National Academies Press: OpenBook

Systems Practices for the Care of Socially At-Risk Populations (2016)

Chapter: Appendix A Example Implementation Strategies and Case Studies

« Previous: 2 Improving Care for Socially At-Risk Populations
Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×

Appendix A

Example Implementation Strategies and Case Studies

As described in Chapters 1 and 2, the committee reviewed both the peer-reviewed and grey literature in order to identify strategies providers disproportionately serving socially at-risk populations have implemented to improve care and outcomes for their patients. As part of this effort, the committee reached out to organizations known to conduct research or represent providers disproportionately serving socially at-risk populations (Alliance of Community Health Plans, America’s Essential Hospitals, America’s Health Insurance Plans, and The Commonwealth Fund) who submitted 60 case studies. The committee also searched the published literature to identify additional examples. Based on a review of the case studies submitted, informed also by the literature and, in some cases, committee members’ empirical research or professional experience delivering care to socially at-risk populations, the committee identified commonalities from which it concluded that six community-informed and patient-centered systems practices show promise for improving care for socially at-risk populations.

This appendix includes a series of tables that provide a selection of implementation strategies and case studies in which these strategies were identified for each of the six systems practices. Table A-1 includes examples regarding a commitment to health equity, Table A-2 includes examples of data and measurement strategies, Table A-3 has examples of components of comprehensive needs assessments, Table A-4 provides examples of collaborative partnerships, Table A-5 offers strategies for providing care continuity, and Table A-6 lists examples of engaging patients in their care. These tables aim to illustrate the range and types of activities that individual health care providers have implemented to apply each of the six systems practices. This appendix should therefore be considered a series of illustrative examples rather than a comprehensive and exhaustive list of organizations and practical strategies identified in the published and grey literature.

Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×

TABLE A-1 Commitment to Health Equity: Example Implementation Strategies and Case Studies

Example Implementation Strategy Example Case Studies
Senior management and clinician leadership commitment to equity HealthPartners Minnesotaa
Kaiser Permanenteb
Integration of health equity into and communication of equity as part of common organization vision, mission, and goals HealthPartners Minnesotaa
Kaiser Permanenteb
Internal leaders designated responsibility for developing and overseeing a strategic plan to monitor and reduce health inequities HealthPartners Minnesotaa
Diverse workforce to provide culturally concordant and culturally competent care HealthPartners Minnesotaa
Hennepin Healthc
Kaiser Permanenteb
Tucson and Southern Arizonad
Workforce trainings and education to improve communication with patients, including cultural competence training and hiring language interpreters HealthPartners Minnesotaa
Interventions to reduce inequities HealthPartners Minnesotaa
Kaiser Permanenteb
Identification and acknowledgment of health inequities and setting measurable goals to reduce them HealthPartners Minnesotaa
Expectations set and feedback provided regarding activities and practices to achieve equity HealthPartners Minnesotaa
Incorporation of health equity into compensation or incentives HealthPartners Minnesotaa
Financial and non-financial resources aligned and allocated to promote health equity HealthPartners Minnesotaa
Kaiser Permanenteb

SOURCES:

a Personal communication, Susan Knudson (HealthPartners) to Charles Baumgart (committee member), December 14, 2015.

b Meyers, 2008.

c Sandberg et al., 2014.

d Klein et al., 2014b.

Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×

TABLE A-2 Data and Measurement: Example Implementation Strategies and Case Studies

Example Implementation Strategy Example Case Studies
Regular, standardized collection of social risk factor data Denver Healtha
Analysis and monitoring of performance data disaggregated by indicators of social risk to identify existing health disparities within organizations HealthPartners Minnesotab
Enhanced risk prediction models Denver Healtha
Montefiore Medical Centerc

SOURCES:

a Hostetter and Klein, 2015.

b Personal communication, Susan Knudson (HealthPartners) to Charles Baumgart (committee member), December 14, 2015.

c McCarthy and Chase, 2010.

