role?
III. COMMUNITY
Under developed
System Dynamics
Improving Interactions
HARDNOT IMPOSSIBLE
SWEDEN
GRAND JUNCTION, CO
INTERMOUNTAIN, UTAH
NEW TOOLS, NEW APPROACHES for COMMUNITIES
• System Dynamics Model– Must capture savings locally for reinvestment– Then critical sequencing (where to invest)
• CHW-network (invest first)– For supporting clients between between visits,
between institutions, and between EMRs– For saving money– For supporting chronic conditions and healthy
behaviors
• Improving interactions between institution (ongoing investment)– ACH-REC
CRITICAL COMMUNITY LESSIONS from
Rippel ReThink Health Model
1. Capture and Reinvest
2. Whole Community
3. CHW-network
29
Some communities that have used the ReThink Health systems dynamics model
Cambridge Management Group
Community System Levers
Cambridge Management Group 31
Medical System
COMMUNITY
4 Categories for Effecting Change
Redesign the Professional Workspace
Finance a New System
Focus on Upstream
Community Opportunities
Cambridge Management Group 32
Manage Health in the
Community Space
Finance a New System
1. Establish Innovation Fund
2. Capture & Reinvest Savings
3. Pay Providers for Performance
4. Expand Insurance Coverage
Cambridge Management Group 33
Redesign the Professional Workplace
Create medical homes
Recruit primary care providers for safety net clinic
Recruit primary care providers in private practice
Redesign primary care practices for efficiency
Improve hospital efficiency
Prevent hospital-acquired infections
From ReThink Health, Fannie E. Rippel Foundation
Cambridge Management Group34
Between Visits & Between Institutions:
Person-centric
Coach & coordinate health care
Improve routine preventive and chronic
physical illness care
Improve care for chronic
mental illness
Enable healthier behaviors
Extend hospice & end of life choices
Discharge
Improve post-discharge care
Provide adherence support for routine
care
From ReThink Health, Fannie E. Rippel Foundation Cambridge Management Group 35
the Community Space
Community Health Worker Innovations
Curriculum Work force Grass roots
ACH role?AAA role?PHD role?
A Community Network View
How to create conditions for EFFECTIVE care:Trustworthy
SafeEquitable
Timely and Efficient (affordable)
Q: Current State ofCare Coordination?
Q: Current State of Client Coaching?
Q: Current State of Navigating?
Hospitals,
Skilled Nursing
Facilities,
Therapies,
Pharmacies,
Diagnostics,
Behavioral
Health
Addiction &
RecoversPractice
Scheduler
Practice
NursePhysician
Care
COORDINATORHousing
FoodTransportation
Family Support
Crisis
Intervention
Legal Aid /
Criminal Justice
Education
Jobs /
Employment
Finanical
Services
PIECESHUMPTY DUMPTY?
GLUE?
COMMUNITY
Personal Care
Workers
FAMILY Care
Givers
Person
Patient
Client
HOME
Community
Based
NAVIGATOR
COACH
COMMUNITY
Community
Health Workers
(Neighborhood
Support)
Volunteer
Parish Nurses
PEER
Supporters
NEIGHBORHOOD
Practice
Scheduler
Practice
NursePhysician
Care
COORDINATOR
PRIMARY CARE
Education
Finanical
Services
Jobs /
Employment
FoodTransportation
Housing
Legal Aid /
Criminal Justice
Family Support
Crisis
Intervention
SOCIAL SERVICES
Addiction &
Recovers
Behavioral
Health
MEDICAL SYSTEM
COMPONENTS
Hospitals,
Skilled Nursing
Facilities,
Therapies,
Pharmacies,
Diagnostics,
Integrating Social and Medical Services through a Network of CHWs
OR NETWORK
CONNECTIONS?
PIECESHUMPTY DUMPTY?
GLUE?
43
Cambridge Management Group - West
BETWEEN
Life occurs in the large spaces
• Between visits
• Between organizations
• Between EMRs
Which organizations and technology will support people in between?
SOME COMMUNITIESWILL CHOOSE TO MANAGE THE
INTERACTIONS.
NOT FOR THE FAINT OF HEART
Attempts by Non-trustworthy Parts will FailCompetitors must become alliesIntegration trumps improvement
Right sequence essentialCourage and experience
May 6, 2015 Cambridge Management Group 46
May 6, 2015Cambridge Management Group 47
Criteria for Prioritizing Improvements
Focus on Interactions
Map System Connections
Create Shared System Purpose
Work Together for Population Health
Ideal Design
Reinvest Savings on Interactions
Linkage Mapping
48
It Takes a Community
Linkage Mapping SessionMay 6, 2015
WORTH THE EFFORT & RISK?
Mindset
Mood
Scale
Time
Sequence
Organizations will emerge to manage the interactions, above the competition.
BUT it will be sustainable only when there is an ability to capture the
savings and reinvest locally!
Enlightened Local Payer Function
Three Silver Bullets
• Integrated Communities for Health & Social Services
– Accountable COMMUNITY for Health
• A PLACE for innovation and development
– Integration of Community Health Workers
• Build the bridges BETWEEN the parts
– Integrative Design and Learning Centers for Population Health
Final Gentle Reminder
• It is about people working together
• It is about place.
• It is about conversations that lead to commitments.
• We all have the know how. Only the stakes and the scale are higher than usual.
• Good luck! You can do this!
Establish Sponsorship
1: Form Guidance Group; Design Communications Methods & Plan
2: Develop System Linkage Maps
3: Strategic Community Care Services
4: Design an Ideal Community Health Worker Network
5: Explore/Design All-Payer Community Financing
6: Conceptually Design an Accelerated Solutions Environment
7: Engage Local Employers in Supporting Whole System Innovation
A Phased Approach for Community-level Change
Project Work StreamsPre-work
Cambridge Management Group (West) 57
