PAYING FOR POPULATION HEALTH: CASE STUDIES OF THE HEALTH SYSTEM’S ROLE IN ADDRESSING SOCIAL DETERMINANTS OF HEALTH Support for this report was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. Table of Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Burlington, Vermont: Reducing Health Care Costs and Homelessness through Temporary and Permanent Supportive Housing Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 History of Investments in Collaborative Housing Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Local and State Health Care Environment: Coverage, Health Care System Structure and Payment . . . . . . . . . . 7 Other Enabling Factors: Making a Difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Considering the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Cincinnati, Ohio: Reducing Infant Mortality through Community-Clinical Collaborations . . . . . . . . . . . . . . 10 History of Aligning Community and Clinical Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 The Local and State Health Care Environment: Coverage, Health Care System Structure and Payment . . . . . 13 Other Enabling Factors: Making Collaboration Possible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Considering the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Greenville, South Carolina: Building an Accountable Care Organization for the Uninsured . . . . . . . . . . . . . 15 History of Care Outside Clinical Walls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 The Local Health Care Environment: Coverage and Health Care System Structure . . . . . . . . . . . . . . . . . . . . . 18 Other Enabling Factors: Making a Difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Considering the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Muskegon, Michigan: Improving Health through Community-Based Care Coordination . . . . . . . . . . . . . . . 20 History of the Health Project: Coalitions and Community Health Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 The Local and State Health Care Environment: Coverage, Health Care System Structure and Payment . . . . . 22 Other Enabling Factors: Incentivizing Systems to Invest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Considering the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 2 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health INTRODUCTION With support from the Robert Wood Johnson Foundation, AcademyHealth launched the Payment Reform for Population Health initiative in 2016 to explore improving community-wide health through the transformation of the health care payment system. As part of their efforts to identify the opportunities and challenges associated with linking payment reform to population health, AcademyHealth requested development of four case studies of sites where health systems were actively involved in addressing social determinants of health (SDOH) including housing, employment, education, food security, transportation, healthy behaviors, and neighborhood and built environment. With these criteria, the following case study sites were selected having respectively developed interventions focused on medically complex homeless individuals, people with chronic diseases, pregnant women and their newborns, and uninsured individuals with multiple chronic conditions: Burlington, VT; Muskegon, MI; Cincinnati, OH; and Greenville, SC. Each of the following case studies includes a detailed description of the intervention, outlines enabling factors, and provides considerations for the future. To learn more about the Payment Reform for Population Health initiative, visit www.academyhealth.org/p4ph. PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 3 Burlington, Vermont: Reducing Health Care Costs and Homelessness through Temporary and Permanent Supportive Housing Programs The joint effort that started in 2013 has resulted in the devel- Project Partners opment of 23 permanent and four short-term housing units United Way of Northwest Vermont for medically fragile individuals as well as 59 motel beds with Burlington Housing Authority supportive services. Vermont’s unique health care environ- Community Health Center of Burlington ment and cross-sector financing and collaboration has made Champlain Housing Trust it possible for the housing investments to be in the hospital’s Champlain Valley Office of Economic Opportunity financial interest as well as aligned with its mission. Steps to End Domestic Violence Howard Center Chittenden County Continuum of Care History of Investments in Collaborative Fanny Allen Foundation Housing Initiatives Vermont Housing & Conservation Board In 2010, two homeless men froze to death. The state of Ver- Vermont Community Loan Fund mont responded by expanding access to temporary motel Vermont Community Foundation vouchers but, by 2013, costs for these motel vouchers had State of Vermont Agency of Human Services tripled, so government administrators limited eligibility. The Other state agency & development partners stricter state rules made it difficult for mental health, sub- stance abuse and other health and human service providers to discharge or domicile homeless people whose medical Over the last four years, the University of Vermont Medical needs made it risky for them to be on the street. For the Center (UVM Medical Center) in Burlington has worked UVM Medical Center, the new restrictions created an op- with public and private partners to support three supportive erational problem: homeless people remained as inpatients housing projects for homeless people with complex medical or in the emergency department (ED) even though they no needs. The hospital was facing significant challenges finding longer required that level of care. Yet, discharging fragile discharge options for their homeless patients. Additionally, people to the street put patients at risk and often resulted in as a founder of the statewide Accountable Care Organiza- more frequent readmissions. tion (ACO), the UVM Medical Center’s business model increasingly focused on controlling costs, while improving health outcomes. As the only hospital in Burlington, they First Housing Initiative bore all the risk for avoidable acute and emergent care relat- At the same time, the Champlain Housing Trust (CHT) ed to patients’ social determinants of health. was re-directing some of its affordable housing focus to the burgeoning homelessness problem. They believed they However, pressing need was not the only reason invest- could operate a more efficient motel structure than the state’s ing in housing became the hospital’s strategy. There were commercial motel program. Jointly with the United Way, they other strategic alignments. The United Way of Northwest approached the UVM Medical Center to try to solve a shared Vermont had been a driving force in shaping the region’s problem. The Trust had the capacity to acquire, renovate, and homeless service agenda; their executive director sat on manage property for low income individuals; and the Medical the hospital’s community benefits committee. The hospital Center had a community benefit commitment and a growing medical director led UVMMC’s population health efforts care delivery and cost problem. In November 2013, CHT pur- and understood the potential value of upstream strategies. chased a 59-room commercial motel, remodeled and opened Finally, there were willing and knowledgeable housing, it as Harbor Place, temporary housing with supportive ser- supportive services, and investment partners. vices for homeless individuals. CHT was able to undercut the state’s prior rate for commercial motel shelter services by 40 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 5 percent. The state, in turn, agreed to help finance a $300,000 based on a Vulnerability Index. Because early experiences with operating reserve and committed to reserving at least 30 Harbor Place indicated that stabilization of some of the dis- beds each night for qualified people. United Way, the Fanny charged homeless residents required more and lengthier clinical Allen Foundation, and the UVM Medical Center financed the and case management support than previously anticipated, rest of the operating reserve and the UVM Medical Center CHT converted a second motel to provide permanent support- prospectively purchased 550 bed nights for the first year for ive housing to those at the top of the wait list, including those patients who would be discharged from the hospital. The at Harbor Place. Beacon Apartments opened in January 2016, agreement allowed five other local health and human service providing housing to 19 medically complex people and many providers to refer clients to Harbor Place. This commitment with physical and behavioral comorbidities. of rooms by the state and the UVM Medical Center allowed As of December 2016, 16 of the 19 original residents remain CHT to secure $1.85 million in financing for acquisition and housed at Beacon. After a year at Beacon, all residents are provision of rehabilitation services. eligible for a flexible rental subsidy from the Burlington Housing Authority they can use anywhere in the communi- This initiative is a true collaborative effort. The UVM Medical ty. As of January 2017, however, none of the residents who Center’s discharge planners place patients at Harbor Place qualified for the vouchers accepted a move. Safe Harbor who are homeless or unstably housed or who have medical or staff believe that residents stay at Beacon because of the functional needs that prevent them from returning home. The accessible web of services embedded there, the community median length of stay at Harbor Place is eight days, although of residents that is forming, and the fact that many are still guests can be there longer. CHT provides the property man- adjusting to life in permanent housing. agement services and three additional organizations provide case management services to motel guests: Safe Harbor, the Community Health Centers of Burlington’s Healthcare for the Third Housing Initiative Homeless program; the Champlain Valley Office of Economic Through 2016, the UVM Medical Center faced an ever-ex- Opportunity; and Steps to End Domestic Violence. In year panding need for community housing that could support two of the project, the UVM Medical Center estimates that patients with short-term medical needs post discharge. At the Harbor Place resulted in $500,000 in savings in inpatient same time, the housing providers recognized that some of the admissions. Additionally, CHT reports that homeless people most medically and behaviorally complex homeless individ- temporarily housed at Harbor place are five times more likely uals in Harbor Place or on the housing waitlist required a to end up in a permanent home than if they had gone to a more supportive environment than Harbor Place or Beacon commercial motel through the state’s voucher system. Harbor provided. In December 2016, CHT and UVM Medical Center Place provides an entry point for case management and other announced that CHT had acquired and would convert a third services that support housing readiness. motel into four one-bedroom units of permanent supportive housing for the more complex individuals identified through UVM Medical Center Use by Harbor the 100,000 Homes vulnerability assessment, and four units Place Residents: 2013-2015 of temporary housing for eight patients discharged from the Patients Discharged from the Hospital: 95 hospital but requiring short- and medium-term medical sup- Reduction in ED Visits: 42% port. The new development will have on-site medical support Reduction in Inpatient Admission Costs: 81% and around-the-clock, non-licensed awake staff. The UVM Hospital Savings: $10,300/person Medical Center will invest $3 million for this new develop- Overall Hospital Estimated Savings: $1M ment: $1 million for CHT’s purchase and rehab of the facility and $2 million for rent and operating costs for the support services provided by Safe Harbor. Second Housing Initiative As Harbor Place was completing its first year, the original Building on Success: Beacon Apartments collaborators, along with the Burlington Housing Authority and n Operating reserve from Harbor Place helps support Beacon the Chittenden County Homeless Alliance, began a new project n UVM Medical Center expands