We revisit an earlier episode with Yates Lennon, MD, President of CHESS Health Solutions who who provides a concise overview of value-based care and questions providers should be asking

Yates Lennon, MD, MMM, currently serves as the President and Chief Transformation Officer for CHESS Health Solutions. He is nationally known for his work in quality, previously serving on the American Medical Group Association (AMGA) Quality Leadership Council and presently on the National Association of Accountable Care Organization’s Quality Committee. Dr. Lennon’s background includes 23 years as a practicing OB/GYN and a Fellow of The American College of Obstetricians and Gynecologists. He served as Chief Quality Officer for Cornerstone Health Care before joining CHESS in 2018 as Chief Transformation Officer. Dr. Lennon assumed the role of President in 2021. He has a deep understanding of practice transformation and how to engage physicians and their staff. His value-based care expertise allows him to translate his knowledge into initiatives that health care teams understand and can implement to ultimately transform patient care.

Episode Transcript:

Let’s start at the very beginning. What is value-based care and why does it matter?

So, what is value-based care. I tend to think about population health and value-based care side by side. And, in some ways, it’s value-based care is population health plus a payment structure that you find in value-based care models to create sustainability for those pop health efforts. So, when you think about population health, you’re thinking about groups of patients, whether that’s groups of patients by demographics, by disease state, by recent hospitalization. They’re all ways you can slice populations. And you’re thinking about caring for that group of patients. Now at the end of the day, population health is delivered one patient at a time, generally speaking, in my mind anyway. But, when you add value-based care to it, you’re creating an incentive structure that creates sustainability so that you can deliver the services you need to care for those populations of patients as they move through the continuum of care. So, from the outpatient setting, to inpatient, to home, to skill nursing facility, back home.

That’s a very broad definition, but when you dive a little bit deeper into value-based care as a clinician, I’m thinking about value-based care as a way to support resources that will assist me in caring for those patients. So, it’s not all falling on the physician or the advanced practice provider at the point of care in the office.

What is the triple aim and how does practicing value-based care help to achieve that?

So, the triple aim was coined back in 2008 and it really aims to do, as you might guess, three things. One, is to improve the patient experience of care. The second is to lower the cost of care. And then the third would be to improve quality or improve the health of populations. Value-based care, and as we discussed already, is perfectly suited to solve these.

So, if I start with improve the patient experience, or patient satisfaction. The fact that a patient is able to access a care team larger than just the provider and the nurse, I think, moves us in that direction. The other aspects of care when you think about, I think about my parents, so, and their encounters with the health care system. And how it’s been traditionally very disjointed. Still is. They live in a part of the state where value-based care is not really penetrated very well. And it’s very disjointed. My Mom gets information from her providers and her payors, and she’s confused. She doesn’t know what’s real, what she should respond to, you know, is this a scam, just all kinds of questions. So being able to reach into a care team on a consistent basis is very important. And especially for that generation. They don’t want to bother their physicians. We could have a discussion about whether that’s the right thing to do or not. But, that’s just the way she thinks. I don’t want to bother anyone. So having a care team whose proactively reaching out to a patient, especially following an important transition, goes a long ways towards bringing comfort and to that patient. And when I hear the stories from our Care Coordination team, including our social worker, the impact their having on patient’s lives is profound. They are addressing things that I as a clinician would never get into in an office visit. In part sometimes because I was afraid to ask the question because I didn’t have any resources to deal with what I figured the answer would be.

To improve the quality or improve the health of populations, so we’re focused on quality, closing care gaps. We’re focused on an Annual Wellness Visit, which is designed to allow a provider to look at a patient’s whole picture. So, where are they receiving care, do they know who their providers are, do they know who their durable and medical equipment providers are. Are they up to date on screening procedures and are they up to date on any disease-specific quality measures that they should have addressed, like hemoglobin A1Cs, or blood pressure under control? Those types of quality measures.

And then finally, lowering the cost. So, I go back to Care Coordination again. Thinking about chronic care management, transitional care management, trying to reduce readmissions. And also to try and prevent unnecessary admissions as you engage with patients in the their the management of their disease states. I think the other thing that value-based care does is it puts the right incentives in place for provider access. When I’m talking to physicians and they ask, you know, what do we need to do, there’s always one answer that you can do tomorrow, and that is improve access. So, the idea that we’re going to be open 8 A.M. to 5 P.M. and shut our phones off at lunch is a bit antiquated. That might be ok for a fee-for-service world, when your schedules full, and that’s the thing that matters most. But, in fee-for-value, if you can provide access to patients when they need it, so that they can receive care for non-emergent conditions in a non-emergent setting, then that saves money for the system and will loop back to the first thing I talked about, and it improves the patient experience of care. I don’t think there’s anyone, very few people if any, that enjoy sitting in the emergency room waiting. And, if you’re condition is not an emergent one, if you don’t have an emergency situation, then you tend to be triaged to the end of the line and you spend more time there in the waiting room, which is not good for patient experience, which is not good for provider experience, which is not good for patient experience ratings for the provider. So, it’s kind of, it gets to be a snowball effect.

And you know, a few years ago, I’m not sure who gets credit for this, but physician burnout we all know is a huge issue and COVID has not done anything but accelerate that problem. And so, someone term the quadruple aim, adding physician or provider experience as the fourth arm of the quadruple aim. And we’ve already touched on this a good bit, but from a physician’s standpoint, value-based care aims to implement team-based care. So, they’re not the same, but they go hand-in-hand. In team-based care, the purpose, the aim there is to be sure that everyone on a provider’s team, those people in the office, those people behind the scenes who may be in a hub somewhere or perhaps embedded in their physical facility in a room where they’re not focused on the patients who are coming in and out each day, but those patients who are at home, they’re trying to outreach. All of those people together, working at the top of their license, is what we aim to do in value-based care. For physicians, we would like to see them doing the things that only physicians can do. The things that other people on the team can do, then let’s let them do those things. And let’s use protocols and evidenced-based guidelines to direct care for the 80% of the population, I always laugh and say the 80% of the population that’s read the textbook, and they kind of behave according to the textbook. There’s 20% of the population that don’t. And that’s, you know, the medical background and training that physicians and APPs have. Decision making comes into play there. You can’t necessarily follow an evidence-based guideline for whatever reason. We know that everyone won’t just fall into a nice, neat, little box. So, really putting their decision-making skills, their assessment skills, their diagnostics skills to work in that part of population that won’t fit the rules.

And then, I just learned recently that there is now the quintuple aim, which is adding in health equity. And as I think about what we’re trying to achieve by improving the outcomes of care for all patients by removing barriers that they face and typically those are, you know, social economic barriers. Value-based care is set to address that. When I look at the patient stories and hear the patient stories that come from our care coordination, pharmacy, social work hub, they are constantly working with individual patients to identify barriers to improving their care and ensuring that they have outcomes that are equal to those who are not facing the same barriers. Value-based care is perfectly set up to address each of these stakeholders. When I think about, you know, the medical industry, if you will, in it of itself, but also the providers, the patients, and the folks around them that we would call their care team.

I’ve heard you say that making the move from Fee-for-Service to Fee-for value, aka value-based care requires a new way of thinking. Can you elaborate on this?

Sure, be glad to Thomas. So, I go back to the old fee-for-service world. The world I grew up in. And I still remember asking myself that question the first time I sat through a meeting about value-based care. And, as an OBGYN by training, this was 12 years ago now. I went home after that first meeting and I thought, now what do I do differently tomorrow. And I struggled for a little while to understand the only thing that I could come up with was continue to deliver high-quality care, have access for my patients, and, you know, don’t sent people to the emergency room or labor and delivery unless they need to be there. See them in the office if its possible.

But as I understood the concepts more, I think there are several areas that we can call out and kind of make a comparison between the two worlds. We’ve touched a lot on consumer experience or the patient experience already. So, in the old world, confused, frustrated, you know, not knowing what’s going on. Provider A is not talking to Provider B. Provider A didn’t get the referral letter from Provider B when the patient was sent to the orthopedic surgeon, the cardiovascular surgeon, or the endocrinologist. And communication is just not taking place between providers. So, this leaves patients trying to navigate a very complicated system on their own. In a fee-for-value world, that patient experience should lead one to feel valued and engaged. So, there are resources at play from the care coordination teams, the pharmacy teams, our quality teams, we’re just reaching out, pulling that patient in, and making sure they feel supported throughout their care journey.

From a care delivery standpoint, we’ve always been reactive. So, we’re responding to illness in a fee-for-service world traditionally. Now, there had been progress around preventive medicine and addressing cancer screenings, for instance. Colorectal cancer and breast cancer screening. And a lot of that work has been done and is important, but I wouldn’t say that’s really geared at overall health so much. And, even in the fee-for-service world, we still were largely reactive. In a fee-for-value world, we’re more proactive. So, we’re using data, we’re using our various teams to identify patients. Like I said earlier, not just who are at increased risk today, but who we believe are at risk in the future of some untoward event. Whether that be clinical, or clinical and financial. And so, that shift in focus for deliver of care is very critical. Care coordination, just by virtue of the term, almost didn’t exist in the fee-for-service world. We didn’t have technology. We didn’t have data and analytic. Again, paper charts, telephone calls, that was about it. In this fee-for-value environment, our infrastructure’s set up to give us access to much more data, which we can then use to identify patients to be more proactive.

Finally, just thinking about cost, so I believe that a strict fee-for-service environment really is a bit of a perverse incentive. I mean, you, people say you, whatever you incent is what you will receive, what you will get. And incenting people to do more usually gets you more. And that’s the way the fee-for-service structure was set up. It’s set up to do more. See more. So, the important thing was, you know, who’s on my schedule, do I have enough people to see, am I seeing as many as I possibly can. In a fee-for-value world, the financial construct is more conducive to seeing the right patients, at the right time, and in the right location, and doing the right thing. So, it’s not necessarily doing more. But it again focus on doing the right things for patients. And so those are, there’s certainly more ways, but in my mind, those are some of the big differentiators between how we think in a fee-for-service world versus how we think in a fee-for-value world.

In this episode of the Move to Value Podcast we catch up with Colleen Hole, Vice President of Clinical Integration in Population Health at Atrium Health to learn about the new partnership with the retailer Best Buy, the impact of the merger of Atrium Health and Advocate Aurora Health on the Hospital at Home program and Colleen’s experience as a presenter at the global Hospital at Home Congress held in Barcelona Spain.

You know, the last time we talked, we talked about the Hospital at Home program, and you gave some great information. A back story. And so, how’s it going? Is it still a benefit to the community? Is it still being used in the ways that it’s supposed to be? I mean, how is it? How are things transpiring?

I would say we're continuing to gain momentum in the program. So, as we talked about several weeks ago, it was born out of the COVID crisis if you will. For that, I am grateful for the pandemic because in most large somewhat risk averse organizations these things don't happen very easily. You tend to meet and meet and meet and then finally maybe put together a proforma and do a small pilot. We bypassed all of that. We did a big pilot, um, out of necessity. So, what we're doing now really is pivoting from COVID, which is now less than 10% of our patients, to other diagnoses which I think I mentioned last time: heart failure, COPD, various infections, but then going into oncology, neurology, surgical trauma. Other patient categories that even some established programs I think are not pursuing. Bottom line is we've not been diagnosis specific in this program. We've been more general clinical eligibility first, by clinical condition, and then what diagnosis fit in it. And then obviously once we've got a clinical clearance, you got to look at the social determinant of health and all social determinants of health and all those other factors that play into whether the patient would be successful.

But no, it's going great. We have every intention to scale as far as we need to scale to continue to decompress our hospitals. And, your point, it is making a difference in the community. We get a lot of letters and feedback from patients that say please don't ever make me go back to the hospital, I was so much more comfortable here, I feel safe here, I got to be with my dog. You know, that sounds small but it's not small. So again, as we find our population aging with more and more chronic conditions in their senior years, hospitals can be pretty risky places for those patients who are often disoriented, tend to fall at a higher rate, they're at risk for infections, they don't typically eat as well, sleep as well, and they don't move. They tend to stay in their bed with the door shut. Who wants to go down the hall in a hospital gown? So, all of these reasons in most cases make the home a better place for healing.

So, we got some big news that hit the media about the partnership with Best Buy and Advocate Health Atrium. How did this come about and how does it work? It’s fascinating.

Two very large health systems coming together to be one. And looking for the synergies that happen when you do that. Now there are naysayers out there that say stop the madness, health systems shouldn’t be merging. They are in Milwaukee, Chicago Illinois market. We're down here in the South, in North Carolina, South Carolina, Georgia, and a tad bit of Alabama. So, we're not in, you know, competing overlapping markets. They're almost identical in size.

So let me back up a tad. Advocate and Aurora merged four years ago to become Advocate Aurora. Now that has merged with Atrium Health. So, the national name is Advocate Health, but each market will retain their brand that is known in that community. So, we're still Atrium Health. What I’ve been involved in is just integration work around nursing. So, how do we align nursing around standards both structurally and clinically? How do we align some of this space that huddle lives in, which is this space between brick-and-mortar hospitals and clinics, this home-based care space. So, we're doing some work around what do they have, what do we have, what can we learn from each other. So, a lot of it right now is what we're calling discovery. We're just learning oh you all do it like that. For example, they don't really have a hospital at home program. They did a little bit of that at the peak of COVID. saw a few patients in their home, but not much. So, they're real interested in figuring out what we're doing down here. But the different markets matter because in the South we're still largely fee-for-service, not a lot of value-based care yet. You and I would love to see that get driven forward. Up there they're further down the value-based their contracting and care models.

There are really two reasons to hospital home broadly. One is you've got a capacity issue, which is our driving force here. They have value-based care and not so much of a capacity problem. So, their reasons for doing it would be different but all being involved and evaluate does this make sense for you all and how could we stand that up. So, the Advocate Aurora thing was cooking, I don't know how long ahead, far way, before I knew about it. But that it's a thing. Separate from that is our partnership with Best Buy. So, Best Buy five or six years ago said you know we're really good at tech, we're really good at logistics, what else would we want to lean into. Is it communications? They had five or six things health being one of them. And they felt like, you know what, we'd like to get into the business of health. So, they created Best Buy Health and started looking for partners to operationalize some of their skills.

