SINK OR SWIM:
Strategy Considerations for
Success in an Evolving
Health & Human Services
Market
Steven Ramsland, Ed.D.
Senior Associate
OPEN MINDS
Rick Smith
Chief Information Officer
ELWYN, INC
Dan Jimmerson
Director of Marketing
CoCENTRIX
TECHNICAL DETAILS
Technical
Details
AGENDA: HIGH-LEVEL LOOK AT STRATEGY FOR HHS ORGANIZATIONS
Industry
Trends that
Drive Strategy
Organizational
Requirements for
Competitive
Advantage
1
 Short-Term
 Long-Term
 Market Position
 Financial Position
 Operations + Business
Process Management
 Clinical Service Performance
+ Clinical Outcomes
 Technology Infrastructure +
Analytics
3
2
Organizational
Strategy Issues
INDUSTRY TRENDS THAT DRIVE STRATEGY
Rates
“Narrow networks”
Administrative
requirements –
Gain sharing models
authorization,
documentation, billing
Performance reporting
requirements
Performance-based
contracting
PRIME MOVER: THE TRIPLE AIM
IHI TRIPLE AIM: Industry-wide focus on achieving the
Triple Aim
HEALTH OF
POPULATION
EXPERIENCE OF
CARE
PER CAPITA COST
TRIPLE AIM MODELS: PORTER’S VALUE AGENDA
TRIPLE AIM MODELS: PATIENT CENTERED-MEDICAL HOME (PCMH)
Patient-Centered Medical Home (PCMH)
is a Triple Aim Model for coordinated and
personalized patient care
PCMHs:
Each consumer has a primary care team
responsible for coordinating all of
his/her care -- across all settings and
specialties.
PCMH connects traditional health
providers, community organizations,
and family into “healthcare
neighborhood.”
ACCESSIBLE
ACCOUNTABLE
PATIENT + FAMILY CENTERED
COMPREHENSIVE
CONTINUOUS + COORDINATED
PCMH +HEALTH CARE NEIGHBORHOOD
COMMUNITY
ORGANIZATIONS
ACCESSIBLE
ACCOUNTABLE
PATIENT + FAMILY CENTERED
COMPREHENSIVE
CONTINUOUS + COORDINATED
HEALTH IT
HEALTH
PROVIDERS
5 ATTRIBUTES OF PCMH
As defined by AHRQ, the PCMH is:
1
Patient-Centered
4
Comprehensive
2
Coordinated
5
Committed to
Quality and Safety
3
Accessible
TRIPLE AIM MODELS: HEALTH HOMES
Health homes are a population-based care
management model focused on consumers
with multiple chronic conditions.
Health Homes:
Grew out of the PCMH model
Build on the medical home model’s focus on acute care by
incorporating linkages to other community and social supports
Enhance coordination of medical and behavioral health care in
order to better meet the needs of people with multiple chronic
illnesses
CORE HEALTH HOME FUNCTIONS
Comprehensive care management
Care coordination
Health promotion
Comprehensive transitional care from
inpatient to other settings
5 Individual and family support
6 Referral to community and social support
services
7 Use of health information technology, as
feasible and appropriate
1
2
3
4
CORE HEALTH
HOME MEDICAID
FUNCTIONS
DIFFERENCES
BETWEEN
HEALTH HOMES AND PCMH’S
TRIPLE AIM MODELS: ACOs
Groups of health care providers that share
mutual responsibility for a population of
patients
Accountable Care Organizations (ACOs)
Aim:
Improve quality and health outcomes
Reduce health costs and inefficiencies
Reimbursement based on metrics of Quality Care, Patient
Satisfaction, and Reductions in Cost of Care
Population Health Management approach:
Maintaining and improving people’s health across full
continuum of care
ACO SNAPSHOT
1 366 Medicare ACOs currently in three programs:
Medicare Shared Savings Program
Advanced Payment ACO Model
Pioneer ACO Model
2 There are 606 total public and private ACOs in all
50 states and the District of Columbia
3 More than 50% of Americans live in area with ACO
coverage
Clinical Innovation
EHR &
Medication
Management
Meaningful
Use
Clinical
Decision
Support
Care Coordination
Primary Care
Integration
Information
Exchange
Reduce Cost
Business Efficiencies
Hosting &
SaaS
Revenue Cycle
Management
Managed
Services
Technology
Partners
Population &
Community
Health
Management
Delivering Accountable Care
Improve Outcomes
DELIVERING ACCOUNTABLE CARE
KEY TRIPLE AIM COMPETENCIES
Robust EHR and the ability to do health information exchange
Organizational performance metrics available with the use of metrics-based
management to improve performance, and manage financial risk and unit cost
Deployment of automated clinical decision support tools across all chronic disease
states
Infrastructure to locate and coordinate both health-related services and non-health
social services
Systematic approach to consumer engagement and improving the consumer
experience
TEN HEALTH IT TOOLS TO ACHIEVE TRIPLE AIM
Population Health
Analytics
Health Information
Exchange
Risk Stratification +
Predictive Clinical
Analysis
Remote Monitoring
Web-based
Consumer SelfManagement
Telehealth
Patient Portal
Automated
Outreach
ONC-ACB Certified Electronic Health Record
Referral Tracking
Swimming To
Success In A
Turbulent,
Evolving Market
ORGANIZATIONAL REQUIREMENTS FOR COMPETITIVE ADVANTAGE
1
Market Position
2
Financial Position
3
Operations and Business Process Management
4
Clinical Service Performance and Outcomes
5
Technology Infrastructure and Analytics
GETTING STARTED
Long-term success in an
evolving health and
human services market
is an open-ended
commitment--not a
one-shot effort.
Get started by:
Investing in IT
Measuring outcomes and
quality
Understanding costs
Implementing team-based,
collaborative, integrated care
Analyzing your position in
local market
LONG-TERM CONSIDERATIONS
In the new pay for value environment, what is the vision of your
organization’s role in the future?
What are the market scenarios that are likely in your market
– and how does that vision “fit” in each?
Which structural options are possible within each market
scenario?
What are the programmatic options that would work in
each market scenario?
SPECIALIST ORGANIZATION BUSINESS MODEL OPTIONS FOR
PARTICIPATING IN INTEGRATED SERVICE DELIVERY
1
Specialist organization adds primary care capacity
2
Specialist organization co-locates services in primary care organization
3
Specialist organization merges with primary care organization
4
Primary care organization provides behavioral health services using specialist webbased and telehealth services
5
Care coordination through shared consumer data
THREE STEP MODEL IN EVALUATING INTEGRATION OPTIONS
FOR SPECIALIST ORGANIZATIONS
Payer Market Mapping &
Identification Of
Opportunities
 Payer market share
 Payer reimbursement
model
 Payer reimbursement
rates
 Competitive
relationships for payer
volume
Service Model
Development
Financial Sustainability
Modeling
Integrated care model
Staffing
Operating processes
Costs of licensure and
accreditation
 EHR platform
 HIE connectivity
 Decision support tools
 Breakeven analysis
 Profit/loss projections
 Cash flow
requirements