Safe Harbor support to to create permanent housing for chronically homeless people provide case management who are the most medically vulnerable. Using the national n Modeling on similar patients allowed the hospital to 100,000 Homes Campaign approach, volunteers conducted a project 60% cost reductions for year one of Beacon community survey resulting in a wait list that prioritizes people 6 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health Local and State Health Care Environment: Fletcher Allen Health Care was formed by the merging of Coverage, Health Care System Structure and two hospitals and an academic faculty practice, giving birth to the state’s only academic medical center – now known as Payment UVM Medical Center. This was followed by physician prac- Coverage tice restructuring and expanding experience in risk-based In the late 1980s, Vermont began implementing health payment arrangements. When the hospital’s NPR exceeded coverage programs for uninsured populations. Incremental targets last year, the UVM Medical Center sought partial changes in insurance coverage, care delivery, and payment allocation of its over-budgeted revenue for the financing of strategies continued to re-shape the healthcare environment the newest supportive housing project. The UVM Medical for the next 20 years. A decade ago, legislation reformed the Center was the first hospital to request funds to be redi- non-group market, expanded an employer-based premium rected for any purpose other than insurance rate relief, a assistance program, created a subsidized public insurance position not well-received by the insurance industry. program, and established a state-led Blueprint for Health, a platform for systematic change. In 2011, legislation creating Other Enabling Factors: Making a Difference the state’s health exchange also laid out the framework for Market dominance, an ACO structure, philanthropic progressive movement toward a single payer system. As of history, and payment reform experiences would not have early 2015, the state had near universal coverage with 96 inherently prompted the UVM Medical Center to invest in percent of Vermonters insured. supportive housing for their homeless patients. Other histo- ries, relationships, and resources were central to mounting this successful population health strategy, including: Blueprint for Health A program for integrating a system of health care for n A History of Collective Action: The Burlington area has patients, improving the health of the overall population and a long history of cross-sector engagement in civic problem improving control over health care costs by promoting health solving. The United Way of Northwest Vermont (UW) has maintenance, prevention, and care coordination and man- played a particularly important role in facilitating collab- agement. (18 VSA Chapter 13) oration. In 1996, UW convened a year-long community consultation in response to concerns regarding the planned hospital and medical practice mergers and federal threats to block grant Medicaid. Fletcher Allen provided signifi- Health Care System Structure cant support for this process, which both eased the devel- The 2011 statute also created the independent Green opment of the academic medical center and resulted in a Mountain Care Board (GMCB) which is responsible for 20-year healthy community strategy. CHT and its partners controlling health care costs through hospital budget au- have continued to provide a platform for ongoing support- thorization, regulation of insurance companies, oversight of ive and affordable housing, among other community health rate setting and payment reform, and innovation, including development efforts. supporting the development of all payer ACOs. The GMCB approves hospital budgets and sets Net Patient Revenue n Cross-Sector Resources & Alignment: The three sup- (NPR) targets. Hospitals that exceed their NPR target are portive housing projects would not have been possible asked to provide rate relief for commercial insurers. Most without CHT and its successful history in leveraging recently, in October 2016, the Centers for Medicare and property acquisition, rehabilitation, management, and Medicaid Services (CMS) approved Vermont’s all payer operational support. CHT also brought to bear critical waiver that establishes a statewide ACO. By the end of 2022, state and local public agency support in acquiring an the state expects that all Medicaid, approximately 90 percent operating reserve, motel and permanent housing vouch- of Medicare, and 70 percent of commercial insurer benefi- ers, collaborative case management support, and backing ciaries will be attributed to an ACO. from political leadership. A well-functioning Healthcare for the Homeless program, Safe Harbor, based at the Payment and Financing Community Health Centers of Burlington, brought expe- The UVM Medical Center, in collaboration with Dart- rienced clinical and case management capacity, otherwise mouth-Hitchcock, founded OneCare Vermont in 2014. unavailable through the UVM Medical Center. Addi- This transition has been facilitated by its 20-year process of tionally, a network of other skilled service providers in hospital acquisitions and mergers, beginning in 1995 when domestic violence, mental health, and addiction services PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 7 has assured access to multiple evidence-based approaches Considering the Future to the chronically homeless population. Despite the successes to date, these novel supportive hous- n Hospital-Community Collaboration: There are exten- ing programs face several future challenges. Housing invest- sive historic and current financing, board membership, ments for complex individuals do not inherently result in coalition and other relationships in Burlington that reduced health care spending. While there was immediate shaped these projects. Of particular note is the role UW financial and operational relief for the UVM Medical Center plays as one of six community members of the 12-mem- with the opening of Harbor Place, the return on investment ber UVM Medical Center community benefits commit- for the second, Beacon Apartments, is less clear. Residents tee, the Community Health Investment Committee. The stay longer and have fixed and ongoing support costs. They committee is unusually situated to help align investment also have fewer hospital stays from which ongoing savings strategies both with other philanthropic organizations can be realized. Additionally, where Beacon was envisioned and with its own financing and policy development in the to be a renewable resource that graduated tenants to more health, human services, and housing sectors. traditional permanent housing with the dedicated vouchers, the first-year experience is showing that this transition is n Integration of Population Health and Community more uncertain. Benefits within the Hospital: The UVM Medical Center’s Chief Medical Officer serves as the ACO’s population health leader and developed the Community Health “A hospital bed is one of the most expensive Investment Committee – which makes investments in places you could stay…This is exactly the kind the community to improve community health and also of investment we need to make if we’re going to reduce costs. Additionally, as an emergency medicine achieve the goal of improving the health of our doctor, he knows the challenges that homeless patients communities while controlling costs.” present clinically and operationally to the hospital. Like his collaborators at CHT, he has been able to leverage – Hospital Executive critical utilization and cost data to evaluate the hospital system’s community benefit and population health invest- As they move ahead, the Burlington collaborators face many ments. questions shared by other health systems investing in social n Timing and Other Unique Circumstances Introduce determinants of health: Opportunity: Constrained shelter resources created n How important is the impact the investment has on pay the initial emergency that prompted this cross-sector for performance requirements?; response. Neither the hospital, nor local philanthropy could answer the problem alone. CHT’s decision to ex- n Does financial ROI need to be demonstrated and, if so, is pand their mission provided an opportunity for collective the required time horizon going to be sufficient?; action. The Burlington area had availability of nearby n Is it possible to better account for total cost of care across vacant and under-utilized vacation motel properties that sectors?; could readily be converted for temporary and perma- n How do systems adjust their strategies in the face of un- nent housing use. Some of the community collaborators certainty regarding the complexity and duration of patient had already been working together in the prior shelter support needs?; and and their experience and resources were well-situated to make these new endeavors successful. Finally, the state’s n How do sectors build joint strategies when there may be progress in supporting population health strategies and multiple investors but savings accrue to a single sector? moving regional areas towards becoming accountable health communities had built a shared framework for Finally, as policymakers and health care leaders focus improving health by addressing social determinants, on controlling health care costs, these supportive hous- including housing. ing projects represent a unique circumstance of health care premium dollars being very explicitly transferred 8 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health to non-healthcare functions through the decision of the ly-held community concern and are demonstrating success Green Mountain Care Board. Finding mechanisms to in the housing and care of complex homeless individuals. actively shift health care resources to another sector has The UVM Medical Center investment is responsive to been challenging in the population health arena and the operational needs and increasing payment and performance likelihood of its replication in Vermont for this or oth- related risk, even as there is uncertainty about how, over er health concerns tied to social determinants, like the time, these investments will be supported. The UVM Medi- current opioid crisis, is unclear. The insurance industry cal Center understands that to be successful in the evolving was not supportive of this transfer and the GMCB has a alternative payment environment it must embrace total pop- primary obligation to control health care costs. ulation health management. In a Fee-for-Service payment world, housing is a good idea, but not a great investment. In Despite the challenges, these supportive housing projects Vermont, however, where patients are increasingly covered provide a robust example of population health strategies by value-based payment arrangements, housing may be a that are cross-sector in development, investment, and good investment afterall. management and hold great promise to improve health care delivery, outcomes and cost. The projects address a broad- PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 9 Cincinnati, Ohio: Reducing Infant Mortality through Community-Clinical Collaborations due to several unique community collaborative resources Cradle Cincinnati Vision & Partners including: Every child born in Hamilton County will live to see his n Cradle Cincinnati and its facilitation of cross-sector or her first birthday. partners; Hospitals: Christ Hospital; Cincinnati Children’s n Prenatal care quality improvement efforts co-led by Tri- Hospital; Mercy Regional Health; TriHealth; University Health, Children’s and University Hospital clinicians; of Cincinnati Medical Center n Active involvement of community social service organiza- tions, including Health Care Access Now (HCAN); Community Service Providers: Every Child Succeeds; n Targeted philanthropic and governmental financing; and Health Care Access Now; Healthy Moms & Babes n The broader health care delivery transformation, data and Public Sector & Philanthropy: Cincinnati Health planning support provided by The Health Collaborative. Department; Hamilton County Health Department; While building strategic alliances across health and human Interact for Health; March of Dimes; United Way