In March 2014, the Chicago-based NextLevel Health Partners (NLHP), a care coordination entity (CCE), was awarded a contract from the Illinois Department of Healthcare and Family Services (HFS) to provide care coordination services to seniors, people with disabilities, and those newly eligible under the expansion of Medicaid under the Affordable Care Act (ACA).
According to Michael Kinne, president and chief operating officer of NLHP, the CCE organization takes a unique approach to caring for its members—they do it from their community, wherever that may be, including homeless shelters, food banks and employment offices. Kinne, a clinical gerontologist who spent 23 years in executive-level positions at Fortune 500 managed care companies including accountable care organizations (ACOs) and health maintenance organizations (HMOs), knew that with the shifting healthcare landscape, post-ACA, business had to change.
“Providers, in the old days, used to discharge people into the community and had no idea what happened in the form of follow-up. With managed care companies, physical health was the focus, but there was nothing regarding behavioral or mental health,” Kinne says. “Now things have changed, so you can’t make money by doing a bunch of stuff. You have to improve quality and outcomes. And that’s how it always should have been, but it took us a while to get there,” he says.
Fast-forward to the contract award from HFS. The utilization of health IT to support NLHP’s community-based care model became a necessity, notes Kinne. As such, NLHP partnered with the New York City-based Virtual Health to implement a cloud-based care coordination system providing a high-tech solution to support NLHP’s high-touch care coordination strategy. Note: this project was recognized as a semifinalist in the 2015 Healthcare Informatics Innovator Awards Program.
“This platform gives everyone in the healthcare ecosystem—whether you’re a payer or provider or patient or caregiver or coordinator—a full Health Insurance Portability and Accountability Act (HIPAA)-compliant view about what’s going on with that patient,” says Kinne. “Back in the day before the Internet, we had the intranet, where you could communicate great with the people in your college. Then the Internet allowed you to communicate from college to college to college. Facebook took that model and ran with it, and that’s what’s being created here. Obviously this isn’t for social media, but in terms of imagery that’s how you could look at it,” says Kinne.
NLHP takes care of two distinct populations in Cook County, Illinois—seniors with disabilities and newly eligible ACA adults, who previously were not eligible for Medicaid, but now have insurance for the first time ever. Historically, Kinne notes, you had a very hostile provider network that didn’t want to see these patients as they were very difficult to treat, and the physicians wouldn’t be reimbursed for their care. But now since these patients are insured, providers are finding out more about them, starting with the fact that they have enormous amounts of behavioral and mental health needs.
As such, NLHP now has the ability to take in all of the historical claims data on these patients, any encounters they might have had, and automatically have it risk-stratified using the chronic illness and disability payment system (CDPS), the Medicaid-specific risk adjustment system. “We can use that in the field at the moment we have the membership in the platform—it’s automatically risk-stratified,” Kinne says. “We know everything that has happened to them previously, we know what their patterns of care looks like, what their cost looks like, and it gives us insight into what’s been happening. We’re going from playing Checkers to playing Chess. The idea is to think five or six moves ahead so that we can avoid easily avoidable high-expense items such as intuitional care,” says Kinne.
NLHP’s three-fold care teams—made up of a nurse, a behavioral or mental health specialist, and a community health worker—are equipped with tablets and mobile phones, giving them the ability to have the full breadth of the technology platform’s capabilities while accessing members at their homes, at providers’ offices, at hospitals, and at various community-based sites, notes Kinne. What’s more, the platform provides real-time communication and data exchange across various entities within the healthcare continuum to empower care coordinators and providers to improve health outcomes for NLHP members, their households, and communities, he says. “I can tell a care team member to go to a person’s house, and I can note where they are at a given moment to look at their efficiency and effectiveness,” Kinne says. “We want to bring the medical home to the patient rather than what they’re used to, which is going to the ER,” he says.
NLHP’s clinical team of nurses, care managers and a PhD-level epidemiologist worked with the Virtual Health team to build out the necessary tools, algorithms, dashboards, and business rules, allowing for innovations in risk stratification, population management and use of data analytics to provide actionable interventions. As a result, to date, NLHP has been able to actionably engage with more than 50 percent of its member population in a matter of months, a statistic that is a far outlier among care coordination given the transient nature of the member population, its officials say.
“When we walk into our providers’ officers, we are handing them epidemiological data that they’ve never seen before,” Kinne notes. “They are saying things like ‘Wait, these are my patients?’ We have been able to, from a data analytics and population health perspective, enlighten providers and give them insight they never had before. All they knew before this was went on in the clinical setting, and the electronic medical record (EMR) is just that, it doesn’t give you a strong view of what else is happening. And we have seen an increase in primary care and decrease in emergency care and urgent care as a starter,” he says.
Another benefit of the virtual platform is being able to find members, Kinne says. Many managed care companies have their care coordinators sitting in an office rather than roaming in the community or be mobile, he adds. “You can’t do disease management on the telephone. If they have a telephone, and you actually have the right number, they don’t want to be using their minutes to talk to you. You need that face-to-face interaction. It allows us to find a member, identify them, and provide types of care coordination in their social context that coordinates with the days they live, rather the one that a hospital or provider lives. And it’s all on a platform that everyone can see. It really is the Facebook of healthcare,” Kinne says.
One challenge, notes Kinne, is that despite the move to a pay-for-performance healthcare, some physicians just want to go back to their old playbook. “Everything is moving to risk and bundled payments, so people will naturally pivot back to what they’re used to,” Kinne says. “Or you’ll have doctors that have invested millions into an EMR, and like poker you don’t want to fold the hand because there’s a lot of money in the pot. But the reality is they’ll lose the hand unless they pivot to something more modern, not so antiquated. So really, fear of change is the biggest challenge,” Kinne says.
A complete list of the 2015 HCI Innovator Award Winners can be seen here.