SOME CLOSING THOUGHTS
Wide variations by market: state policy, dominant payers, system
consolidations, consumer demographics
“Footprint” of insuring organizations is important
Policy and payer movement away from FFS. Payment Reform is happening.
But when? How?
Planning the future sustainable role of specialists is a matter of market
analysis and organizational competencies
Accountable care models are heavily dependent on sophisticated health IT
and analytics
Care integration is here to stay. What will be your role?
Case Study
Rick Smith, CIO, Elwyn Inc.
ABOUT ELWYN
Non-profit Human Services Organization
 Serve over 12,000 unduplicated consumers per year
Large and diverse
 Serve over 12,000 unduplicated consumers per year
 ~3,500 Full time equivalents
 Multiple funding streams and contracts
Six Service Areas


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

Supports for Living
Behavioral Health Services
Early Childhood Services
Work and Adult Day Services
Education Services
Research and Health Services
Provide Services in Four States


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Pennsylvania
New Jersey
Delaware
California
GOALS AND OBJECTIVES
Thrive in changing healthcare environment
 Shift to Pay-for-Performance (metric & outcomes)
 Continued delivery of high quality, cost effective care
 Emergence of “Risk-Bearing” entities (ACOs, MCOs)
Coordination of Care
 360 Degree view of a consumer
 Timely access to data, when and where needed
 Inclusion of all involved in consumers “Circle of
Support”
GOALS AND OBJECTIVES
STRATEGIC INITIATIVES
Strengthen Organizational Capacity and Capability
Electronic Health Record
Health Information Exchange
Staff Training / Competency
Technical Infrastructure
Data Governance
PRIVATE HEALTH INFORMATION EXCHANGE
PUBLIC HEALTH INFORMATION EXCHANGE
TECHNOLOGY INFRASTRUCUTRE
Questions
Contact
Information
http://cocentrix.com
Email: [email protected]
Thank you for your time.