services in Cincinnati has been challenging, addressing infant mortality has had a galvanizing effect for joint action. Over the last five years, Cradle Cincinnati, also referred to as Cradle, has worked to reduce infant mortality in southwest History of Aligning Community and Clinical Ohio. As a cross-sector collaboration of hospitals, govern- Strategies ment agencies, social service organizations, philanthropy, From 2011 to 2015, 508 babies died before their first birthday and community advocates, Cradle’s objective is to optimize in Hamilton County, ranking it in the lowest 10 percent of clinical care while meaningfully addressing the social deter- urban counties in the US. In 2013, Cradle Cincinnati was minants of the health of pregnant women and their infants. formed as a deliberate effort by public and private entities to Multiple clinical, community support, and health care strategically align community and clinical approaches to im- financing efforts have been brought to bear locally and in prove birth outcomes and reduce the estimated $402 million conjunction with statewide work at the Office of Medicaid cost of preterm births in the county. Since the negative health and with the Ohio Perinatal Quality Collaborative. This case outcome and economic effects of birth outcomes are diffusely study looks at a current multi-partner effort to expand the experienced because women’s health, maternity, and infant roles and numbers of community health workers (CHW) clinical providers and affiliated hospitals are silo-ed, Cradle supporting pregnant women within a community experi- developed a collective impact approach across systems and encing ongoing care delivery transformation. sectors. Housed at, but independent of, Children’s Hospi- tal, Cradle Cincinnati supports multiple strategies, which With a local population of approximately 300,000, Cincin- address three core objectives: pregnancy spacing; reduction nati’s six hospital systems serve a broader catchment area of smoking during pregnancy; and safe sleep. Their efforts of 2.1 million, encompassing areas of two adjacent states as are geographically targeted and focus on improving com- well. Urban and rural poverty, along with long-term racial munity activation, connecting moms with needed resources, and ethnic health disparities, shape patterns of health status and supporting learning collaboratives focused on prenatal and care utilization. In Ohio, infant mortality among Afri- care improvement. CHWs and home visitors have also been can Americans has persisted at almost three times that of central to providing support to those moms at highest risk. whites. Hamilton County, where Cincinnati is located, ranks Over the last eighteen months, this neighborhood-focused, as one of the two counties with the highest infant mortality cross-sector collaborative, Start Strong, has documented a 17 rates in the state. Yet there are promising improvements percent decrease in infant mortality. 10 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health that specify strategies which lead to measureable outcomes. In Community Health Access Program Low Ohio, performance-based payments related to pathway com- Birth Weight (LBW) Prevention Outcomes pletion incentivize efforts to achieve positive outcomes. Ohio n Reduction in LBW (adjusted): 36% Medicaid managed care plans first recognized these “pay points” n Estimated Cost Savings/ Every $1 spent: in 2010 for the pregnancy-related pathways. The added value of – 1st Yr of Life: $3.36 the HUB is its provision of a community-wide platform for care – Long-term: $5.59 coordination across agencies that serve targeted populations and geographies and address specific social and economic support needs. These HUBs, located across the state, provide a standard- Based on these efforts, Cradle Cincinnati and its partners were ized approach to assessment and intervention strategies while well-positioned to receive one of nine grants from Ohio Medic- regionally organizing referral processes and data collection. In aid’s 2016 initiative to support “community-driven proposals to turn, it reduces fragmentation within the human services sector combat infant mortality… and connect women and infants to as well as between human services and primary care. quality health care and care management.” These funds expand upon existing Cradle-related efforts and will allow for the “I couldn’t get through one appointment at deployment of 13 new CHWs to serve 1,000 pregnant women the free clinic before I needed the CHW. The over the next two years. The Pathways HUB model, launched in patients often needed the CHW more than Cincinnati seven years ago by HCAN, will be the platform for they needed me…It’s great to have that RN referrals, training, and data collection for the CHWs who will following someone’s diabetes but it’s also great work out of four care coordinating agencies. Besides increas- to have someone follow people and make sure ing the availability and roles of trained CHWs through this they have enough food and that their utility bills standardized mechanism (Pathways), the grant seeks to improve are being paid.” the front door access for pregnant women with an expanded 211 service referral system operated out of United Way. Cradle – Physician Executive and HCAN also hope to better analyze the cost and impact of the Pathway HUB in a manner that can inform future payment Changing the trajectory of preterm, low-birth-weight strategies. Current Medicaid managed care rates under-fund the (LBW) babies has been a priority for the Ohio Medicaid CHW and HUB operating costs by as much as 40 percent. The program. A four-year evaluation of the HUB model pro- Ohio Medicaid grant will augment the work of Cradle’s Learn- gram in another region, Community Health Access Project ing Collaborative which has spent the last three years building (CHAP) in Richland County, Ohio, revealed impressive clinical-community teams focused on quality improvement impacts on LBW and associated savings. In 2013, it was in prenatal care, including effective linkage between provider estimated that two-thirds ($373M) of total prenatal and practice sites and CHWs. delivery care costs for Medicaid beneficiaries were due to the 13.79 percent preterm rate. Building Performance-based Pathways to Health HCAN emerged from a multi-year community and health Modeling their efforts after CHAP, HCAN has shown system consultation and pilot project conducted by the Health promising results in its 2012-2016 interventions focused on Foundation of Greater Cincinnati (now Interact for Health) and LBW. Last year, 85 percent of their infants were full-term focused on improving the health of low-income individuals. and 84 percent weighed within normal ranges. HCAN has Care coordination was identified as a priority because of its also diversified its portfolio of work and financing, now potential to effectively bridge health and human services. Begun operating with an annual budget of over one million dollars. in 2009, HCAN adopted the Pathways Community HUB model HCAN’s strategy is to align the Pathway services with the previously launched in central Ohio. The Pathways HUB frame- performance measures mandated by Ohio Medicaid for the work relies upon a structured approach to the social determi- managed care plans. With this focus on alignment, HCAN nants of an individual’s health: a comprehensive risk assessment has launched an emergency department super-utilizer (Find); assignment of pathways for intervention (Treat); and the intervention with documented cost avoidance; initiated a systematic tracking of connections to care (Measure). collaborative chronic disease management intervention with the residents in the adult faculty medical practice at Tri- Health’s Good Samaritan Hospital; and negotiated contracts The HUB has several characteristics that distinguish its with the four state Medicaid managed care plans that pay for approach from prior care coordination and CHW efforts. It pregnancy care coordination. HCAN, along with the other consists of 20 social need and health care utilization pathways PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 11 six HUBs in Ohio, are now uniquely capable of meeting the an accountable care organization (ACO), serving 100,000 plans’ new birth outcome reporting requirements. commercial and 60,000 Medicare patients under risk-based payments. The TPHO, which includes both employed and HCAN now has 18 affiliated CHWs operating through its aligned physicians, has worked closely with TriHealth’s pregnancy care coordination sites: hospitals on clinical integration and quality improvement n The Cincinnati Health Department and its primary care initiatives. network; “The maternity space has been mostly acute- n Crossroad Health Center, an FQHC; and focused, differentially on negative maternal n Healthy Moms & Babes, a Catholic home visitation and health outcomes. Working in the prenatal space community support organization. is opening up this whole world of upstream The new Cradle Cincinnati grant from Ohio’s Department risk and working on social determinants of of Medicaid allows HCAN to expand its pregnancy-related health… we’re focused on infant outcomes in interventions and collaboratively model a more integrated collaboration with the moms.” approach to CHW support for pregnant moms in Cincinna- – OBGyn Physician ti. Funding for three new CHWs will go both to the existing HCAN care coordination sites at the Health Department and Healthy Moms & Babes, as well as to two new sites at In 2010, TriHealth adopted the Primary Care Medical Home Every Child Succeeds, a home visit support program for (PCMH) as the preferred model of care for its employed new moms in Southwest Ohio and northern Kentucky; and physician practices and, since that time, they have been TriHealth Outreach Ministries. active participants in Ohio’s Comprehensive Primary Care (CPC) and CPC+ (Centers for Medicare and Medicaid During this two-year Medicaid-funded effort, HCAN will Services-sponsored) initiatives supporting regionally-based manage referrals to the care coordination agencies, conduct multi-payer payment reform and care delivery transforma- training and staff development, and host the data regard- tion. All of TriHealth’s employed practices participate in ing client engagement and completed referrals through the CPC+ and the system now has 150 National Committee for Pathways Care Coordination System (CCS). By expanding Quality Assurance (NCQA) certified-certified PCMHs. its connection to other pregnancy support home visiting and CHW programs, HCAN – and Cradle, the lead on TriHealth has supported efforts to work with free health cen- the grant – are also testing a broader platform and more ters and the TriHealth Outreach Ministries, which provides regional approach to Cincinnati’s existing HUB. TriHealth, health screenings, health education and other services in through its Outreach Ministries, is a partner in this grant. local parishes. These two commitments figure considerably into both the ongoing TriHealth care delivery transforma- The Role of Mission and Strategy tion and their current participation in the Medicaid-funded TriHealth is one of five health systems actively engaged with Cradle Cincinnati initiative. Through the free clinic, volun- Cradle in improving pregnancy outcomes in Cincinnati. Its teer physicians have had the opportunity to see the impact commitment to community health has a long history in the of integrating CHWs in their practice, which informed a Catholic and Methodist hospital systems that joined in 1995 TriHealth system-wide study and consultation last fall that to become TriHealth with five hospitals and over 130 care has resulted in forthcoming changes to their PCMH mod- delivery sites. TriHealth is an integrated not-for-profit health el. CHWs will be teamed with nurse care managers both system that also operates or includes network affiliates pro- because of the unique roles they can play in care coordina- viding preventive, wellness, rehabilitation, homecare, skilled tion and addressing social determinants of health (SDOH). nursing and hospice related services. In 2015, TriHealth To support that change, TriHealth is investing in preparing posted revenues of $1.8 billion. a workforce that will be