HPC Transforming Care - January 2019

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Massachusetts Health Policy Commission

January 2019

Welcome!

This New Year’s edition of the newsletter focuses on reflections from 2018 and opportunities for innovation in 2019. It features reflections from different members of the health care workforce – a wellness activities coordinator, a nurse practitioner, and a social worker – and highlights two recent HPC presentations given at the Academy Health Annual Conference on the Science of Dissemination and Implementation in Washington, D.C., one on the CHART Program and the other on HPC’s ACO Certification program.

Let us know if there are particular care delivery transformation topics or work in the Commonwealth that you’d like to see the HPC showcase in this newsletter. We'd love to hear from you! Email us at [email protected] .

Regards,

Team HPC

SPOTLIGHT:

2018 Conference on the Science of Dissemination and Implementation

HPC staff delivered panel presentations on the Community Hospital Acceleration, Revitalization, & Transformation (CHART) and ACO Certification programs at the 11 ^th Annual Conference on the Science of Dissemination and Implementation on December 3-5 in Washington, D.C. The HPC’s strategic investment and certification programs have supported innovation in care delivery transformation in the Commonwealth since the HPC’s inception in 2012 and have garnered attention from other states. These presentations expanded upon existing transforming care reports and helped to share the insights gained from these programs to a broader audience.

Gabriel Malseptic, Senior Program Manager for Strategic Investment, presented on the panel “Implementing Policy for Population Health.” He focused on sharing lessons learned about population health management strategies from the 27 CHART hospitals over the course of the investment program, noting that “ the goal is to create an accessible, insightful, and detailed set of lessons to help the next wave of population health managers.” Topics included lessons learned from CHART hospital programs regarding management of high-risk, complex populations by identifying, engaging and collaborating with patients, staffing and managing a team, and measuring for improvement to prevent future avoidable acute care utilization. These key lessons, combined with a curated appendix of tools and resources utilized by CHART hospitals, will make up the forthcoming CHART Playbook. This session focused on implementation of population health interventions in a variety of settings.

Catherine Harrison, Deputy Director of Policy for Care Delivery Transformation and Strategy, presented on the panel “Implementing Health System Transformation.” Her presentation overviewed the 2017 HPC ACO Certification program and insights gleaned from the 17 HPC-certified ACOs in Massachusetts. Catherine described the HPC’s findings on the state of ACOs in Massachusetts and highlighted the HPC’s goals for reporting findings from the program, which include enhancing transparency and contributing to the evidence base for ACOs. Catherine concluded her presentation by highlighting outputs based on ACO Certification data, including ACO Policy Brief #1: An Introduction to ACOs in Massachusetts, ACO Policy Brief #2: How ACOs Manage Population Health, and Profiles of the 2017-2019 HPC-Certified ACOs. The session focused on initiatives aimed at transforming the health care system through analysis of claims data, interviews, and administrative data.

The Annual Conference on the Science of Dissemination and Implementation, co-hosted by AcademyHealth and the National Institutes of Health, aims to strengthen the connection between research, practice, and policy. This year’s theme, “Scaling Up Effective Health and Healthcare: Advancing the Research Agenda and Necessary Infrastructure,” engaged over 1,300 attendees from across the country and overseas in considering strategies to share knowledge gained from effective interventions and scale up such interventions, particularly in low-resource communities.

LESSONS FROM THE FIELD

Reflections on a Year of Care Delivery Transformation through the HPC’s Targeted Cost Challenge Investments (TCCI) Program

A Nurse Practitioner from Commonwealth Care Alliance’s (CCA) Ambulatory Intensive Care Unit (ICU) Program

CCA, an integrated payer and care management organization, created a disability-focused ambulatory ICU to integrate primary care, behavioral health care, dental care, palliative care, and chronic disease management for its members. One such partnership is an enhanced dental care program supported by the Harvard School of Dental Medicine (HSDM) which coordinates dental care for members who would otherwise face access barriers due to complex care needs. Reflecting on the program’s impact over the last year, one nurse practitioner (NP) said that she feels like she’s making a difference in people’s lives, and that the relationship with HSDM further improves care for her members. Through the CCA partnership with HSDM, members are able to receive timely and accessible care that accommodates their needs, including dentist visits in members’ homes and adaptive hardware and anesthetic approaches.

