12 June 2019

The Time Is Now for Health Systems to Get Serious About Social Determinants of Health




A fundamental question continuing to face many health system executives is: How do we comprehensively address the needs of patients when those needs extend beyond the boundaries of traditional clinical care?  As President and CEO of PCCI, we have been focusing on this very challenge since 2012.  And while there has been much talk and excitement about social determinants of health (SDOH), we believe that ~90% of the health system market still does not leverage social/economic information when designing population health programs, developing patient-specific treatment plans, locating new services, or conducting community needs assessments. But before health system executives can design an effective SDOH strategy for their organizations, they must first assess where they are and where they would like to be based on the insights and advantages a progressive SDOH strategy would offer. PCCI’s Social Determinants of Health Maturity Model can help executives take this critical step.

Social Determinants of Health Maturity Model

Level Zero: Incomplete Picture of an Individual’s Environment

Realistically, this is the starting baseline for most organizations. Often, teams will attempt to use clinical and claims data ALONE as a means to segment patient populations and project the impact on a patient or cohort. This rarely works; rather, it often leads to late treatment in acute environments, sub-optimal interventions, and erroneous insights about specific patients, patient populations, or geographic markets.

Level 1: High-Level View of SDOH, Using Specific Social and Economic Indicators as Proxies

Teams can extract basic information from claims or clinical data that could serve as effective SDOH proxies. An example would be to look at the number of changes in addresses in a specific record, over a 12-month period, as a strong indicator of housing instability.  At the highest level, teasing out information from existing records can begin to illuminate some of the critical social and economic challenges that may present for individuals in a given community. This level of insight also allows health- system teams to test basic assumptions about a market. We’ve seen teams fooled when the employment level appears to be relatively stable, only to subsequently discover that much of the employment is via low-wage jobs with very poor benefits.  If you begin to see that people are moving around even though the employment statistic looks stable, you begin to realize that the actual stability of your community might not be what you perceived it to be.

If at Level 1, Leadership Teams Should Be:

  • Developing high-level proxy indicators to reflect underlying social and economic challenges that could play a significant role in health status or the ability to access services.
  • Understanding the payer mix; who you serve and, even within the insured population, understand the wage/income levels because there is a high percentage of employed, low-wage individuals that have vulnerabilities associated with transportation, housing, affordable daycare, etc.
  • Becoming familiar with existing local or state connected communities of care programs or activities aligning providers and community-based organizations, such as food pantries, to streamline assistance efforts, reduce repeat crises and emergency funding requests, help address disparities of care, and improve the health, safety, and well-being of residents.

Level 2: Root Causes Understanding of Poor Outcomes at the Population Level

The rubber hits the road at level 2 and teams begin leveraging local data that directly reflect variation in social determinants. We believe that to understand root causes and build actionable models for patient engagement and support, you must evaluate data at the block level. Zip-code level aggregation often masks important details. This is particularly true in highly populated municipalities that can see a tremendous amount of social determinant variation within a 0.1 mile distance. For example, if I had block-level information providing insight that a six-block neighborhood within my market was having transportation-oriented issues and concentrated pockets of non-violent crime, I would model these insights into the deployment of my mobile diagnostic clinics or my development of innovative models to improve access.  Also, if I was discharging a patient who resided in that neighborhood, I would rethink how to schedule follow-up appointments, since the chances of the patient keeping the visits are extremely low. This level of insight and actionability would be missed at the zip-code level.

In collaboration with DFWHC Foundation, Community Council of Greater Dallas, and the University of Texas at Dallas, PCCI built a platform for Dallas called Dallas Community Data for Action and/or Community Data Insights [CDI].  CDI ingests and organizes multiple, publicly available data inputs, such as housing, education, food availability, and 911 and 311 data to generate real-time, actionable dashboards containing over 60 factors that all point to specific social determinants.  In Dallas, use of this data has been vital in understanding pockets of need and in locating areas where the impact of interventions can be the most profound.  You can also use this data more broadly to generate support to build community cross-sector collaboration, by enabling health systems to effectively  engage and coordinate with local municipality officials on community-based support services and planning, and also by helping philanthropic organizations to better understand (and track) community needs in order to invest in/prioritize funding areas that will produce the greatest impact.  In addition to having a detailed and dynamic picture of social and economic needs (demand for services), the CDI dashboard can quickly map out where support services are available/delivered and map/model the interdependencies and concentration of chronic health conditions with social support needs.  As this model is rapidly scalable, PCCI is already working with others across the country.