better able to integrate SDOH concerns and interventions into care giving. Nurse care TriHealth has been aggressively transforming its system of managers have been charged with developing the workflow care in anticipation of more value-based purchasing. Along and assignment strategies, while TriHealth and its corporate with its Physician Hospital Organization (TriHealth PHO co-sponsor, Bethesda, Inc., have launched a collaborative or TPHO), TriHealth has been increasingly engaged in training program with HCAN in the adult medicine residen- alternative payment and delivery models. In the Medicare cy program. In a joint effort with United Way, TriHealth is and commercial spaces, TriHealth and TPHO function like also building incumbent CHW workforce training to provide 12 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health career opportunities for their entry level staff. The Local and State Health Care Environment: CHWs have been part of TriHealth’s Parish Nursing Pro- Coverage, Health Care System Structure and gram for eight years, and, for most of that time, they worked as part of the HCAN HUB. Three years ago, the Parish Payment Ohio has recently seen a substantial reduction in its un- Program moved from TriHealth’s community benefits office insured population from 15 percent, prior to Affordable to the Department of Medicine at Good Samaritan Hospi- Care Act implementation, to 6 percent in 2016 resulting tal. This relocation effectively integrated the CHW role into in 700,000 newly covered beneficiaries through Medicaid Good Samaritan’s clinical care delivery system. As a result, expansion alone. Increased coverage has also been accompa- the HUB Pathways screening and referral documentation nied by considerable state leadership in care delivery and fi- have been incorporated into EPIC, the electronic health nancing changes. The Medicaid state agency has been elevat- record, and the internal referral process has been consoli- ed to the Cabinet level and a gubernatorial Office of Health dated. Supervised by a lead nurse, CHWs receive referrals Transformation was created with the goals of modernizing that come from the parishes, the hospital, or outpatient Medicaid, streamlining health and human services, and pro- clinics and practices. While they spend most of their time moting value-based payment. The state and collaborating on the road visiting with their pregnant patients, the CHWs health systems have been aggressive in pursuing numerous have offices in each of the parishes and at the Good Samar- CMS initiatives in care delivery improvement, coordination, itan Hospital where they can access EPIC to coordinate integration and financing, including Medicare Shared Sav- patient care. The primary pathways they engage are prenatal, ings programs and next generation ACO development. post-partum, adult and infant medical home, and those associated with housing and social service support. The state distinguished itself in the 2013 Round 1 of State Innovation Model (SIM) grants as one of only two CHWs generally follow a woman through her pregnancy in the country to get the maximum allocation to devel- and the first year after the child’s birth. Funded through op multi-payer payment and delivery models. Reducing Outreach Ministries, the CHWs are now part of TriHealth’s infant mortality is a focus of Ohio’s SIM population health operating budget. As services for the community which are improvement strategies. Now in the Round 2 SIM testing otherwise non-reimbursable, the CHWs constitute part of phase, the state is focusing on PCMH) and episode-based TriHealth’s overall community benefit effort. With strong payment developments. CHW outcome data from TriHealth’s collaboration with Cradle’s Start Strong initiative, Good Samaritan is moving The Cincinnati area has been well-positioned to engage to further align CHW work with prenatal care delivery by these efforts, in part, because of the capacity that The Health moving the workers into the OB/GYN department in sum- Collaborative, and its predecessor organizations, have mer 2017. brought over the last two decades. Created in 2015, the Col- laborative combines the historic health information tech- It is from there that the new collaboration with HCAN nology and health information exchange roles of Health- under Cradle’s Medicaid grant for prenatal CHW expansion Bridge, the hospital quality improvement and transparency will occur. Three more CHWs will be added to the cohort functions of the former Greater Cincinnati Health Council, and allow TriHealth to fully cover the zip codes identified in and the Health Collaborative’s practice transformation and the Good Samaritan / TriHealth Community Health Needs payment reform technical assistance and analytic functions. Assessment. TriHealth is already experiencing the impact Particularly relevant to this case study has been their history of improved birth outcomes on their system as neonatal of facilitating cross-hospital, provider, and payer collabora- intensive care unit (NICU) costs – and thus hospital revenue tions in area PCMH development, and their prominent role – drops. As TriHealth looks ahead at a meaningful business in convening cross-sector heath planning. The Collaborative model, they do not consider reimbursement through the has led the area’s CMS Comprehensive Primary Care (CPC) Pathways “pay points” an effective financing strategy over Transformation and the follow-up CPC+ projects with over time, seeking rather to identify potential shared savings that 500 practices now participating in advanced care man- can be recognized in adjusted capitations. agement and payment transformation. The Collaborative’s recent award of a CMS Accountable Health Communities grant will further local health and human services referral, data sharing, and analytic capacity. PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 13 Other Enabling Factors: Making Collaboration collective impact framework for Cincinnati; and the successful Possible Accountable Health Communities grant holds the promise of Aligning interests and efforts in a competitive health care creating the next stage of development in addressing SDOH market is challenging. Several strategic resources are making through community-clinical linkages. a difference in building a collaborative response to infant mortality in Cincinnati. The Collaborative’s Aligning Forces for Quality (AF4Q) grant allowed payers and employers to come to the n A Backbone Organization: Cradle Cincinnati is a model ex- table with hospital systems to prepare for payment ample of backbone organizations referenced in the population reform; it created a culture in the community focused on health literature. It has successfully improved health and human addressing both quality and cost. service system alignment and infant health outcomes. The use of learning collaboratives is clearly one of the mechanisms that contributes to its success. Considering the Future Cradle Cincinnati and its collaborating organizations are poised to A State with a History of Innovation Using Community realize ongoing improvements in birth outcomes. Their Learning Health Workers: Ohio’s unique history of practice, evaluation, Collaborative continues to shape both clinical practice change and certification, and financing in CHW use had contributed to community engagement. The Ohio Medicaid grant will support the development of the Pathways HUB model and other CHW more trained CHWs and participating sites as well as improve and home visitation efforts. The health outcomes focus of these analytics regarding payment for Pathway HUB services the efforts to address SDOHs holds great promise for successful expanded use of the 211 system in both the state Medicaid and the integration with evolving PCMH and accountable care organi- new Accountable Health Communities grants will help to solidify zations. a platform for intake and linkage across health and human service sectors. System-wide commitments to addressing social determi- Philanthropy Focused on Transformation: Participating hos- nants of health, like TriHealth’s plans for CHW inclusion in pri- pital systems, local industry, and foundations have invested con- mary care medical homes, hold out the hope of both better patient siderable financial and other resources in Cradle’s infant health outcomes and potential health system savings. With Cradle as a strategies. Playing a particular role has been Bethesda, Inc. with strong backbone organization in the infant mortality arena and their focus on delivery transformation within the TriHealth The Health Collaborative providing broader system data, analyt- system and more broadly in the region. They funded Cradle’s ics, and convening functions, Cincinnati appears to be uniquely Start Strong effort; helped build the Cradle Learning Collabora- situated to address diverse population health needs. tive; directly supported a number of Cradle collaborators; and currently fund several initiatives to model more integrated care, “We need the health and human service entities to including the new HCAN collaborative with TriHealth’s Faculty work closer, trust, coordinate, align and share… Medical Center. They also were an early funder of The Health Everybody is doing their own thing.” Collaborative’s PCMH development. n A History of Building Healthcare Industry Engagement: For – Human Services Agency Director twenty years, Ohio payers, hospital systems and employers have been building a platform for health data analytics and system Nonetheless, the challenges of a competitive market environ- collaboration through what is now The Health Collaborative. ment are considerable. Those difficulties are not just located within and between clinical settings, but also are represented Their efforts are an extraordinary testimony to the possibility of in efforts to successfully align human services. The struggles aligning certain business interests in a competitive environment. to figure out when to build vs. collaborate are not unique to The Collaborative’s role in supporting health planning and an- Cincinnati, nor are the challenges of where to locate relevant alytics is an important part of the backdrop for Cradle’s success data collection (in EPIC, in the HUB, or both) and how best and for future community-clinical collaboration. Although its to structure appropriate payment incentives (in Pathways “pay core products are focused on healthcare industry data man- points” or a better capitation rate that may recognize shared agement and related needs, they have increasingly been the savings). The need to improve health outcomes while realiz- venue for broader health planning. The Health Collaborative’s ing efficiencies requires optimizing strategies in both health management of the Robert Wood Johnson Foundation-spon- and human services. Cincinnati may have a unique oppor- sored Aligning Forces for Quality (AF4Q) grant secured the tunity to strategically align models of SDOH assessment, capacity for primary care practice transformation in the area. Its intervention, data collection and linkage in a manner that can collaboration with Re-Think helped build a population health substantially shift health care delivery, outcomes, payment, and savings. 