Innovative health and social care systems: What the CARE Model means for Workforce

Jason Helgerson
Chief Solutions Officer/Founder
© Helgerson Solutions Group

Integrated Accountable Collaborative

Organizations from
across the spectrum
of healthcare, as well
as social and human
services working
together to improve
patient and
community health
Individuals and
organizations are
constantly looking
for new ways to
better serve their
patients and
communities
Everyone accepts
responsibility for
improving patient
and community
health
Empathy is the prime
directive. Empathy
for patients, families,
caregivers…
everyone
Collaborative Activist Responsible Empathetic

• Wildly successful model on path reducing avoidable
hospital use by 25% by 2020
• Best funded CARE effort in the world
New York - Performing
Provider Systems (PPS)
• Closely modelled on NY
• Relies less on hospitals and more on community
providers to help lead the effort
Washington State -
Accountable Communities of
Health (ACH)
• Another US state driving payers and providers
together for improved patient outcomes
• Cut emergency room visits and costs, raised primary
care visits, and achieved a 50% increase in medical
home enrolment*
Oregon State – Coordinated
Care Organizations (CCO)
© Helgerson Solutions Group * www.healthaffairs.org/do/10.1377/hblog20170110.058188/full/

6.6 million people
on Medicaid
(1/3 of the State’s
population)
Annual budget of
$68 billion
2nd largest in the
country
Medicaid is the
largest purchaser
of healthcare
services in the
State
(c) Helgerson Solutions Group

Goal:
Reduce avoidable
hospital use –
Emergency
Department (ED)
and Inpatient –
by 25% over the 5
years of DSRIP
Remove Silos
Develop Integrated
Delivery Systems
Enhance PC and
Community-based
Services
Integrate
BH* and PC
(c) Helgerson Solutions Group * Mental health & substance abuse

• DSRIP built on Center for Medicare and Medicaid Services (CMS)
and State’s goals towards achieving the Triple Aim:
• Better care
• Better health
• Lower costs
• To transform system, DSRIP focuses on provision of high quality,
integrated primary, specialty & BH care in community setting
with hospitals used primarily for emergent & tertiary level of
services
• Its holistic & integrated approach to healthcare transformation
is already having a positive effect on healthcare in NYS

A PPS is composed of regionally collaborating providers who
implement DSRIP projects over a 5-year period & beyond.
PPS include providers to form an entire continuum of care
Statewide goal:
• Reduce avoidable hospital use by 25% (re-admissions and ER
visits)
• Activating New York State's fragile safety-net network
• Shift 80-90% of Medicaid managed care payments from fee-for-
service payments to value based payments
• Hospitals, Systems • Mental Health, Substance Abuse Providers
• PCPs, Health Homes • Skilled Nursing Facilities, Clinics
• Home Care Agencies • Community Based Organizations

New York is on Track to Meet Performance Goals
21% Reduction in avoidable hospital use statewide
• 11 PPS have seen more than 25% reduction
95% of all available funds have been earned
Statewide accountability measures have been met each year
70% of managed care payments are value-based
• 45% are in higher-level risk sharing agreements

• NSW Health is helping to deliver integrated care by investing in the
right technology, education and resources to strengthening the
connection between general practice, hospitals and other health
providers to create a more holistic view of patients’ health needs and
health history.*
• Local health districts and two specialty health networks have been
funded by NSW Health to develop their own models of care.
NSW, Australia
• ‘One system, one budget’ has resulted in system supporting more
people in their homes and communities and has moderated demand for
hospital care, particularly among older people
• Compared with rest of NZ, Canterbury has lower acute medical
admission & readmission rates; shorter average length of stay; lower
emergency department attendances; higher spending on community-
based services; and lower spending on emergency hospital care
New Zealand
* https://wnswlhd.health.nsw.gov.au/integrated-care/latest-news/Documents/WNSW%20Tele-
home%20monitoring%20trial%20Dubbo%20Media%20releaseFNL.pdf

Health care providers join with social care and human
service organizations and see improved
patient/community health as their common goal
Aggregation
These systems not only gather data, but actually use itData-driven
These vanguards aren’t afraid to try new models of
care and are constantly looking at ways to better serve
patients and the broader community
Willingness to Innovate
They understand that the real cause of bad health
outcomes is often poverty, inadequate housing, food
deserts, social isolation, etc
Embrace the Social
Determinants of Health
Collaboration requires powerful organizations to give
up power for the greater good
Willingness to
give up power

Real World Examples

Training the future healthcare workforce
• 70 students from five high schools visit once a month to investigate
and explore a variety of healthcare occupations
• Students exposed to front line clinicians such as nurses and
doctors, but also to other careers in a hospital setting such as
finance, billing, human resources, carpentry, maintenance, security
services and information technology
• "To see their excitement and energy gives me hope for the next
generation” RN, Bassett nurse educator and Scrubs Club instructor
• Each new school year, the Scrubs Club will welcome a new group
of students and the future of the healthcare workforce