If at Level 2, Leadership Teams Should Be:

  • Integrating SDOH market insights into your strategic planning process and your community engagement plan
    • Use block-level SDOH in community needs assessments
  • Anticipating and predicting the correlations between multiple social and economic factors to inform your patient flow and access strategy (including your telehealth strategy). Start conducting trend analyses to anticipate and forecast the changes in local-market dynamics that will impact utilization, payer mix, and social/economic barriers to health.
  • Crafting a data-driven engagement plan to align more directly with local municipalities and local philanthropic organizations.

Level 3: Comprehensive Partnership Between a Community’s Clinical and Social Sectors

Participating organizations across a community are collaborating on one Information Exchange Platform and are connected through an innovative closed-loop referral system allowing them to communicate and share information with each other. Success at this highest level requires both a strong technology infrastructure and consistent programmatic deployment [at scale] across a community. This is what we’ve done in Dallas with our technology partners at Pieces Technology Inc.; effectively managing the right balance of people, processes, and technology has allowed us to achieve the positive results that we’ve seen.

Level 3 means a significant investment and a multi-year commitment, not only by the anchoring healthcare system or systems, but also by the local community.  It requires an initial investment and a robust sustainability plan that can ensure that the platform capabilities evolve with the changing needs of the community.  Deployment requires not only new technology, but an engaged local governance structure, new legal and data sharing agreements, and further refinement of data integration and advanced analytics at the individual level.  Integrating these into new/updated clinical and community workflows enables teams to proactively predict specific health and social/economic needs, the complexity and co-dependency of needs, and the ability to act real time at the point of care to address these needs.  This can facilitate making real-time referrals for community support services, tracking whether individuals accessed suggested medical or community resources (and what specific services were provided), and measuring and tracking the impact to individual/community resiliency, self-sustainability, health outcomes, and cost.  In Dallas, we’ve also started to leverage advanced data algorithms to risk-stratify individuals based on their health and social/economic needs to better prioritize and tailor resources and to proactively target high-risk individuals for engagement and follow-up via digital technology.

At levels 2 and 3, a health system must also think about how to leverage its foundation resources and internal employee community-outreach volunteer programs.  Once you better understand the patients that you’re serving in your market and the community-based services they access, you can better deploy employee-based efforts and philanthropic activities that align with the strategic efforts and provide maximal impact.

If at Level 3, Leadership Teams Should Be:

  • Crafting the information exchange platform governance infrastructure to delineate key roles, essential participants, and shared objectives.
  • Committing to cross-community collaboration [potentially including competitors] and a long-term effort; recognizing that your health system might be an anchor organization, but it cannot independently solve the entire problem.
  • Selecting and deploying the technology infrastructure [Pieces Iris™, TAVHealth, Unite Us, etc.] to enable cross-community engagement.  Develop updated clinical and community-based workflows.

In summary, if you’re just starting to address SDOH, you’re late.  It is critical for health systems to begin their SDOH journey today, especially if you serve a vulnerable population and/or operate in a market dominated by uninsured and Medicaid patients.  Addressing SDOH is also equally important for organizations managing a lower-wage, commercially insured population and for any health system that is actively managing or considering taking on risk-based contracts.

If you’re well on your way up the SDOH curve and actively integrating SDOH into your strategic and care-delivery models, then start working on new models to bridge social isolation (physical and mental) and to better understand (and develop strategies to address) challenging behaviors, including chronic helplessness.