14 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health Greenville, South Carolina: Building an Accountable Care Organization for the Uninsured HOP provide a platform upon which the GHS community Greenville Health System by innovations sit, substantially expanding the health system’s the Numbers ability to shape a virtual “ACO for the Uninsured.” GHS now Hospitals: 11, including specialty serves 3,000 individuals annually through the HOP and Ac- cessHealth programs and measures of health care utilization Physician Practices: 180 and outcomes are promising. Patients: 3.3M outpatient visits; 52,000 hospital discharges This case study exemplifies how communities, amidst con- Revenue: $2.1B straints in government funds and opportunities from adhoc Insurance: 30.4% Commercial; 40.4% Medicare; philanthropic grant resources, can find themselves knitting together services to treat one overarching social determi- nant of health – access to health care itself. Preparing for a more value-based and risk-bearing pur- chasing environment, Greenville Health System (GHS) has History of Care Outside Clinical Walls evolved as an integrated health system over the last decade In 2010, 27 percent of the residents in Greenville County incorporating a population health management strategy were uninsured. Having realized earlier gains in quality and focused on care delivery transformation and quality and costs through care integration and coordination for cov- cost improvement. This case study describes its strategies to ered populations, GHS started to look at options for better address the needs of uninsured patients in its catchment ar- managing uninsured patients. The health system had begun eas. GHS has built a multi-layered approach to creating what building data analytics related to high utilizers of ED ser- they call Accountable Communities. Core to their model are vices and emergency medical services (EMS). Maps of high Patient-Centered Medical Neighborhoods (PCMNs) nested impact communities led them to assess community-based in broad-based community-level interventions. Unique to options to stabilize patients and divert potential admissions. the GHS strategy is their development of Neighborhood Already a part of a national consensus process regarding Health Partners (NHP), a multi-pronged, targeted response community paramedicine, GHS and the Greenville County to the non-clinical determinants that can influence their EMS received a three-year contract from BlueCross Blue- patients’ health. Shield of South Carolina (BCBSSC) Foundation to model a triage and enhanced paramedicine practice called Commu- Diverse financing strategies have supported interventions to nity Care Outreach. decrease excess emergency department (ED) and inpatient use and to improve health outcomes, particularly among Greenville County 911 dispatchers transferred non-emer- the uninsured; these efforts have moved GHS upstream and gency calls to specially trained nurses who consulted with outside its clinical walls. Community Paramedicine, Com- the patient and facilitated medical and social service refer- munity Health Worker (CHW), and Mobile Clinic services rals. Through this grant, GHS also began the development of now focus on people in five “hot-spot” medical neighbor- medical neighborhoods, a geographic approach to mapping hoods, coordinating safety net medical and social service need and deploying medical and social support resources to providers with hospital-based care. Over the last five years, uninsured community members. GHS has become part of two major statewide initiatives focused on uninsured patients’ care access and coordina- tion. AccessHealth, funded by the Duke Endowment, seeks Paramedicine Practice Community to create innovative health care access for the uninsured Care Outreach through community and hospital partnerships. The Healthy Year One Results (6/2013-8/2014) Outcomes Plan (HOP), a project of South Carolina’s Medic- n 462 Averted ED Visits: $367,208 in savings aid program, supports similar linkages focused on chron- n 887 Avoided EMS Transports: $352,139 in savings ically ill, uninsured individuals. Together, AccessHealth and PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 15 Successes in the first grant period brought additional CHWs, and administrative staff, the Mobile Health Clinic BCBSSC funds as well as social innovation dollars from the brings its services to community organizations already pro- national Nonprofit Finance Fund. GHS was committed to viding support to help people meet their basic needs. These the Fund’s “pay for success” model and had access to claims sites include Triune Mercy Center, a church that works with and medical record data analytics from their Care Coordi- the homeless, and Phillis Wheatley Community Center, a nation Institute, which supports GHS’ population health multi-service organization that has served the black com- management business intelligence. GHS invested in data munity for over 90 years. In less than a year, the MHC has infrastructure, building software systems to support clinical served 900 individuals in 149 community clinic days at 10 and social support referral processes. sites. They also have identified 31 ED diversions related to their support and are currently completing their year one “The need for services and access to care is analysis. Of the first 900 patients, 71 percent were uninsured and 655 people were subsequently referred to AccessHealth over-whelming. We arrive on scene every day and HOP. This referral process illustrates the critical con- and realize that patients are using EMS and the nection between the population health strategies GHS is 911 system as a healthcare safety net. What deploying and these wrap-around coverage programs for the they really need is access to social services, uninsured. transportation and affordable primary care.” – EMS paramedic Roger Dobbs Wrapping Care around the Uninsured South Carolina has historically struggled with high un-in- surance; over 500,000 non-elderly adults lacked coverage In 2015, the Community Paramedicine pilot launched, in 2015. Additionally, low Medicaid provider participation focusing on uninsured individuals in the five PCMNs that compromises access even for qualified beneficiaries. As a had the highest rates of ED and EMS utilization. In collab- result, the state has consistently been between 40th and oration with local EMS, GHS built NHP Care Teams with 46th in America’s Health Rankings and significant income social workers and paramedics. Already familiar with many disparities, as well as racial and ethnic health disparities per- patients, the paramedics can pinpoint opportunities for sist in obesity, infant mortality, diabetes, and hypertension, interventions likely to reduce unnecessary hospital use. The among others. State and local entities have been aggressive NHP Care Teams conduct home visits, provide episodic in getting federal discretionary funding for indigent care. medical care, assist in medication management, provide post discharge support, and facilitate access to community resources for issues as diverse as housing insecurity and Neighborhood Health Partners cleanliness, neighborhood safety, food, and transportation. Care Team Results (2016) Routine, non-urgent home visits are made for patients with ongoing chronic needs. n Total Home Visits: 1,185 n Total costs decreased by $554,504 ($7,779 per pt.) Delivering community supports through the NHP Care n Hospital admissions decreased by 44.4% Teams is both effective in decreasing hospital admissions n Readmissions decreased by 50% and costs and in improving primary care utilization. How- n Emergency room visits decreased by 29.3% ever, the teams also became aware of significant difficulties n Primary care utilization increased by 41.4% many patients faced in accessing appropriate primary care, given limited accessible and affordable transportation. The n Specialty practice utilization decreased by 28.4% health system had seen similar challenges within its low-in- come Medicaid and Medicare populations. Therefore, in February 2016, GHS purchased a Mobile With support from community, healthcare industry, and Health Clinic (MHC) with funding from several founda- other philanthropic actors they have, over time, created tions. The MHC focuses on the same PCMNs as the NHP what is now a network of 264 low-income health clinics, Care Teams and brings comprehensive care closer to where including 22 Federally Qualified Health Care Centers people live. Staffed by a Nurse Practitioner, a paramedic, (FQHCs) and 41 free clinics. Nonetheless, building coordi- 16 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health Healthy Outcomes Plan (HOP): Absent Medicaid expansion, SC AccessHealth’s Mission the state adopted the 2013 HOP, an initiative to bring medical Support communities in creating and sustaining care and support to uninsured individuals with chronic coordinated data-driven provider networks of care that conditions. Funded through state-only dollars, HOP is part provide medical homes and ensure timely, affordable, of the Legislature’s Medicaid Accountability and Quality Im- high-quality healthcare services for low-income unin- provement initiative. The state seeks to incentivize hospitals sured people to improve care delivery, coordination, and outcomes for high utilizers of ED services. All Medicaid participating hospitals with EDs are involved and cumulative enrollment across the nated strategies for ambulatory and inpatient care access for 44 HOP sites through 2016 was 23,000. uninsured individuals has been challenging. AccessHealth: In 2008, the Duke Endowment launched what has become a statewide 29-site approach to coordinat- The Role of Free Clinics in South Carolina 2015 ed systems of care for the uninsured. AccessHealth is not n 41 clinics; 47 sites insurance but rather a care model that facilitates access to n 38,961 patients medical homes, social resources, and care coordination and n 132,199 medical patient visits management for uninsured adults below 200 percent of the n 4,865 volunteers federal poverty level. A little over 10 percent of these low-in- come uninsured individuals live in Greenville County. n 305,206 volunteer hours n 358,675 prescriptions ($45M value) The Duke Endowment primarily awards AccessHealth grants n $90M estimated value of services $14M to hospitals which then connect qualified individuals to pri- operating budget mary care providers in their health systems or in community n $14M operating budget practices, including local free clinics and FQHCs. Addition- ally, they seek to address transportation, financial, and other barriers patients face in using available care. AccessHealth programs function as community healthcare hubs. All Ac- Hospitals have obligations for the HOP consumers they enroll. cessHealth sites have target enrollments; in 2015, they served They must conduct a comprehensive physical exam and com- over 45,000 individuals statewide and were responsible for an plete a bio-psychosocial (GAIN-SS) screener and a state-devel- estimated 21.1 percent reduction in inpatient discharges. oped assessment of social determinants of health. They measure patient activation (PAM), build a care plan, identify a medical GHS manages two AccessHealth programs that serve four home, and provide patient-level data, including NCQA satis- counties. In 2014, GHS acquired Oconee Memorial Hospi- faction measures and patient narratives. In addition, they are tal, which had been operating a two-county AccessHealth required to build partnerships between acute, primary care, and site since 2011. That same year, GHS received the Access- non-medical service providers and demonstrate impact on at Health Greenville County grant, which also covers two least one of ten chronic conditions. Addressing social determi- counties, when it transferred from its prior management nants of health is a strong expectation. under the United Way of Greenville County. GHS originally situated their CHWs and care transition coordinators in Hospitals also have considerable incentives to be a part of hospital EDs. While the strategy proved effective at “cap- HOP: they receive program start-up and care management turing” patients, it was not successful in maintaining them funds and retain disproportionate share hospital (DSH) in care, one of AccessHealth’s goals. Now GHS has located dollars and enhanced primary care physician payments. They their care coordinators in community-based clinics, alcohol also receive enhanced Medicaid rates for existing beneficiaries treatment and detox settings, and other behavioral health, to address some of the uncompensated acute and special- welfare and social service settings that uninsured people rely ty care for HOP enrollees. Safety net providers, including upon. In 2016 alone, GHS served more than 1,800 people FQHCs and Free Clinics, also receive funding to support through AccessHealth Greenville County and now serves the patients they manage. Extensive technical assistance and approximately 3,000 people across the four counties. analytic support is provided to participating sites through the Medicaid Policy Research Division of the University of South Carolina (USC) Institute for Families in Society. PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 17 With data now available for two full