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Staten Island Healthcare Leaders Make Medicaid Redesign and Population Health Work

March 7, 2018
by Mark Hagland
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Healthcare leaders on Staten Island have achieved considerable success as they’ve participated in a Medicaid reform initiative, and turbocharged their population health efforts

Numerous healthcare industry observers have noted that the opportunities being afforded patient care organization leaders under state Medicaid programs are becoming more and more numerous and robust. Indeed, one area that’s seen a great deal of activity in recent years is around Delivery System Reform Incentive Payment (DSRIP) programs and other Medicaid Delivery Transformation Section 1115 Waiver programs, which are working to expand Medicaid eligibility and clinical services for low-income residents in participating states. In New York state, up to $6.42 billion is allocated to the state’s DSRIP Performing Provider Systems, with payments based on achieving performance improvement results in system transformation, clinical management and population health.

On Tuesday at HIMSS18, being held at the Sands Convention Center in Las Vegas, Joseph G. Conte, executive director of the Staten Island Performing Provider System (SI PPS), one of the 25 PPS in New York, shared with his audience how he and his colleagues have been achieving New York state’s DSRIP project goals, and what they’ve learning from their experiences so far; and he was joined by his organization’s technology partner, who shared insights on the technology infrastructure involved.

“Let me talk to you a little bit about the Medicaid design project, about DSRIP,” Conte told his audience. “New York state is the eleventh state in the country involved in Medicaid redesign, following the lead of California, Massachusetts, and several other large states. $7.4 billion was the agreed-upon amount, working with CMS [the federal Centers for Medicare and Medicaid Services], to create a transformative strategy to redesign Medicaid in New York state. So for 6 million people at $60 billion per annum,” he said, describing the number of New York state residents who are Medicaid recipients, and the annual cost of their healthcare, “CMS and Medicaid have a lot at stake. CMS paid for half of the $7.4 billion.”

Conte told his audience, “This is really a disruptive time for providers, healthcare systems, and patients as well—everything we are used to, is changing over time. The DSRIP program is funded over five years, and it really is a value-based program, to the extent that money must be earned in every period, to receive distributed funds. We have about 75 partners—major hospitals, nursing homes, FQHCs, etc.” And one key focus, he noted, has been the social determinants of health. Broadly speaking, he added, 180,000 of the 500,000 residents of Staten Island are potentially affected by this work.

As for data and information technology, Conte told his audience, “Early on, we recognized that identifying a partner to create a business intelligence platform was very important, and that working with old claims data would not provide the BI we needed. And we found a great partner in SpectraMedix”—the East Windsor, N.J.-based SpectraMedix, a data analytics company that specializes in helping providers transition to value-based payment models. “And the Department of Health recognized early on that their partnership was important in helping us to transform care delivery. Bringing in EMS data, getting information from school health, from all the clinical partners in the community, is incredibly important. And when you’re in an at-risk environment, that is absolutely essential to be successful.”

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“CMS and the New York Department of Health agreed on about 60 metrics” that would be used in this program to evaluate outcomes, Conte reported; and, in relation to those metrics, he said, “We’ve been extremely successful in the first several years. Among the gains: “We’ve been able to double the amount of reversible preventable ER use, including around substance abuse.”

Speaking of his company’s technology partnership with SI PPS, Raj Lakhanpal, M.D., CEO of SpectraMedix, told the audience, “In DSRIP, you have lead providers and lead partners, and other partners.” In the Staten Island initiative, Lakhanpal said, “They all started giving data, and that gave us a very robust platform.” What’s more, he said, “The dirty secret in data analytics is that 90 percent of the work involves cleaning, normalizing, and compartmentalizing data. That was very helpful. And then the analytics that were produced, and then the project management office could look at the data and say, these are my projects, these are the metrics we need to address, and to incent.”

In all that, Conte told the audience, “Hot-spotting and geo-mapping have been important. We’ve found out where there have been disconnects between services and the need for services. For example, we discovered that, while the north part of the island had nearly all of the substance abuse clinics, the patients in need of that treatment mostly lived on the south side of the island.”