To learn more about our Dallas journey, please visit our website and see what our team of PCCI experts is doing to make a difference or visit our technology partners at Pieces Technology to experience the Pieces IRIS™ technology.

14 November 2018

World Diabetes Day




Today, November 14, is designated as World Diabetes Day to unite the global diabetes community to produce a powerful voice for diabetes awareness and advocacy. According to the World Health Organization (WHO), over 425 million people are currently living with diabetes, prevalence is continuing to rise, and one in two people currently living with diabetes is undiagnosed.

Living with diabetes is a daily struggle, but many organizations have worked to create programs to decrease the struggle of those impacted. Ms. F, a 62-year-old African-American female with diabetes who relies on getting her nutrition from a food pantry, is a great example of someone that has benefited from these programs. Ms. F struggled with making proper food choices, adherence to proper medication, and transportation to make regular doctors’ appointments.

Through part of PCCI’s Connected Communities of Care program which shares patient’s information between providers and community-based organizations, Ms. F’s health and social service providers were able to connect and share information regarding her condition. When Ms. F visited the food pantry, staff members were aware of her diabetes. This knowledge enabled the staff to effectively guide her through her diet choices. This pilot program between three food pantries and Parkland Health & Hospital system helped many patients in taking the steps needed to control their disease.

In addition to limited access to healthy food choices, many patients in underserved communities have limited access to transportation. This challenge has made the remote monitoring of patients a critically important component in managing diabetes. PCCI is partnering with Parkland Health & Hospital System’s Global Diabetes Initiative to explore innovative approaches to improving the care of diabetic patients with foot ulcers which can lead to amputations if unresponsive to care. By acquiring data from home glucose monitoring devices and making real-time changes to treatment without physically having to see the patient, the (soon to be launched) study aims to create a sustainable remote glucose monitoring care system. This system will improve glucose control, promote faster healing of foot wound, and reduce long-term healthcare utilization and ultimately, reduce the burden cost of care for individuals and families.

Resources:

https://www.worlddiabetesday.org/

https://www.idf.org/e-library/epidemiology-research/54-our-activities/455-world-diabetes-day-2018-19.html

https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

7 August 2018

The Tech Tribune: 2019 10 Best Tech Startups in Dallas




The Tech Tribune staff has compiled the very best tech startups in Dallas, Texas. In doing our research, we considered several factors including but not limited to:

  1. Revenue potential
  2. Leadership team
  3. Brand/product traction
  4. Competitive landscape

Additionally, all companies must be independent (un-acquired), privately owned, at most 10 years old, and have received at least one round of funding in order to qualify.

20 July 2018

Obtaining Results in Population Health Management




THREE FUNDAMENTAL ELEMENTS

True population health management requires at least three fundamental elements to drive transformational change and meaningful results:

  1. Aligned incentives across payers, health systems, post-acute care providers, and physicians.
  2. Technology and framework fit for engaging an entire community that leverages resources for care coordination and addressing social, economic, and behavioral needs
  3. Personal engagement to drive activation, behavioral modification, and create a foundation for shared decision making.

HOW ASTHMA AFFECTS POPULATION HEALTH

While this framework is required for managing all populations, it becomes critical and complex when managing chronic disease. For example, asthma is a common disease, but it’s rarely recognized as one of the most common chronic diseases for children under the age of 18 with 6.2 million affected individuals. Over 8% of children have asthma, most with symptoms occurring before five years of age. Asthma disproportionately affects low-income, minority, and inner-city populations with African-American children being at the highest risk. It is a significant driver of school absenteeism, with an estimated 12-15 million school days lost per year.

Asthma impacts both families and the healthcare system financially as well as socially. Childhood asthma is the cause of nearly five million physician visits and more than 200,000 hospitalizations each year. Medical expenses for a child with asthma are almost double than those for a child without the disease. Given these statistics, there’s a compelling need for early identification and effective intervention to control this disease.