years, HOP statewide seven medical campuses, 23,000 covered lives in their em- has demonstrated that it successfully targeted people with ployee health program, a Medicare Shared Savings Program complex chronic and behavioral health conditions. Six- (MSSP) serving 58,000 individuals statewide, and a Medicaid ty-three percent have a diagnosis of asthma, diabetes, and/or managed care contract. It is the dominant healthcare system hypertension and over two-thirds have a behavioral health in the Upstate region. As a result, GHS directly experiences or substance abuse diagnosis. HOP patients cost the system burdens of the negative health status and uncompensated care more in the first year, but pent-up unmet need is likely the needs of the uninsured populations. driver of these initial expenses. Preliminary cost effective- ness analyses show that, if trends continue through FFY18, GHS leadership is committed to population health man- projected cost avoidance statewide will be $99.4M. agement and has put in place multiple care integration and quality improvement efforts over the last decade, including NCQA medical home certification for many of its physician 44 Healthy Outcomes Plan Programs practice sites. Selective clinical interventions shifted practice in several medical care delivery arenas and have increas- & Partners ingly focused clinicians and administrators on upstream n 58 Medicaid participating Hospitals risk. Involvement in the state’s Birth Outcomes Initiative n 68 Free Clinics, FQHCs, & Rural Health Clinics (BOI), for example, significantly changed prenatal clini- n 19 Behavioral Health Clinics cal management. GHS adopted Centering Pregnancy, an n Local Social Service Organizations evidence-based model of prenatal education and support focused on the non-medical barriers to safe pregnancies. n State Correctional, Mental Health, other Agencies GHS HOP Partners Other important benchmarks are also promising. Enrolled n Four GHS Hospitals patients show better behavioral health status and increased n Bon Secours St. Francis Health System engagement, a change important to improving care utilization n Greenville County EMS and outcome. Through its HOP program, GHS accounts for n New Horizons Family Health Center (FQHC) approximately 10 percent of cumulative statewide enrollees. In n Carolina Health Centers, LLC (FQHC) a January 2017 report, the GHS HOP has patients with more acute needs at baseline who, in aggregate, achieved greater n Greenville, Taylors, Clemson, reduction in hospital and ED use compared to the rest of the n Rosa Clark, & Good Shepherd Free Clinics state. Several factors account for this differential. GHS’ HOP n Phoenix Center has a medical neighborhood strategy and utilizes their commu- nity paramedicine and mobile health clinic resources. They also n Department of Mental Health engage community health workers through PASOs, a statewide n Department of Health and Environmental Control Latino organization of health promotion promotores. USC eval- n Greenville County Medical Society uators found that those HOP sites, like GHS, that had a history n United Way as AccessHealth sites are more successful. The Local Health Care Environment: Coverage and Health Care System Structure Greenville Health System also brought PASOs promotores GHS entered into the HOP program with considerable sys- in-house to support the social, legal, and economic chal- tem development experience. It had been the area safety-net lenges faced by Latina women, the system’s largest growing hospital and had a long history working with other communi- cohort of pregnant women. The PASOs staff is now fully in- ty-based medical and social services that addressed the needs of low-income individuals. Extensive care delivery transfor- tegrated in GHS’s OB care delivery. Most recently, GHS has mation, hospital and physician network acquisition and con- adopted a multi-pronged effort to address addiction among solidation, and increasing managed and risk-based contract- pregnant women and reduce neonatal abstinence syndrome. ing had focused their quality improvement and cost control They are working to align medical management and critical strategies. The location of the nation’s newest medical school community support. The GHS Accountable Communities on their main campus two years ago also brought GHS new Office and its projects are a product of that intersectional capacity for care delivery and innovation. By 2016, GHS had strategy and the basis for GHS’s HOP success and their 18 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health ongoing efforts to shape an “ACO for the Uninsured.” They community health more broadly, has led them to sponsor are aggressive about testing and measuring interventions as the state’s free clinic organization as well as the Alliance they prepare for future payment environments. for a Healthier South Carolina, a cross-sector group focused on improving the state’s population health more Other Enabling Factors: Making a Difference broadly. In a state with limited health-related resources Two streams of innovation at GHS have built a platform outside of the hospital systems, SCHA works to build for improving the health of uninsured individuals. Clinical collective impact approaches. care-oriented population health management successes moved the organization to thinking about community-wide GHS Investment in Human Resource Development: population health. The resulting Accountable Communi- Beyond its many service initiatives, GHS invests in ties Office has built an increasingly diversified portfolio population health by building “non-traditional” health of data-driven, community-based interventions, focused and human workforce participants as well as knowledge- simultaneously on access to care, SDOHs, and the reduction able community leaders. They helped drive community of avoidable ED and hospital use. Beyond the role of pop- paramedicine and CHW state certification, partnered ulation health-focused leadership, there are several unique with local technical and other colleges regarding training factors contributing to this evolving story and to Greenville’s for these workers, and engaged medical school and local success in HOP and in its broader uninsured strategy. undergraduate students in health promotion in their PCMNs. In 2014, as part of their Accountable Commu- Strategic State Medicaid Leadership: The state Medicaid nities initiative, GHS began its Medical Scholars program, office put in motion a number of unique interventions from an invitation-only educational program designed to bring 2011 through 2013 that shaped responses to SDOH and local business and community leaders together to learn negative health outcomes. Forging a collaborative strategy about the healthcare industry and the challenges of the with BCBS and the South Carolina Hospital Association Upstate populations, seeking ambassadors and contribu- (SCHA), Medicaid prodded providers and hospitals by tors to future solutions beyond clinical care. leveraging reimbursement incentives across payers and sys- tems. Learning collaboratives and other technical support Considering the Future produced knowledgeable partners and improved outcomes. Despite the remarkable progress, GHS faces considerable These developments created a favorable environment for challenges moving upstream to deal with the SDOH for HOP that similarly relies on Medicaid incentives to engage those patients who lack insurance. Their effort to support hospitals in care and quality improvement for the chron- care for uninsured individuals ultimately relies on the ically ill uninsured. incentives of the state, the generosity of volunteer providers, and an unspecified commitment from the hospital to assure Significant Analytic and Technical Support: The state’s access to needed health care. The HOP project is still too investment in the University of South Carolina Institute’s early in its implementation to fully understand the relative Division of Medicaid Policy Research brings tremendous data costs and contributions, as well as the potential viability of an access, analytic capacity and programmatic support to bear eventual state Medicaid coverage strategy for this population. in all the Medicaid-related initiatives, including HOP. With 20 years of experience with the state’s Medicaid data and with Moreover, Medicaid’s ongoing commitment to HOP is un- program expertise regarding low-income populations, the Di- certain, given the program’s legislated status and the critical vision functions as an integral part of the conceptualization, transitions in Medicaid leadership. In fact, last year Medicaid benchmarking, quality improvement, and evaluation support defunded its innovative CHW program. HOP has faced as HOP seeks to meet the legislated program goals. other challenges across the state, some of which Greenville has also experienced. Extending resources to critical social A Long History of Philanthropic & Hospital Associa- support agencies, as Greenville has with PASOs, has been tion Engagement: For over 100 years, the Duke Endow- limited; transparency regarding hospital investments has been ment has been investing in hospital care for uninsured difficult to achieve; reliable data transfers between hospitals individuals. AccessHealth is just a recent example of their and community partners and hospitals and the state have focus to establish collaborative networks of primary care been a struggle and are a work in progress. Nonetheless, for this population. Facilitated by the SCHA, the Access- Greenville Health System – and the state of South Carolina – Health model has leveraged philanthropic commitments provide important lessons and important hope for progress in from the BCBSSC Foundation, United Way, and others. addressing the health and healthcare for the uninsured. The SCHA commitment to uninsured individuals, and to PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 19 Muskegon, Michigan: Improving Health through Community-Based Care Coordination part, rely upon upstream interventions that address social Mercy Health Muskegon determinants of health. Additionally, as the sole provider of n Teaching & Community Hospital System acute and emergency services in a community with a large n Four Hospitals serving 5 counties uninsured population, Mercy Health Muskegon views the Health Project as a means to connecting people to cover- n Inpatient Discharges: 17,000 age and other charity and social support that can improve n Physicians: 375 in Affinia Health Network (PHO) primary care utilization and reduce avoidable hospital and n Behavioral Health, Pharmacy, Homecare, Hospice, emergency department (ED) care. and Visiting Nurse Services Since 2000, Mercy Health Muskegon has been part of n Annual Revenue: $538M Trinity Health, a nationwide Catholic hospital system that strives to be an innovator in population health and has directly funded some of the Muskegon efforts. The follow- Over the past eight years, Mercy Health Muskegon, and its ing sections look at the history of the Health Project, the subsidiary, the Health Project, have demonstrated that com- local health care environment, and factors that have enabled munity health workers (CHWs) connected to, but situated the success of the Pathways HUB program and the Health outside of the medical system, can increase access to care, Project as a whole. improve health outcomes, and reduce costs for low-income at risk populations. Through its Pathways programs, CHWs are placed at care coordination agencies in the commu- History of the Health Project: Coalitions nity and at clinical locations within the hospital system and Community Health Workers with the goal of addressing social determinants of health The Health Project was formed in 1992 as a product of the and improving access to health care. Referrals come into a Comprehensive Community Health Models of Michigan central Pathways HUB based at the Health Project and all (CCHMS), a joint initiative of the W.K. Kellogg Foundation organizations – those within Mercy Health Muskegon and and the Community Foundation for Muskegon County. From independent community-based organizations - use the same the beginning, its advisory board represented key community care coordination software. The Health Project has served