Integrating Healthcare and Human Services Shelly Johnson, RN, MPH, - PDF document

10/24/2017 Integrating Healthcare and Human Services Shelly Johnson, RN, MPH, MBA, FACHE Chief Operating Officer, Spectrum Health Gerber Memorial Dave Wingard, MSW, Ph.D. Director of Research and Strategic Development, TrueNorth Community Services 1 Objectives • Compare collaborations to collective impact integration • Discover the benefits of an integrated approach to determinants of health • Consider the use of the collective impact framework for your community partnerships 2 1

10/24/2017 Background: TrueNorth Service Areas • Statewide NPO • Self-Sufficiency services available in select counties only • Use of an evidence based scoring matrix to categorize individual’s needs 3 Background: Tamarac • Comprehensive wellness center used for chronic disease management • Prevention programs • Well-educated, certified and trained staff • Health coaches • Dieticians • Diabetes management • Physical, occupational • Fitness specialists and speech therapy • Personal trainers • General wellness programs • Weight management 4 2

10/24/2017 Cross Sector Partnership Drivers TrueNorth self-sufficiency participants with untreated medical barriers Medical system has unengaged rising risk/high cost individuals 5 Collective Impact • Common Agenda: Improve the health of individuals in the community by addressing determinants of health and health behaviors • Share Measurement: Strategic plan outcomes and County Health Rankings • Mutually Reinforcing Activities: Work together on issues, NOT our regular/traditional work • Open and Continuous Communication: Frequent meetings, emails, phone calls, structured agendas • Backbone organization-Spectrum Health Gerber Memorial • https://www.youtube.com/watch?time_continue=92&v=pz mMk63ihNM 6 3

10/24/2017 How is it different? 7 Collective Impact https://www.youtube.com/watch?v=dPsqVhWBlKc County Health Rankings • Overall from 64 th to 46 th • Improvements in teenage pregnancy, high school education, smoking 8 4

10/24/2017 MI Way to Thrive Project Early Development • Followed the Institute for Healthcare Improvement model: ■ Plan our target population, purpose statements, metrics ■ In-depth interviews with those we are serving ■ Integrating interview results into pilot design ■ Start small with 5, then PDSA cycle, scale to 25, PDSA cycle, then 125….. 9 Initial Patient Interviews • Important part of the process • Used certified wellness coach and MSW • Met in public places or at homes • Used tools: Harms8, ACE, HRA, PHQ-9 • First target population in primary care • Completed multiple interviews-8 • No commonality, all well engaged, minimal impact potential 10 5

10/24/2017 Hit the Pause Button • Keeping to the IHI Roadmap, halted program development • Regrouped and had robust discussion • Revisited purpose, population and metrics • Flipped the model from primary care to human services • New interviews with new target population • Commonalities and themes in needs, disengaged from primary care, poor health literacy, poor health behaviors 11 Current MI Way to Thrive • Improve quality of life for families by building self- sufficiency and effective engagement with the health care system • Flipped the traditional model • Examples of barriers addressed by MI Way to Thrive:  Health behaviors  Insurance  Navigating healthcare system  Budgeting  Education  Transportation  Health literacy  Jobs 12 6

10/24/2017 Implementation: Core Components • Participant centered – screening and assessment driven • Fluid service delivery in participant’s home • Improve general self-sufficiency, quality of life, health outcomes • Reduce need for public assistance and healthcare costs 13 Model Implementation: Care Model Design Health and Wellness Support (Spectrum Health Agency) Mental Health Human Support Services (Newaygo Support County Mental (TrueNorth Health Agency) Agency) Community Health Worker Client 14 7

10/24/2017 Our workforce and roles Role Agency Definition Community Health Worker Spectrum Health Removes barriers, makes referrals, helps navigate system, basic health literacy Self-Sufficiency Specialist TrueNorth Removes barriers, promotes self- sufficiency, educates Health Coach Spectrum Health Higher level health behavior and promotion Fitness Specialists Spectrum Health Personal training Diabetes Educator Spectrum Health Certified in diabetes management Social Worker Newaygo County Mental Health Short term counseling services Health Educators Spectrum Health and Michigan Program specific: smoking, nutrition, Health District etc. Primary Care Varied Pending role fit to model Initial Metrics Dimension Proposed Measure Data plotted on run chart Data Source Research Question Variables (Y/N) Stress Index Score (BHLC) TrueNorth Socioeconomic stress scale Aggregated and weighted measures of effect size calculated on three variables (to be determined) in a cost utility model Population Health Time series data will be used to Do patients in the IHI pilot improve Pain and Anxiety and self-reported health status EQ5D develop a predictive exposure/ their health status on specific question. response model indicators? Effect size from pre and post measures (Cohen’s d) Participants survey Experience Survey Experience of Care Time run chart for experience and Do patients participating in the IHI pilot pre ‐ post measures for PAM improve their experience with care? Patient Activation Measure (PAM) PAM survey Effect size from pre and post measures (Cohen’s d) Per capita cost including energy assistance and Average annualized cost reduction Per Capita Cost healthcare will be compared to predictive Payer, clinic and TrueNorth Does participation in the IHI pilot result in disease cost burden models for reduced on average per capita cost? Direct monetary average cost to the funding entity general populations 16 8

10/24/2017 IHI BHLC • Valuable experts in a wide variety of fields • Best practice tools • Best practice programs around the world • Builds upon assets, not just needs • Includes participants in design and evaluation • Mentorship • Accountability 17 Data and Metric Development • What is meaningful to your organization? • What would success look like to you? • Would this be useful to you? • Tools and Resources • Toolkit • healthystartepic.org/wp- content/uploads/2015/04/CollectiveImpactToolKit.docx • Integration Assessment 18 9

10/24/2017 Discussion/Questions 19 10