This is the first in a series of live blogging posts from the 2015 CFHA Conference in Portland, Oregon. Check back for two more!
Dismantling a Partialist Healthcare System: Implementing a Vision for Comprehensive Population Based Care
CFHA 2015 Conference PLENARY SESSION 1
Thursday, October 15, 2015 - 6:00 p.m. to 8:00 p.m.
Moderator: Kristian Foden-Vencil, Reporter and Producer, Oregon Public Broadcasting
The CFHA opening plenary, “Dismantling a Partialist Healthcare System: Implementing a Vision for Comprehension Population Based Care” was a powerful opener to the 2015 conference in Portland, OR. Each panelist described their perspectives on promising research, clinical innovation, and health policy change germane to the advancement of integrated behavioral health and primary care.
Panelist One: Maggie Bennington-Davis, MD, Chief Medical Officer, Health Share Oregon
Jennifer Hodgson: The plenary opened with a question posed by Kristian to Maggie Bennington-Davis. He asked whether or not the changes we are making to the healthcare system are working. Dr. Bennington-Davis is a psychiatrist who has experience administrating services across the lifespan with a keen respect for cultural competence in the delivery of healthcare services. She is on faculty at the Sanctuary Institute and Oregon Health Sciences University and expressed great interest in how we can think differently about workforce redistribution and healthcare expenditures. She shared examples of Coordinated Care Organizations targeting energies and services to those who use healthcare the most. These programs were effective in reducing ER visits and connecting high utilizers with the primary care system; however, she wonders how we can prevent patients from becoming high utilizers. Her focus has shifted over the years to wrapping care around early life (i.e., children) and those most at risk, lowering cumulative disadvantages and eventually high utilizers.
Laura Sudano: According to Dr. Bennington-Davis, childhood events impact mental health conditions in later life which affects individuals as well as the healthcare system. So the question becomes what does it mean to be “Kindergarten ready”? How can we prevent unwanted and high risk pregnancies? Wrap around programs are a different level of integration and service.
Kristian: What kinds of wrap around services can you provide to head things off?
Maggie: The way that Health Share approaches this is to identify moms at great risk (e.g., substance use disorders). Interventions include parenting lessons, housing/food, safe environment, and staying with them for up to a year in order to provide skills for that child.
Kristian: How about the money?
Maggie: It is a $60,000 question or more! If that program prevents that one child to have months in a prenatal intensive program then you have paid for the program; however, it is tricky. Oregon needs to follow its own values and look for a way to transform health to make a difference in that way.
Jennifer: I just admired how she is thinking about prevention as a part of health and not exclusively treatment only after pathology has taken root. Her words illuminated an opportunity for healthcare providers to exercise being strength-based and channeling money toward prevention. I have been waiting my whole professional life to hear it spoken so eloquently! Music to my ears!
Laura: Barry Jacobs (audience member with a question) works in a super utilizer program and questions what you need to get the most bang for your buck. What are the resources you need to put in place for a program to be successful? He has witnessed the most need for housing. The other question is how to make changes sustainable and to help others take control of their own lives?
Maggie Bennington-Davis: Redistribution. Some services have fewer resources than traditionally and this is a hard question. At the ACO level, there is incentive money in Oregon transformation system to use it to explore to use it more upstream. In regards to housing, Maggie suggests that you need to work with social services to coordinate this.
|Panelist Second: Jennifer E. Devoe, MD, DPhil, Associate Professor, Oregon Health & Science University, Department of Family Medicine; Chief Research Officer, OCHIN Community Health Information Network
Jennifer: Dr. Jennifer Devoe is a highly funded PCORI researcher and a recently elected member of the Oregon IOM and helps lead the innovative OCHIN. She said there is some thinking outside of the box with Medicare and sending insurers a bill for not offering preventative services. Dr. Devoe shared a story of a patient who was self-medicating, self-mutilating, had a trauma history and rendered Dr. Devoe feeling incredibly helpless against the issues that weighted her down. Her patient is now more stabilized and functional: She is now out of the ED, ICU, is not cutting or utilizing as much. Dr. Devoe credits that to the care of the biopsychosocial team. She stated that as a healthcare worker she knows now that she can provide better care alongside a biopsychosocial team and prefers it that way.