PCCI’S POPULATION HEALTH FRAMEWORK

The Parkland Center for Clinical Innovation (PCCI) has developed sophisticated predictive models to proactively identify children at risk for asthma exacerbations and has combined this powerful engine with a comprehensive population health framework to:

  • Reduce asthma emergency department visits and hospitalizations
  • Increase patient adherence to medication and clinic visits
  • Increase evidence-based leading practices at the provider level

 

Figure 1 Highlights the PCCI Pediatric Asthma Framework

Figure 1. PCCI Pediatric Asthma Framework

PCCI’S PEDIATRIC ASTHMA MODEL AT WORK

Through tailored clinical workflows, monthly provider reports, point-of-care EHR integration, and patient-centric mobile messaging applications, the framework can engage providers, communities, patients, and their families to optimize care, drive engagement, and reduce unnecessary utilization.

Within three years, deployment of the program in the Dallas metro-area by a large health plan resulted in:

  • 32-50% increase in the appropriate use of controller medications
  • 31% reduction in ED visits
  • 42% reduction in asthma-related inpatient admissions

This framework has resulted in more than a 40% drop in the cost of asthma care with the health plan saving over $18 million for both patients and healthcare providers.

ENGAGEMENT IS KEY

The key to PCCI’s pediatric asthma framework is that the clinicians, patients, and health systems are all engaged which generates value for all parties involved. With a foundation in literature-based evidence, the framework aligns with national and international guidelines. It is also both modular and patient-friendly – offering different levels of interventions based on patient risk score, needs, and available resources.
By utilizing our sophisticated predictive model to identify children at risk for asthma proactively, we are able to combine it with a comprehensive population health framework to:

  • Increase patient adherence to medication and clinic visits
  • Educate patients in care and self-management
  • Optimize health plan to care manager outreach and workflow
  • Engage physicians via direct EHR alerts
  • Reduce preventable asthma ED visits and hospitalizations

CURRENT DEPLOYMENT

Twenty-one community clinics in the DFW area receive real-time alerts embedded in their EMR and monthly progress reports. These activities resulted in 32% to 50% improvement in asthma controller medication prescriptions and a 5% improvement in the asthma medication ratio (a HEDIS metric). Some clinics are using the reports to redesign asthma care delivery programs and roll out shared medical appointments as needed, while others use the reports to guide spirometry scheduling.

ENGAGEMENT WITH THE POPULATION HEALTH FRAMEWORK

High and very high-risk patients can engage through succinct, precise, and educational text messages delivered by a simple effective mobile platform. Patients are surveyed about their condition, emergency inhaler usage monitored, and they are reminded of upcoming appointments and medication refills. These innovative features allow continuous symptom monitoring by the clinician to ensure continuity of care and positive outcomes. Patients have displayed satisfaction with the program, with over 70% top box satisfaction and an attrition rate of less than 15% on mobile engagement over a two-year period.

Community engagement is a critical element when trying to ensure not only coordination of care, but referrals and connections to community resources. Providers at either hospitals or the clinics, receive best practice alerts and utilize technology to identify SDOH needs. They can also refer families to community-based organizations (CBO) for assistance with critical daily needs. Currently, we’re in the process of expanding interactions and engagement with local schools, so that school nurses concurrently receive alerts on high risks children and can help coordinate care in those settings.

COMPETING POPULATION HEALTH FRAMEWORKS

While there are multiple and broad initiatives occurring in every market, results have displayed limited to incremental progress. PCCI has demonstrated that transformational change and meaningful results are achievable. Meaningful results require concurrent engagement and coordination of payers, providers, community, and patients via advanced risk-predictive stratification algorithms and deployment of information via new/updated workflows at the point of interaction. Figure 2 highlights the difference and impact our comprehensive program has across a market.