TABLE A-3 Comprehensive Needs Assessment: Example Implementation Strategies and Case Studies

Example Implementation Strategy Example Case Studies
Proactive health assessment tool completed by patients Kaiser Permanente Colorado PATHWAAYa
Community Care of North Carolinab
Analysis of data from a variety of sources (including performance data, utilization data, clinical notes, patient observations, and patient-generated data) Denver Healthc
Kaiser Permanente Colorado PATHWAAYa
Information-exchange portal for clinical providers, social service agencies, public health agencies, and community organizations to share information (with patient permission) about social needs Colorado Coalition for the Homelessd
Parkland Hospitale

NOTE: PATHWAAY = Proactive Assessment of Total Health and Wellness to Add Active Years.

SOURCES:

a ACHP, n.d.-c.

b Klein and McCarthy, 2009.

c Hostetter and Klein, 2015.

d Klein, 2014.

e Personal communication, Doug McCarthy (The Commonwealth Fund) to staff, January 12, 2016

Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×

TABLE A-4 Collaborative Partnerships: Example Implementation Strategies and Case Studies

Example Implementation Strategy Example Case Studies
Medical neighborhoods/accountable health communities Colorado Regional Care Collaborative Organizationsa
Hennepin Healthb
Minnesota Accountable Communities for Healtha
Oregon Coordinated Care Organizationsa
Care teams including non-medical professionals Citywide Colon Cancer Control Coalitionc
Hennepin Healthb
Truman Medical Centerd
Open-access/same-day appointments for ambulatory care The New York City Health and Hospitals Corporatione
Alaska Native Medical Centerf
Denver Healthg
New technologies (e.g., teleconference, videoconference, and mobile screening units) that bring clinical care to patients Montefiore Medical Centerh
West County Health Centersi
Community Health Centers, Inc.j
Project ECHOj
Regional collaborations with other health care providers Western New York, West Central Michigan, Southern
Arizonak
Health Share of Oregonl
Hennepin Healthm
MetroHealth Care Plusn
Involvement and collaboration with social service and public health agencies and community organizations Colorado Coalition for the Homelessl
Hennepin Healthb
Montefiore Medical Centerh
Neighborhood Health Planp
UPMC for You Cultivating Health for Successq
Denver Healthg

SOURCES:

a Corrigan and Fisher, 2014.

b Sandberg et al., 2014.

c Itzkowitz et al., 2016.

d America’s Essential Hospitals, 2015.

e McCarthy and Mueller, 2008.

f Murray et al., 2003.

g McCarthy et al., 2007.

h McCarthy and Chase, 2010.

i Hostetter and Klein, 2014.

j Felland et al., 2013.

k McCarthy et al., 2014.

l Klein, 2014.

m Hostetter and Klein, 2015.

n Cebul et al, 2015.

p Silow-Carroll and Rodin, 2013.

q Lovelace, 2016.

Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×

TABLE A-5 Care Continuity: Example Implementation Strategies and Case Studies

Example Implementation Strategy Example Case Studies
Coordinated care teams Priority Health Tandem 365a
Kaiser Permanente Colorado PATHWAAYb
Fallon Health NaviCare and Summit ElderCare Programsc
Hennepin Healthd
Denver Healthe
Truman Medical Centerf
Case management by trained clinical or lay person care coordinators/patient navigators Geisinger Health Plan Medically Complex Medical Homeg
The New York City Health and Hospitals Corporationh
Health Care Homes in Minnesotai
New technologies (teleconference, videoconference, shared data) to coordinate care between clinical and social service providers West County Health Centersj
Collocating clinical, behavioral health, and social services Priority Health Tandem 365a
Colorado Coalition for the Homelessk
Hennepin Healthd
Cherokee Health Systemsl
Truman Medical Centerf
Eskenazi Hospitalm
Patient education about care transitions Geisinger Health Plan Medically Complex Medical Homeg

NOTE: PATHWAAY = Proactive Assessment of Total Health and Wellness to Add Active Years.

