Lessons from the Field


co_ramsay_rebecca_-5x7_3-002CareOregon
is a non-profit Medicaid health plan located in Portland, Oregon.

“We had to take a variety of issues into consideration as we grew our enhanced care model to meet the needs of our target members in our network. We don’t have an integrated delivery system, so we’re fully contracting with all of our providers. We rely on a variety of types of providers — about 50 percent are county clinics or Federally Qualified Health Centers (FQHCs) and another 50 percent are small, independent practices that often have even less resources. Our patients are spread across those systems. The models are different depending on the infrastructure and the amount of support and commitment the particular provider system has, and we have to customize to some degree, which is less efficient.

We also have to make decisions about if we’re going to provide some staffing to the care team, which we can’t do efficiently in small clinics where there’s only a small proportion of CareOregon membership. So we tend to do these models in clinics that have a large number of CareOregon members. That leaves us with a more centralized model of supporting these smaller clinics, and that’s not ideal because we know that supporting those patients telephonically isn’t as effective as doing it on the ground in the clinic where their medical home is. So it’s that challenge of dealing with a varied network and at the same time hitting as much scale up as we can.

Another consideration to growing is finding the providers who are early adopters and want to work with us to implement the program. We have used a variety of strategies, starting with opinion leaders in the community and early adopters, to spread the word of how beneficial our support and workforce additions have been to bring their peers along. We’ve set up a steering committees and stakeholder collaboratives to share best practices. We’ve developed a lot of materials and toolkits that help the practice launch the model. If we’re trying to scale up a program across multiple clinics, we pilot it with a couple of smaller, committed early adopter clinics and learn lots of lessons with them. We can then spread it once we’ve worked out the kinks, and provide some documentation and some assistance in implementation to other clinics based on our learnings. Some of our clinics are incentivized when they can maintain lower utilization rates for their patients in the Emergency Room. We have paid stipends to physician champions in clinics that are taking specific time to devote to participating with us in this high-risk work. Those are some ways that we’ve engaged more and more primary care practices, and I think they’ve been successful ways of mitigating the challenge of growing to a certain extent.

As you scale up, the program becomes more expensive for whoever is funding it. It’s really important that where you scale, you have the appropriate population segments to intervene on. I would not scale up if there wasn’t a location or a clinic where we had enough high-cost, high-risk patients or members being served because then what you’re getting into is the cost of an additional staff person, but not the appropriate expensive target population that will give you that return if you improve their care.

We also have to think about whether we have the appropriate infrastructure internally to support the scale up. As the enhanced care model team has gotten bigger, we have had to make different decisions about the kind of mobile technology we provide them, rules around mileage payments, and the number of clinical supervisors we need to be able to continue providing the appropriate clinical supervision to the staff at it grows. We had to go from having one big weekly huddle — where we talk about complex needs patients and do case-based learning — to splitting that one huddle into three, resulting in figuring out if we have enough supervision and staffing to lead those three huddles. We also had to have the workspace for those staff. Those are some of the things that we have had to really think about.” Rebecca Ramsay, BSN, MPH, Executive Director, Population Health Partnership, CareOregon


elenicarrCambridge Health Alliance is a public safety-net health system located in Cambridge, Massachusetts.

“When we started we had a very strong strategic need to redesign care for our population with complex needs and high costs. We were working with one payer, with whom we had a risk-based contract. We started out as a centralized team of four or five care managers and worked diligently to grow our program. We started with a handful of patients and grew our caseload to just over 110 patients relatively quickly.

While this centralized team got this program off the ground, we expanded the following year by embedding care management teams in four primary care practice – two people per team. We added teams over the course of the following two years, bringing us to a total of over 15 care managers in the organization, and we’re now care-managing about 700 people — and we’re still learning all the time. We are now integrating community care coordinators who facilitate care transitions between hospital and home or skilled nursing facility to home with the goal of reducing the risk of re-hospitalization during this vulnerable period by linking patients to the community based supports they need to help create stability and support care givers. We spent a lot of time developing our care model and focusing on patient engagement. We also spent an inordinate amount time with our data management systems and information technology, and trying to build tools in the electronic medical record (EMR), which is labor intensive. Today we have a number of functional tools built into our EMR and we rely both on internal data and payer based data to inform our program, seeking to identify the patients who we might want to engage and who stand to gain the most from care management support.”

Eleni Carr, MBA, LICSW, Senior Director of Care Integration, Cambridge Health Alliance

allurelogovnsnyVisiting Nurse Service of New York (VNSNY) is a not-for-profit home- and community-based healthcare and hospice organization in New York and The Allure Group, a network of skilled nursing facilities and rehabilitation centers in NYC. 

“One challenge is collecting data that is not readily available and getting shared understanding of the data across the partners. Allure gave VNSNY access to their EMR which helped with data collection. At the beginning of the work, defining what each piece of data meant and marrying that across the two organizations was a challenge. We had to work through a process to define different statuses at referral; to understand the difference between somebody who may be in the trajectory for hospice, in the “pipeline” versus an active referral coming onto service. We really just stayed with it and worked with the teams. Every week we reviewed the data on our check in huddle call. We jointly developed a quality scorecard which was another venue to educate each other about how we measure the different indicators, agreeing what those are, and using the Triple Aim framework as a guideline to develop our metrics and inform us about our progress.” Adina Kolatch, Consultant, Visiting Nurse Service of New York

jeremylongDenver Health is an integrated safety net health care system in Denver, CO.

“In engaging senior leaders and payers, it is kind of the opposite of the appreciative inquiry— it’s more like the appreciative delivery of a message that it is both morally and fiscally sound to make that investment, and that the return on investment that is going to be realized in a week, a month, or possibly even a year. The attention to just the business side is shortsighted; as we move toward population health and redesign of payment models, it’s much more important to think about things like patient satisfaction and a lot of other pieces.

What we’re doing in our efforts to meet the needs of high utilizers is providing a road map to getting to the future payment model. So, there’s a lot of different ways to state a business case for this work that don’t simply rely on saying, ‘We’ll reduce admissions by 40 percent,’ when we believe that’s not really the best argument. Maybe three years ago, that was a valid argument, but now we know that there’s so much more than that. That’s the kind of advocacy that has to be done.

There’s also a provider piece. Providers have more energy to deal with the patients who are right in front of them, so if you’re a provider in an ambulatory ICU, or a clinic like that, you have better staffing. I am much more energized by seeing five homeless, substance-addicted patients than I am by seeing 10 patients in primary care where I feel like I’m giving inadequate care to all 10. So, I think there can be a win-win when you offload some of the toughest cases from PCPs, and you’re up-staffing the people who are working in the ICU. There are lots of different angles to take when you try to advocate for why this type of program could be evidence-based, financially based, morally based, if you want to build an initiative like this. I think that you should try all of those angles because you might have to use all those different arguments among your executive staff or and other stakeholders.”

Jeremy Long, MD, MPH, Division of General Internal Medicine with the Denver Health and Hospitals, Department of Medicine