Laura: Dr. Devoe notes that her satisfaction improved because she was able to provide comprehensive care to her patient once a behavioral health provider was integrated into the clinic. How are we going to measure what we are doing in care? We saved on healthcare cost, but now they are incarcerated for the next 20 years. They dropped out of school but are on welfare. She notes, “Dare I say, but we might actually need to spend more money on certain healthcare services. On primary care.” We need to look at wrap around services to provide preventative care services. We’ve come along baby since 2003! But, we are revisiting history and we are learning how.
Jennifer: What Dr. Devoe described as being immeasurable, is how much better she feels as a provider. She stated “We have come a long way baby!” …but we need to think about how we are going to reimagine and rethink measurement. How are we going to measure what we are doing here? How can we invest on the front end and spend more money on certain healthcare services (e.g., primary care, behavioral care) and save people from unemployment, the prison and foster systems, etc which also results in great costs.
I like her systemic perspective and agree completely that measuring gains cannot be exclusively done by examining the healthcare system’s bottom line. We have got to think about the entire service system…there is no wrong door for patients to gain access to healthcare. Lastly, Dr. Devoe stated that the voice of the patient is critical. The patient with their healthcare team should decide how the money is best spent. She wants to know when integrated behavioral health care will be the standard of practice! This blogger agrees!
Laura: Dr. Devoe also believes we need to scale it, sustain it, and study the who, what, when, and where. We need systematic approaches to figure it out. The question becomes: Can technology help? Who needs the care? And who needs to provide it? Measuring needs to happen and how to do it is important. Where should care be delivered? What are the patients’ expectations? When should we refer? When will integrated care be standard practice?
|Panelist Third: Somava Saha Stout, MD, MS; Executive Lead for 100 Million Healthier Lives at the Institute for Healthcare Improvement; Lead Transformation Adviser at Cambridge Health Alliance (former Vice President).
Jennifer: The third panelist, Dr. Somava Stout, is Executive Lead for 100 Million Healthier Lives at the Institute for Healthcare Improvement and also the Lead Transformation Adviser at Cambridge Health Alliance. She recently received one of 10 inaugural Young Leader Awards nationally from Robert Wood Johnson Foundation for leadership and dedication to improving health and healthcare. She wants us to push integration models and find who is doing integration successfully and why. She described how Cambridge Health Alliance is a Safety Net System and they invested in behavioral and primary care. She said they flipped their finance model from fee for service to a global payment one, now being able to cover 60% of patients. Subsequent to the change, providers reported that they enjoyed their jobs more and felt they could do things now to actually save patients’ lives.
Laura: Somava: She describes herself as a primary care clinician and is interested in how to change the system to provide comprehensive care. Why should there be a public health care system by 2020? It would improve experience for people and population health, and lower costs. It will be worth supporting for the Massachusetts. What would it be like to transform the system from the population up? In 2008, we need to flip it to fee for service to global patients. Sixty percent of patients were covered under the global payments, and the transformation was fulfilling. The satisfaction and joy of meaning and work went up for both physicians and mental health clinicians.
Jennifer: Dr. Stout argued further that everyone who touches the patient is a part of their outcome. She expressed that there is great joy and satisfaction for patients in knowing they can get help no matter where they lived. She noted, “If you could know that you could lower absolute healthcare costs and improve outcomes on the mental health and medical side….that is the Holy Grail right?” She then said, “That is really only the beginning of the story. We now need alternate payment models and have nothing to lose by trying. We have to move beyond screening for behavioral health issues only and then medicating poverty…the silent cause. I do not recommend medicating poverty. We need to do something about it. We need to be part of a system that takes care of patients holistically” Her solution-focused perspective was infectious and her belief that we can make a difference is exactly what we needed to hear at the start of the conference!
Laura: Somava notes that we need to include the social and behavioral determinants of health (SDOH). If there is no housing, then that doesn’t help anything. I (LS) think it is important to capture SDOH in primary care, and wonder how primary care clinics can capture this data in our electronic health records. Also, I wonder how people are teaching primary care providers SDOH.
Housing seems to be a theme between all presenters. Housing is an important aspect for individuals and we, healthcare providers, need to recognize this as an impact on patient’s health. Employees who can address SDOH have improved provider satisfaction across the board, i.e., staff, physicians, behavioral health, etc.
It costs 46,000/year a year to incarcerate one person. Dr. Stout notes that we should consider assessing SDOH and notes that patients are grateful for the questions. The challenge becomes how we ask the questions, when we ask the questions, and how we enter the data and track the outcomes.