So, they’ve got as I mentioned logistics and technology, we’ve got know-how from a clinical and operational perspective. So, what could we partner on and focus really in this home-based care space? And there's a lot in there, it's not just hospital at home. It's home health, it's virtual, you know, initiatives that we take care of people managing their blood pressure at home or their heart failure. So, that's really what it's about. We're going to work on some things together and the media kind of grabbed ahold of the Geek Squad thing which is one of them. They’ve done Geek Squad for two decades. They're looking at a Health Geek Squad. So, helping people manage health-related technology in their home. That's probably the clearest, easiest one that we're talking about working together on. What it looks like past the product development I have no idea, but that that's really what it's about. Everybody wants to get into the home-based care space knowing the cost of brick and mortars is too high, we've got access issues, we've got health equity issues, we've got rural health specific access issues. This stuff actually addresses all of that.

Has it been operationalized, or is it still in more of the strategy planning development stage?

It’s really still in the strategy development planning stage. We're just beginning to meet to figure out what makes sense to do together. So, I know I sound vague but there's truly not a lot of definition yet to it. We just think there's stuff that we could marry up that they’re good at and we're good at to create something that really advances health. And we're not the only people in the country trying to do this kind of work. I think everybody agrees current health system structures they're just not work for the long haul. And I really heard it in Barcelona. They’ve got more of a national view of health far more than we do and it isn’t saying we need socialized medicine, I'm not going to get into any of that, but they really do look at the whole of it. And we still are built around how we fund healthcare. We build stuff that is billable versus what the patient actually needs to live their best life. And that's why I'm such a big fan of Hospital at Home. It is not a physician-centric model, it is not a facility-centric model, it's not a payment-centric model, it's a patient-centric model. Yay.

You mentioned Barcelona. So, just for reference, you recently were in Barcelona for the World Hospital at Home Congress, and you mentioned that it was quite an honor. And I can think of no one more deserving. Did you hear any other really off the wall, creative ideas about what’s happening outside of our borders that people are doing in this space that maybe we should pay attention to?

Um, I didn't hear anything like, I never would have thought that, oh my goodness. But they're further along in some of the things. But not as far along as in others, particularly around tech. You know, I think, we're ahead of them with tech enablement. Like since I've talked with you, we've implemented our remote patient monitoring. So that allows us to have 24/7 visibility, audio, video connection to our patients. That's awesome. In the countries that are doing it well, Spain, for example, it's just become the way they take care of people. We're still far more tentative about it. You know, Doctor Bruce Left started this at Hopkins 20 plus years ago aimed at seniors who he knew, as a geriatrician, didn't do well in hospitals. But his program is still pretty small. I believe the potential is gigantic and other countries have really scaled a whole lot better than we have. They are starting in Spain, a master’s degree program in hospital at home which I thought was cool. We could sure do that with our Wake Forest academic arm. I would love to see that. But, yeah, nothing revolutionary really.

The type of patients was seemingly similar across all the countries that I saw. The only thing that kind of shocked me was Israel. Where we are very careful about patient selection and making sure that it's for all, but yet that the home environment is safe enough to do this kind of care. It's become such a way of doing things that they don't screen for that as much. They talked of case studies where a patient lives alone and decreased mobility and no one there to help with food and meds and that's one of their patients. We wouldn't do that. Like we would not leave the patient without someone in the home to help them if they were that fragile. But they have to because they have no beds.

So, when I hear you say that, so from a technology standpoint we seem to be ahead but an implementation standpoint where, eh, middle of the pack.

Yeah. They've been at it, not all, but many have been out a lot longer than we have. Like decades, 30 years.

So, now that we've had this partnership unfold with Best Buy, which is I guess known for tech. I mean for nothing else they sell it right. But they've got the Geek Squad. They fix my parents’ computers time and time again. Do you see this as a really good opportunity for, of course it is a good opportunity to serve the patient, but really the things I think about is our underserved population. Folks with some economic, social determinant issues, health equity. How do you see, you know, something that's a technology barrier from a cost standpoint being implemented to serve this patient population that could really benefit from the service?

So, when you look at social determinant issues the digital divide is the thing. And you know there's a federal movement to try to address this with policy and infrastructure. But, um, that actually did come up a good bit in Spain. So, we've implemented a product called Current Health. That is our remote patient monitoring product. It's actually owned by Best Buy Health, but it carries the connectivity in the device. So, we actually said before we implemented remote patient monitoring, we're going to do it for all but we're not doing it at all. And so, we didn't want the haves and the have nots to experience this differently. So, rarely we still can't get a connection, we can resort to a phone, you know, in other words it's not a deal breaker no matter what. And there are connectivity issues urban and rural. It’s both. Some of it is just the towers aren't there, others the patient doesn't have the means to have it. But we did not want that to be a barrier for them to receive care.

So, that interestingly ,I was on a call with some folks from Mexico last week who thought I should come and help them build a Hospital at Home program in Mexico, but they were talking about the mountains in parts of South America and how that stops, you know, this is not my expertise, but signals get broken in the mountains and how would we mitigate that. And I'm like whoa, it's interesting, different parts of the world they've not built the infrastructure we have in America. And so, that's part of the tech problem. You know, any companies are going to sell it to them, but it won't work if they don't have, you know, the infrastructure in the country.

This sounds like an amazing opportunity for cost savings in patient care, which is one of the aims of value-based care. Do you see more initiatives of serving patients where there are on the horizon?

Yeah, I mean not so novel really, but just technology, virtual care, all of that I think partly empowers patients to direct their own care a little bit. Because in addition to our health systems being built around payment and largely physicians, it's paternalistic. We set it up with we know what you need and you're going to do what we say when we say and where we say to do it and if you want our help, you're going to come to us. And that's how we built it. This flips all of that on its head and by helping the patient with some technology, you empower them to actually self-manage, which does 100 million things, not the least of which is you get far better compliance and far better outcomes when the patient actually one understands and two says I can do this. So, that's what I love about the technology.

We've also shaken the paradigm of well it won't work for older people, that's intimidating to them. We haven't found that to be true at all. It's actually been fun to see older patients go oh I don't like computers, but this is really cool. So, you know, I think it doesn't replace the care, but it can certainly enable it and allow you to take care of a lot more people. So, you could monitor hundreds of patients because you get a feed from their wearable device and be able to see 24/7 real time who might be in trouble, who needs a phone call, who needs a visit by a community paramedic. You can just be more efficient with how you deploy your resources, which lowers the cost.

Thank you, Colleen, for joining us today on the Move to Value Podcast.

Thank you. It’s been my pleasure.

A conversation with Dr. Elizabeth Vaughan, associate professor and physician scientist at the University of Texas Medical Branch, as well as a Texas Community Health Worker instructor, about her research in health disparities and the role of the Community Health Worker in improving diabetes outcomes in low-income populations.

Doctor Elizabeth Vaughan welcome to the move to value podcast

Thanks so much for having me, it's a pleasure to be here.

So, tell me Dr. Vaughan, how did you become interested in researching the impact of community health workers?

Like many things in life, I fell into the interest. I had done the international work since I was in high school and I always had an interest of low-income healthcare, low-income populations. As a 16 year old I went to Ecuador and you know I was a what you call an army brat, my father was in the army, and really a pretty isolated world. And I saw poverty like I had never seen. I realized that Spanish was not just punishment that I had to take in high school that other people were really speaking Spanish and I really fell in love with the people in Ecuador. And then I continued traveling and you know fast forward that 20-30 years now and I've gone most of Central America, South America, and the Caribbean over and then over to Africa and India. And through those travels the people that I worked with were precious and yet I always sensed a distance between the people I worked with and me. And particularly after I finished medical school and I was now doctor Elizabeth or doctor Vaughan, most countries it was doctor Elizabeth, there was a greater separation. So there was a socioeconomic separation there was a cultural separation there was an education separation. And yet I saw the locals and the way they interacted with local individuals, and I thought there's something different here, they seem to be able to reach these individuals.

Then when I was in India in 2011 I worked with a group of promotoras, or more referred to as community health workers, in India and I anticipated that I would be the physician going into the villages and the towns and I quickly realized that they wouldn't let me because it was the HIV trip. And so I stayed back in the in the clinic and I taught this group of promotoras. And I at first was disappointed thinking man I don't get to have the fun only to be on the front lines and yet I quickly saw that teaching blood pressure, teaching hydration, teaching triage, led into a world where they could triage patients appropriately and they could reach far more patients than I could ever reach as an individual person. And so then I realized this is something and so fast forward another ten years and I became a community health worker instructor myself, started working and founded some groups here in Houston, TX of promotoras and have just seen amazing work of what they do and how they are able to connect with the patient and bring things about from a patient that I never could bring out and offer insight that I would never have.

Tell me why, in your opinion, do you feel like folks respond to other individuals in their community more than they would someone who's a physician. Someone who comes in with the technology and the knowledge from first world country. Why do you feel like there is a barrier there to the to the general population who needs those services?

It's a great question. So, there's, different cultures have different barriers. I think in the Latino culture pleasing in and kind of letting the doctor know that that you're trying to do what they said, I think is important. I think there's a there's amount of respect, they say you're the doctor you're and help me and so if they don't, I think there is some sometimes there's a feeling of shame in there. And so, my experience with the Latino culture is, many times the reason they don't - I've had one patient in you know 13-15 years of practice that just had the medications on the desk would not take them. Not to say there aren't others but, you know, most reasons that they don't take medications, they don't adhere to treatment, are far beyond what I would ever understand, or that they might be willing to tell me and it might be embarrassing.

We had a patient that we could not figure out why she would not apply for eligibility of the clinic, you know it's free service we thought we you know the community health workers were helping her and taking and what's going on with this? And finally we, the community health worker not me, learned that she was in an abusive relationship and that the husband would not let her have her tax papers, and that's what she needed to prove income status at the clinic to prove that she was eligible for the low income clinic. And she never wanted me to know that she wanted me to know that she's trying her hardest to do what I asked her to do and she really wants her diabetes to get better and her health to get better. It's embarrassing and maybe they know deep down the side I will never understand what life looks like in a in another world. And truly there's a world I'll never understand what it means to be undocumented. I will understand what it means to not speak English as my first language. I will understand what it means not have transportation to get to the clinic when I need to do so.

So, there's a variety of barriers but I think just wanting to do what the doctor wants to do I think that's a major barrier that that they that they face that they may feel much more comfortable talking to a community health worker who they trust who might have the same barriers and often have the same barriers as they have.

Sometimes we forget the barriers we often think about are you know literacy, transportation you know language barriers, but we often forget about some of the barriers that are much more challenging like clinic eligibility, like medication eligibility. For instance we have medication programs called PAP, prescription assistant programs, and on paper they're great. But I am not the first investigator to say that there's a lot of holes in the system. What these are, it's a way to get these expensive meds, so out of the 11 oral diabetes meds, three of them are low cost. And so how do you get the other eight to them? So some of them are eligible through this process, but every med has a different process. Sometimes you apply and you might wait a month or two or six or nine months to actually get the med and then you have to reapply after the next year. And so you know put yourself in the shoes of someone who doesn't speak English, who may not use the Internet, who doesn't understand all this paperwork, and didn't even know that after all of this, they have to renew every year. And so just imagine how, and that's one pill of the maybe five or six that you're taking and maybe you have to do this for every different pill.

And so barriers like that are things we often forget about and we say oh you know patients can just they can take these meds you got them they're available there's a supply, and it's like well put you know once you kind of walk that path, and I never walked it. I prescribe it was easy and then I realized when the promotoras brought it to my attention, well they did this this and this and they're having XYZ barrier, I realized oh my goodness. There are numerous barriers to this system. Once it works it's great, but getting there and getting it to be sustainable it is markedly extremely challenging.

So, tell me how community health workers go about effectively educating and triaging members of their community?

Well the first way for them to educate, is they have to be educated themselves and they have to have some sort of foundation of their own training. Every state is different, some states have very rigorous programs, training certifications, recertifications, some states do not, but nationally, there are national standards. And so that's one thing that is ongoing in legislation, so we've got to make national standards for this if we're going to really get these individuals on the you know on the line items of a budget.

So first it is you know what other certifications so what does it mean to be CHW? First place, if I say I'm a physician, you have a pretty good idea of what training I've done. For a CHW it's a little more nebulous. So the first after the second after their education is educating actually what they're doing. So, I learned what a CHW is in my certification process, but I don't know what HIPAA is, I don't know what PHI is, I don't know what telehealth is, or telemedicine is. I have to learn all of these terms. I'm not medical. I've never stepped foot in the hospital before unless it was for my own care, and so they need to be educated in the realms where they're going to practice.

Then they need to be educated in triage. In other words, someone calls them, my blood pressure is 230 / 110 and if they say, what do those numbers mean, we have some problems. We had a patient you know they often call the community health workers first. They're trusted individuals of the community by definition and you know by definition this this person called they didn't call their doctor they call the ER and they said I'm having this left sided facial numbness. And thankfully we had taught our community health workers what triage means, education, and you know when you know when you call and when you don't and so thankfully the community health worker knew what to do, direct the person to the ER, they were able to get this person the appropriate treatment before they had long term sequelae of what we now know was a stroke. But if a community health worker doesn't understand what blood pressure is or what normal numbers are, and we tell them you know make sure they check, make sure they recheck, we tell them how they check, they're not doctors, and they know that. There's a very very, but they have to understand how to get a history so they can help the patient.

So if I were to frame that entire question that you asked, how do we effectively educate and triage it comes back to the education. It comes back to educating them appropriately and then supporting them. When they have a question when they're out in the field who do they call? Who do they get help from? If it's a you know Tuesday night at 8:00 PM, do they have a way to get, someone a lot of times that's when they work with the patients because that's in the patients aren't working, and is there a mechanism if not we worry about them doing harm because there's no mechanism of help and support.

