HPC Transforming Care

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Massachusetts Health Policy Commission

May 2018

Welcome!

This month’s newsletter features partnerships to address social determinants of health. We are excited to share key takeaways from the HPC’s recent special event “Partnering to Address the Social Determinants of Health: What Works? ” The morning session highlighted the novel partnerships and approaches of several HPC investment program awardees as well as an HPC-certified ACO and featured a robust policy discussion about those approaches.

Let us know if there are any other 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:

Spring Care Delivery Event: Partnering to Address the Social Determinants of Health: What Works?

On May 17, over 150 representatives from healthcare provider organizations, community based organizations, payers, government, academia, and the interested public attended the HPC’s special event, “Partnering to Address Social Determinants of Health: What Works? ” A recording of this event can be viewed here .

Keynote speakers Dr. Alice Chen, Chief Medical Officer of the San Francisco Health Network (SFHN), and Dr. Monica Bharel, Commissioner of the Massachusetts Department of Public Health (MDPH), provided context on the importance of addressing social determinants of health (SDoH) and spoke passionately about their own experiences working in service of vulnerable populations.

Dr. Chen described the importance of transportation, nutrition, and housing to health outcomes and cited examples of the health system addressing SDoH through work such as a new Medicaid initiative in San Francisco that is looking at the value of providing therapeutic meals to reduce hospital readmissions for patients with congestive heart failure or Type 2 diabetes. She also spoke about the role of poverty as a primary driver of SDoH, and presented the historical and structural causes of cyclical poverty including structural racism and the poverty threshold definition. “The poverty threshold has been a way for us to exclude people from benefits,” she said.
Dr. Bharel reminded the audience that while Massachusetts was named the healthiest state in the nation in 2017, not every individual or community within the Commonwealth is equally able to achieve optimal health. “Where we live matters for our health and access to health, and race matters,” she said. She also noted three roles for MDPH in addressing SDoH: 1) improving access to and translation of data; 2) developing the workforce; and 3) providing regulatory guidance.

A panel of speakers representing HPC-funded and HPC-certified organizations and their partners, moderated by Dr. Don Berwick, HPC Commissioner and Senior Fellow at the Institute for Healthcare Improvement, discussed practical approaches for health care providers to partner with the social service sector to address SDoH.

Selena K. Johnson of Heywood Healthcare, and Mark J. Pellegrino, Superintendent of Gardner Public Schools, described their HPC CHART-funded initiative designed to promote access to behavioral health care through partnerships between local schools and health care providers.
Dr. Katherine Moss, Vice President of Integration for Behavioral Health Network, and Israel Ortiz, Director of Residential Programs for WayFinders, Inc., discussed their HPC Health Care Innovation Investment (HCII) award, which has focused on coordination between behavioral health, primary care providers, and housing services to connect families to stable housing.
Robin Hynds, Vice President of Care Continuum at Lawrence General Hospital, representing the Merrimack Valley ACO, and Vilma Martinez-Dominguez, Community Development Director of the Mayor’s Health Task Force (MHTF) for the City of Lawrence, discussed their partnership to address population health issues with particular relevance to the greater Lawrence community (see Lessons from the Field below for more details).

Common themes across the panelists’ remarks included:

The wellbeing of families and patients is a shared responsibility across the health care and social services sectors.
Successful partnerships not only accomplish the goal of collaboration itself, but also advance the unique mission of each participating organization.
Expanding the adoption of value-based payment models, increasing the supply of affordable housing, addressing patients’ behavioral health and social needs, and mitigating data collection barriers are critically important policy efforts.

A second panel discussed policy solutions to support and optimize partnerships, moderated by Audrey Shelto, President of the Blue Cross Blue Shield of Massachusetts Foundation.