A Social Worker from Care Dimensions’ “Palliative Care+” (PC+) Program

Care Dimensions’ PC+ program bridges the service gaps between curative care, palliative care, and hospice services for patients with serious illness by integrating palliative care staff into North Shore Physician Group’s primary care sites. Reflecting on the program’s impact over the past year, one PC+ social worker noted the impact that even small gestures have on patient well-being. Through regular interactions with PC+ team members, PC+ patients experience a greater support system. Patients are appreciative of the support the social workers offer, whether they are actively helping patients to navigate palliative care, or simply checking in on patients’ well-being over the phone. The social worker’s goal, and that of the entire PC+ team, is improved continuity, effective symptom management, and a better overall experience for patients and their families at home.

A Wellness Team Activities Coordinator from Hebrew SeniorLife’s (HSL) Right Time, Right Place, Right Care (R3) Program

HSL was awarded a TCCI grant to develop the R3 program, which embeds wellness teams comprised of a wellness coach and wellness nurse into supportive senior housing sites to coordinate care for residents. According to one R3 activities coordinator, the impact of the R3 wellness teams transcends traditional physical health and wellness benefits. She noted that educational activities and classes offer residents an opportunity to engage in targeted educational programming and also support socialization among participants. Isolation is increasingly recognized as one of the biggest health risks to the elderly, and R3 emphasizes human connections. “Yes, they also learn what a carbohydrate is, and why eating proteins is so important, but it’s the connection with a real live person that matters.”

PATIENT STORY

Reflections on a Year of Patient Care

As described in the “Lessons from the Field,” HSL’s R3 embeds wellness teams within supportive housing sites for seniors to coordinate care for residents.

One resident of an HSL supportive housing site, an armed services veteran, was leading an independent, solitary life with early stage Parkinson’s disease and dementia. The resident initially became interested in R3 to access more exercise programs. After a comprehensive needs assessment, the team was able to connect the resident with an adult day health program, paid for by the Veteran’s Administration (VA). As the R3 team members became more involved in the resident’s care, they started to receive calls from various providers, including the adult day health program, VA, and state case worker, concerned about the resident’s overall health. The R3 team became a central point of contact for the resident’s various services and care teams, executing a critical component of the R3 program’s goal to improve overall health and independence.

The R3 wellness team helped coordinate care and information for this resident between HSL, a nurse at the adult day health program, a VA NP, and a case worker at the local Aging Services Access Point (ASAP). The adult day health nurse and the VA NP were able to discuss the resident’s medications to support increased adherence. The wellness team was also able to help resolve housekeeping issues with the ASAP by having the services scheduled on a different day than the adult day health program. With this coordinated effort, R3 was able to facilitate communication and better understand and address the resident’s multifaceted needs. By coordinating care for participants, R3 wellness teams helped residents access timely, appropriate care while reducing visits to the hospital and emergency room, and supported residents to live safely and as independently as they choose.

PUBLICATIONS, PRESENTATIONS, & RECOGNITIONS

Three ACOs Achieve Full HPC ACO Certification

The HPC congratulates the following ACOs for achieving full HPC ACO Certification in December 2018:

Health Collaborative of the Berkshires, LLC
Mount Auburn Cambridge Independent Practice Association, Inc.
Merrimack Valley Accountable Care Organization, LLC

Perinatal-Neonatal Quality Improvement Network of Massachusetts Conference

On Tuesday, December 11, PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts) hosted its biannual conference “Improving the Care of Newborns and Mothers Impacted by Perinatal Opioid Use: A Massachusetts Statewide Initiative.” With the goals of promoting early identification and engagement of pregnant women in treatment and providing ongoing support for mothers and their children, the conference offered participants the opportunity to hear from patients, providers, and public health representatives about a number of promising practices and approaches to providing family-centered care. Mary Lou Sudders, Secretary of the Executive Office of Health and Human Services, delivered the keynote address and underscored the importance of collaboration in providing care to families impacted by opioid use. For more information on PNQIN, please visit their website .