That leads into my next question of how do we go about verifying that these CHW's are going to do more good than harm for the patient. I realize, you know, and we think we all realize, that there's definitely a good intent and a willingness to care, but you know when you start to jump into cultural norms that might not always be the best policy for healthcare, how do we how do we go about verifying that that the information is accurate that they're providing?

Yeah so doing harm you know relates to the question we talked to before, making sure they're perfectly trained, make sure they have the appropriate education and support. I think that that key piece, a lot of times I'll see in programs they're trained. Maybe it's a one-time training, maybe it's a two-time training, oh we we've got them certified, we've got them but there's no ongoing support. You know when I did residency you know that's you know 3-4 years of you're in the hospital and you know you have this system of you know the duck and the ducklings to make sure that you weren't going to harm patients. And so I knew whenever I got in the spot where I wasn't comfortable I always knew I had someone to call, 24/7, and that's critical to do no harm. I've seen situations in medical training where residents don't have someone to call, and that's what harm is done. Because they don't they don't know who the call they don't know who to ask and there's fear there. And so the same principle with community health workers.

The training that we have we have a website now, mipromothorasalud.org, and we've posted our trainings on it and we're just kind of getting all four segments on it. So, in the first training we have an introduction. this is OK what does this mean, community health worker 101. It's like a four-hour course and this is all your HIPAA and PHI, what does it mean to be CHW, what does it mean in the specific place I'm working. You know, beyond where's the bathroom, how do I how do I work what are the kind of the rules of the land in where I'm working. The second and third training are the immersion. So for us we work in diabetes. So, the first part is we got to learn about what diabetes is. What's an A1C? What's a blood pressure? We got to learn all about that, so just the really concrete knowledge. Then that we take it after that, once they're actually working with patients, then we have in an immersion training on what are all the medications, what are the side effects, because you know they're going to be calling them and saying my legs are swollen, and if we don't know if they don't know the Actos can cause that swelling, and the patient was just put on Actos, we've got a problem.

And so they need to understand what the patients are going, just like if you're in the in the visit with your doctor and your family member. A lot of times they tell the family member, particularly if the family member is older or needs some help, they tell the family member to make sure you know this and this. Now the family member, it typically goes over their heads. But a lot like that the community health worker almost acts like a family member.

And then the last part of it is the sustainability and so we take questions that community health workers have asked us over the years and we just answer them in the last training. You know what about what why do I take a statin, these silly rules that keep changing, I don't understand, my LDL's right, it's 90, I thought they had to be less than 100, well yeah we changed the rules again on you. So you know explaining that so when the patients asking that, they know very clearly they do not make the decisions, they are not medical decision makers, they take a history and then they triage appropriately to the to the appropriate person.

That makes a lot of sense. So let's talk about you for a moment. I'd like to hear more about your research with diabetes and underserved patients and how you've used the time model and the simple model and how they differ and perhaps which is more effective.

Sure, so the TIME model is an acronym telehealth integrated community health workers medication access and education and group visits. And so if you were to simplify what is this model, it is a group visit so patients come to the clinic once a month for their care and they see a physician and they have education, everything is run by community health worker, the large group education, the small group education, they run monthly for six months, and now we actually have a model extends to a month nine and month 12, because we get to six months and we said we're not quite there yet. So we kept it kept going a little longer. And that model is very much you have almost the cream of the crop patients and so it's hard to compare it to our other model which is a SIMPLE model the simple model is OK take everything in TIME, you basically make TIME really simple.

So in SIMPLE instead of physically coming to the clinic for the group visit education or small group, they sit on a YouTube modality for about you know 5 to 15 minute videos and then you have the community health worker and instead of them physically sitting down they call them up and ask them how they how they're doing. In both of those models we have what's called a feedback loop because inevitably they will see the doctor or they will talk to the doctor in clinic on one day and the next day they call the community health worker and say I don't have my pills and you just saw the doctor well I don't know. And so there's some sort of communication gap that happened there, and it happens even though they just saw them. And so that feedback loop goes from the community health worker and there's a champion but then feeds into the clinic who has a champion and say hey patient so and so doesn't have their you know ACE inhibitor and now we need to you know what happened, oh I thought we were supposed to put this at Walgreens we called them into the wrong place. So, you know a lot of times it's just an easy communication gap and that feeds back to the community health worker and they can tell the patient. What usually happens is, I don't have my pills, I call the clinic, I get voicemail, they call the patient, the patient's phone has been disconnected, they don't have enough data, so they wait for three months to get an appointment, have high blood sugar the entire time, finally go see the doctor and hope it gets right this time, if not then wait another three months, and the same cycle continues. And you know we see in in in this population the A1C's or the other glucose levels they go up and down and up and down and up and down from really controlled to really bad really and I thought why in the world is that and I did a study one time I just looked at patient notes and I thought oh that makes sense they're on their meds off their meds on their meds off their meds. And a lot of times the gap is, like we talked about before, the medication eligibility process or it's also just communication gaps that they have.

So what's better between the two of them, it's hard to compare because they're a little bit apples and oranges where the TIME these are patients who are motivated to come to clinic and they typically have transportation to get to clinic, they have more resources, typically. We see an A1C drop you know .5 is considered significant we see drop typically of two to 2 ½. In the SIMPLE model we still lower drop. These are patients though that's more of a kind of opt out, like hey we're running this program if you don't want to join it no need to and then I'm sure I'll do it. So these are not your cream of the crop patients. These are the patients that are what if they can't come to clinic, what if they don't want to do group visit, how do we reach the people who are maybe less motivated or don't have transportation or work a lot. So these A1C drops are typically one 1-1 ½, still clinically significant and still a nice drop. And the good thing about the SIMPLE models is it is much more scalable, because it's not an intense monthly come to the clinic, you can run it with 2-3-4 times the amount of people that you could run in the TIME model. So both of them are good models. I don't have a bias I like them both. I think they're both great for but it really depends on the clinic situation and depends on the patient situation, but SIMPLE was named simple for the reason, it's simple.

With this patient population, how has deploying community health workers on the frontline changed outcomes?

There's a lot of literature out there about changing diabetes outcomes and there's a many many interventions, you know, educational interventions, medication interventions, and so I thought, you know, what CHW, what's different, you know, why have ACH in in this this part, when there's other literature that shows we could do other things. And you know we don't compare these arms, typically we typically have different studies, so it's hard to compare them. In looking back at some of the things that we've done, the community health...

Today we have the second in a series of conversations about ACO REACH with Melissa Pollock, Director of ACO Compliance and Regulatory Affairs at CHESS Health Solutions, who continues to navigate and lead through the intricacies of the newest CMS payment model.

So, last time we talked about a lot of the history behind the reimbursement models for CMS and went over some of the history, and what CMS is trying to achieve, and how they've moved down this timeline and value, and we've landed on an ACO REACH model. What happened from “hey let's do this,” to “we're doing this now.” Because it seems really easy to say but I know that a lot went into it. Can you walk us through that?

Yeah. So, I think we had looked at the direct contracting model and just financially it didn't make sense. So, you know, we talked a little bit about the Next Gen model coming before it and how it was never really certified as a as a full program because CMS didn't think that it created as much savings as that should have. You go to direct contracting and they've kind of put into direct contact some very steep discounts. Discount not being a good thing. Right? Discount being they're going to take money straight off the top to make sure that they get the savings that they're trying to generate in the model. When they revamped direct contracting, renamed it, refocused it as ACO REACH they kind of backed off on some of those discounts, which was helpful I think to a lot of us that were in the healthcare space. So, you know, all the Next Gens are providers. We're all providers. We're, you know, trying to do value within the health systems. We don't have, for most of them, a lot of you know commercial companies outside of this.

And so, as we started to look at ACO REACH and the requirement or the ability within the model to take on claims processing, that is a whole other realm that we had not been. In claims processing, I mean, obviously, there are entire companies that do nothing but claims processing. And so, we had to decide is this something we're going to take on? Do we outsource it? What kind of you know organization do we partner with to do this? And we have to go through the entire process of an RFP, a request for proposals, to determine OK who can do this, who's done it before in direct contracting that we can also use in this process, and how do we move forward. So, there was a lot of time spent in determining number one what is our downstream model going to look like, how are we going to reimburse these providers, and number two, can we do it, can we set it up in a relatively quick time frame and do we have the expertise in-house to do that or do we need to look outside. So, there was a lot of conversation around that.

I mean, obviously, the application process for ACO REACH was a lot. It was unlike any other application that CMMI had ever put out, the Innovation Center, had ever put out. It was very detailed. They were asking very specific questions about governance structure. They were asking a lot of questions about health equity, what are you already doing in the health equity space, which is you know what they're looking towards. They're looking at this focus of how are we going to really affect care in the underserved communities that has traditional Medicare beneficiaries. And so, there were, you know, we had to look at what do we have now, what are our gaps in care, where do we think our populations are, what zip codes are they in. It was kind of a new foray into looking at data from a lens that we hadn't really looked at before. Or if we had, hadn't done a really deep dive into. So, I think those were kind of the two big things that we had to really prepare for. From a compliance and governance standpoint, we were set. That wasn't different. And having been in Next Gen, we were very used to those types of you know the audits and the things that come with being in an innovation model that's very different from MSSP. But from kind of a structural, internal claims processing, being able to take that claims file and figure out what we're going to do with it and how are we going to set this up, I think it took it took us a long time to just OK let's walk through these steps and what is this going to look like in the future.

What do you feel like was the most difficult part of that process?

Honestly, to determine how we were going to structure the downstream contracts was difficult. I just the process of OK what is it going to look like for us to process claims, who can we partner with. I think that was really difficult because we had never done it before. I don't have expertise in that. You know, nobody specifically at CHESS did. And so, I knew we needed to bring in people that had that understanding, software that had that that ability. So, I think, trying to work with our revenue cycle teams and making sure that you know they know that the money is not coming from CMS anymore, it's coming from CHESS, and how to post that, and work within their systems that they already have to make this work, I think was pretty difficult. There's just a lot of moving parts in ACO REACH. There are a lot of different things going on at once. It's a very complex contract. And so, to make sure that we have understanding and educate on it too, I think was really difficult. We spent a lot of time on doing internal and external webinars and meetings to explain what is ACO REACH. People are hearing about it, they don't know what it is, how is this different, why does this matter. So, for me it was just a lot of education that to be done. A lot of reading on my part getting up to speed. And then, having to, you know, field lots of different questions on how it works. So that was a lot of my time was spent doing education on it as well. Not so much difficult, just time consuming.

So, we talk about in ACO REACH there's the health equity component and that's new. And I think that's a really big deal as we look into population health. Right? Because we can segment populations in so many different ways, but why was there a determined need for health equity? Who is this becoming equitable for? What types of populations are we talking about here?

Yeah, that's a great question. So, I think, you know, the COVID-19 pandemic really revealed a lot about our American healthcare system, in that you're seeing some populations of patients have access to testing really fast, they know where to go, they know what to do, and other populations of patients don't. And so, I think that realization that you know you're seeing higher levels of death in certain ethnicities, those types of things, just made it very clear that health is not equitable within the United States. So, OK we need to address this and how do we do that?

So, really the population that we're looking at, and within the ACO REACH model they are using something called the area deprivation index or ADI to kind of score patients as to whether or not they're in underserved communities are considered underserved patients. It's kind of on a decile scale. You've got, you know, those that are in really affluent communities on one end and then you've got those that are in very underserved communities on the other end. And being able to take your patient population and look at them from this kind of score and determine OK I've got a lot of population of patients, probably you know minorities, in certain areas of on our map, right, certain zip codes, certain census blocks, and I know that there seems to be in our data that we're getting from CMS for this model that there is a, you know, a lack of colorectal cancer screening. OK that's a gap. So, what are we going to do about it? So, I think it's looking at those populations of patients more directly than just, “hey it's a population of ACO patients. Let's try to you know do what we can to affect care and value,” but really calling out smaller underserved communities within the population and saying, “what does the data look like for those people and how can we affect care specifically for those patients?”

Well, that that ties into a lot of the things that we work on here and that the buzzwords that we've talked about and one of those is social determinants of health. So, we talk about health equity and then we talk about social determinants. Is there flexibility since we are doing a lot of our own claims processing to make judgment calls on how we can address some of those social determinants that are outside of the clinical space? So, I know that there might be a lack of colonoscopies and mammograms and there might be a higher rate of diabetes, we talked about food deserts, we talked about hunger, we talked about transportation. Is there a leeway where we can make our own determinations about models that we set up programs initiatives that are allowable now with this new payment model?

Definitely. So, one of the benefits of being inside of ACO REACH is that you have, kind of, at your disposal a fraud, waste, and abuse, and safe harbor waivers to affect care in ways that otherwise would have been considered kind of like a kickback or of those types of things. So, there's different waivers, sanctioned waivers, within the ACO REACH model, the ones that we know like the telehealth waiver or the skilled nursing facility three-day waiver, there's a gift card program, that you can do at-home care management home waiver. These types of things. But I think broader, there is the ability to take some of the money and determine OK how can we use this money to really affect a social determinant for underserved populations. Does that look like partnering with a food bank to offer food to diabetic patients that are in this zip code because they don’t, they can't get a medically tailored meal. That's a that's a possibility, and the ACO technically could pay for that. In traditional Medicare, outside of the ACO structure, that would be considered illegal because you're providing something that Medicare is not paying for. But within the ACO structure, they know that this could be a way to turn around someone's health in a real realistic way.

