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Connecting Medical Care and Social Service Needs: Chicago Health Leaders Take Charge

August 21, 2018
by Rajiv Leventhal, Managing Editor
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A new project will investigate the most effective means for connecting medical care and social service needs

In the new and constantly evolving healthcare landscape, patient care organization leaders are now coming to a near universal acceptance that paying more attention to social determinants of health data has become vital to improving care and lowering costs. Indeed, across the country, there are countless projects that are examining, in various ways, how health outcomes are influenced by factors such as social circumstances, behavioral patterns and environmental exposures.

One example of this is in Chicago, where a group of healthcare leaders have been working on creating a seamless and purposeful link for sharing health and other information between social services agencies and patient-centered medical homes (PCMHs) to improve the health of those most at-risk and address social determinants of health.

Medical Home Network (MHN) is an organization that manages a Medicaid ACO (accountable care organization), comprised of nine federally qualified health centers (FQHCs) and three hospital systems serving approximately 80,000 Chicago area Medicaid beneficiaries. Earlier this year, MHN and the National Committee for Quality Assurance (NCQA) launched a joint research project to study the effects of connections between Medicaid patient-centered medical homes and community-based organizations (CBOs) that provide social services. For this project, a CBO is defined as any social service provider organization that serves an individual but is not responsible for providing “whole person care” in the same way that a PCMH or a hospital is held responsible, officials noted.

One of the driving factors for the research grant—managed by the Systems for Action National Program Office with support from the Robert Wood Johnson Foundation—according to officials, is that addressing social risk factors has been challenging for medical homes as most do not have adequate mechanisms for referring patients to services. Additionally, most CBOs do not have electronic health records (EHRs) and cannot easily communicate with medical home EHRs. Issues of protected health information and privacy have also blocked progress in this area, according to NCQA and MHN executives.


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As such, through this research, the organizations set out to investigate the impact of connecting medical homes and CBOs using a web-based system. More specifically, NCQA, MHN and Cook County Health & Hospitals System (CCHHS) are partnering in this effort with medical homes and CBOs in Cook County, Illinois. As many as 200 medical homes and 25 hospitals will link to a variety of CBOs using a web-based communication and care management platform, known as MHNConnect.

“We want to see how connecting medical and social service care teams can help people with social risks,” Sarah Hudson Scholle, vice president of research and analysis, NCQA, said at the time of the project launch. “For example, if the medical care team and social service agencies coordinate to help people with immediate problems (substance abuse, food, housing, jobs), will that help them manage their health needs better or keep them out of the hospital?”

Cheryl Lulias, president and executive director of Medical Home Network, notes that the need for this connectivity is an outgrowth of MHN’s core premise of creating a community care record across all venues, while being able to communicate and collaborate between the agencies caring for its patients, and the care teams at the primary care practices who are managing the population throughout the continuum. So the question became, Lulias, says, “How do we connect and communicate, and enable communication in a meaningful way?”

Prior to this project, MHN had built foundational connectivity, and was exchanging real-time alerts and a longitudinal record between 27 hospitals and about 200 medical homes in Chicago. “We connected the acute system, but that wasn’t enough,” says Lulias. “Then we moved to start to connect the sub-acute [system], the behavioral health [facilities] and the community agencies. There are a lot of great systems on the market that do referrals to social service agencies from the medical home primary care practice, but we want to enable conversations and share relevant information on the patient to enable seamless transitions and ongoing communication between care teams serving the patients, as well as provide a more coordinated expedience,” she says.

Cheryl Lulias

As an organization, MHN is no stranger to researching how social determinants of health affect patient outcomes. A prior study done by researchers at MHN, and others, found that many risk factors outside of the traditional medical model may be associated with higher utilization and costs. That research, published last year in the Journal of Community Medicine and Public Health Care, found that some addressable factors are associated with greater medical and pharmacy spending, such as needing help getting food, clothing or housing, reporting fair or poor health status, and experiencing transportation challenges. The six most common addressable factors were all associated with higher hospital readmissions; most of them were linked significantly to greater subsequent inpatient stays and ED visits, according to the study’s results.

“We’ve proved that these social issues are critical to predicting the rising risk patients and predicting prospective cost and utilization,” Lulias asserts. “We now know that someone with transportation issues is X percent more likely to have a readmission or to go the ER within three months.” As such, the next step of MHN’s work, she adds, is to analyze how connecting medical homes and CBOs affect the use of hospital and ED services, and affect health outcomes of at-risk populations.

This project is currently in phase one, in which 12 behavioral health agencies and a home health agency in Cook County have access to the Community Care Connect tool—which is a module within MHNConnect—to simply search for patients and better coordinate care for those that are seeking services at their facility, says Sana Syal, project manager, Medical Home Network.

“What we are building out now, and finalizing the requirements for, is opening the messaging center to share that information and coordinate care between care managers at primary care settings and a case manager on the other end, which is likely a behavioral health or home health agency,” Syal explains. She notes that while there are plenty of good resources that provide social service directories for care managers to be able to refer patients, oftentimes, those referrals happen on paper or by phone, which in turn creates a gap in truly knowing what happened to that patient. “Did the patient have a good experience when I referred him or her to the food pantry, for instance? We can track those referrals and close the loop so that we are coordinating care in the best way,” she says.

Sana Syal

Syal adds that referrals “have been happening since there were patients,” but the interest in what has happened at that service or that agency, and knowing how to track that, has long been a gap in care. “And the [providers] wouldn’t know unless the patient comes back and tells them. Maybe the patient says that he or she wasn’t eligible for what the [provider] referred him or her to, or the patient was turned away, or the wait time was three months. We are looking to fill that gap by connecting these different entities together,” she says.

What’s more, in addition to doing quantitative analysis, by comparing pre- and post-implementation of the web-based platform, MHN and NCQA will also be conducting interviews of patients and their providers, offers Keri Christensen, director for research innovation at NCQA, and formerly at Medical Home Network. This will involve interviewing a patient, a community-based organization staff member, and a medical home staff member, she says. “The patient will be at the center of the interview and we’ll also be interviewing the two care providers from the two different organizations that are caring for him or her. We want to understand how the connectivity has assisted in their workflows and how they have seen things change over time—both for the specific patient we are talking about and for the organization as a whole,” says Christensen.

Keri Christensen

Going forward, both MHN and NCQA leaders believe that this project will further prove the value in this new paradigm of connectivity to enable better coordination and better health. “It’s a simple concept, but not one replicated in many places today,” Lulias attests. “And it’s all part of the need for better coordination to drive better care. I hope that this connectivity becomes a ‘need,’ as opposed to a ‘nice to have’ when it comes to population health, and connecting the social with the medical,” she says.

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NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
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The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.


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Kerda DeHaan

We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.



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