 

Figure 2. PCCI Pediatric Asthma controlled analysis. Comparison 1: DFWHC Medicaid <18 yo: 5% drop in asthma ED visits. Comparison 2: All Health Plan Members <18 yo: 10% drop in asthma ED visits. PCCI Asthma Program: 31% drop in asthma ED visits

Additional Innovations

Despite tremendous success, opportunities still exist to improve results and continue to further engage providers and patients. We are designing and rolling out two additional innovation pilots:

  1. Testing the effectiveness of disease-specific in-home personal assistance devices (Amazon Echo) to engage groups of homogeneous, high-risk, pediatric asthma children in a gamified home environment.
  2. Integrating within a home or community to allow remote monitoring of asthma medication adherence and in-home air quality by using “Internet-of-Things” integration.

The framework is designed with adaptability in mind and is ideal for environments where providers hold risk-based contracts. Future applications will include other patient populations and health conditions. PCCI’s Pediatric Asthma Population Health Framework has not only reduced unnecessary utilization and costs, but it has also improved the healthcare experience for hundreds of pediatric patients and their parents.

Central to the work of PCCI is its strength in predictive analytics/modeling and building connected communities using intelligent, integrated, electronic information exchange platforms. Our state-of-the-art programs and advisory services deliver exceptional value to Parkland Health & Hospital System, the local community, and the broader healthcare market.

Learn more about PCCI’s collaborations, or stay up-to-date with our recent news by following us on Facebook, Twitter and LinkedIn!

12 June 2018

The Increasing Importance of Social Determinants of Health




IMPACT ON HEALTH OUTCOMES

Over the last few years, it has been very clear from research that Social Determinants of Health (SDOH) variables have a major impact on health outcomes. It is estimated that close to 80% of health outcomes are impacted by SDOH. With the rise of population-based risk contracts in both the commercial and government sector, it is essential for both providers and payers to collaborate in the identification of best practices to address these SDOH variables. This is especially relevant as providers such as hospitals assume greater risk in arrangements with plans throughout the country such as Accountable Care Organizations (ACO) and bundled payments.

NATIONAL INTEREST AND PROGRESS

Many national associations such as the American Hospital Association (AHA) and America’s Essential Hospitals have developed resources and launched learning collaboratives for hospitals and health systems to address these variables such as food insecurity, housing, and transportation. Health system innovation and care-redesign models driven by organizations such as Healthbox and AVIA have launched collaboratives and forums to educate and address SDOH initiatives. The May 3, 2018, Healthbox forum discussion on “Challenging the Status Quo of Social Determinants” visually captured the opportunities and challenges ahead into one image (Figure 1):

Social Determinants of Health

Figure 1: Image captured during Healthbox Executive Panel Discussion, May 3, 2018. Chicago, IL

These variables have always been a focus of many health systems in terms of articulating their benefit to the community, but now they have particular importance given the rise of more population risk contracts.

Several major barriers have impeded the industry’s progress in addressing SDOH variables: funding and regulations. Fortunately, we have begun to see opportunities in both areas emerge in 2018!

MEDICARE UPDATES AND THE BENEFITS OF SOCIAL DETERMINANTS OF HEALTH DATA

Medicare Advantage (MA) has a regulation titled “Uniformity Standard” that requires all of the plan’s benefits, including cost-sharing, be the same for all plan enrollees. On April 2, 2018, the Centers for Medicare & Medicaid Services (CMS) outlined several widespread changes in this regulation that both providers and plans have advocated for over the last several years in their 2019 Medicare Advantage Call Letter. CMS expanded the flexibility of lifting the uniformity of supplemental benefit to allow different segments of an MA plan to offer specific benefits to a targeted population like diabetics. This can begin in CY 2019 (January 1, 2019) after the plan designs are approved by CMS. An example could be reduced cost sharing for foot or eye exams. In their official bids that were submitted by the June 4, 2018 deadline, the MA plans can include any of these supplemental benefit elements. Hopefully, providers will see many of the plans deciding to include these additional benefits in their MA bids to address the SDOH variables.

Additionally, in the Bipartisan Budget Act (BBA) that was passed in early 2018, Congress has taken it further by extending the lifting of the uniformity of the supplemental benefits to all chronically ill members of the MA plans effective January 1, 2020. This reinforces the need for us to gain valuable lessons during 2019 in order to determine what works and what doesn’t before it is transitioned to a broader population.