One of the things that Conte and his colleagues did was to leverage EMS (emergency services/ambulance) data, to address the “frequent flyers”—individuals who literally were accessing medical care in emergency departments as many as 200 times a year. Clearly, Conte said, these people were over-using EDs relative to their levels of care need. Identifying those individuals, and connecting them with care management, was a major step. The same principle applied to mapping the high level of incidence of urgent interventions among school-aged children with asthma, relative to the availability of school-nurse care.  With geo-mapping, he said, “You can identify areas that are lacking in key services. And in creating maps of the population, we can filter in on specific conditions, and if we were able to hover over a specific area within a specific map, we have three years of claims data, and can figure out utilization, including hospitalization, medications, etc. And we can filter by demographics, by types of chronic illness etc.”

 “Taking the data, normalizing it, and putting into the EDW”—the enterprise-wide data warehouse—in order to do “predictive modeling and simulation around high-risk patients,” has been one key basis for advancement in the initiative, Conte said. One of the next steps will be to obtain data from the Department of Health that is timelier. “Right now, we have data that’s from May 2017,” he said, “which is not so effective in terms of [achieving] of real-time or near-real-time analytics.”

And, ultimately, Conte said, “When you think about improving care for the population, and realize that the patient encounter accounts for maybe 30 percent of those results, you realize you have to work with partners outside the purely clinical realm, to achieve success”—meaning addressing issues such as nutrition/food deserts, housing, and a wide variety of other issues.

One excellent example of that, Conte said, has been around diabetes management. “When we started looking at individuals, we were able to look at the types of services they needed, and understand when talking to individuals out there, they’re important, and providing peer education by fellow diabetics, and providing them access to free fruits and vegetables through the Single Harvest program. These are all things that, again, by looking at cold, flat, one-dimensional data, you’re never able to really raw out of that. But looking at the social determinants, at such demographic elements as country of origin, at where providers are—when you can overlay all those factors, you can have a big impact.”

Asthma management in children and teenagers was another example. “When we started looking at avoidable ED use and hospitalizations, it became very clear that adolescent use of EDs was off the charts,” Conte said. “Children didn’t have medication administration forms on file, so if they had an event, they ended up in an ambulance. And sadly, we’ve had two asthma-related deaths in our schools in the past years. So those triggers prompted us” to take action. “Now, we’re working with emergency departments, school nurses, and emergency services. We want to send people into people’s homes and figure out what the triggers are. Did they get the right advice, the right medication? And if there’s mold, peeling paint, pesticides, cats—all those things that create triggers for asthma—we have an asthma home visit program we run, and that’s made an enormous impact. The plans absolutely love it, because they’re not paying for claims. But getting them to understand that value-based plan redesign is very important. In the value-based purchasing world, this really makes a lot of sense to the health plans in the value-based world. And these individuals go out and educate them, they’re community health workers.”

Meanwhile, intense collaborative efforts with police and other entities, have led to a dramatic lowering in mortality rates among individuals who overdose on drugs. “We’ve been successful in going from the highest mortality rate per capita of the five boroughs in 2016, to the lowest, in 2017,” Conte said. “Working with the police department, district attorney’s office, and recovery centers—that partnership has worked. We do detailing of physicians’ offices, to get them used to the idea that these patients are your patients, you can be trained… and we’ve gone from the lowest amount of medication-assisted interventions, to the highest in 2017.”

In the end, Conte said, several elements have turned out to be critical success factors. “Data is the oxygen that enables delivery system reform. Aggregation and governance of data is key; data form outside sources is essential; data needs to be turned into business intelligence,” Conte said. And such tactics as hot-spotting, geo-mapping, and population health data virtualization are critical tools, he added. “Technology enables program developments and performance improvement.”

 

 


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Precision Medicine Alliance Brings Democratization of Precision Medicine

October 5, 2018
by Damon Hostin and Robert Weil, M.D., Industry Voices
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The goal is for every patient to have access to the best treatment possible, when and where they need it.

Hospitals are built on data. Most often, medical data for research pile up in silos instead of being appropriately shared to develop more innovative ways to treat patients.

At Catholic Health Initiatives and Dignity Health, we have started to think differently about the possibilities that surround the data and expertise our clinicians bring to solving our patients’ care needs.  It’s why we joined forces to create the nation’s largest precision medicine partnership.

Because of that spirit of innovation, investment and the information-sharing agreements we established under the Precision Medicine Alliance, LLC, about 12 million patients in 16 states will have access to more promising treatments based on a genetic understanding of their disease.

The alliance currently is focused on advanced diagnostic tumor profiling. However, we are preparing ourselves to provide more specific diagnostic and personalized therapies for a number of genetic and acquired conditions, including cardiovascular medicine, neonatology and pharmacogenetics.