And so, you have the ability to model these types of programs and to partner with community organizations that are already in this space and have the resources to be able to do this. I mean, I know I don't have the resource to stand up a food bank but there's one down the road that I could say, “hey I really need to you know to try to provide care or provide a meal to these patients because they're diabetic and they can't leave the house and they don't have transportation.” And that's another thing is transportation issues. We have the ability to provide rides to primary care offices. So, if a patient says I know I need to come in for my primary care visit or for X, Y visit and I can't make it, I don't have a car, or I can't drive, we have the ability to pay for that ride and to offer them a ride to get to their provider. Instead of the alternative being calling an ambulance and the ambulance showing up at their house and taking them to the ED, which obviously is way more expensive than if they just needed a ride to their doctor's office. So, there are a lot of a lot of creative things you can do. I think a lot of it is, man there's so much, how do we even start? Where do we start? And I think that really is where you rely on the data that you get, the claims data you get from CMS, the clinical data that you have from the you know the health systems, your value partners, and really putting that together and find that form a holistic picture of your population specifically in the underserved communities and determining OK where do we think we can really affect care with these patients.

I really like that because that is what it's all about. You hear so much about the financial components, and I realize that people need to be compensated for the work that they do. Not everyone has the means with which to be philanthropic with their time, which is the greatest gift you can give. Right? Everybody's got to eat. Even those that help other people eat. And it's nice to hear about the Feds saying hey we realized that it's not necessarily a straight clinical solution to optimal health and I think that's a huge leap. So, we began at CHESS, we began ACO REACH on January 1, 2023. How's it going so far? Do we have any data? I mean we're a couple of months into it, how's it? I'm sure that the road is bumpy and there's warts and all of those things. But, you know, as one of the first group of ACOs to be tackling this, how's it going? Is it working?

Yeah. I mean I think it has been bumpy, I'm not going to lie. It hasn't been smooth sailing just because we, you know, a lot of this is new and anytime there's new, you're doing something new and different, there's things that have to be ironed out. I think so far we're doing well. I think we, on purpose, are starting kind of slowly into the model and haven't availed ourselves of all the waivers that are out there just because I personally I wanted us to get our feet on the ground and just let's just get a really solid foundation for how we're going to do some of this stuff instead of trying to boil the ocean. Right? So, I think we're doing good. And I think we are affecting care. Some of the data’s been delayed coming from CMS, which usually happens. I mean, I get it, it's new. Some of this is new for them too, right. So, there's going to be things that have to be ironed out. But, so far, I'm really optimistic about what we're doing and how we're affecting care.

I think we have a really great opportunity within the health equity space and that's what we're really working on right now. So, for ACO REACH, we have to create a health equity plan and we have to submit that to CMS the end of March. And so, right now, really trying to determine OK based on the data that we've received from CMS so far, where are the gaps in care, what can we do to really affect underserved communities. And then, using the next three years, 24, 25, 26 to really roll that plan out and see care effective in communities. So, we're in the staging processes of health equity within ACO REACH. I'm sure there’s others that are farther down the road than us, but I think I think we're doing OK for where we should be.

So, we decided we were going to participate in ACO REACH and we went through all of the hurdles, all the rigmarole, all of the vetting. Is this something that is available every year? So that next year, some ACOs out there who were just didn't have the bandwidth because oftentimes ACOs are pretty lean run operations right and unfortunately those operations might be in communities that are best served by this type of program which is why the ACOs exist in the first place, would they have the opportunity to apply to begin next year? And if so, what advice which you give to them?

So that's a great question. Actually, there are no more applications for ACO REACH. So, this this was the last, this was the cohort. So, a lot of the direct contracting entities that started in 2022, some started part of the way through 2021, they were kind of grandfathered in, and then you had this kind of cohort of applications for the 2023 start, and they've shut down applications for the future. So, for organizations that think hey this might be something that we would want to be a part of, they would have to look at joining someone that already has a contract with CMS for ACO REACH and then you know approach those different organizations to talk through what it would look like to join in 2024 through 2026.

Well seeing as how other ACOs would need to become a partner with ACOs who are involved in REACH, how difficult would that be? How does that work?

Yeah, I think it would have to go through some type of vetting process, from my standpoint. So, you know, yes, there would be obviously contracts would have to be drawn up, but we would want to look at the people that are interested in joining a current ACO. Like if it were ours, our CHESS ACO REACH, and saying is this a good fit for this advanced of a model, you know, do they have history in value based care, are they already doing things that are affecting health equity, how do they feel about taking on downside risk, are they an organization or group of organizations that feels like they want to do that, or you know how can we model something different specifically tailored for this group that wants to join. Would it look different?

And that's the other thing within ACO REACH, you know, I talked about previously in our other podcast about it's kind of like putting a contract within a contract, but you can alter those contracts. So, one participant within the model, like one health system, their contract of how they're paid could look different from another contract of how another value partner or health system is paid. And so, you'd really have to do that that vetting process of determining is this something that looks like it would be a good fit based on you know their history and are they ready to take that leap, really. I mean, I think a lot of value-based care is more of a cultural change than anything else. It's really trying to address the mentality of providers, and educate them on what this means, and how it's going to be beneficial for the patients. And sometimes that it doesn't go over well. I'll be honest, you know, you have some that don't really latch on to it. And so, there would have to be that willingness at the executive leadership position, this is something we're really going for and we're going to drive the culture in our organization in order to make sure that we're successful in this model.

Have providers noticed those who are now with it have a patient population that is part of ACO REACH? Have they noticed a difference? Are they doing anything differently with how they provide care for their patients or is it just continuing along the standard successful value-based care workflows?

I think from a provider lens, especially with the with the organizations, health systems, that we currently have in ACO REACH, they've been doing value-based care for such a long time that they don't see a lot of the difference. And I would say a provider, on purpose, does not want to know oh this is a this insurance patient, and this is the this one, and this is this. That idea of treating each patient before you equally no matter what their insurance plan looks like, I think is very important to a provider. And that's where we, as CHESS, kind of wrap services around the provider to help drive value-based care. Yes, there is some education that has to happen, and there might be workflow changes within an EMR, or things that have to change, education that would help drive value. But I think two, a lot of this work are things that we do as CHESS to try to help them. So, you know, care coordination services and pharmacy services. A lot of those things happen a little bit on the back end, a little bit out of the spotlight of that care that is you know the 30-minute visit of a patient in front of a provider.

Our mission, and one of the basic tenets of the quadruple aim, is to help providers just take care of their patients, right? And provide the best care that they can because that's really why they got in the business. I mean because they’re caregivers. Do you feel like this new model is going to help the provider give better care to their patients?

Yes, I think it will. I think it will...

In this episode we talk about the role of the community health worker in case management with Kari Curry, director of clinical services for Emtiro Health, where she oversees the delivery of their population health management program.

Kari Curry, welcome to the Move to Value Podcast

Thank you

Tell me about your role at Emtiro Health. Who is your patient population and how are you assisting them in obtaining the best possible outcomes?

Well my role at Emtiro Health is the director of clinical operations. We case manage the managed Medicaid population. I've been with the organization even before it was Emtiro. I was a care manager myself and I covered Davidson County. I then was a supervisor for the care managers covering Davidson County when it was Northwest Community Care, so my role with Emtiro then moved to manager of clinical services and then I moved to the director position of clinical operations. I believe the past roles I've had allowed me to truly understand the role of the care manager, including you know barriers that they encounter with patients. And working with the Medicaid population is a passion of mine as well. As Emtiro as a whole, we've worked with this vulnerable population for years and we continue to provide efficient care to the Medicaid patients. So our vision here at Emtiro is to coordinate care, improve health outcomes, build strong communities, and health equity and I truly believe we work hard every day to meet that vision and we are passionate about working with the vulnerable populations and improving their health outcomes.

So in your Move to Value Summit presentation, you mentioned that case management is like a puzzle. Tell us why this is so and how do you work to solve it.

Yeah so I'm sure my staff is tired of hearing me say that but it's true. The first thought came to me when I was doing case management in a hospital. So I was a discharge planner and I did utilization review for patients admitted to the hospital and when a patient was nearing discharge, I would need to make sure they had a safe discharge plan. So to ensure they had a safe environment, such things as utilities in the home, any medical equipment that they may need making sure they have their medications, and so on. So each part of that discharge plan was like a piece of a puzzle where each piece must fit together to see the discharge plan be successful. And that theory has carried with me here at Emtiro and I still find it true today.

So as a care manager for managed Medicaid, each area is the puzzle piece. Each patient is assessed for medical conditions education, social determinants of health, medications, etcetera. So each area must come together to see the patient situation and what steps are needed to ensure the patient receives what they need.

Well how have you seen the impact of the community health worker in care delivery and how is this impact achieved?

So when I first started my nursing career, community health workers were not a title that I was aware of or that you heard a whole lot. It has become more popular and a more popular term over the last few years. However, the work of a community health worker has always been there. So when I started in care management, I did it all. I made home visits, worked with the patients on their medical conditions, assessed for social determinants of health, and set up the patients with those services if they were needed. And I can honestly say as a nurse, I wish I would have had more time to focus on the patient's medical conditions and providing that education to reduce risk of ED visits, or readmissions, or overall living, you know, as far as a healthier lifestyle for those patients.

So the role of the community health worker of course is designed to tailor you know and meet the needs of communities they serve. Community health workers have made a huge impact on the services provided to patients because they focus on the social determinants of health in ways to make sure the patients receive the appropriate community resources and appropriate services. It makes the job of the care manager a bit easier because it is more streamlined, and the roles are more defined. So, like I said earlier you know we could all be considered a puzzle piece because we all have a specific role to play to improve that patient outcome.

Emtiro manages primarily a Medicaid population so if you would, tell me some of the responsibilities the community health worker has in working with this population.

There's always been a stigma attached to Medicaid patients and the Medicaid populations and the patients feel that. So the Medicaid population can be considered a vulnerable population. But it does not mean that they deserve any less care or services than other populations. So here at Emtiro, we work hard to reduce and redefine that stigma. We advocate for our patients and ensure they get the services they need in order to live a healthy successful lifestyle. And I can say I've had times where I go to see a provider and they have their laptop or iPad in hand, and they never look at me while I'm talking to them and let them know what's going on with me. So that could be very disheartening even for me much more for a vulnerable population.

Our community health workers at Emtiro help focus on the patient as a whole. They build rapport with the patient they meet the patient where they are in their current situation. They advocate for their patients and work hard to ensure the patient has the community resources they need. But it doesn't just stop there. They follow up with the patient to assess that the community resources were successful and make the patient know that they care about their health and want to see them succeed. Having a personal relationship with the patients can go a long way.

So Emtiro employs community health workers?

Correct

Was having community health workers always part of the strategy or was that something that was implemented as the need arose? Can you speak to that a little bit?

So when we were Northwest Community Care, it was more RN focused and the RN did it all. So when we went with Emtiro Health and knew that we were going to manage managed Medicaid patients, we took a look at what all services we could provide as a whole. So that included RN's, it included a pharmacist for a while, community health workers, even LPN’s. So we wanted to encompass all of that to provide our you know services to the patients to the best of our ability. And what we have found doing that care model is the patients are receiving better care. They're having that one-on-one conversations the one-on-one attention that they need to really focus on their health, so I think it's been a great thing to have.

Well would you mind sharing a story about how you've seen a community health worker impact the outcome of a patient in a positive way?

So I'm sure the community health workers can offer lots of stories, but one of them came to me and provided a story about how she had been working with a patient who was living in a homeless shelter. And a situation happened, occurred and the patient had to leave the homeless shelter. So she was living in her car. Well, the community health worker engaged her, reached out to her, come to find out she had a mental health diagnosis and that prevented a lot of the shelters from taking her. So, the community health worker took the extra step. Partnered with the community resources within that county. They are currently looking for her a permanent place to live but they did find a shelter that was willing to take her and she's allowed to stay there until her permanent residence is set up. So that was a really great thing a very positive story.

We have another story to where one of the community health workers was working with the mom with small children in the home and the mom wasn't worried about herself so much but feeding her kids. So the community health worker worked with her and a local food bank and food pantry and set her up to receive food every two weeks and that continues to happen now. In that circumstance, the care manager is also working with her and she has reduced her amount to the ED, which is great, so we've had a really good outcome with that.

So, while these folks are doing all of this amazing work, it has to be difficult and there are plenty of barriers that pop up in various ways, either with a patient or with a collaborative organization or just rules and regulations.

Right.

What have you seen that are some of the issues or barriers that the community health worker faces?

So, I really like this question because I think we can talk all day about the amazing work that the community health workers do but it's also important to assess the issues and barriers they face. So I think one of the biggest challenges for the community health workers is just unable to reach patients with the phone numbers provided. So when the wrong contact information is listed, the community health workers have to do more research on their end to try to engage the patient. So that can be looking for information in an HER, maybe looking at claims data to see if there's a pharmacy listed, call the pharmacy to see if they have an updated number for the patient, and also just engaging the patients can be a difficult task. This is where motivational interviewing comes into play, especially when you were actually able to engage them. So some of the other challenges could be social conditions, mental health status of the patient is a big one, because I think we lack a lot of community resources based off that. So I believe it's important to continuously to assess those barriers and brainstorm of ways to reduce them if at all possible.

So, as you are well aware, health care is making a shift to fee for value and it is proven that the community health worker impacts a lot of the work flows in a positive way, such as reducing utilization, helping to reduce cost. How do you see the community health worker making a difference in value based care?

So with North Carolina Medicaid they continued to reform you know delivery of care, and payment, with the goal of improving the health of patients overall. I think it's important to keep the focus on the whole person and centered care whole person centered care and ensure those services not only address medical but non-medical conditions as well. So, assessing those social determinants of health is a key part of providing well-coordinated care to the Medicaid population. I believe being an advocate for the patient is also a key driver, having to be that bridge between providers patients and community resources is crucial in having positive desired outcomes for any vulnerable population.

So, when you talk about community resources what do you see as one of the most utilized resources out there? What do people need the most?

I think food. Food banks, food pantries right now. Even now with the cost of food going up. A lot of patients can't afford it. So you know then you run into what the pandemic you know the effects of the pandemic had on those resources as well. You know we had a lot of food banks that just didn't have enough food to cover those patients. So that's when churches got involved, that was always helpful. But I think food insecurity is probably the top. The most needed is mental health, by far.