members, including payers, providers and residents. Its goals multiple populations through the Pathways HUB and its of expanding health care access also embraced prevention and recent success in a Centers for Medicare and Medicaid Ser- health system efficiency, objectives that continue to inspire the vices (CMS) demonstration grant has resulted in the Path- Health Project’s work. Their cross-sector strategy emphasized ways HUB program becoming part of the operating budget the inter-connection of health and human services providers in of the hospital. The Health Project’s rigorous evaluation collaboration with local government, business, and community program has documented improved health outcomes and organizers. Over the years, the Health Project has created multi- reduced costs across populations. In addition to Pathways, ple program lines and, once acquired by Mercy Health Muskeg- the Health Project operates multiple programs including on, became its community benefits office. Coalition work has cross-sector public health coalitions, health and other helped to frame the Health Project’s major initiatives, including benefit enrollment services, and mobile health screening. the Pathways HUB community health worker projects. Its medication assistance program alone serves over 3,000 people annually with more than 8,000 prescriptions. As the community benefits arm of Mercy Health Muskegon, Goals of Comprehensive Community the Health Project also conducts the hospital’s Community Health Models of Michigan Health Needs Assessment and supports implementation. n Establish an inclusive, accountable health care decision-making process; With a $4M budget and 30 employees, the Health Proj- n Improve health by increasing access to affordable ect has been the community health arm of Mercy Health Muskegon since it was acquired in 2008. As part of a next coverage; generation ACO with increasing performance-based pay- n Increase health system efficiency …that emphasizes ment experience, the hospital anticipates a future where health promotion and disease prevention. achieving better health outcomes and lower costs will, in 20 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health Coalitions: Tackling Community Health Challenges vices researchers to study their impact on health outcomes and Coalitions bring disparate groups together to develop a cost. Through these early projects, the Health Project refined its shared sense of a problem and a common agenda for its approach by identifying which tactics were most effective with resolution. Over 25 years, the Health Project has supported different populations. Table 1 below outlines specific projects, the development of coalitions to tackle seemingly intracta- target populations, funders, and results. ble problems, including improvements in health care access, health disparities, homelessness and high rates of substance In 2007, the Health Project adopted the Pathways Community use among youth. It has incubated 24 separate coalitions HUB Model developed by Sarah Redding, MD, MPH, with her and formalized that work in 2002 by hiring a coalitions husband, Mark Redding, MD. The Health Project serves as the manager, still with the organization today. HUB, a central point of entry for referrals. Initial screening is conducted and clients are assigned to care coordination either In an environment with limited resources, coalitions play through the Pathways HUB’s own CHWs or those employed an important role in minimizing duplication of services and by collaborating agencies. A standardized assessment of the efficiently focusing investments. Health Project coalitions social determinants of clients’ health defines “pathways” through use a logic model that requires participants to define the which CHWs guide and support members. Risk scores help problem and identify root causes and local drivers before prioritize interventions that address diverse issues, including developing strategies. They are also required to be trained domestic violence, housing instability, food insecurity, and in the Collective Impact model, a collaborative approach lack of access to transportation. Depending on their focus and for tackling complex social problems that cross sectors. This skillsets, CHWs are cross-trained on health-related informa- approach trains people to develop five conditions that lead tion regarding pregnancy, addiction and mental health, and on to results: a common agenda; shared measurement systems; health promotion skills including motivational interviewing and mutually reinforcing activities; continuous communication; the Stanford chronic disease model. and backbone support organizations. Michigan Pathways to Better Health: A Federal Demonstration and an Evolving Strategy The role of the Health Project’s Community In 2012, the Health Project was prepared to play a leadership Health Workers is to stabilize people socially so role in developing and implementing the CMS Innovation that they can connect medically. Grant because of the experience it had gained in earlier projects as well as the structure it had established with the adoption of the Pathways HUB model. Led by the Michigan Public Health Institute, the goal of this federal demonstration grant, Pathways After the failure of national health care reform in the early to Better Health, has been to increase primary care utilization 1990s, the Health Project started a coalition to improve and decrease emergency department (ED) visits and inpatient access to health care that resulted in an affordable health admissions by connecting chronically ill Medicaid and Medicare insurance program for the uninsured, called Access Health. beneficiaries to health care and to other services that address Now a separate entity, Access Health has provided coverage their social determinants of health. The Center for Medicaid to approximately 1,000 people annually in Greater Muskeg- and Medicare Innovation (CMMI) funding enabled the Health on through a product for businesses employing low-income Project to dramatically expand the reach of its CHWs by hiring workers. Access Health is notable among similar programs more staff and formalizing its network of partner organizations. around the country for its longevity, its unique “three share” financing model (employer, employee and local govern- CMS funding also supported nursing and social work staff ment) and its population health management program. In based in the hospital case management department, provid- 2014, Access Health was certified as meeting the Affordable ing clinical supervision for the CHWs and assuring close Care Act’s (ACA) minimum essential coverage requirements coordination with hospital-based care. This “hard-wiring” of for compliance under the individual mandate. the Pathways HUB to the hospital system has been bene- ficial for both. The hospital gains improved care coordina- Community Health Worker Initiatives tion and the CHWs benefit from understanding their role Ten years into its existence the Health Project began piloting in helping clients achieve better health. Based on earlier programs that use CHWs to connect people to public benefits experience, the Health Project designed this initiative as an programs. From 2007 to 2011, the Health Project tested several interim care model. On average, clients become more medi- population-specific programs and partnered with health ser- cally and socially stable after ten months. PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 21 TABLE 1: The Health Project’s Community Health Worker Programs and Results Dates Who Intervention [# served] Funder Stated Results 2007-09 Hi-risk diabetics CHWs conduct home visits to Blue Cross Blue HA1C scores for the intervention group educate clients and connect Shield lowered by 7% (avg of 7.89 pre-test to back to office-based primary 7.3 post-test) at 6 months of enrollment care [138] and after 2 home visits 2007-13 Medically fragile Navigators connect recent Michigan Dept. of Reduced recidivism from 46% in 2007 parolees parolees with health coverage, Corrections to less than 22% in 2012 for 2-year a medical home, medications, parolees (AHRQ) and help them obtain their prison medical records [500+] 2011-15 Hi-risk pregnant CHWs support clients in the March of Dimes, Reduction in low birthweight babies women community with basic needs Trinity Call to Care and fewer infant health issues at birth; (housing, food), connection to mothers in program less costly than pre-natal care, and education on average Medicaid mother despite higher birth and newborn care [150] risk factors 2012-16 Chronically ill CHWs connect patients to CMS Innovation Official CMS results not available until (Medicaid or primary care and to services that Grant July 2017 although early data suggests Medicare enrollees) address social determinants of reductions in ED visits and hospital health [5,700+] re-admissions Now, the Health Project have CHWs based at nine locations Pathways to Better Health CMMI – five community-based Care Coordination Agencies and Partners four clinical settings within Mercy Health Muskegon. Path- n Mercy Health Muskegon ways to Better Health is now one of the Health Project’s four n Senior Resources of West Michigan care coordination programs, which also includes Pathways n Hackley Community Care (FQHC) to a Healthy Pregnancy, Pathways to Re-Entry, and Pathways to a Healthy Future, the most recent being a youth-oriented n Every Woman’s Place (Domestic violence org) strategy. Since 2013, Pathways has referred 6,000 individuals n Affinia Health Network (PHO) with between 1,200 and 1,500 individuals now served annu- n Mission for Area People (Anti-poverty org) ally through the Pathways HUB. n Community enCompass (Housing agency) The Local and State Health Care Environment: Coverage, Health System Structure and Payment Through the grant, the Health Project was also able to fur- Coverage ther adapt the SDOH assessment tool and the data platform The Muskegon area has suffered from high un-insurance on which it sits, improving both referral patterns and analyt- rates, poverty and poor health outcomes. As of 2015, around ic capacity regarding client risks, service utilization, and eight percent of Michigan’s non-elderly adult population was health and social status outcomes. Additionally, close col- uninsured. In contrast, the three immediate counties served laboration with Trinity Health has led to the development of by the Health Project (Muskegon, Oceana and Newaygo) an electronic system that facilitates the sharing of Pathways have un-insured rates ranging from 14 to 19 percent. In client information with patient electronic health records, 2014, Michigan expanded its Medicaid program through building improved communication between clinical provid- an 1115 Waiver covering an additional 605,000 people, ers and the Pathways HUB. When the CMS grant ended last with the vast majority being adults below 138 percent of year, Mercy Health Muskegon recognized early indicators of the federal poverty level. In 2012, Michigan was ranked the the project’s success with some of its most difficult patients 37th healthiest state in the nation with the three counties and decided to support the Pathways HUB’s continuation as surrounding Muskegon ranked 65, 60 and 67 out of 82 in part of its operating budget. the state. Muskegon County, with the highest population of 22 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health these, ranked lowest in the state regarding numerous health includes convening partners to address community health indicators: smoking; obesity; physical inactivity; drinking; needs, creating linkages between health care and commu- sexually transmitted infections; and teen birth rates. nity organizations that are addressing social determinants of health, and increasing the number of people enrolled in Health Care System Structure patient centered medical homes (PCMHs). In 2008, Mercy General Health Partners and Hackley Health System merged to form Mercy Health Muskegon, making An Acquisition, Alignment and Investment: Trans- it the only acute and emergency services provider in the forming a Community Partner Lakeshore area. As a single, consolidated entity, Mercy Health Shortly after Mercy Health Muskegon became the commu- Muskegon has been able to dramatically