REPORT SEPTEMBER 2019 Course Corrections: How Health Care Innovators Learn from Setbacks to Achieve Success Sarah Klein Martha Hostetter Douglas McCarthy Consulting Writer and Editor Consulting Writer and Editor Senior Research Director The Commonwealth Fund The Commonwealth Fund The Commonwealth Fund ABSTRACT TOPLINES ISSUE: Setbacks and outright failures are inherent to innovation and Many health care organizations provide an opportunity for health care leaders to learn as they design have not developed the new care models that improve health outcomes while reducing costs and discipline to learn from failure. unnecessary service use. Unfortunately, many organizations have not developed the discipline for learning from such challenges. To truly meet patients’ needs, health care leaders may need GOAL: To share methods innovators used to develop new care models and to shake up their traditional overcome obstacles during their implementation, as well as lessons from staffing. their failures. METHODS: Interviews with care model innovators. FINDINGS AND CONCLUSION: When designing new care models, leaders should strive to understand which patients fail to benefit and consider changing staff to better meet patients’ needs. They should seek to identify which elements of their models are most essential and find common ground with health care payers on how to measure and reward success. Course Corrections: How Health Care Innovators Learn from Setbacks to Achieve Success 2 INTRODUCTION The people and organizations developing these models During the past few years, Commonwealth Fund also faced similar challenges: finding sustainable payment researchers have examined new models for delivering and sources, recruiting the right staff, and obtaining support paying for health care to better serve vulnerable patients, from leadership to institute new approaches, among including people with multiple chronic conditions, many others. serious illnesses, or functional limitations, as well as those at risk of developing health problems because of their LESSONS LEARNED social circumstances or behavioral health conditions. To spread promising approaches, we’ve showcased 1. When refining a new care model, examine models that improve quality of care and health outcomes which patients don’t benefit. while lowering costs or reducing unnecessary health Shreya Kangovi, M.D., M.S.H.P., an internist, pediatrician, care use. Along the way, we’ve interviewed health care and health policy researcher at the University administrators, clinicians, researchers, and payers of Pennsylvania, led the team behind IMPaCT to learn how they developed and implemented these (individualized management for patient-centered targets). new approaches. The program uses community health workers to help some of the poorest and sickest patients navigate the Because our case studies focused on successes, we missed health system and achieve their goals, such as finding an important part of the story: what innovators learned better housing or losing weight. when things didn’t work out as planned. In circling back to ask this question, we soon learned these individuals didn’t view their setbacks as failures, but rather as opportunities to rethink and refine their models. In this report, we share the methods innovators used for developing their models and overcoming obstacles — from deliberately searching for blind spots and using iterative testing to knowing when to quit. We’ve summarized their approaches and lessons here to help others as they design new health care models or adapt them to new settings. Many of care models we’ve profiled rely on similar strategies, including: • risk prediction and segmentation techniques to distinguish those who would benefit most • proactive management of chronic diseases or serious illnesses • managing transitions among clinicians and care settings • identifying and addressing patients’ social needs. ROSE WONG commonwealthfund.org Report, September 2019 Course Corrections: How Health Care Innovators Learn from Setbacks to Achieve Success 3 learned from studying the individual experiences of patients. At the time she created the model, sending There’s a substantial subgroup advanced practice nurses into hospitals and patients’ of people who are discouraged homes during transitions — such as after a major illness by failure, and we just keep or surgery — to help coordinate care and offer services was a novel concept. hitting them in the face with their failures. Naylor sought to understand why some patients benefited from this support and others didn’t. When her team began poring over the data and conducting interviews with Shreya Kangovi, M.D., M.S.H.P. patients, families, and clinicians, they found having the developer of IMPaCT, a community health same