The Chronic Care Act of 2018 extended the Center for Medicare & Medicaid Innovation’s (CMMI) Valued-Based Insurance Design Model to all 50 states in 2020. This model was launched in 2017 to allow Medicare Advantage plans to offer supplemental benefits and reduced cost-sharing to seven conditions including Coronary Artery Disease or Congestive Heart Failure. The model focuses on four approaches:

  1. Reduced Cost Sharing for High-Value Services
  2. Reduced Cost Sharing for High-Value Providers
  3. Reduced Cost Sharing for enrollees participating in disease management
  4. Coverage of additional supplemental benefits such as transport or meal delivery

The creation of more supplemental benefits will enhance the quality of services we provide for our patients especially in terms of addressing the SDOH. Encouraging the inclusion of these targeted supplemental benefits will allow us to partner with payers to improve the health of the country in a more innovative way.

ADDRESSING SDOH WITH HEALTHCARE PROVIDERS AND COMMUNITY RESOURCES

At PCCI, we have been directly involved in national and state-driven education forums, presentations, and roundtables directed to design and deploy local models for the Connected Communities of Care program (previously known as the Information Exchange Portal) that bring together providers, payers, philanthropic organizations, community-based organizations (CBO), and local/state government entities. While most markets continue to be in a learning mode, significant and tangible activities are being initiated in a number of municipalities, including Dallas, Raleigh-Durham, Louisville, Detroit, Chicago, Phoenix, Salt Lake City, as well as across whole regions. For example, North Carolina recently requested proposals for the development of a North Carolina Resource Platform via the Foundation for Health Leadership & Innovation. The goal of this multi-year program is to connect over 3,000 statewide community-based organizations via technology, and facilitate SDOH. This will be completed through a programmatic coordination of referrals between healthcare providers and community resources to comprehensively identify and address the needs of individuals across the state. On a broader level, the Accountable Health Communities Model deployed in 2017 is engaging 31 organizations across the country to address a critical gap between clinical care and community services in the current healthcare delivery system. This is being done by testing the process of systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services to see if it will impact healthcare costs and reduce healthcare utilization.

SUCCESS IN SIX TRACKS

Our experience over the last five years across Dallas tells us that models will need to address six tracks to be successful: Governance, Legal, Technology, Clinical Workflows, CBO Workflows, and Sustainability (Figure 2). The maturity and evolution of the models need to develop and be staged within a multi-year deployment framework (concentric circles in Figure 2 represent the progression and evolution of the model with outer circles representing mature and more sophisticated models).

Social Determinants of Health

Figure 2: Connected Communities of Care program multi-year deployment framework

There is also a critical upfront readiness and deployment/implementation assessment that is important in order to stage the deployment of a Connected Community of Care program. This broad representation of the community’s fabric is critical to ensure that:

  1. A community is ready to undertake the operational and financial requirements associated with deploying a Connected Communities of Care program
  2. The healthcare and social needs of the community are at the forefront of the customized design of the platform (something most for-profit technology vendors offering an out-of-the-box solution either cannot do or fail to do properly)
  3. The design is sufficiently flexible to adjust as the healthcare or social needs of the community change

Addressing SDOH is finally moving from a “buzz” word to implementation pilots. While we talked a lot about population health over the last 10 years, doing population health without a truly engaged and “Connected Community of Care” is like focusing on rescuing people from drowning in a river vs. building a bridge so they can cross it safely. As we continue this journey, let us make sure we build a bridge that adapts to the needs of each community and has emerging local and national models of care to ensure sustainability. We don’t want to end up with a bridge like the Choluteca Bridge in Honduras, connecting nothing to nowhere.

Acknowledgments: Valinda Rutledge, PCCI Executive Advisor and Lindsey Nace, PCCI Marketing and Communications have contributed to this article.

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