Before the alliance was formed, access to precision medicine-based care was inconsistent to all populations, making it available primarily to the well-insured and those with the personal wealth needed to pay for the specialized tests.

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In a sense, the alliance represents the democratization of precision medicine. That’s because, for the first time, we have created a cost-efficient program that allows community-based hospitals, both large and small, to become partners with the alliance and introduce these vital programs locally.

The alliance highly complements national oncological programs at CHI and Dignity Health, which together serve more than 100,000 patients annually. Starting this fall, each oncology patient at active sites will be matched to all biomarker-appropriate therapeutics and will be screened for eligibility to enroll in a clinical trial. This makes Englewood, Colo.-based CHI and Dignity Health, which is headquartered in San Francisco, the first health systems in the nation with their own precision medicine program with reach across a national footprint. Together, the two systems have 139 hospitals and hundreds of other care sites.

The alliance couldn’t have happened soon enough amid the rapid pace of advancement in cancer treatments. Identifying new genetic markers and their effects on cancer occurrence, prognosis, and treatment options occurs at a staggering pace. Even the best-informed physicians may struggle to keep up with new treatment regimens for the most common cancers, let alone rarer forms. 

The alliance is working to accelerate change. It is switching how we view and treat oncology patients throughout our network as well as working on wellness and prevention among our higher risk populations.

By actively screening patients and learning more about how genetic makeup and some environmental factors may influence health and care, we are far better positioned to identify and intervene earlier.

We already have hundreds of thousands of patients under management in the system today—a mega-community of actionable medical information. That community is enabling CHI and Dignity Health caregivers to share—in real time—their insights and outcomes on patients with cancer.

At CHI and Dignity Health, we see our early work as a catalyst for furthering this emerging science, using next generation strategies, technologies and a strong partnership.  Our precision medicine alliance is not centered on discovering the next major genetic marker.  We view our purpose as creating a model that disseminates the benefits of precision medicine to more patients and more caregivers.  Access is equity and it is dictated by our mission.

Through the alliance, CHI and Dignity Health caregivers can more effectively identify the best drug therapies and possible clinical trials for their patients. Besides changing the way we treat some of our patients, we are also creating a repository of data to drive better clinical decision-making and treatment discoveries for generations to come.

We believe our early commitment to precision medicine through the alliance has helped set the stage for even greater and wider use of this promising methodology. With that, every patient can have access to the best treatment possible, when and where they need it.

Damon Hostin is the CEO of the Precision Medicine Alliance of Catholic Health Initiatives and Dignity Health.  Robert Weil, M.D., is senior vice president and chief medical officer of Catholic Health Initiatives and a board member of the Precision Medicine Alliance.


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On Staten Island, a Highly Innovative Program That's Redefining What’s Possible Under Medicaid

September 17, 2018
by Mark Hagland, Editor-in-Chief
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Healthcare leaders on Staten Island have been achieving exciting success in care management and population health management in their community’s Medicaid and uninsured populations

Even as one hears constant complaints and concerns about the challenges facing healthcare leaders who are attempting to help shift the U.S. healthcare system from volume to value, more and more truly encouraging stories are emerging about pioneering organizations that absolutely are moving the needle, in the present moment. One of those encouraging stories absolutely revolves around the Staten Island Performing Provider System (SI PPS), a unique organization whose leaders describe it as a “Medicaid redesign program implementation enterprise.” Under the leadership of Joseph Conte, Ph.D., CPHQ, its executive director, SIPPS has been forging a path forward around robust population health for Medicaid recipients on Staten Island, the New York City borough that is the by far the smallest in population (479,000, compared to Brooklyn, at 2.6 million in population) yet third-largest in land mass, among the city’s five boroughs.

The Staten Island Performing Provider System has been participating very successfully in the Delivery System Reform Incentive Payment (DSRIP) program under the aegis of the federal government. What is involved in New York State’s DSRIP? As NYSDRIP’s website notes, “DSRIP is the main mechanism by which New York State will implement the Medicaid Redesign Team (MRT) Waiver Amendment. DSRIP´s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25 percent over five years. Up to $6.42 billion dollars are allocated to this program with payouts based upon achieving predefined results in system transformation, clinical management and population health.” The federal Centers for Medicare and Medicaid Services (CMS) approved New York State’s Medicaid waiver requested in the amount of $8 billion over five years, in April 2014.