Rep. Jeffrey Sánchez, Chairman of the Massachusetts House Committee on Ways and Means, commended both MassHealth’s commitment to integrating health care and social services, and the Commonwealth’s significant investment in health care through the state budget.
Dr. Myechia Minter-Jordan, President and CEO of The Dimock Center, emphasized the importance of leveraging many sectors, and housing in particular, to make the strongest business case for investment in social determinants.
Ellen Lawton, Co-Director of the National Center for Medical-Legal Partnerships at The George Washington University, described the value lawyers can offer to organizations seeking to navigate regulatory barriers to integration, and the ways in which the legal profession can learn from health care.
Lauren Taylor, co-author of The American Health Care Paradox, described three sensible policy initiatives: 1) investing in technical assistance for community-based organizations; 2) increasing the flexibility of funds; and 3) connecting community organizations to legal expertise that can guide them through regulatory challenges, especially around data privacy. She also delineated the financial business cases for investing in SDoH (i.e., investing in SDoH will decrease health care utilization and total cost of care, and provide benefits for society) as well as a moral case for addressing SDoH. "[T]here are also things that may not have a business case at all, but are worth doing because it is the morally right and just thing to do," she said.

David Seltz concluded the event by reiterating the HPC’s interest in investing in SDoH through the SHIFT-Care challenge, and in partnering with institutions and organizations that are involved in this space to move policy ideas forward.

The HPC would like to thank all the speakers, moderators, and attendees of the event for a thought-provoking and engaging conversation.

LESSONS FROM THE FIELD

A Practical Partnership to Address the Social Determinants of Health: Merrimack Valley ACO and the Lawrence Mayor's Health Task Force

Speakers at the HPC’s special event (see Spotlight above) not only sounded the call for more and stronger partnerships between the health care and social services sectors, but offered insights on how to develop and sustain effective partnerships based on first-hand experience. Under the leadership of the City of Lawrence, a wide array of community leaders have come together to promote a “health in all policies” philosophy and tackle some of the city’s key health-related challenges in concert with the region’s new accountable care organization, Merrimack Valley ACO (MVACO).

MVACO is a partnership between Greater Lawrence Family Health Center (GLFHC) and Lawrence General Hospital (LGH), the two main providers of primary, specialty, and acute care in the greater Lawrence area. Both GLFHC and LGH serve on the Executive Committee of the Lawrence Mayor’s Health Task Force (MHTF), a multi-sector coalition with more than 80 partner organizations. The MHTF promotes health equity through advocacy, education, capacity building, and networking. It also supports the data collection process for local community health needs assessments, and assists with the implementation of population health improvement plans through five working groups organized around the priority areas of: 1) adolescent health and youth leadership, 2) behavioral health, 3) healthy active living, 4) homelessness, and 5) research on important under-studied topics including health disparities. Leveraging funding from the MDPH Determination of Need process as well as the health center and hospital’s community benefits funds, the MHTF has led the assessment of the health-related community needs in Lawrence, resulting in recommendations to improve population health, the City’s public health department and implement an aligned framework for addressing social determinants in the city.

At the event, Robin Hynds, Vice President of Care Continuum at LGH, and Vilma Martinez-Dominguez, Community Development Director for the MHTF, talked about why they partner and what has made their partnership successful. Hynds spoke of LGH’s commitment to population health management and described MVACO’s involvement with the MHTF as one way that the ACO invests in the health of the community as a whole. In speaking about the rationale for partnering, she commented that “ addition and multiplication are better than division and subtraction.” Martinez-Dominguez stressed the importance of selecting areas of focus that are relevant to the local community in seeking grant support and obtaining buy-in from elected officials and community leaders. They both referenced the importance of getting and using data effectively to understand community needs and to show the impact of their work.

Both Hynds and Martinez-Dominguez described trust and true commitment to the work as the glue that binds the partnership, and also noted that receiving Delivery System Reform Incentive Payment (DSRIP) funding through their participation in the MassHealth ACO program will be helpful to strengthening their ongoing collaboration with the MHTF.

PATIENT STORY

Multidisciplinary Partnerships to Assess and Support Whole Families

Behavioral Health Network, Inc. (BHN) offers addiction, crisis, family, developmental, mental health, domestic violence, and healthcare integration services throughout Hampden County. BHN is an HPC Targeted Cost Challenge Investment (TCCI) Program awardee pursuing cost savings through the Behavioral Health Integration challenge area. Through their HPC award, BHN has created Project FIT (Families in Transition), through which they collaborate with housing organization partners to find stable housing for families who have undertreated mental illness or substance use disorder and are homeless or have recently been homeless. BHN shared the following patient story highlighting the complex needs of the families they serve through Project FIT, and how critical a multidisciplinary approach is to addressing those needs.