nurse practitioner visit patients in the hospital and worker program designed to help patients make behavioral changes their homes was pivotal because it engendered trust and led to clearer communication about their goals.2 Engaging family members was also essential to improve outcomes. Three randomized controlled trials demonstrated this “That emerged from deliberately studying the experience approach helped many patients, but Kangovi wanted to of patients over the long term. It was people telling us know why it wasn’t effective for every individual. When 1 what was important to them,” Naylor says. her team began interviewing patients and accompanying Program leaders have also relied on data to find blind community health workers on home visits, they found spots. Denver Health, the largest safety-net provider in their explanation. “When some people hit setbacks Colorado, conducted a cluster analysis to determine like breaking their diet or having too many snacks, for instance, they saw them as learning opportunities,” which patients might benefit from an intensive she says. “But others had a very different reaction. They outpatient clinic it had created for those who had been became really discouraged and blamed themselves. hospitalized three or more times in a year. Data showed They stopped weighing themselves or checking their the clinic did a good job of engaging older, homeless men blood sugar. They just disengaged from the community with substance abuse problems but was failing to recruit health workers.” and retain others, including homeless women who had experienced trauma and Spanish-speaking patients Interviewing patients also revealed how their life who had high medical costs but otherwise led stable experiences shaped their health behaviors. In one case, lives. 3 By recognizing this issue, the health system is now community health workers discovered that an obese designing tailored approaches to reach these groups, says woman struggling to lose weight had grown up poor and Tracy Johnson, Ph.D., Denver Health’s former director of often hungry. Thus, a strict diet disrupted her sense of health reform initiatives. security. To uncover patients’ unconscious motivations and help them avoid shame, community health workers But learning from failure is not always easy. One of the began asking them more open-ended questions and challenges of deliberately looking for blind spots, as these offering coaching to help recast their setbacks as teams did, is that many health care organizations haven’t opportunities to learn. developed the discipline for doing so, says Don Goldmann, Mary Naylor, Ph.D., R.N., a professor of gerontology M.D., chief scientific officer emeritus and senior fellow at at the University of Pennsylvania who designed the the Institute for Healthcare Improvement (IHI). “You need Transitional Care Model in the early 1990s to reduce to have a culture where people aren’t going to be slammed avoidable hospitalizations among older adults, also for failing,” he says. commonwealthfund.org Report, September 2019 Course Corrections: How Health Care Innovators Learn from Setbacks to Achieve Success 4 Goldmann remembers one quality improvement meeting during which a presenter displayed a run chart that clearly demonstrated her unit’s failure If we figure out there is to sustain a new approach. “I asked why she was something we can do better, willing to share what was obviously not a success, we try it literally a day or a and the presenter said, ‘I thought we were coming week later. It’s gotta be fast, here to learn,’” he says. “There was a profound lesson there. She and her colleagues wanted others to help and you’ve gotta be willing them figure out why they were unsuccessful, but to fail. You actually have medical culture doesn’t always encourage this kind of to plan to fail at first. transparency.” 2. Don’t be afraid to try new approaches. Rushika Fernandopulle, M.D., M.P.P. Iterative tests and creative problem solving are needed Iora Health CEO to refine new care models, but this might be easier in startup environments than in larger or more tightly regulated organizations. Rushika Fernandopulle, “We were ready to test it the next morning,” M.D., M.P.P., who launched Iora Health in 2010 to redesign Fernandopulle says. This rapid response was enabled by Iora’s weekly monitoring of the Net Promoter Score, primary care, adopted the Silicon Valley ethic of failing in which patients are asked how likely they would be to often and fast as a way of moving forward. Iora did this recommend the organization to a friend or colleague. in Las Vegas soon after clinic leaders noticed that patient satisfaction was dropping as walk-in rates increased. The Sometimes the signs that change is necessary are rush of same-day visits disrupted