Why?

I think the majority of our population has a mental health diagnosis. There's not enough resources for these patients. There's too many and a lack of resources even in trying to get them involved in a behavioral health facility or mental health provider. It can be difficult because, one, the patient, sometimes they require group therapy and the patient doesn't feel like talking in front of others. So that's always a problem. Transportation to those facilities is always an issue, but I do think there's just a lack of mental health availability to these patients.

Has there been an uptick in this mental health crisis that we're in, or has it always been there and just not acknowledged? Or do you feel like there is a catalyst for this that's only going to get worse or has been making things worse?

I think it's always been there. It's always been an issue when it comes to healthcare especially care management. So, I think it's always been there, but I think it has gotten worse and especially with the pandemic as well. You know, even health care providers, you know look what we had to go through as well, and the burnout. So, I think it continues to be a need. However, I do think it has increased due to the pandemic. I also think just with the way the world is now, you know things are different than they were even ten years ago, and I think I can see an increase in the younger population, too, as well. So, school age kids from elementary to high school you know have really struggled because we did remote learning, and you know they were isolated for so long and the fear of going out. So, you know that doesn't just go away overnight because we didn't get into it overnight. So, I think that it continues to be a high need and I don't see it changing. I really don't. I think if anything there needs to be more of a spotlight on mental health.

Are you, as a leader at Emtiro, thinking forward about how the pandemic is going to impact care delivery for your organization over the next 5-10-15 years?

Absolutely, because I think when you talk mental health, your body responds to that as well. So you know you could see such things as you never had high blood pressure before but now you do. Well was it anxiety driven? Is it just behavioral driven? So I think that with the younger population we're seeing now, they're going to have a lot more when it comes to medical conditions as they continue to get older. We just have to be ready. You know we have to be ready to provide those resources to them, educate them, get them set up with the providers and whatever that they need in order to manage that, but I also think with mental health and even with children, education is also key. You know there's a lot of unknowns, so I think when you provide that education and let them know that you do care you know you're not just providing them education to you know provide it to them you are truly caring about what happens to them, that is a key driver in the future of healthcare in general.

What do you see as the future for community health within the healthcare system and do you feel there is a need for a shift in healthcare as a whole to compensate for these issues?

So, community health workers have emerged as key players in value-based care and a value-based care model because they're responsible for not only supporting patients and addressing social determinants of health and improving care coordination as a whole. I would honestly like to see more certified community health workers. So, making sure they receive that appropriate training and building that confidence, it's there, sometimes I just don't think people, especially community health workers know where to find it. So, you know I want to be an advocate for that and you know say here it is you know it's waiting on you. Because I think the more knowledge and education you have the more confidence you have in providing good patient care.

I would also like to see the increase in community resources available to patients and I believe it's a constant need to research and link more community resources to organizations so that patients can receive appropriate care. So, I do see the role of the community health worker expanding through healthcare. The work is being done but there's just not a title to it. So I think there's always room for improvement in healthcare, it's ever changing, nothing stays the same but I do see an increase in the role of a community health worker across all of healthcare organizations.

Outstanding! Kari Currie, thank you for joining us today on the Move to Value Podcast.

Thank you so much. Have a great day.

In this episode we continue our conversation with Colleen Hole, Vice President of Clinical Integration in Population Health at Atrium Health, about how the Hospital at Home care model contributes to value-based care and better patient outcomes.

Colleen, in our last episode we left off talking about holistic patient care in the home. Having cared for several elderly family members myself, I have seen the difference that it made for them to be in familiar surroundings versus being in the hospital. I guess home is where the heart is, right? Would you share with us the Hospital at Home Scope of services being provided?

So essentially anything you could receive in a brick and mortar facility, we can do in your home. Short of an invasive procedure or surgery, obviously, we don't do that and advanced imaging like MRI and CT scan, although that technology exists, we're not quite that there yet. But you can get pretty much any medical nursing intervention that you would get in a hospital, respiratory treatments, oxygen therapy wound care, IV fluids, IV antibiotics, chest X-ray, ultrasound, I mean though that's mostly what you're going to hospital for, obviously your medications we provide all of that is provided by 24/7 virtual nursing team. That patient can hit a button and have my nurse pop up on a screen just like a call bell in a hospital. They also get two visits by our community paramedicine or mobile integrated health team, you might hear it called both things, they're in the home twice daily for anywhere from 45 minutes to an hour twice daily. That is absolutely more time than you've got a clinician in your hospital room. You also have a daily virtual visit with the provider who is on camera real time doing an assessment while the paramedic is in the home. We've got electronic stethoscope, they could listen to your heart and lungs, they write orders, and then our nursing and community paramedic team carry out those orders. We also have, just like in a in a hospital, pharmacy, care managers, social work, respiratory therapy, physical therapy, occupational therapy, behavioral health, chaplains, all of those things mostly provided virtually, which we learned how to do now after three years of COVID. The other in-home service sometimes is our therapist, our physical therapy and occupational therapist. But a good bit of their work is done just literally on camera in a virtual visit. So it's hospital level care delivered in the safety and comfort of a person's home

I didn't realize that it was such a comprehensive program. That's pretty amazing that the capabilities for that are there. I think that's definitely a good thing and can you tell me how this model enhances value-based care and what is the typical savings here?

So, the purest definition I know of value is the same or better quality at a lower cost. I mean that's maybe oversimplified, but the hospital home actually does that. Our Ed visit, readmissions, mortality, all of those are lower than brick and mortar and our patient experience is higher significantly higher, not surprising probably, right? But when you have the opportunity to actually go where patients actually live, you can address some of those issues that are causing this repeat readmission. When we go to the home and we look in their pill box and it's empty or there's no food in their refrigerator or it's 100 degrees and their air conditioner is broken, you can hopefully address some of those things. Cost wise significantly less costly and there's research out there Mount Sinai has published several have, it’s estimated 20% to 30% and maybe more less costly than brick and mortar hospitalization. So again if you think about the drive value how do you deliver the same or better outcomes at a lower cost. This is certainly that.

You also just by being in a physical facility utilization tends to be higher. For example, you're in the hospital bed and you need a chest X-ray. oh but while you're here we might as well do that CT scan, and we might as well run that other panel of labs while you're here, you can see how costs will escalate because of the availability of services. And that's a that's a gray line, one could say well they really need all of this. Maybe, but if we can deliver the same outcomes and not do all that stuff, it it's probably the right thing to do

That's definitely a cost savings. You know in value based care we talk a lot about the triple aim and that's moved into the quadruple aim. How have you seen if at all with that fourth quadrant being provider burnout, have you seen any movement in the provider satisfaction with the hospital at home program?

I believe we absolutely have. I've got six provider FTE's designated for this program. So this is all they do. They provide this care and they all came out of traditional hospital medicine within our health system, and they love hospital medicine but you know just being up on a nursing unit in a hospital, it's noisy and it's distracting and it's a wheel, I mean they're just constantly running. They're very busy in our program. They care for as many patients as they do in the hospital. They round if you will on anywhere from 14 to 16 patients each every day. But they find that they've got more time to focus and spend with the patient and also the nurse and the paramedic are in the home when they are doing that virtual visit so it really feels multidisciplinary. And they're able to see the patient in their own environment so they make a better assessment and a better plan of care.

One of the most compelling examples of this, we also are an academic health system, so we've sent some or that by their selection some residents through our family medicine program residency have come through as an elective in their coursework, and one of them wrote the most beautiful letter about her experience actually caring for patients in their home and she called it a sacred trust. She said it's so true it's true of home health nurses and anyone who has the privilege of delivering care in the patient’s environment it's a complete power shift. In a hospital we put you in our gown in our bed and we tell you when you're going to eat and sleep and bathe. But in the home environment, there is a power shift to where the patients in charge, as they should be. So the physicians that we, and we use some APP's, I think that's going to be even more in the future, they love this model of care because like me they learned about holistic care in medical school and rarely have a chance to practice it in our traditional care settings

That's powerful. I guess the patients are better off in this setting, in your in your mind, and I tend to agree. Do you have a story that you can share where hospital at home impacted a patient?

Yes. I have a lot. We have our quantified data that comes from our patient experience surveys so that's scored, but the best stuff comes from our anecdotal letters or comments within there. So we've countless stories from the patients themselves, from family members, even from neighbors who said you know we were so scared with our neighbor how sick they were but it was so comforting to see the Atrium vehicle pull up in their driveway because we knew oh they're getting what they need today. And many patients, particularly more elderly fragile patients have had very negative experiences in hospitals to where they didn't do well and did so much better at home.

A recent example and I think I did share this on our recent Move to Value Summit, but was an elderly couple, the wife had pretty advanced Alzheimer's, but the daughter wrote us a letter thanking us. Both parents had COVID, so if you remember early COVID, you were isolated family could not visit and many patients died alone, which I think is the greatest tragedy of the whole thing. But here was the couple with COVID the husband had had very bad experiences with delirium and confusion in the hospital in the past. But they were able to be at home. The daughter was able to visit them in their home. They had their pets which is a huge part of healing, honestly, able to be at home. So the husband recovered and did well and was back to gardening and enjoying his life in the summertime. The wife did pass away but she was able to be there with her family when that happened. So I've told that story a zillion times because it really pulls together the whole sense of community and family and dying alone and so that should never happen.

I just you know it's not perfect. We're still learning and iterating on this model, but if you just go from the basic principles of value based care, holistic care, lower cost care, and better outcomes, I know this is the best thing since sliced bread to do that in healthcare. So I'm excited to kind of see where this goes over the next few years I wish this had happened when I was in my 30s, and I'd have more of a runway to see it through, but I think we're on to something here.

The last thing I'll mention is partnering with community agencies. So when we go in and we see the issues that are keeping patients from living the best life they can despite poverty, despite chronic conditions, we can actually do something about it. So we are partnering with some community agencies around food insecurity that extends past their hospital stay, frankly, to make sure they can continue to do well, nutritionally. And also safe housing so where we identify a leaking roof, or unsafe stairwell, or they need a shower bar, we can work with some community agencies to get those things put in to avoid the falls, to avoid you know the diabetic who isn't eating perfectly. All of those things help patients live their best life and frankly put our money where our mouth is. If we if we say we believe in health equity and lowering the cost of care and we believe in access, then we have to do it differently than the way we built it half a century ago.

I like that. What's the plan going forward?

So, as I mentioned, we are currently running a census around 30. Our next milestone is 50, which is just around the corner I hope by year's end where it's 75 or perhaps even 100 patients on service. Again from a operational administrative perspective our whole reason for being is still largely capacity management. Our hospitals remain beyond full and I don't see that changing anytime soon, particularly as the community continues to grow at about 100 hundred people a day I think or something crazy. We do also though believe that this is transformative care, which again in the drive to value that's what we're supposed to be building toward. So I do think much like Mass General Brighams is planning, this could be 200 plus. If you think of 20% of your market beds could approach 500. So to be seen and determined.

I don't know but I know we're not stopping here. We didn't talk about payment models, but a lot of this is contingent on what CMS decides to do at the end of the two year CMS waiver extension. So Medicare will be covered at full inpatient DRG through the end of 2024. We still have to work within our state licensure and CON restrictions to figure out what this means, because quite frankly they don't know either. And then payers are coming along with covering the service, again, I would say they need to put their money where their mouth is and work with us to deliver care differently and better. So all of that legislative and payment work is still underway and it's a pretty heavy lift but we decided as a health system we're doing this regardless of the payment model because it's the right thing to do.

I couldn't agree more, and I look forward to checking back in with you in the near future and seeing how things are going if you would be so kind as to join us again to talk more about this program. I think this is outstanding work that you're doing.

I would be more than thrilled to come back hopefully I've got even more wonderful stories to tell.

Well, you've been a delight. Colleen Hole, thank you for joining us today on the Move to Value Podcast!

Thank you for having me.

In this episode we learn about the Hospital at Home care model from Colleen Hole, Vice President of Clinical Integration in Population Health at Atrium Health, responsible for integrating the principles of Population Health and value-based care into clinical and operational practice.

Colleen Hole, welcome to the move to value podcast

Well thanks Thomas I'm really glad to be here

I'm curious Colleen, how did you become interested in population health?

Not to show my age but I've been at nursing for many decades and most of those years were spent in acute care in a hospital. And to be honest I think most folks in a hospital just work to get through their shift without really any visibility upstream or downstream as to what brought that patient in or what we're sending them off to. So, we often, not often, always do incredible care in that moment but it's really hard to have visibility into what else is happening in that patient's life that's making them struggle and circling back through our Ed and our hospital. And really, I could see miracles where we save lives every single day but largely in silos, but our patients don't actually live in a silo, they live everywhere else but the places that we take care of them.

So about 10 years ago or so clinical integration became a thing, and I was intrigued by that because I saw it as aligning care really across the continuum. Now our focus was more internal, how do we align care within our health system, but it was about providing care like we had been doing but more about coordinating that care among silos. And I always thought gosh there's got to be more to this than just what we're doing here. And then about seven years ago here at Atrium Health we launched population health and it kind of hooked that to the drive to value. And I was lucky enough to be part of that pretty early on and really loved seeing how health systems were starting to take responsibility for what happened outside of hospitals, around food insecurity and livable safe housing etcetera and then the social determinant of health thing became a thing. So, I guess it's evolved over many decades but really excited I think where I see health systems going now with pop health.

So, I know that you're involved with the Hospital at Home program can you tell me about this program as just an overview perhaps about how this concept came about?