Serious and Advancing Illness Care in Value-Based Payment Models: What ACOs in Massachusetts are doing to document and honor patient wishes

The Massachusetts Coalition for Serious Illness Care and the Health Policy Commission (HPC) are hosting a webinar on January 24, 2019 12:00pm-1:30pm regarding ACOs' efforts to support the wishes of patients facing serious and advancing illness. This event will highlight the activities of ACOs in adopting innovative and effective approaches to serious illness care in the Commonwealth and provides an opportunity for care providers, health care administrators, and policymakers to learn about effective training mechanisms on advance care planning and provision of serious illness care. The webinar will include a panel presentation moderated by Maureen Bisognano, Co-chair of the Massachusetts Coalition for Serious Illness Care & President Emerita and Senior Fellow at the Institute for Healthcare Improvement, followed by an opportunity for discussion. Panelists will include: Adrianne Seiler, MD, Medical Director, Baycare Health Partners; Leslie Sebba, MD, President and Chief Medical Officer, Lahey Clinical Performance Network; and Charles Pu, MD, Medical Director Care Transitions & Continuum, Center for Population Health, Partners HealthCare.

To participate in the webinar , please register here .

HPC Announces Partnerships with Digital Health Startups to Address Health Care Challenges

The HPC will be working with three startups as a dedicated advisor in the MassChallenge HealthTech (MCHT) 2019 cohort:

Buoy Health – a chat bot that has been clinically trained to converse with people to help make decisions about where they should seek care (e.g., urgent care, emergency department, primary care office)
DynamiCare Health – monitoring and rewarding recovery from substance use disorders
Marigold Health – mobile app for anonymous text-based group psychotherapy for patients in substance use disorder care, moderated by a peer/clinician

Through these partnerships, the HPC seeks to promote community-based providers’ access to digital health solutions, and to identify digital health startups that address high-priority policy areas, including timely access to behavioral health and reducing avoidable emergency department use. If you are interested in learning more about this new initiative, please email [email protected] .

Boston Young Health Professionals (BYHP) 4 ^th Annual Conference: “The Future of Healthcare”

BYHP held its 4 ^th annual conference on Friday, December 17 called “ The Future of Healthcare: Bringing it Back to the Basics .” Dr. Ashley Yeates, Chief Medical Officer and Vice President of Healthcare Quality and Clinical Integration at Beth Israel Deaconess Hospital-Milton, a CHART hospital, and Vivian Haime, HPC’s Manager for Care Delivery Transformation and Strategic Partnerships, participated in a panel discussion on patient-centered care. Panelists discussed the importance of eliciting and documenting patient goals of medical care as well as their behavioral health and social needs. Panelists also noted opportunities to innovate in the context of payment reform, and to leverage different members of the health care workforce (e.g., community health workers and peer recovery specialists) and new enabling technologies (e.g., telehealth) in order to improve quality and accessibility of care for patients.

Published case study of CHART Program caring for childbearing women with opioid use disorder (OUD)

The journal Maternal and Child Health has published a paper authored by HPC staff titled “Coordinating Outpatient Care for Pregnant and Postpartum Women with Opioid Use Disorder: Implications from the COACHH Program” describing the work of the Hallmark CHART team. This paper describes promising practices and implementation challenges from the Collaborative Outreach and Adaptable Care at Hallmark Health (COACHH) program, which utilizes a collaborative care team to coordinate outpatient care for pregnant and postpartum women with OUD. The study identified care delivery and program design considerations that may inform others who wish to coordinate care for pregnant and postpartum women with OUD. Highlights included the challenges of enrolling patients and measuring outcomes, reflecting the need for tailored approaches and metrics for this population, the diverse professional skills deployed by the team, and the emphasis on building trusting relationships with women with OUD. For a PDF of the manuscript, email [email protected] .