SOURCES:

a ACHP, n.d.-d.

b ACHP, n.d.-c.

c ACHP, n.d.-a.

d Sandberg et al., 2014.

e McCarthy et al., 2007.

f America’s Essential Hospitals, 2015.

g ACHP, n.d.-b.

h McCarthy and Mueller, 2008.

i Felland et al., 2013.

j Hostetter and Klein, 2014.

k Klein, 2014.

l Personal communication, Doug McCarthy (The Commonwealth Fund) to staff, January 12, 2016.

m America’s Essential Hospitals, 2014.

Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×

TABLE A-6 Engaging Patients in Their Care: Example Implementation Strategies and Case Studies

Example Implementation Strategy Example Case Studies
Patient education about self-management, healthy behaviors, and care coordination Genesys HealthWorksa
Cook County Health & Hospitals Systemb
Culturally sensitive, targeted, and tailored patient education New York City Citywide Colon Cancer Control Coalitionc
UCare (UCare Response to CMS)d
Denver Healthe
Tailored care plans easily understood by patients Geisinger Health Plan Medically Complex Medical Homef
Kaiser Permanente Colorado PATHWAAYg
Clinician and non-clinician patient/health navigation Best Babies Zoneh
Genesys HealthWorksa
New York City Citywide Colon Cancer Control Coalitionc
New technologies (telephone consultation, videoconference, mobile screenings, smartphone apps, etc.) to promote healthy behaviors and reduce health risks Columbus Regionali
Genesys HealthWorksa
West County Health Centersi
Reach patients through community centers, homeless shelters, religious organizations, schools Best Babies Zoneh
Health Plan of San Mateoj
Hennepin Healthi
Denver Healthe

NOTE: CMS = Centers for Medicare & Medicaid Services; PATHWAAY = Proactive Assessment of

Total Health and Wellness to Add Active Years.

SOURCES:

a Klein and McCarthy, 2010.

b America’s Essential Hospitals, 2014.

c Itzkowitz et al., 2016.

d Personal communication, Mark Hamelburg (America’s Health Insurance Plans) to Charles Baumgart (committee member), December 18, 2015.

e McCarthy et al., 2007.

f ACHP, n.d.-b.

g ACHP, n.d.-c.

h Foubister, 2013.

i Hostetter and Klein, 2015.

j Personal communication, Doug McCarthy (The Commonwealth Fund) to staff, January 12, 2016.

Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×

REFERENCES

ACHP (Alliance of Community Health Plans). n.d.-a. Fallon Health Navicare and Summit Eldercare programs. http://www.achp.org/wp-content/uploads/report-Innovation_ElderCare_FALLON.pdf (accessed December 14, 2015).

ACHP. n.d.-b. Geisinger Health Plan’s medically complex medical home program. http://www.achp.org/wp-content/uploads/report-Innovation_ElderCare_GEISINGER.pdf (accessed December 14, 2015).

ACHP. n.d.-c. Kaiser Permanente’s PATHWAAY program. http://www.achp.org/wpcontent/uploads/report-Innovation_ElderCare5.8.15_KP.pdf (accessed December 14, 2015).

ACHP. n.d.-d. Priority Health’s tandem365 program. http://www.achp.org/wp-content/uploads/reportInnovation_ElderCare_PRIORITY.pdf (accessed December 14, 2015).

America’s Essential Hospitals. 2014. Community-focused steps to boosting nutrition, wellness. http://essentialhospitals.org/quality/community-focused-steps-to-boosting-nutrition-wellness (accessed March 18, 2016).

America’s Essential Hospitals. 2015. Improving care transitions for socially, medically complex patients. http://essentialhospitals.org/quality/improving-care-transitions-for-socially-medically-complexpatients (accessed March 18, 2016).

Cebul, R. D., T. E. Love, D. Einstadter, A. S. Petrulis, and J. R. Corlett. 2015. Metrohealth care plus: Effects of a prepared safety net on quality of care in a Medicaid expansion population. Health Affairs 34(7):1121–1130.

Corrigan, J. M., and E. S. Fisher. 2014. Accountable health communities: Insights from state health reform initiatives. http://tdi.dartmouth.edu/images/uploads/AccountHealthCommWhPaperFinal.pdf (accessed March 7, 2016).