Sure so if you go back 100 years ago where there weren’t brick and mortar hospitals much, many patients received what you might call hospital level care in their home. But with Hill-Burton and post-World War Two we built a whole bunch of brick and mortar across the world. But about I guess 30-35 years ago, the concept kind of came back around more in Europe and even Australia, where for various reasons health systems were starting to go back into homes to deliver hospital level care. And then here in America at Hopkins, Dr. Bruce Leff, a gerontologist, started a program there focused on the fragile elderly primarily recognizing that hospitals presented some risk to this population. So he started a small program and even today, it it's not 100 patients per day, but I think of him as the father of hospital at home if you will. And then when the pandemic hit many health systems were challenged with capacity. So it gave all programs a lift and here we are today with over 200 health systems approved for the CMS waiver which covers at full inpatient DRG, a Medicare hospital stay. So lots more to tell about that but it's kind of evolved over the past several decades, but never with the momentum that it us now

Can you tell me a little bit about and give me a timeline about the Atrium Hospital at home program and why it's been so successful?

Sure so I was busy doing my population and health work, I also serve as the chief nurse executive of our very large Medical Group, and I thought I was plenty busy. But on March the 13th, I was called to a meeting with seven people couple of physicians, couple of administrators, me representing nursing, and we recognized we had a tsunami of patients coming with COVID. We frankly didn't know much about how to take care of them. We didn't know much of anything all we knew was our hospitals in the winter were already full and then some. Traditional flu and all of those viruses, and really in in almost a panic mode of what are we going to do? We were watching Europe and Italy and New York and figured we got to do something quick. So it was kind of like an Apollo 13 moment where they throw all the stuff on the table, here's what we have what are we going to do and failure was not an option, honestly. So about seven days later on March 20th of 2020, we saw our first patient in hospital at home. Part of the benefit of being a large health system is you have a lot of stuff to cull together to make something. So we had clinicians who were available partly because we had closed some services, at least for a time. We also had a pretty robust mobile integrated health or community paramedicine program. So honestly threw all that stuff together, wrote some clinical protocols, work with our IS folks to build them in our EMR and got busy.

So we've been on a 3 year journey to iterate that program which essentially was an outpatient program for which we didn't send a single claim for a whole year, to a full blown inpatient level of care covered under the Medicare waiver. I often say it was the funnest silo busting I've ever done in my 40 years, because everybody leaned in to help. I picked up the phone and said Hey pharmacy I need some help we need medications. We’ll help. Respiratory therapy. We’ll help. It's kind of like a code and a hospital where regardless of the tension that there might be among you know respiratory and nursing, everybody leans in and saves the patient. That's what it felt like and that honestly the adrenaline rush that comes from doing that kind of work has really been the fuel, I think, to sustain the program. Because quite honestly, we're still in a capacity crisis. Our hospitals remain 110% to 120% occupied. And so, we still at least in this market have a have a capacity crisis. So that's still is the burning platform but obviously there are numerous other reasons why we're still at this business.

How is the hospital at home program doing now? Tell me how things are going now that we're sort of, I don't want to say on the backside of the pandemic because I do realize that there's still a lot of issues, but now that things have have become a new normal where do we go moving forward from here?

Yes so we were all COVID in the beginning and we were so unsure that when a patient showed up at the ED, they knew about hospital at home, and it was an automatic, oh good send them home with hospital home. COVID? Send them to hospital home. Over the past three years the pandemic has waxed and waned obviously. In January of 21 so almost one year in we had a peak census of 130 patients on census. That was our highest COVID peak in in our market. So you know literally chest pain in that moment, but since then COVID has only about 10% of what we're taking care of. So we've had to figure out how do we draw patients with heart failure, COPD, various other infections. So really we've seen probably 150 different diagnostic groups if you will of patients still mostly medical but we also will do some post-op surgical patients who often stay in the hospital for lab you know labs to settle or frankly even to have a bowel movement. That that's not a really good reason to tie up hospital beds so we're really constantly looking at what other populations would do better in a home recovery than in a hospital.

I will tell you it's still a challenge to find those patients we've got over 2000 inpatient beds in this greater Charlotte region, and I'm budgeted for a census of 32. So we run high 20s low 30s census daily but most experts in this space believe that 20 to 25% of a market beds could be done with hospital at home. So we've got a long way to go that would be a couple of 100 patients on surface at least. I think it's completely possible Mass General Brigham for example is going for 200 plus. I hope to get to 50 to 75 by end of year but we've still got to decompress our hospitals. They're still full not of COVID but of chronic conditions that didn't get enough attention through COVID. So these patients are sicker than they might have been 3-4 years ago.

So again, being in a growing market is the blessing and a curse. People are still moving here to North Carolina, we've got to make room and building brick and mortar beds is costly and time-consuming and a waste. So if you're talking about value based care that's not value added to build beds at anywhere from a million to five million a pop just to create room, when we know this model works.

Agreed. That's some great insight. When you presented at the move to value summit recently you were talking a lot about holistic patient centered care. Why is providing care in the home, in your opinion, better than in a clinical setting and would there not be risks involved?

Well there's risk everywhere. But I'll talk to that in a minute. I learned about holistic person-centered care and nursing school nearly four decades ago. And I was so excited about it I thought wow this is so cool and we wrote nursing care plans that considered the whole person. And when I became a nurse in a real hospital it was pretty evident that that's not how we actually practice. Because we're built around professions and payment not patients. And I know that's a provocative statement, but in truth how we get paid is how we build health systems. So they're clunky and there's a lot of waste in them and they're expensive. We also know through value-based models and population health that only about 20% of a patients well-being is the medical care that they receive, and even of that 20% of medical care only a small part of that is the physician or provider orders that are written. The rest of the story is where I think our opportunity is in healthcare. What else is preventing that patient from living their best life even with chronic disease that they inherited, can't do anything about that, but how do we help them live their best life to decrease the need for these high cost complex medical interventions? And unfortunately, that's the stuff that most payers still don't cover in America. All the things that we know health coaches and care managers and what nursing does. The domain of nursing is mostly not a line item on a bill. So we've got our priorities kind of messed up in this country. I may not live to see it different, but I'm going to keep pushing because I think it could be done so much better. Other countries in the world spend far less on healthcare and have better outcomes at a lower cost.

Now about the risk thing. About 30% of Medicare patients have a harm event, some severe, when they enter a hospital, about 30%, that's coming straight out of CMS. So, it's true, hospitals are dangerous places. Patients fall, they get infection, they have delirium or sundowner syndrome, they don't sleep well, they don't eat well, and they don't move well in a brick-and-mortar facility. If you've ever been there you know it to be true. Hospitals, they're dangerous places but we'll always need them. Why would we not develop care models where patients can be cared for in the familiarity and comfort of their home. Yes patients fall at home they got rugs that are in the wrong place and they slip, but I guarantee they find their way to the bathroom a whole lot easier and safer in a familiar environment. So we know that some homes are not safe, they've got no air conditioning, or the roof leaks, there are there are stairs to navigate. But in most cases, if you do a good evaluation of appropriateness, the home is a safer place for most patients so they also tell us that's where they want to be that's holistic patient centered care.

Colleen Hole, thank you for joining us today on the Move to Value Podcast!

Thank you for having me.

Today we have the first in a series of conversations about ACO REACH with Melissa Pollock, Director of ACO Compliance and Regulatory Affairs at CHESS Health Solutions, who was instrumental in navigating all of the processes for acceptance into the newest CMS payment model.

I want to talk about the new ACO REACH model. Before we dig into the nuts and bolts of how it works, can you tell us briefly what has been happening at CMS and how we got here?

Yeah, that's a great question. So, you know, historically beginning with the Affordable Care Act, really CMS has been focusing a lot on how do we fix the healthcare system, what can we do. We know the Medicare Trust Fund is going to run out of money eventually. So, you know, how are we going to fix this? And over the course of the past 10 to 12 years, have been looking at so many different models of what's going to work and most of those models are coming out of the Innovation Center at CMS. So, what's going to work and how do we fix these different problems? And then that, you know, kind of birthed the value movement as we know it today. And then you see kind of the models that we know that have been kind of tried and true, which is the Medicare Shared Savings Program model which has you know multiple tracks and different levels of participation for different health care systems. Again, all focused on traditional Medicare patients.

And then in I think it was 2016, 2017 I can't remember exactly they started the Next Generation ACO model, which was kind of the precursor to ACO REACH. So, Next Gen was really kind of a way for healthcare systems to take on 100% shared savings, upside, downside shared savings. And what that means is that they're completely accountable for the care that they provide for these patients. And that's slowly morphed into, we'll probably talk about this later, but direct contracting is morphed into this direct contracting which then was renamed and revamped into ACO REACH.

Can you tell me why did they sunset NextGen? Was it not working or was it just not fulfilling the need?

Yeah, that's a good question too. So, I think part of the issue was that you know these models have to go through the process of being certified if they're going to be put into regulation. So, all the models that the Innovation Center does are kind of like testing grounds. Let's see what's going to work and are we actually going to save money with this model. And then, after they've run their course, they go through a process where they are looked at under scrutiny trying to determine “hey did this model actually save us money or is the money that we paid out to the health system, did we really not save a whole lot of money for the for the Medicare trust fund?” And so there was, you know, they have like the OMB and different arms of the government that are looking specifically at the model to figure out did we save money or did we not.

So, that certification process came back saying we did not save as much money in this model as we thought we would. Now I will say that there are a lot of people that say that there are some issues with the underlying methodology of how they went through the process of determining whether savings were there or not. And a lot would say there is savings, you're measuring the savings in an incorrect manner or there's intangible ways to measure value being created in these health systems that you can't really put a price tag on. So, there was a lot of back and forth in that arena, but it kind of came down to CMS as a whole does not believe that this model saved as much as it should have. So we need to go ahead and sunset it and come up with another model that is going to advance care and value and really kind of do a little bit more to save the Medicare Trust Fund money.

Is ACO REACH an acronym?

It is an acronym. So ACO, obviously accountable care organization. REACH standing for realizing equity, access, and community health. So really kind of a turn towards let's look at the communities, let's look at health equity with a greater lens, let's look at you know accessibility of care for populations of traditional Medicare patients.

So then, what is this new payment model trying to achieve? Can you tell us why they feel there is a need for a new model?

It's kind of interesting what happened. So, with the sunset of Next Gen, everybody was like ok what do we do next? What’s the next round of innovative, cutting-edge models from the Innovation Center? And they stood up this direct contracting model, and then eventually kind of steered it towards more of a health equity lens and renamed it ACO REACH.

What’s really different in this model is that it has, kind of, a quasi-capitated payment model. And that's really something that CMS has never done. So, when we talk about capitation in an insurance plan or program, you think per cap. Right? It's per head. So, you're getting paid kind of a, you know, a specific amount of money per patient. That's the money that you get, the money goes into your bank account. This is obviously way oversimplified, but the money goes into your bank account once a month. Here's the amount of money we're going to pay for you to take care of these patients. You can pull from this money, but when you run out of money, there's no more money. We're not going to give you any more money for these patients. So, it's a capped amount of money that they're giving you.

I think what's interesting is that really ACO REACH is disrupting the payment flow for the provider directly from Medicare. And so, the provider submits the claims to Medicare and then depending on the structure of Medicare can return either a percentage of that money directly to the provider or none of it if you decide to take 100% capitation. And then instead, that money will come to the ACO as a payment directly from Medicare and then we downstream pay the providers based on these contracts that we put in place. So, that really drives incentive for us, as an ACO how can we take the money that we're getting from CMS and become really innovative and creative to come up with different ways to incentivize providers. You know, what are the levers that we can use to pay them in different ways than maybe traditional Medicare would have ever paid them. And drive value through that payment process rather than a fee-for-service structure, which we know is just you're getting paid per, you know, widget and widget out type thing you're just getting paid whatever you bill.

How did we get the autonomy to do that? That seems like there’s, I don’t know, an accreditation or a lot of trust that’s involved that there’s not waste, fraud, or abuse of some sort because we’re getting big checks and then it’s up to us. I mean I’m sure that there’s a bad apple there, how do they determine who’s worthy or who’s respectable?

So, I mean first of all we had to apply for being in the model and the application process was not a small feat. They're going to look at ok, historically, CMS is going to look at have we participated in these models before? Did we perform well in these models before? You know, what kind of integrity is there? There's a lot of checks and balances in place for that. And then at the same time, you know, we as the ACO are contracted with Medicare to do this process. We then contract with all the different value partners or health systems that are in the model to say, “hey this is exactly how we're going to reimburse you, and this is exactly what you're agreeing to,” and make sure that contractually that's all tight. So that, you know, when we start getting money as CHESS, we know exactly how we're going to reimburse it downstream so that everybody is getting what they thought they would be getting.

Recap what’s been happening and explain some of the main differences between the MSSP, NextGen model and the new ACO REACH model?

Sure yeah. So, I think I mentioned this earlier, but Medicare Shared Savings Program (MSSP) is still fee-for-service. It’s kind of fee-for-service with a shared savings portion layered on top. You know, at a very high level, it’s a benchmark. You get paid. CMS is expecting that you will spend this amount of money on the patients in the performance year. If you go over that amount of money that they thought you were going to spend, that target benchmark, then depending on which track you are in, you have to pay it back. But all the while, fee-for-service is still underlying everything. Right? So, the provider is still seeing the patient, submitting claims to Medicare, Medicare’s still reimbursing them normally. And this is kind of like a second layer on top of fee-for-service. Ok, let’s see if you actually saved money compared to what we thought you were going to save, etc. The thing with MSSP is that it only goes up to 75% shared savings on the upside. Meaning that whatever savings you generate, you only get to keep 75% of it.

Next Gen was 100% risk, and that meant that whatever you saved, you get to keep all that you saved. So, you know, if you saved $3 on your entire patient population for the whole year, you get to keep those $3. Right? But, if you lost $3, you have to pay $3 back. So, that’s what they call first dollar savings and first dollar losses. But, you know, same with if you were able to generate $14 million in savings, you didn't have to pay a cut of that back to CMS. You got to keep the full amount of savings that you generated. So, that was kind of what Next Gen was. Next Gen also provided some really, kind of, interesting waivers that hadn't been tested before. So, they were trying to test some of the new waivers with Next Gen, so Skilled Nursing Facility Waiver (SNF) kind of started the Next Gen program before it moved to MSSP.