And SI PPS manages the care of 130,000 Medicaid recipients on Staten Island, in addition to managing the care of 50,000 uninsured Staten Islanders.

According to SIPPS leaders, “Staten Island Performing Provider System (SI PPS) is an alliance of clinical and social service providers focused on improving the quality of care and overall health for Staten Island’s Medicaid and uninsured populations, which include more than 180,000 Staten Island residents. We are co-led by Staten Island University Hospital and Richmond University Medical Center. Our network of over 70 partners includes skilled nursing facilities, behavioral health providers, home health care agencies and a wide range of community-based hospitals, clinical facilities, treatment centers, social service and community organizations, primary care physicians and medical practices across the island. SI PPS is expected to bring more than $200 million to Staten Island over 5 years if successful in transforming our care delivery system. Our mission is to engage partners and stakeholders in the planning and implementation of DSRIP as we move towards a value-based payment model for Medicaid in New York State.”

Among the goals that SI PPS leaders have set for themselves:

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> Develop an infrastructure that lays the foundation for delivery system reform by transforming the Staten Island community through investment in technology, tools, and human resources that will strengthen the ability of providers to better serve our community

> Improve health literacy and share cultural competency knowledge

> Expand access to the appropriate level of care for all patients, including reducing barriers to care

> Expand outpatient and community services including home care, ambulatory detox, behavioral health/substance abuse, and primary care to reduce avoidable hospital/emergency department use on Staten Island

> Improve coordination of care and develop an integrated network

> Improve care management and disease management for high-risk patients, including patients with chronic conditions and behavioral health diagnosis

> Improve population health by addressing social determinants of health

> Integrate technology to allow for the secure exchange of health information across the PPS

> Reduce the per person cost for providing care

> Engage the uninsured, and underutilizing/low utilizing Medicaid patients and connect them to primary care and social services

> Implement innovative and evidence-based care models throughout the care continuum

> Implement training programs and learning collaborations between PPS partners that allow for the sharing of best practices

SI PPS leaders state that “These goals are being reached by implementing 11 DSRIP Projects, identified by a Community Needs Assessment, to address primary care, mental health, substance abuse, chronic disease, long term care, social determinants of health, and population heath.”

SI PPS leaders add that “We leverage a seamless platform that gathers data from multiple sources -- claims data, core reports, department of health information and the like -- and that data is inserted directly into the electronic data warehouse. With geo-mapping, we can identify areas that are lacking in key services. In creating maps of the population, we can filter in on specific conditions, and if we hover over a specific area within a specific map, we can see three years of claims data. We can figure out utilization trends, including hospitalization, medications, etc. We can also filter by demographics, types of chronic illness, etc.” Among the data sources they are make use of include direct data feeds from partners; lead providers’ clinical data; other partners’ clinical and billing data; data from care management partners; and public data; among other sources.

In addition, the SI PPS leaders have plunged into behavioral healthcare management. They note that they are pursuing “a population-health and community wide effort that aims to build capacity across systems by leveraging and developing partnerships to provide a quality integrated health care system, effective, high quality, person-centered care that supports improved health outcomes and optimal physical and emotional well-being. BHIP priorities focus on increasing and sustaining mental health/SUD provider service capacities, assisting community members to navigate behavioral health services, providing support to individuals and providers through education and technical assistance, addressing co-morbidities and co-occurring disorders, and reducing stigma and raising awareness about behavioral health wellness.” Among the numerous individual programs encompassed by the Behavioral Health Infrastructure Program (BHIP) are programs to expand the capacity of professionally certified peer workers in addiction and mental health, to help tackle the substance abuse program; the engagement of patients in the Emergency Department with substance use issues by clinicians and certified Peers to expedite linkages to behavioral health providers and reduce preventable ED visits; an innovative pre-arraignment diversion program designed to redirect low-level drug offenders to community-based health services instead of jail and prosecution; and numerous other programs.

Recently, Dr. Conte spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the progress being made at SI PPS, and the implications of his team’s work for transformation across the U.S. healthcare system. Below are excerpts from that interview.

Can you explain the basic funding mechanism or model that is supporting your organization?