Felland, L. E., A. E. Lechner, and A. Sommers. 2013. Improving access to specialty care for Medicaid patients: Policy issues and options. http://www.commonwealthfund.org/~/media/files/publications/fundreport/2013/jun/1691_felland_improving_access_specialty_care_medicaid_v2.pdf (accessed March 8, 2016).

Foubister, V. 2013. Case study: Louisiana’s poor rankings make improving birth outcomes a state imperative. http://www.commonwealthfund.org/publications/newsletters/qualitymatters/2013/february-march/case-study (accessed February 4, 2016).

Hostetter, M., and S. Klein. 2014. In focus: Innovating care delivery in the safety net. http://www.commonwealthfund.org/publications/newsletters/quality-matters/2014/december2014-january-2015/in-focus (accessed February 2, 2016).

Hostetter, M., and S. Klein. 2015. In focus: Segmenting populations totailor services, improve care. http://www.commonwealthfund.org/publications/newsletters/quality-matters/2015/june/in-focus (accessed March 8, 2016).

Itzkowitz, S. H., S. J. Winawer, M. Krauskopf, M. Carlesimo, F. H. Schnoll-Sussman, K. Huang, T. K. Weber, and L. Jandorf. 2016. New York Citywide Colon Cancer Control Coalition: A public health effort to increase colon cancer screening and address health disparities. Cancer 122(2):269–277.

Klein, S. 2014. Colorado Coalition for the Homeless: A model of supportive housing. http://www.commonwealthfund.org/publications/newsletters/quality-matters/2014/octobernovember/case-study (accessed February 2, 2016).

Klein, S., and D. McCarthy. 2009. North Carolina’s ABCD program: Using community care networks to improve the delivery of childhood developmental screeing and referral to early intervention services. http://www.commonwealthfund.org/publications/issue-briefs/2009/aug/north-carolinas-abcd-program-using-community-care-networks-to-improve-the-delivery (accessed March 8, 2016).

Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×

Klein, S., and D. McCarthy. 2010. Genesys HealthWorks: Pursuing the triple aim through a primary care-based delivery system, integrated self-management support, and community partnerships. http://www.commonwealthfund.org/publications/case-studies/2010/jul/genesys-healthworks (accessed February 2, 2016).

Klein, S., D. McCarthy, and A. Cohen. 2014a. Health Share of Oregon: A community-oriented approach to accountable care for Medicaid beneficiaries. http://www.commonwealthfund.org/publications/case-studies/2014/oct/health-share-oregon-aco-case-study (accessed February 2, 2016).

Klein, S., D. McCarthy, and A. Cohen. 2014b. Tuscon and southern Arizona: A desert region pursuing better health and health system performance. http://www.commonwealthfund.org/publications/case-studies/2014/apr/tucson-and-southern-arizona-a-desert-region-pursuing-better-health-and-health-system-performance (accessed March 8, 2016).

Lovelace, J. 2016. Integrating health care and supported housing to improve the health and well-being of the homeless: A population health case study. http://nam.edu/integrating-health-care-and-supported-housing-to-improve-the-health-and-well-being-of-the-homeless-a-population-health-case-report/ (accessed March 29, 2016).

McCarthy, D., and D. Chase. 2010. Montefiore medical center: Integrated care delivery for vulnerable populations. http://www.commonwealthfund.org/publications/case-studies/2010/oct/montefiore-medical-center (accessed March 8, 2016).

McCarthy, D., and K. Mueller. 2008. The New York City health and hospitals corporation: Transforming a public safety net delivery system to achieve higher performance. http://www.commonwealthfund.org/~/media/files/publications/fund-report/2008/oct/the-new-york-city-health-and-hospitals-corporation--transforming-a-public-safety-net-delivery-system/mccarthy_nychlthospitalscorpcasestudy_1154-pdf.pdf (accessed February 4, 2016).