So, with the ACO REACH model, you still have providers that are submitting claims to CMS as you would in fee-for-service, but they have the ability to take out that reimbursement on fee-for-service. So, MSSP and Next Gen, they were still getting paid fee-for-service under everything. There is the ability, based on how you structure your ACO REACH model, to say, “Hey. You're not going to get, the provider's not going to get any money from Medicare at all.” And instead, that payment's going to come through come through the ACO, the ACO will get that money, and they're going to reimburse you based on how they decide to do it. It’s almost like putting a small, mini contract inside of a larger contract. Right? So, you almost like a Medicare Advantage, not in its entirety, but you're putting a smaller contract within this larger ACO REACH process. And, you're saying, “OK. We're going to make you accountable for these quality measures, or for annual Wellness visits, and you can earn some of this money back based on how you perform on these metrics.” Or some just say, “hey we're just going to pay you a straight PMPM, a per member per month. You have 10,000 patients in the model, we're going to pay, you know, whatever PMPM, and that's your pot of money that you get. We're not going to process claims at all. We're just going to know that you're doing what you should be doing to send that claims data to Medicare.” Because, you know, I mean, I think they're thinking that these the providers that are in these have been doing value-based care for a long time. And so, the quality measures that are required in MSSP that we're so used to, the web interface quality measures, you know, your colonoscopy screenings, your mammogram, all those things, we should be doing that for all patients. So, by the time you get to something as sophisticated as ACO REACH, they're saying “OK now you guys come up with the quality measures. What do you think is going to drive care and lower cost of care?”

Would it be typical for, in this new model, is it an upfront payment where the entity would receive the $14 million and then, oops you’re out, now you have to absorb the cost of care for if you go over? Or at the end of the of the year, do they make the accounting decisions and then send you a check of what the savings would be?

So, it kind of depends on how they structure, how you decide to structure your ACO REACH. So, we as the ACO, are getting weekly payments from Medicare based on the claims that were submitted the week before. So, we get a weekly claims file from Medicare that says, “hey in the last week, here's the claims that were processed, and here's the pot of money you can use to pay that.” But, at the end of the year, it's all going to be reconciled. Right? As you were saying, they're going to look at that benchmark that they've set, that target amount, at the end of the year and they're going to look at all the payments they gave us throughout the year, and they're going to determine was there any savings generated based on those payments that we gave you. And if so, you know, what do we need to claw back from you guys or what do what do what do you actually get in payment.

So, it just depends on how the ACO decides that they want to downstream pay their providers. I think one of the benefits of ACO REACH is that there is a lot of upfront money. Right? With MSSP, you had to wait you know a year, eight months after the performance year was over to actually see did we save anything, did we not, are we going to get a big payment. And I think REACH provides that kind of comfort in the days of COVID, when people are very low on cash, and you know scrambling for money for some of these places to stay open, REACH was very attractive because the ACOs could provide that upfront cash during each month or even on a weekly basis depending on how they wanted to structure things. And that, you know, gives them a little bit of a peace of mind. Now again, it'll all be reconciled on the back end, but that was a little bit of the of the upside to ACO REACH was that upfront cash flow for a lot of these smaller practices that were struggling.

I think that would be a huge benefit because then you could invest in the equipment, you could invest in the staffing, rather than trying to make do with you know everybody working three times as hard to make it happen. You could go ahead and get different things that you need.

Well, there was conversation in 2021/2022 about direct contracting. Where does that or where did direct contracting fit into this transition?

Yeah, so direct contracting was kind of the next iteration of what Next Gen was supposed to be. So, when Next Gen started sunsetting, they said OK the next thing is going to be direct contracting. And basically, that idea of the ACO is directly contracting with the providers. Which is what we see in REACH. This kind of idea of like setting a smaller plan, so to speak, inside of a larger framework. But what they noticed was, when they put out applicants for direct contracting, there were a lot of private equity firms that decided, “Hey. We’ve been in the MA market for a very long time. We’ve been able to, you know, approach or have a lot of patients via Medicare Advantage Plans. We’ve never really had a crack at traditional Medicare patients. The only way we get to the accountable for the patients cost of care is if they convert to an MA plan. And so, a lot of private equity firms spun up organizations in order to enter direct contracting. Because this was a new piece of the pie that they hadn't previously had access to, because it was just CMS, and the patient, right, and the provider. And there was no, you know, commercialization so to speak. I don't know if that's the best term to use, but it's a way to think about it.

So, there's a lot of private equity that entered the space, and then there was a lot of pushback on the hill from different senators who had heard that direct contracting was taking the rights of the traditional Medicare patient. You know, one of a patients’ rights is to be able to go anywhere. They can see whoever they want to see. There's no restriction like there is in other plans, where you have narrow network and things like that. A traditional Medicare patient should be able to see whatever provider they wanted to see. And there were some groups that were very vocal in their disagreement with the direct contracting plan, and really thought that this was kind of the death to traditional Medicare, is that it was you know bringing in this these new elements. Which is not true. There's a lot of misinformation out there, but it was heard at higher levels. And so, in an effort to make sure that the program, direct contracting, wasn’t scrapped altogether, CMS really put together some efforts to try to put protections around the patient, put a lot of transparency in the companies that were trying to come in and be in direct contracting. They wanted to look at governing bodies, who owns what company in this scenario, and they wanted that transparency in governance structure. And then, they also set up this kind of health equity lens, which is kind of one of their main goals for the next 10 years for the Innovation Center is to start to put health equity components in all of their models.

So, there was a really big focus on OK, lets make sure first of all we have transparency, second of all we're protecting the rights of the patients, but third we need to make sure that the patients are being treated equitably. And if anything, COVID really exposed the inequity in healthcare, right? It really did. And so, I think they realized this. We all realized that as well. And so, this is the first foray into really, OK, how do we how do we address this? And I don't think anybody has the right answer. You know, we hear the adage, if you see one ACO, you’ve seen one ACO. And so, all the populations are going to be different. So, how do we do this? I don't think anybody has the magic golden ticket of what to do, but we’ve got to start somewhere.

Well as, I'm going to put a spotlight on you for a moment, as someone who has been doing this for quite some time and who I consider you know one of the leading experts in this in the nation. What's your take on direct contracting?

That’s a really great question. Personally, I really felt like, it did, you did see some very odd companies trying to come into the traditional Medicare space. And then, kind of use the population of patients to convert them to their traditional MA plans. So, they were using direct contracting, and I will say this is what I’ve heard, but they were using some of those patients lists to do some things that they should not be doing with patient lists, like marketing them for MA plans or getting them to convert to MA plans, those types of things. So, you saw some kind of nefarious things happening that we heard whispers about. I think it's an interesting concept to allow this to happen, and I think if it's going to actually drive change in health populations, then let’s do it. But if it’s going to drive everyone to the all-mighty dollar, then I don’t know if I’m a fan of it. Personally, I want to see what’s best for the patient. I want to see, if this is going to help a patient population, OK then let’s help a patient population. But what are the motives behind that? So, I don’t know. We’ll see what happens. It was a little, I think there was a little bit of both sides. There was some misinformation at the congressional level, the senate level, of really the understand of what direct contracting was. And so there was a large effort from advocacy groups to try to combat that misinformation and help them understand how the patient is being protected. But at the same time, you have others coming in who just see, my...

Today we continue our conversation with CareNet’s Laneita Williamson to dig deeper into the effect of trauma on well-being and the impact of adverse childhood experiences on a patient's health. Laneita Williamson welcome back to the move to value podcast

Thank you so much I'm glad to be here

Last time we talked quite a bit about trauma and trauma informed car. Can you share how health care providers can help patients address their trauma?

Yes, so healthcare providers can learn about trauma-informed care and they can use that at the individual level, the organizational level and even advocate at the system level through legislation. But at the individual level once you learn about trauma-informed care, there are four Rs that we kind of want everybody to be utilizing with every person they come into contact with. Those four Rs are realizes, recognizes, responds, and resist.

So realizes means that we realize the widespread impact of trauma on patients. That there are adverse childhood experiences that changes the architecture of the brain when it's pervasive and toxic and then those changes create a latency period to adulthood. And then there's around 40 plus diagnosis that have a correlation to those childhood adversities and just knowing how many people, nationally and globally, have childhood adversities is the first step. We want to realize that the people we are treating today we are seeing the symptoms of what occurred decades ago in their childhood.

So when we realize that, our next step is going to be to recognize what those signs and symptoms are. How they show up in a clinic setting. Is it showing up through their social status? Is it showing up through their behaviors? Is it showing up through their inability to be part of the treatment plan, leaving against medical advice? Is it showing up with diagnosis that we know are correlated to that adversity or that trauma in childhood?

And then once we recognize those signs and symptoms, the our logical next step is, well how do we respond? You know, what do we do? Well we respond by fully integrating our knowledge about trauma with that individual you know asking them you know how are things in your life impacting you? What in your life has impacted you that may be working against you with your health right now? That can open up a discussion with the patient. Another way that they can, physicians or providers, can respond is to look at the hospital policies, procedures, and practices. What are we doing that may be hurting our patients instead of actually helping them?

Which that leads us into our last and final R which is resist. We want to seek to actively resist retraumatization and that may look different from one patient to the next. But once we become trauma informed, we learn very quickly to ask what makes you feel safe. We want to make sure that we're helping you in the space that you're in, and we do things from a lens of curiosity. Is what I'm about to do possibly a trigger for a person? And if it is, how can I work with this patient to help them know what may be part of their treatment plan and how we can navigate through it so that they are not traumatized.

So although there are four R's that will know of in trauma informed care, there are two more Rs that have been used in a recent book that I'm familiar with, and the first is repair and the second is resilience. Repair means it's important for us to acknowledge the ways in which our systems and our communities have been harmed through judgment, rejection of abuse, and how we have impacted those trauma survivors. And then resilience it's important that we recognize individuals may not have resilience. Resilience comes from having tools provided to an individual family or community that allows them to build resilience. So as we're working with our patients, what can we offer them to help any repair that may need to happen and to build their resilience to help take care of their health?

Our next Move to Value Summit is about community health workers and community resources and we talked a little bit about this leading up to our Nursing event that we held in December of 2022. I'm curious as to what community resources might be available to support trauma outside of the practice that a provider might be able to say “hey between our visits here somewhere you can go and talk to someone” - or if that resource isn't there, do you see a need for one?

So community resources is a challenge and the reason it a challenge is that nationally and globally we have not recognized the impact of trauma until we’re already behind the curve. So we don’t have enough centers or organizations to handle the influx of the trauma outcomes that we are seeing but what I want to, you know, encourage, is that communities can help heal from within. So part of trauma-informed care and being a provider is giving education. Just like we give education to new parents about covering up their outlets or using a car seat, you know, how to feed their babies sitting up and in ways to sleep, or if you're an adult your risk factors for smoking and what that does to you. As clinicians, we provide ongoing education every single day. So one of the things that's so good about trauma informed care is that we can provide education to our patients to take back into their communities and communities can utilize this information to heal in the way that they need to heal because every community has different historical trauma. different adversities. They know what they need. They also have the wisdom to heal from the inside out once they get the knowledge. Once they understand how they've been impacted and have been validated. Now that's not to say we don't need to continue to advocate for our nation to help our healthcare systems have more resources in the community, such as CareNet or Parenting Path, which is here in Winston-Salem, or Forsyth Family Services, there's so many good organizations going on, Smart Start. But we need more of those. So our social workers do have relationships with the agencies within our area that we can send people to, but we also want to encourage community self-healing and give that education to them.

Very well said. So what are adverse childhood experiences, also called ACEs, and how do they impact adult health?

Adverse childhood experiences or ACEs are potentially traumatic events that occur in childhood before the age of 18. So from that zero to 17 years. They include some main categories like abuse, neglect, and pervasive household dysfunction, Now underneath those categories you're going to have subcategories such as in abuse you may have sexual abuse, or physical abuse. In neglect it may be physical neglect, or emotional neglect. Then in household dysfunction, it can be examples such as a parent who has an unmanaged mental illness, substance misuse, interpersonal violence within the home, incarceration. All of these things can be impacting that child's brain development. So that's why we're calling them adverse childhood experiences.

These traumatic events again create this latency period to the onset of poor health outcomes later in life. These adversities, we now know that by the time there are six or more of those categories that I just spoke to, in the original adverse childhood experience study those patients that had six or more of those, their life expectancy was 20 years less than children who had none of those adversities. So we really want to understand that these patients had this 20 year reduction in life expectancy. But even before that, they were already having chronic illnesses, health issues, behavioral challenges, substance misuse, social issues, and these are things that again we want to be able to repair and help each patient build their own resilience. And as we've learned about adversities, there were those 10 original adversities from the adverse childhood experience study, but we know those are not the only things that impact children or they're developing brain.

So for example North Carolina has developed the North Carolina resilience community, has developed a tree that has four dimensions of adversities. The first one is going to be your adverse childhood experiences that I just discussed. The second will be the adverse community experiences. This is what's impacting our population – poverty, structural racism, community disinvestment, police violence, lack of affordable housing, lack of opportunity and economic mobility, discrimination, disconnected relationships, unemployment, and deteriorating built environments.

The third area of the tree is adverse climate experiences. These include examples such as climate change, wildfires, droughts, hurricanes, earthquakes, environmental injustice, pollution, floods, and COVID-19, which is very critical for our healthcare system. We were addressing the pandemic as it was occurring, but while it was occurring all of these adversities were impacting these children, which means there's a latency period that we're going to see in our future, whether that's 10-20 years, of an influx of these children who were experiencing these traumas in their homes when they were not at school, when no one was watching, or when their parent had to go to work and leave them there, maybe without food. So there's all of these challenges that's coming from the pandemic which is under the adverse climate experiences.