schedules and added to impossible to ignore. After a patient’s murder by her wait times. They decided to try adding a second track for abusive husband, leaders of the Women’s HIV Program walk-in appointments with a dedicated clinical team in at the University of California, San Francisco, recognized hopes of keeping all teams on schedule. their model was not meeting the unique needs of women, including those whose illness, and often substance use, were rooted in traumatic experiences such as sexual abuse or intimate- partner violence. The tragedy prompted clinic leaders to ask patients about their adverse life experiences and offer different forms of therapy. They also continued to assess patient outcomes commonwealthfund.org Report, September 2019 Course Corrections: How Health Care Innovators Learn from Setbacks to Achieve Success 5 throughout treatment, since some patients who initially improved ended up relapsing. “We had to think through the steps, services, and interventions I would say the models are needed to solidify gains” and ensure patients who did one-third of the story. The relapse had support, says Edward Machtinger, M.D., people who operate within the the program’s director. models are two-thirds. The team also recognized they needed a different approach for patients who were still in the throes of Sachin Jain, M.D., M.P.H. addiction and either didn’t engage or wouldn’t stay engaged in treatment. “What we’ve done is move CareMore’s CEO toward early-phase interventions that are more focused on safety and stabilization,” Machtinger says. This includes a support group that focuses on reluctant to let go of patients. “I see that throughout health reducing women’s isolation through shared meals and care,” says Timothy G. Ferris, M.D., chairman and CEO of conversations. Counseling and creative art therapies also Massachusetts General Physicians Organization, which encourage patients to address past trauma. oversees the care management program. “You protect established relationships because those are the ones you 3. Embrace change, even if that means know and you’ve already invested in.” saying goodbye to people. What can help: managing patients’ expectations at the As innovators gain insight into what does and doesn’t outset by making clear that some services, like care work for particular patients, they may need to disrupt management, are intended to be transitional. And for established relationships, which can make patients staff, stressing the importance of ensuring access for new and staff uncomfortable. This includes the relationship patients may make it easier for them to let go of others. between care managers and patients who no longer require high-touch services. Leaders at Mass General also found they needed to make clinical staffing changes to better meet patients’ needs. The program replaced all but one of its psychiatrists with psychiatric social workers, who were not only less expensive but also more effective at solving problems like lack of reliable transportation. Program leaders also brought in nurse practitioners from Mass General’s palliative care team to offer one-time consultations, often in patients’ homes, to help with care decision-making. Massachusetts Sutter Health, an integrated delivery system in Northern General Hospital, which launched California, faced a similar challenge when it developed the Integrated Care Management the Advanced Illness Management (AIM) program to help Program in 2006 to provide nursing patients with terminal diagnoses manage symptoms and and social work support to patients make end-of-life care decisions. Leaders recognized they with complex needs, found that needed a way to transition some patients to less intensive some of its care managers were services once they were stable. commonwealthfund.org Report, September 2019 Course Corrections: How Health Care Innovators Learn from Setbacks to Achieve Success 6 Today, most of the program’s patients receive four to done. It’s remarkable the shift that can happen in the six home visits by nurses and social workers and then quality of performance once you get the right people in receive check-in calls and case management services from the right places.” telesupport nurses trained in the AIM approach. Staff review patients’ cases in daily huddles and can deploy 4. Know which parts of the model are nurses or social workers to cope with unexpected events, essential. such as an after-hours call for severe pain or an emergency department visit. Sutter is also planning to use community Another common stumbling block for innovators is health workers to expand its capacity to provide both trying replicate their care models at other locations or telephone and in-person support. institutions. Naylor of the University of Pennsylvania