reduce its inpatient nity’s sole hospital system, it acquired the Health Project. footprint. In 1995, there were 800 licensed inpatient beds in While the Health Project had been successful in obtaining Muskegon. However, the hospital projects it will have only program-based funding, it struggled to find support for its 270 by 2019. Having made its most costly operations more general operations. Although the hospital had always worked efficient, Mercy can focus on prevention efforts, such as those with and supported the Health Project, under one corporate identified in its 2016 Community Health Needs Assessment: umbrella, the Health Project and Mercy Health Muskegon increasing the supply of primary care and behavioral found even more concrete ways to align their work. The health providers, developing better non-urgent medical Mercy Health System is learning how to better solve prob- transportation for people living outside the urban center, and lems with community members, and the Health Project has connecting people to health and social services resources. reliable connections to the health care resources its clients and coalitions need. This collaboration has also resulted in ad- If someone were to ask me how to replicate ditional unexpected benefits for both partners. For example, this, I would say first, merge all hospitals so that the Health Project works with the hospital’s financial services there is no local competition. Second, merge department to find patients on its “bad debt list” who are eli- the physicians so they are not competing. Third, gible for Medicaid, Access Health or charity care. At the same time, for insured patients who are part of the health system’s create a Health Project. – Hospital Executive risk-based contracts, any savings the Health Project achieves by better supporting appropriate care use accrues directly to Mercy Health Muskegon as the sole hospital and ED in town. Payment and Financing Although most of its reimbursements are still on a Fee-for- Other Enabling Factors: Incentivizing Systems Service basis, both Mercy Health Muskegon and its physicians’ to Invest organization, Affinia Health Network, participate in some Hospital consolidation, adoption of clinical population value-based reimbursement models including the Medicare health strategies, ongoing levels of un-insurance and poor Shared Savings Program and risk-based contracts with Blue health outcomes, and increasing alternative payment ar- Cross Blue Shield of Michigan. The hospital and physicians’ rangements are all factors that have contributed to Mercy organization have taken initial steps to respond to anticipated Health’s investment in the Health Project Pathways. Other payment reform, purchasing a patient registry and building in enabling factors are the strong mission of the hospital, a more clinic-based care coordination as well as becoming a Next commitment to evaluation and quality improvement, and Generation ACO. In addition, changes are occurring at the state a local culture rich in social capital (i.e., social cohesion, level to support these upstream efforts. The Michigan Depart- interdependency, creativity). ment of Health and Human Services is developing a Medicaid Shared Savings Program. This initiative is one of many pro- Mission as Strategy: For Mercy Health, and its corporate grams that are part of the Department’s five-year strategic plan, parent, Trinity Health, mission is about both history and the Blueprint for Health Innovation, focused on testing payment market distinction. Commitment to the poor, justice, and delivery reform approaches. With funding from the CMS stewardship, and integrity are core values that were State Innovation Model (SIM) program, the state is rolling out foundational and continue to shape their care delivery this plan in five regions, including Muskegon. and community collaborations. Trinity’s mission shaped Mercy Health’s decision to acquire the Health Project to The Health Project’s successes in bridging community and support its growth and development. A Catholic health clinical interventions have positioned it to serve as the back- care delivery system now located in 22 states, Trinity in- bone organization for their region’s test initiatives. That role vests in local efforts that it believes can be transformative PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 23 elsewhere in its system. Helping to finance the acquisi- recently embarked on a new Pathways initiative: Pathways tion of the Health Project, Trinity is now implementing to a Healthy Future focused on youth aged 12-18 in an the Pathways strategy across other sites. The simultane- effort to address behavioral risk factors. Their data-sharing ous focus on social determinants, improved health care platforms have improved communications with clinical use and outcomes, and efficient use of resources aligns settings. Mutual respect and collaborative approaches are at with Trinity’s population health goals. the core of the Health Project and its health and social sys- tems relationships. Nonetheless, challenges exist, including: Commitment to Evaluation and Quality Improvement: The Health Project has consistently applied logic models n Improvements to the interface of the community-based care and evaluation strategies to its activities. Even before coordination with clinic-based care delivery and population becoming a part of Mercy Health, the Health Project en- health management; gaged evaluators to assess the health and other impacts of n Culture change within the hospital and outpatient settings to their programs. They also have been committed to quality assure trust in these care extenders in the community; improvement, engaging early on in the national Pathways n New skill development within the Pathways HUB staff and learning community. Integrating into the Mercy system CHWs; has enhanced their focus on demonstrating returns on the hospital investments in cost avoidance, savings where n Even more effective linkages between community and clin- possible, and the improved health outcomes that will be ical resources as the Health Project moves into its backbone the expectation of future payment models. role for the regional initiatives; and n Improved integration of the Health Project’s data systems A Hospital Builds Pathways to Health with the hospital and physician organization’s patient registry The hospital’s continued support for the Health Project software. and its coalitions is a recognition that sometimes a Finding reliable, long-term funding streams to support hospital needs to look beyond its own walls for solu- CHWs is still a work in progress. Expanded Pathways tions to its biggest challenges. require resources beyond those currently provided through hospital operations and community benefits. Hospital executives have approached the state and Medicaid man- Local culture rich in social capital: The existence of the aged care plans regarding fee-for-service (FFS) reimburse- Health Project itself, a sophisticated, innovative, da- ment for CHW services. SIM implementation temporarily ta-driven, and results-oriented organization, is unusual stopped progress in this arena. FFS payments for CHWs will in a community of Muskegon’s size and is enabled by an help to support the Health Project’s workforce but will not environment rich in social capital. Muskegon is noted for provide the hospital system with the flexibility and reliability its history of proactive government support for cross-sec- needed to invest in an array of population health programs. tor cooperative initiatives. It is a city focused on engaged problem solving, including in health. As one Health Project Why Invest in Upstream Investments? researcher noted, “Don’t underestimate the importance of “It’s a sinkhole – you could pour money into the remarkable civil society – and social capital – in that county.” The Health Project is a product of that history. upstream investments. We need to be thoughtful and careful about what’s going to create change. Considering the Future Everything we do has a medical context. We’d The breadth of activities the Health Project undertakes like to prevent crime but we are providers of through Pathways continues to expand. They have just health care services.” completed year one of a Trinity-financed care transitions – Hospital Executive project for seniors with promising early data. They have 24 PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health Like many health systems grappling with upstream invest- Contributing Authors: ments in social determinants of health, Mercy Health faces Ashwini Ranade, M.P.H., Doctoral Candidate and Graduate the challenge of determining which investments will yield Research Assistant, Northeastern University; Kim Shellen- reliable returns. Given the diversity of needs in Muskeg- berger, M.B.A., Consultant, Integrated Care/Communi- on, the hospital struggles to prioritize resources that will ty-based Population Health. improve health and reduce costs. Investing in care transi- tions, outpatient care management, and patient centered medical homes make sense for risk- and performance-based Citations Below from Cincinnati Case contracts. Study and the Muskegon Case Study 1.http://www.leg.state.vt.us/jfo/healthcare/Finance%20prez%20-%20pro- However, Mercy Health has also chosen to invest in com- file%20of%20uninsured%20-%20update.pdf munity-based care coordination through CHWs, a program 2. HCAN is one of only 7 certified Pathway HUBs in the country. For further information, see: Pathways Community HUB Manual: A Guide that has a longer timeframe for a return on investment and to Identify and Address Risk Factors, Reduce Costs, and Improve less certain outcomes. They are seeing positive results but Outcomes. Agency for Healthcare Research and Quality (AHRQ); continue to assess impact. Inherent to the hospital’s success AHRQ Publication No. 15(16)-0070-EF. 2016. Accessed May 3rd 2017. And: Zeigler, B. P., Redding, S. A., Leath, B. A., & Carter, E. L. Pathways in negotiating differential need and investment has been Community HUB: A Model for Coordination of Community Health the extent to which the Health Project has been able to Care. Population health management. 17(4): 199-201. 2014. successfully sit at the crossroads of the community-clinical 3. Cradle Cincinnati: Every Baby, Every Day: Strategic Plan. [PowerPoint interface. This is an unusual accomplishment for an entity Presentation]. Cradle Cincinnati. Oct 2016. http://www.cradlecincinna- ti.org/wp-content/uploads/2014/02/Strategic-Plan-Update-with-Appen- that has become a wholly-owned subsidiary. Continuing dix-10.27.16-Compressed.pdf. Accessed May 3rd 2017. to support the Health Project’s concomitant independence 4. Redding S., Conrey, E., et al. Pathways Community Care Coordination from and strong connection with Mercy Health will be in Low Birth Weight Prevention. Maternal and Child Health Journal. 19(3):643-650. 2015. central to negotiating difficult choices and building effective 5. HUB Replication Team. Replication of the Pathways Community HUB population health strategies for the future. Model. [PowerPoint Presentation].Legislative Briefing Ohio Commis- sion on Minority Health. May, 2015; Sartorius, Peter, “Pathways Model Aligns Care, Population Health”, May-June 2015, Health Progress, pp.25- About the Author: 29 Jean McGuire, Ph.D., M.S.P.H., is professor of practice in the 6. “Community Health Workers: Supporting a People-Centered Work- Department of Health Sciences at Northeastern University. force”, Trinity Health publication, no author, no date; Presentation, Dec. 1, 2016 Pathways to Better Health of the Lakeshore – Muskegon HUB Dr. McGuire has over thirty years of senior experience in lo- 7. Pathways to Community Health, 2016 Community Health Needs cal, state and national public health and disability policy and Assessment for Muskegon, Oceana and Newaygo counties, prepared by program development, management, financing, research Health Project of Mercy Health, July 2015. 8. Kaiser Family Foundation and evaluation. She has her M.S.P.H. from Harvard School of Public Health and her Ph.D. from the Heller School at Brandeis University. PAYING FOR POPULATION HEALTH: Case Studies of the Health System’s Role in Addressing Social Determinants of Health 25