Then there's also atrocious cultural experiences. There's impact with macro and sociohistorical conditions, like slavery, genocide, colonization, segregation, forced family separation, removal of property, and then just a political and social mistrust. So our children who have gone through atrocious cultural experiences, they are impacted through their environment and their community and then that carries over into the next generation.

For the provider, how can adverse trauma experiences be identified in their patients, and how should this information impact a treatment plan?

As clinicians or providers we don't necessarily aim to identify specific adversities but we do walk into every situation, again, utilizing that universal precaution. The vast majority of people have experienced adversities and this is a very different understanding than what we once believed. We historically believe that adversities were rare or children were resilient with no lasting impacts, but now since we know differently, we just walk into every situation wondering what's happened to them instead of what's wrong with them. So a provider should always have trauma at the forefront of how they engage. They should consider how trauma has impacted this patient neurologically, psychologically, socially, and biologically, and again going back to looking at what's happened to them instead of what's wrong with them.

Having this knowledge and this approach alters every action in our treatment. It changes how we engage to minimize triggers. It helps us resist that retraumatization. It changes the questions we create in order to obtain our differential diagnosis. It changes what labs or treatments are to be considered. How we respond to the patient's beliefs, fears, and behaviors. Then we also begin to collaborate differently with other providers and just be cognizant of reporting to each other in a trauma informed approach. Helping a patient, again, can be very simple. Is walking in with this lens of what trauma has done to us and then just making sure that we are not retraumatizating them, that we're working with that patient. And then that approach and that lens impacts every step of the journey through a patient’s health process, whether it is maintaining, improving, or in some cases, even in Hospice care, we want to make sure that we're giving them a trauma informed care approach at every point in time.

Laneita, how can health systems prepare to care for the next generation of patients with adverse childhood experiences?

Make sure that you have a road map or a toolkit in place and different milestones. So you may, for example, have five milestones. The first would be conduct a readiness assessment. Is your organization ready to shift to that trauma-informed care lens. Do you have the leadership buy in or are the leaders actually helping you move trauma-informed care through the organization. You want to define your clinical roles and tasks, who's responsible for what. You want to gather your resources, get to know your network of care. Who around you is also working on the same types of approaches but may not be falling completely under trauma-informed care, but once they learn about it, it brings everybody together to have a better framework. Consider that financing and technology needs. What is needed? Is it that you have financing for trainers in every division or every department, or that you have enough technology to have an Intranet build in your system where your employees and staff can go and look for resources you know who to contact to schedule trainings. And again, you want to monitor, evaluate, and continue to improve you know your processes as you move forward.

Healthcare systems absolutely do need to listen and learn from their communities though, that is first and foremost. We need to discover our communities specific history, take those steps to repair any historical trauma through a trauma-informed care lens so that our healthcare systems will be utilized by those patients who have had mistrust, for very valid reasons. That will help break the cycle of that intergenerational transmission of ACEs into the next generation.

Well what can a provider do starting today to begin to address these behavioral health needs for their patients?

So oftentimes one of the questions that I get from providers is that I love this information you know it makes sense but what do I do with it? And what I tell the providers is that it's important to learn how to respond to someone that either shares that they have a history of trauma or that has been triggered. So the first thing that you can do is say we now know adversities in childhood can impact our adult health, how are body works, and how we cope. How do you feel any adversities in your past may be impacting you now? Often times that allows the patient to open up to share or to express a concern. Typically, they don't because it's such a private moment, they're not going to share a lot, and that's another thing that providers are worried about is the time. Most of the time they will just share something small. But when they do you thank the patient for sharing, validate their strength by stating I'm amazed at how you came through your trauma and are trying to take care of yourself, and then you know once you've asked how they're impacted and you’ve validated them by sharing that you’re amazed how they came through it, you can usually move forth in your treatment plan. They’ve shared something, you validated it, and it gives you the knowledge that you need for that next step of where to go in your treatment plan.

Outstanding! Laneita Williamson, thank you for joining us today on the move to value podcast

Thank you so much it was truly a delight to be here.

Today we talk with Laneita Williamson the trauma informed care manager at CareNet, who shares with us the effect of trauma on a patient, and also ways it can impact their care, and techniques for managing this potential barrier to positive outcomes. Laneita Williamson welcome to the move to value podcast.

Thank you so much I am so glad to be with you today and to talk with you.

Well we certainly are glad that you could join us. So my first question for you Laneita is what is trauma?

Sure, so if we're thinking about trauma we want to think about it as an event a series of events or a set of circumstances experienced as physically or emotionally harmful or life threatening and then has a lasting adverse effect on you, as the individual, or an organization, or communities, functioning. And this could be your functioning mentally, physically, socially, emotionally, and even your spiritual well-being.

So now I want to ask you - what is trauma informed care and what are the benefits?

When we are thinking about trauma informed care we want to recognize that it is an approach. It's an approach that a program organization or system takes when they become informed about trauma and the impacts from trauma. It is the approaches taken by those that realize the widespread impact of trauma and then understands the potential paths for recovery. And then also recognize the signs and symptoms of trauma in your clients, families, staff and the others. They would integrate knowledge about trauma into the policies procedures and practices. And then of course we want to seek to actively resist retraumatization in those clients, family, staff, or each other. And in regards to the benefits of a trauma informed care approach, what it ends up doing is it allows us to listen to our patients more. We begin to practice more patience and then that creates more empathy. We learn to get along better as a team. When a patient or a client or someone does something harmful, we actually began to look at the reason why or understand what is the cause of that action instead of judging that person. We also talk about how our work actually impacts us or affects us and then when we're having that connection and that peer connection with each other, we began to develop tools that help us understand what we need in our work day in order to continue forward. We begin to have new ideas, new creations of treatment plans, you know, recognize how we're to work together as a team or you know to address system issues and just create that connectedness to each other. This all of this allows us to feel more valued and be human and to recognize it's OK to have our human feelings to take care of ourselves and then to come back reenergized and hopeful so that our resilience is increased. The trauma informed care really does have a lot of benefits.

Well can you share an example or two from your own experience of how trauma informed care has been used to improve a patient outcome?

So there's so many examples we can use when working with patients in a hospital system where trauma informed care actually impacts that patient in such a way that it creates a better outcome. And I have so many stories, but it can be something as simple as you as a clinician or provider identify that it's not necessary to get a lab draw in the middle of the night. And the reason for that is that when we are going into a person's private space which is there you know hospital bed, their hospital room, to wake them up, then that can actually trigger them and they will want to leave the hospital. They may go back into a time where that being awakened during the middle of the night was something that was a trauma. So as we begin to think through how we work with our patients we've recognized something as simple as lab draws, we do it at a later time in the morning when they're awake. Or if we have someone who is struggling with addiction and they're in our suboxone clinic, we recognize that getting a lab stick may be a trigger and can actually send them back into injecting again. So we try to minimize those lab visits or have peer support with them so that they've got somebody there to actually help them through the process. So, again, there's so many benefits to trauma informed care but that is one simple you know example that we can use in our everyday practice. Of course there are many more stories that I could share that revolve around things like workplace violence and patients that have shared their stories that wanted to leave the hospital because they were being triggered by maybe a bath and maybe their trauma in childhood was around a bath and we found ways to work with that patient to create a new treatment plan so that they felt safe they had a choice and they were able to stay in the hospital setting.

Laneita, how do we go about discovering what past traumas may be present for our patients?

When we're thinking about our patients coming into any setting, no matter where you may work, we begin with a universal precaution. And that means that we assume all patients have had trauma and then we approach that patient just like we know they're coming in for an acute traumatic violent event. We use some of the same strategies and tools and we may not identify if this patient has had physical abuse, sexual abuse, emotional abuse, or neglect, but we're using the same approaches to that patient so that they already feel safe. They already know that there's someone that is allowing them to be in a space where they have a voice and they can actually feel safe and be a part of the treatment plan. We don't have to necessarily get into specifics of a trauma or ask specific information, like were you physically abused or sexually abused because we're going to be using the same approach no matter what.

It's funny that you mentioned the approach because that leads into my next question. Will you explain to us the six guiding principles of trauma informed care?

When we are approaching our patients through a trauma informed care lens, we do want to use the six guiding principles and the very first one of those is safety.

And of course you know most people in medicine is going to say well we already provide safety. And yes we do have a framework for safety - are they not falling, you know, are they getting the right medicines, the right treatment plans. But what I mean by this is does that person feel psychologically emotionally safe not retraumatized, not triggered. And one of the ways that we can do that is by asking questions. By asking that patient, What makes you feel safe today? How can I help you feel safe? Would you like the door open? The door closed? How would you like me to address you? What are the best ways that you can have this procedure? Is it with a friend? Is it someone there for you? Is there anything you need us to know before we begin this treatment plan? So just identifying safety is the first principle.

The second principle kind of has two components. It is trustworthiness and transparency. Trustworthiness means that we are utilizing concrete information, we are not making promises that we cannot meet, we are being open, we are talking with that patient, we are keeping things factual so that everybody is on the same page hearing the same information and again that transparency, if something has occurred then we talked to that patient. Or if we think there is something that's going to be happening in the near future maybe we want to get an X-ray or we want to do certain treatments or labs, we go in and we say these are the things that we are thinking about, we wanted to share this with you and see what your thoughts are to these treatment plans.

The other thing or the third principle is peer support. Who do you want with you? If they don't have a family member, which they often may not, that they feel is trustworthy, can we offer chaplains. Is there someone that can come visit you? Is there a friend in the community? And if this is a person that has had an injury that's going to be a life changing event, such as an amputation, there are peer support groups for those. Would you like a peer support advocate to come in and be with you.

The fourth is collaboration and mutuality, we're always wanting to collaborate with the patient. Have that mutual decision-making process. Yes we are looking at all of the symptoms and then we are coming up with our differential diagnosis. However, all of that information needs to be shared with that patient and that patient needs to be part of that decision making process of how their health is going to be managed.

We want to empower them so no matter what it may be, if they're coming in and they are just really at a place that they can't cope but we can find one thing that they are doing well, empower that empower that moment with them so that they know that they've got that skill set and then help build them to the next skill set to make it through that journey of their health. Because healthcare journeys can be short or can go on for years. So we want to empower everything that they do that is helping them move forward for themselves at the rate that they can move forward.

We want to give them a voice and a choice. You know, what are their thoughts about their health? Maybe our goals are not their goals so we need to hear what their voice is and we want to give them the choice. You're maybe is something as simple as your A1C is too high we would like to change, which is your blood sugar, we would like to change your meal plans and your diet and your exercise so that we can lower that and actually help you stay healthy for longer. But that may be their meals may be the best that they can do or coping mechanism, so it may not be something that they're ready to do. So we have to give them that choice. We have to think about their culture where are they coming from you know which area or region.

There are historical trauma into any gender challenges that may be coming up while they're in a healthcare setting, which oftentimes may feel like a very unsafe space for LGBTQ community. So we want to actually support them any way that we can. So just to recap the six principles are safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment voice and choice, and then cultural historical and gender issues.

That was a very comprehensive answer. Can you take it a step further and share what a trauma informed care approach would look like in a clinical setting?

Trauma informed care in a clinical setting is going to be literally embedded in everything from governance and leadership to finances. There are 10 organizational domains that is applicable for trauma informed care. And the first is governance and leadership. You have those leaders that understand what trauma informed care means and they are backing it they are finding ways to make trauma informed care education, knowledge, cultural changes take place and they help you lead that mission throughout the entire enterprise.

You're looking at policies. Are your policies trauma informed? Maybe they are maybe they are already as good as they can be or maybe they're missing a component to where we're not helping the employees or the staff feel safe in certain situations. Maybe when it's their annual review or when there is a challenge that comes up. So we're looking at those policies from the same guiding principles that we use with patients.

We look at our physical environment. Is it welcoming? Is it using the correct colors to help calm people? Are there the correct smells? Lighting? Is there lighting in the parking lot? Is there security that's available for urgent needs? You know that physical environment is extremely important. For example when we walk into a spa it's all quiet it smells good and we immediately relax. But when we walk into a clinical setting that is chaos and we don't have an environment set up for either the number of people or the sound and the noise or what we see or what we hear, that actually triggers people in trauma. So we would want to look at those physical environments and actually make it a place that would down regulate those emotional stressors for those sick patients that are coming in with a history of trauma.

We want to have engagement and involvement, not only with each other, but with our community. What is our community saying that they need from our organization. Do they need something that we've never thought about?

We want to look at cross sector collaboration. How do our departments work together utilizing the six guiding principles with each other and thinking about how we can come together and be a team that helps the patient, helps the system and the organization move forward with the safety lens of trauma informed care. When indicated in certain environments in clinic settings or in the hospital and when the organization has reached the point that they are trauma informed.

We can think about screening, assessment, and then referrals or treatment if needed for those trauma survivors.

There is ongoing training and workforce development it can be around safety it can be through workplace violence incidents it can be through annual training modules but we want to make sure that that training of trauma informed care and just continues to help the workforce, especially in hospital settings because there's so much turnover in staff, that trauma informed care is not a one and done is a continual journey. It's not an end goal.

We want to look at progress and monitor what we've been doing. Look at some data see how it's working.

You know think about that quality assurance making sure that we are reflecting upon all of the process changes that we've implemented through a trauma informed care lens and continue to improve upon that or maintain it if we've reached the goal that we want.

We want to think about financing. How does this work? How do we have enough people on board that can help teach others that can provide material and how do we allow enough financing that we can have our clinicians come out of their space for just enough time to get their training and to do some of their research and then practice it and then go back into their specific specialty in space and continue forward with trauma informed care?

And of course, then evaluate all of that. So those ten organizational domains again just to recap those this governance and leadership policy physical environment engagement and involvement cross sector collaboration screening assessment and treatment when indicated training and workforce development progress monitoring and quality assurance financing and evaluation.

Outstanding! Laneita Williamson thank you for joining us today on the Move to Value Podcast.

Thank you so much! I have really enjoyed being with you today and just going through these questions, thank you.