found as the Transitional Care Model was adopted by other Staffing changes were also part of scaling an innovative health systems, home health agencies, and accountable care model at CareMore, a medical provider that takes financial risk for serving Medicare and Medicaid care organizations (ACOs), some key components like beneficiaries in nine states and the District of Columbia. home visits were being jettisoned. Helping adopters The company is known for providing frail and chronically understand the value of each component required ill people with medical and social supports. At more tactical support than Naylor and colleagues had neighborhood Care Centers, nurse practitioners, medical anticipated. “We failed to make clear that adopters needed assistants, and other clinicians provide “high-touch” to do more than screen just for medical risk,” she says. services like wound care or medication reconciliation, while “extensivist” physicians oversee patients’ care But once adopters began to consider social as well as before, during, and after hospitalizations. Expanding medical risk, they began to gain greater traction, Naylor this model into new markets meant recruiting more says. For example, one organization partnered with a food administrators and clinicians who could adapt to bank to prepare nutritious meals for heart failure patients CareMore’s team-based approach and were comfortable who lacked social support. questioning common practices, such as the intensification of treatment as patients with terminal conditions approach the end of life.4 Sachin Jain, M.D., M.P.H., CareMore’s CEO, says many innovators fail to pay enough attention to hiring people who are clinically skilled and motivated to serve. This is more likely to occur when leaders are under time constraints, such as when CareMore expanded into the Memphis, Tenn., market. “When people start to scale new models, the first thing that goes out the window is the focus on people,” he says. “They think their model is what’s driving success, when in fact it’s some combination of the model and program design and having the right people to actually get things commonwealthfund.org Report, September 2019 Course Corrections: How Health Care Innovators Learn from Setbacks to Achieve Success 7 changes in the types of staff deployed to patients’ homes, and differences in how the Hospital at Home service is Without continuously combined with home-based primary care, palliative care, reinforcing the core elements care transitions, and other offerings. of the program with clinicians, 5. Seek consensus on how to measure and you really begin to see drift reward success. and variation. As providers Success does not always beget success, as the Hospital at we like to put our own spin on Home program demonstrates. Even though Leff was able things, and that can lead you to show in a prospective, non-randomized trial that the intervention could cut spending on hospital services by off course. It takes focused as much as 30 percent while improving health outcomes, effort as you expand to keep the model’s adoption has been hampered by lack of a everyone on course. payment mechanism in fee-for-service Medicare, as well as objections that it poses safety and liability risks.5 Those who are reluctant to adopt Hospital at Home often say Sharyl Kooyer, R.N. they need more data to make a decision. But Leff sees Regional Administrator, Sutter Health this resistance as a smoke screen, obscuring health care leaders’ and clinicians’ reluctance to change and fear of losing revenue. “There has never been a randomized Mass General encountered a similar problem when controlled trial of intensive care units and yet every implementing its Integrated Care Management Program at hospital has one,” he says. another hospital within the system, Ferris says. Program developers didn’t realize for a full year that the other To overcome such resistance, innovators should agree hospital wasn’t sending care managers to primary care with payers and health system administrators on practices to meet with physicians and patients. When which measures will be used to assess new approaches. asked why they hadn’t done so, these leaders said they Otherwise, programs that appear effective during pilots had made compromises because of local circumstances, may run into obstacles when payers or administrators Ferris says. They also blamed program leaders for failing demand unduly high levels of evidence or immediate to differentiate between nice-to-have components and financial returns. required elements. To Ferris, the experience emphasized the importance of providing ongoing support rather than Richard J. Baron, M.D., president and CEO of the American just during implementation, and of making clear which Board of Internal