The Project FIT team identified a homeless family—a woman, her boyfriend, and a two-year-old child—temporarily sheltered in a friend’s home, but at risk of soon being kicked out.

By assessing each family member’s needs and goals, the Project FIT team identified that the mother had developmental disabilities and a history of trauma, depression and anxiety symptoms. She was also at risk of losing her teeth due to years of untreated decay. Additionally, her child was recently diagnosed with autism, and had been having seizures. The Project FIT team discovered that the woman was not engaged with a primary care provider or a dental provider, nor was a primary care provider in place for the child. The team introduced her to the team at Way Finders, one of BHN’s award partners providing comprehensive case management and access to housing services, who found the family a slot at a family shelter. The Project FIT team was also able to find a dentist who was able to save her teeth and teach her good hygiene to prevent more extensive health consequences.

With the guiding philosophy of participant self-sufficiency and self-management, the team proceeded to teach the mother how to find medical providers for herself and her child, as well as how to prepare for and understand the outcome of those appointments. The team educated the mother about seizures and the kind of care that may be indicated by these symptoms, and supported her in finding a pediatrician for her child. The Project FIT team also taught the mother how to utilize MassHealth transportation waivers to ensure she and her child can attend their care appointments going forward

The Project FIT team is now working with her to obtain benefits through the Department of Developmental Services for herself and her child, and she is finally in the pipeline for secure, permanent housing. Thanks to the coordinated care and collaboration between BHN and Way Finders, this family was able to move from a very precarious situation with untreated behavioral, medical, and social needs into a more stable environment with skills and supports in place that will help them stay healthier, longer.

PUBLICATIONS, PRESENTATIONS, & RECOGNITIONS

Care Dimensions' Board Presentation

Representatives from Care Dimensions presented to the HPC's Board at the April 25 meeting on the progress of their TCCI award. Care Dimensions’ TCCI initiative, the “Palliative Care+” Program, embeds palliative care support in the form of staff and referral linkages into their non-corporately affiliated partner, North Shore Physicians Group (NSPG) primary care practices. This initiative provides resources for primary care physicians to better identify and navigate opportunities for palliative care services for their patients with serious advancing illness earlier in the trajectory of their illnesses. Care Dimensions ultimately aims to improve patient quality of life, increase palliative and hospice care utilization, and reduce total costs of care by avoiding unnecessary hospitalization and emergency department utilization.

Just under 12 months into their initiative, Care Dimensions is seeing a real improvement in the number and quality of referrals from primary care partners, as well as significant advancements in the completion of medical orders for life-sustaining treatment (MOLST) forms – both key goals of their program. Beyond their key performance metrics, Care Dimensions and NSPG are achieving real practice and partnership change as they work to integrate serious illness and end-of-life care services for their patients.

Berkshire Medical Center Team Presents at Annual APA Conference

The Berkshire Medical Center (BMC) TCCI award team presented at the 2018 American Psychiatric Association Annual Meeting earlier this month in New York City. BMC’s presentation, “Creating a New Type of Telepsychiatry Team: An Innovation Pilot Grant in the Berkshires” featured their TCCI initiative that was well received by conference attendees. The team demonstrated a compelling case for interdisciplinary care through telemedicine in rural Berkshire County, especially in the face of rising suicide rates, opioid and alcohol poisoning rates, poor economic conditions, and shortages of primary care and mental health providers.

Awardee Recognitions

The Massachusetts Association of Community Health Workers released a call for nominations for three separate awards to honor the “outstanding service, dedication, and excellence of individuals and groups of individuals who serve their communities as Community Health Workers (CHWs).” We are excited to announce that members of our CHART Phase 2 cohort received two of the three possible awards! Lowell General Hospital’s Circle Care Program won the Outstanding CHW Program of the Year Award and Southcoast Health’s LICSW, John Kampersal, won the Outstanding CHW Supervisor of the Year Award. Awardees were recognized at the 9 ^th Annual CHW Conference in Norwood, Massachusetts on May 3, 2018.