McCarthy, D., C. Beck, R. Nuzum, and A. Gauthier. 2007. Denver Health: A high-performance public health care system. http://www.commonwealthfund.org/publications/fundreports/2007/jul/denver-health--a-high-performance-public-health-care-system (accessed March 18, 2016).

McCarthy, D., S. Klein, and A. Cohen. 2014. Opportunity for regional improvement: Three case studies of local health system performance. http://www.commonwealthfund.org/~/media/files/publications/casestudy/2014/apr/1737_mccarthy_regional_case_study_synthesis_v2.pdf (accessed March 8, 2016).

Meyers, K. 2008. Beyond equal care: How health systems can impact racial and ethnic health disparities. http://share.kaiserpermanente.org/media_assets/pdf/communitybenefit/assets/pdf/our_work/global/BeyondEqualCare2001_08.pdf (accessed February 2, 2016).

Murray, M., T. Bodenheimer, D. Rittenhouse, and K. Grumbach. 2003. Improving timely access to primary care: Case studies of the advanced access model. Journal of the American Medical Association 289(8):1042–1046.

Sandberg, S. F., C. Erikson, R. Owen, K. D. Vickery, S. T. Shimotsu, M. Linzer, N. A. Garrett, K. A. Johnsrud, D. M. Soderlund, and J. DeCubellis. 2014. Hennepin health: A safety-net accountable care organization for the expanded Medicaid population. Health Affairs 33(11):1975–1984.

Silow-Carroll, S., and D. Rodin. 2013. Forging community partnerships to improve health care: The experience of four Medicaid managed care organizations. http://www.commonwealthfund.org/publications/issue-briefs/2013/apr/forging-community-partnerships-to-improve-care (accessed February 2, 2016).

Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×
Page 69
Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×
Page 70
Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×
Page 71
Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×
Page 72
Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×
Page 73
Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×
Page 74
Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×
Page 75
Suggested Citation:"Appendix A Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2016. Systems Practices for the Care of Socially At-Risk Populations. Washington, DC: The National Academies Press. doi: 10.17226/21914.
×
Page 76
Next: Appendix B Committee Biosketches »
Systems Practices for the Care of Socially At-Risk Populations Get This Book
×
Buy Paperback | $44.00 Buy Ebook | $35.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

The Centers for Medicare & Medicaid Services (CMS) have been moving from volume-based, fee-for-service payment to value-based payment (VBP), which aims to improve health care quality, health outcomes, and patient care experiences, while also controlling costs. Since the passage of the Patient Protection and Affordable Care Act of 2010, CMS has implemented a variety of VBP strategies, including incentive programs and risk-based alternative payment models. Early evidence from these programs raised concerns about potential unintended consequences for health equity. Specifically, emerging evidence suggests that providers disproportionately serving patients with social risk factors for poor health outcomes (e.g., individuals with low socioeconomic position, racial and ethnic minorities, gender and sexual minorities, socially isolated persons, and individuals residing in disadvantaged neighborhoods) may be more likely to fare poorly on quality rankings and to receive financial penalties, and less likely to receive financial rewards.

The drivers of these disparities are poorly understood, and differences in interpretation have led to divergent concerns about the potential effect of VBP on health equity. Some suggest that underlying differences in patient characteristics that are out of the control of providers lead to differences in health outcomes. At the same time, others are concerned that differences in outcomes between providers serving socially at-risk populations and providers serving the general population reflect disparities in the provision of health care.

Systems Practices for the Care of Socially At-Risk Populations seeks to better distinguish the drivers of variations in performance among providers disproportionately serving socially at-risk populations and identifies methods to account for social risk factors in Medicare payment programs. This report identifies best practices of high-performing hospitals, health plans, and other providers that serve disproportionately higher shares of socioeconomically disadvantaged populations and compares those best practices of low-performing providers serving similar patient populations. It is the second in a series of five brief reports that aim to inform the Office of the Assistant Secretary of Planning and Evaluation (ASPE) analyses that account for social risk factors in Medicare payment programs mandated through the Improving Medicare Post-Acute Care Transformation (IMPACT) Act.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!