The New York State Department of Health negotiated a waiver with CMS, and received $7.2 billion over five years to fund the program. About 50 percent of that was guaranteed for pay-for-reporting and program implementation, and 50 percent was set up as pay for performance, so it is very much a pay for performance program. There are 6 million people on Medicaid, and the state spends $65 billion a year, and the federal government pays for half of that; that’s why it’s very much in their interest to fund population health; it pays dividends to everyone.

To take care of the entire Medicaid population on Staten Island?

It’s interesting. We do not pay claims or intervene on behalf of providers, with managed care companies. Our sole purpose is to create innovation and reach population health milestones with providers in the community. So the hospitals, nursing homes, FQHCs, physicians, continue in their payment systems. We exist solely to create innovation and to incent innovation. It’s very much a pay for performance program.

Tell me about some of the main programs that you and your colleagues have been involved in, around this work?

The main initiatives relate to creating integrative care models where we bring in behavioral health providers to work with medical providers and medical providers who work in behavioral health organizations, so people don’t have to shuttle around to access care. We’ve done a great deal in the prevention of avoidable use of EDs for medical and behavioral care; that’s down over 60 percent in the past three years. And a lot of that has to do with looking at data form multiple sources and identifying where initiatives should be implemented. So we have a very big focus on asthma and a very big focus on diabetes. And a lot of the work involves engaging patients with peer educators who suffer from these conditions themselves.

One of the biggest innovations has been doing this with people who have alcohol and substance abuse disorders. We have peers in the EDs 24/7; and the number of people who have engaged in treatment services has tripled in the past few years. We’ve paid the salaries for these individuals, we’ve paid their training, have paid them to go get certified; and as they’ve become certified, they’ve become hired by the organizations, because their services are actually billable. So it helps the individual, helps the patient care organizations, helps the community. And it all comes out of high-level data analytics, doing hot-spotting, geo-mapping, bringing in social determinant of health factors, looking at housing, crime statistics, poverty, graduation lists, things like that. So we’ve done things very fundamental to services, to healthcare services, but in a very smart way. The workforce transformation is also very important; we spend a lot of time and training preparing people for new roles.

What have your biggest lessons been learned so far?

I would say it is that the kind of collaboration that it takes to create transformation is something that people really want to do; but they need organizations like ours that can bring these high-level analytics and resources together. And that includes training to give people new education; as well as providing to organizations high-level opportunities to identify patients most in need. You know, you can hunt for ducks with a shotgun, but it’s not a good idea when you’re trying to conserve ammunition, right? So we’ve helped people put a fine aim on things that need to be worked on, and the community coalitions are very powerful; you can’t go it alone, so working with local governmental units is very important. Also, bringing in information form as many sources of information as possible essential. We bring in ambulance data, social determinants of health data, school data, community data; all are essential.

Have you done geo-mapping or hot-spotting? How did you figure out how to obtain those various types of data?

When we started up, we were a complete start-up; so we didn’t have any legacy systems. So we hired very bright IT people and analysts, and brought the right tools to bear so that we could really be focused on how the resources were applied; that was our core investment.

What advice would you offer the senior healthcare IT leaders in patient care organizations, including the CIOs, CMIOs, CQOs, chief data officers, etc., in terms of what they should think about around all of this?

I would tell them that turning data into business intelligence is critical, and that’s true with respect to everybody. For the medical people, it’s medical business intelligence; for the finance people, it’s financial business intelligence. Don’t get overwhelmed with data; use it to create good information for clinical and business practices, and that will allow you allow you to be successful.

What will happen in the next couple of years?

There are about 13 states that have Medicaid redesign waivers in place now; CA and TX have received extensions, and we’re hoping for an extension. We’re also looking for other opportunities to extend our work; we’ve set up an ACO. We’ve set up a form of consultancy as well.

Where do you hope to go in terms of accomplishments in the next few years?

The important thing is for us to do things that are sustainable in the community whether we continue on or not, and that’s a lot of the work we have done—it is to grow capacity in organizations in the community. And that’s why the workforce work is so important. When people have new skills and training and ability to bring change into their organizations, these certainly are sustainability factors that are important.

Is there anything you’d like to add?

I would say one thing that we’re spending much more time on now, is continuing to try to work in the behavioral health space, because especially in the Medicaid population, any number of people have co-occurring conditions—they have medical and behavioral problems. And these are the patients with the most problems and who need the most services. So giving them access to more services is important, but also being able to be more predictive about when they’ll need those services, so we can be smarter about it; that is really important.

 

 

 

 


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