• Enabled 646 clinicians to achieve patient-centred ‘medical home
designation’
• Invested in training & deployment of Community Health Workers focused
on working with primary care practices
• Prioritised building strong partnerships with primary care and CBOs
(community-based organisations), i.e. the 3rd sector, community,
voluntary and charitable organisations to
 Effectively address economic insecurity of patients
 Implement social needs interventions
Improving quality &
continuity of care
Supporting high-
need patients
Assisting primary care
physicians in engaging patients

• 6 Community Health Workers (CHWs) develop achievable goals on most pressing needs
• CHWs follow up post-ED visit – within 72 hours - with a home visit
• Weekly visits for following 30 days, services provided:
• Warm handoff to health and social care providers
• Help scheduling primary care visits & arranging transportation
• Help with applying for public benefits
• Connect patients with longer-term care management supports
• Since September 2017 enrolled 686 of 1,724 eligible patients – 40%
• Over 75% of enrolees have met own identified goals in acquiring medical care,
transportation, food supports
• 68% met goal of receiving support in applying for housing assistance
Supporting high-risk patients
with unmet social need
CHW screens at bedside & follows-up with
home visit within 72 hours
http://bit.ly/2ILLARc

• Comprehensive community screening intervention
• Focused in high-risk postcodes
• Events in churches, community centres, and schools
Increase the number of touchpoints
for adult preventive care
Reduce preventable
ED visits
Improve overall
population health
 600+ received blood pressure screening, medication
evaluation and education on diet and physical activity
 70% screened had pre-hypertension or high blood pressure
• Screenings in Barber Shops and Beauty Salons some of the most
successful
• Culturally competent, place of trust (video)
• Ultimate goal for clients to become advocates
for their own health

• 620+ clinicians trained to Physician Asthma Care Education (PACE) model,
evidence-based to improve treatment of children
• 26 CHWs trained on asthma basics & home environment assessments
• Clinicians develop AAPs for children with asthma and refer child & family
CBOs with existing CHW programs
• CHWs provide education, support & perform home assessments
• Arrange pest management visits for pest and mold remediation
• Between June and December 2017, paediatric asthma admission rates
decreased by 25% & overall avoidable admissions also fell
• Watch https://nbcnews.to/2pcJ7se
Reduce paediatric asthma admissions CHM home visits

• Allows access to appropriate levels of services, supporting rapid de-
escalation of the crisis
• Provides mobile and intensive crisis services, wellness checks and assistance
with care transitions
• To meet growing demand, service hours expanded from 8-14 hours per day
• Licensed, non-clinical and peer support staff added to assist in recovery
planning and to connect individuals to community supports
Over 12 months
20% increase in response to requests
for face-to-face services
92% hospital
diversion rate
Decreased
staff turnover
https://www.parsonscenter.org/images/SATRI/Psychosis_Hand
outs/BHNNY-Peer-Presentation---Brendon-Smith.pdf

Hire of two peer recovery coaches who have already ‘navigated the system’
from detoxification through rehabilitation and recovery.
In 2018, peer recovery coaches helped ensure:
 100% of the transitioning patients attended 1st appointment
 96% kept their second appointment
 connection to recovery supports in community
 more routine discharges, better transitions and long term engagement
with outpatient treatment
 lower rates of readmission
More info at http://bit.ly/31bH310
Prevented 65 ED visits Yielding ROI of $237K+Prevented 325 inpatient days

• Nursing and Community Health Worker Staff on site
• Nurses perform blood pressure and blood glucose
screening and monitoring
• Participants who are at-risk for diabetes or
hypertension are enrolled in wellness programing
including diet and exercise
• Community Health Worker provides education,
monitoring, follow up and support
• In partnership with an FQHC (federally qualified
health centre), participants are linked to primary
and specialty care
1500+ diabetes or
hypertension
screenings
Monitoring 162
individuals with
hypertension
Monitoring 157
individuals with
diabetes
Provide wellness
programming
approximately 8 times
a month
Nassau Queens PPS & First Jamaica Community
Urban Development Corporation Success so far (August 2018)

and most
importantly……
Empathy
Creativity
Humility
Thoughtfulness
Compassion

• Value-based care = new care models = need for new skills
• Value-based care requires collaboration across
organizations and systems - most health and social care
workers weren't trained to work in that environment.
• Value-based care will shift more of the focus away from
institutions and into the community. We will need to help
transfer the workforce
• The transition won't be easy!

Thank you
Jason will be in the UK in the Autumn delivering a number of workshops.
If you’d be interested in him coming to your organisation to talk with your leadership team
please get in touch via sarah.crick@helgersonsolutions.com
www.helgersonsolutions.com
@policywonk1 @HSG_4_value

Innovative health and social care systems: What the CARE Model means for Workforce

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