Medicine (ABIM), says selecting the right elements were crucial to a program’s success. method for evaluating new care models is critical because different audiences will find different methodologies Still, it’s important to understand that adopters will adapt models to their local circumstances. Bruce Leff, persuasive. During his time as a group director at the M.D., who developed the Hospital at Home program Center for Medicare and Medicaid Innovation, Baron saw at Johns Hopkins Medicine in the mid-1990s to offer how separate evaluations of the same program could certain patients the option of hospital-level care at home, yield distinct results, depending on whether an actuary says he has grown accustomed to modifications to the or a health services researcher was analyzing the data. model: “It’s like a custom-tailored suit. It gets reinvented So while a journal editor might insist on a randomized wherever it is adopted as it is adapted to the local health clinical trial to publish a study, insurance companies and care ecosystem.” Among the alterations are minor the Centers for Medicare and Medicaid Services might find tweaks in the medical eligibility criteria for the program, an actuarial approach more persuasive. commonwealthfund.org Report, September 2019 Course Corrections: How Health Care Innovators Learn from Setbacks to Achieve Success 8 Demonstrating the broader societal impacts of new LOOKING AHEAD approaches may also help innovators win allies. “It’s One of the challenges for all innovators is that health not enough to think about whether we affect care and care payers may not be willing to invest in their vision outcomes for the population we’ve targeted,” Naylor of for transforming care. Payers may focus on improving the University of Pennsylvania says. “We need to look at the quality and lowering the cost of discrete and known the broader context: What impact did that have on use procedures, such as knee replacements, rather than of resources from a societal perspective? We also need accomplishing patient-set goals, such as being able to play to consider what’s important to patients — how do they with grandchildren, says Baron of ABIM. “The people who define success and failure?” are writing the checks need to own the responsibility for purchasing something different,” he says. The federal Some organizations are taking this more expansive view government can play a leading role in supporting new care of success. For example, leaders of Hennepin Health, models, but multipayer initiatives are key to obtaining a county-led ACO serving Medicaid beneficiaries in widespread provider participation and impact. Minneapolis, are measuring whether their investments in housing and rehabilitation result in savings in other Fernandopulle of Iora Health has been selective about high-cost areas, such as emergency shelters and jails. payer contracts to ensure he can maintain fidelity to his model, which was designed to give physicians the time they need to forge trusting relationships with patients. Iora physicians work with small panels — about 650 patients compared with 2,000 or more in many practices — and rely heavily on health coaches, who meet with patients before and after appointments. Such a model wouldn’t be possible under traditional fee-for-service reimbursement, which is why Iora Health enters into capitation contracts with self-insured employers and health insurance companies. It also looks for payer partners willing to invest for the long haul. “We’re changing human behavior and changing biology, and that just takes time,” Fernandopulle says. “You have to align the expectations of payers around that. That’s why we’re now signing 10-year contracts with our payers.” Garnering financial and institutional support for new care models may become easier as health care continues to move toward value-based payment models that focus on results, not processes. Indeed, keeping the future in mind is key to making progress, says the IHI’s Goldmann. “It’s not enough to talk about new scenarios while you continue doing what you’re doing,” he says. “You have to experiment with innovative approaches and recognize instances when what you’re doing now just won’t get you where you will need to be in the future. You’ll fail if you are not adaptable and agile.” commonwealthfund.org Report, September 2019 Course Corrections: How Health Care Innovators Learn from Setbacks to Achieve Success 9 NOTES LIST OF INTERVIEWEES 1. Merritt Edlind et al., “Why Effective Interventions Do Richard Baron, M.D., President and CEO of the American Not Work for All Patients: Exploring Variation in Response Board of Internal Medicine to a Chronic Disease Management Intervention,” Medical Paul B. Batalden, M.D., Senior Fellow, Institute for Care 56, no. 8 (Aug. 2018): 719–26; Shreya Kangovi et al., Healthcare Improvement “A Randomized Controlled Trial of a Patient-Centered Community Health Worker Intervention to Improve Maureen Bisognano, M.S., President Emerita and Senior Post-Hospital Outcomes,” JAMA Internal Medicine 174, Fellow, Institute for Healthcare Improvement no. 4 (Feb. 2014): 535–43; Shreya Kangovi et al., “Decision- Making and Goal-Setting in Chronic Disease Management: Rushika Fernandopulle, M.D., M.P.P., Cofounder and CEO, Baseline Findings of a Randomized Controlled Trial,” Iora Health Patient Education and Counseling 100, no. 3 (Mar. 2017): Timothy Ferris, M.D., CEO, Massachusetts General 449–55; and Shreya Kangovi et al., “Community Health Physicians Organization Worker Support for Disadvantaged Patients with Multiple Chronic Diseases: A Randomized Clinical Trial,” American Don Goldmann, M.D., Senior Fellow, Institute for Journal of Public Health 107, no. 10 (Oct. 2017): 1660–67. Healthcare Improvement 2. Mary D. Naylor and Julie A. Sochalski, Scaling Up: Sachin Jain, M.D., M.P.H., President and CEO, CareMore Bringing the Transitional Care Model into the Mainstream Tracy Johnson, Ph.D., Former Director of Health Care (Commonwealth Fund, Nov. 2010). Reform Initiatives, Denver Health 3. Deborah J. Rinehart et al., “Identifying Subgroups of Shreya Kangovi, M.D., M.S.H.P., Associate Professor of Adult Superutilizers in an Urban Safety-Net System Using Medicine, University of Pennsylvania Latent Class Analysis: Implications for Clinical Practice,” Medical Care 56, no. 1 (Jan. 2016): e1–e9. Sharyl Kooyer, R.N., Regional Administrator, Sutter Health 4. Matthew Allen Davis et al., “Identification of Four Bruce Leff, M.D., Director of Center for Transformative Unique Spending Patterns Among Older Adults in the Last Geriatric Research, Johns Hopkins Medicine Year of Life Challenges Standard Assumptions,” Health Affairs 35, no. 7 (July 2016): 1316–23. Jeremy Long, M.D., Assistant Professor, Division of General Internal Medicine, Denver Health 5. Bruce Leff et al., “Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital-Level Care Edward Machtinger, M.D., Director of Women’s HIV at Home for Acutely Ill Older Patients,” Annals of Internal Program, University of California San Francisco. Medicine 143, no. 11 (Dec. 6, 2005): 798–808. Mary D. Naylor, Ph.D., R.N., Professor of Gerontology, University of Pennsylvania School of Nursing David Share, M.D., M.P.H., Former Senior Vice President of Value Partnerships, Blue Cross Blue Shield of Michigan Jonathan Weedman, M.A., Vice President of Population Health, CareOregon commonwealthfund.org Report, September 2019 Course Corrections: How Health Care Innovators Learn from Setbacks to Achieve Success 10 ABOUT THE AUTHORS Sarah Klein is editor of Transforming Care, a quarterly Douglas McCarthy, M.B.A., is senior research director publication of the Commonwealth Fund that focuses for the Commonwealth Fund and president of Issues on innovative efforts to transform health care delivery. Research, Inc., in Durango, Colorado. He has supported She has written about health care for more than 15 years the Commonwealth Fund’s work on a high-performance as a reporter for publications including Crain’s Chicago health system since 2002 through the development of Business and American Medical News. Ms. Klein received a chartbooks and scorecards on health system performance B.A. from Washington University in St. Louis and attended and case study research on promising practices and the Graduate School of Journalism at the University of innovations in health care delivery. Mr. McCarthy’s California, Berkeley. 30-year career has spanned roles in government, corporate, and nonprofit organizations, including the Martha Hostetter, M.F.A., is a partner in Pear Tree Institute for Healthcare Improvement and UnitedHealth Communications. As a consulting writer and editor for Group’s Center for Health Care Policy and Evaluation. He the Commonwealth Fund and a contributing editor to its was a public policy fellow at the University of Minnesota’s quarterly publication, Transforming Care, she conducts Humphrey School of Public Affairs and a leadership fellow qualitative research on health care delivery system of the Denver-based Regional Institute for Health and reforms and innovations. Ms. Hostetter has an M.F.A. Environmental Leadership. Mr. McCarthy serves on the from Yale University and a B.A. from the University of board of Colorado’s Center for Improving Value in Health Pennsylvania. Care. Editorial support was provided by Laura Hegwer . For more information about this brief, please contact: Sarah Klein Consulting Writer and Editor The Commonwealth Fund skleincmwf.org commonwealthfund.org Report, September 2019 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.