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Suggested Citation:"BA: Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2017. Accounting for Social Risk Factors in Medicare Payment. Washington, DC: The National Academies Press. doi: 10.17226/23635.

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BA

Example Implementation Strategies and Case Studies

As described in Appendixes B1 and B2, 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 BA-1 includes examples regarding a commitment to health equity, Table BA-2 includes examples of data and measurement strategies, Table BA-3 has examples of components of comprehensive needs assessments, Table BA-4 provides examples of collaborative partnerships, Table BA-5 offers strategies for providing care continuity, and Table BA-6 lists examples of engaging patients in their care. These tables aim to illustrate the range and types of activities

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Suggested Citation:"BA: Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2017. Accounting for Social Risk Factors in Medicare Payment. Washington, DC: The National Academies Press. doi: 10.17226/23635.

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TABLE BA-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 Minnesota^a Kaiser Permanente^b
Integration of health equity into and communication of equity as part of common organization vision, mission, and goals	HealthPartners Minnesota^a Kaiser Permanente^b
Internal leaders designated responsibility for developing and overseeing a strategic plan to monitor and reduce health inequities	HealthPartners Minnesota^a
Diverse workforce to provide culturally concordant and culturally competent care	HealthPartners Minnesota^a Hennepin Health^c Kaiser Permanente^b Tucson and Southern Arizona^d
Workforce trainings and education to improve communication with patients, including cultural competence training and hiring language interpreters	HealthPartners Minnesota^a
Interventions to reduce inequities	HealthPartners Minnesotaa Kaiser Permanente^b
Identification and acknowledgment of health inequities and setting measurable goals to reduce them	HealthPartners Minnesota^a
Expectations set and feedback provided regarding activities and practices to achieve equity	HealthPartners Minnesota^a
Incorporation of health equity into compensation or incentives	HealthPartners Minnesota^a
Financial and non-financial resources aligned and allocated to promote health equity	HealthPartners Minnesota^a Kaiser Permanente^b

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.

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Suggested Citation:"BA: Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2017. Accounting for Social Risk Factors in Medicare Payment. Washington, DC: The National Academies Press. doi: 10.17226/23635.

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TABLE BA-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 Health^a
Analysis and monitoring of performance data disaggregated by indicators of social risk to identify existing health disparities within organizations	HealthPartners Minnesota^b
Enhanced risk prediction models	Denver Health^a Montefiore Medical Center^c

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 BA-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 PATHWAAY^a Community Care of North Carolina^b
Analysis of data from a variety of sources (including performance data, utilization data, clinical notes, patient observations, and patient-generated data)	Denver Health^c Kaiser Permanente Colorado PATHWAAY^a
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 Homeless^d Parkland Hospital^e

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.

Page 306 Cite

Suggested Citation:"BA: Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2017. Accounting for Social Risk Factors in Medicare Payment. Washington, DC: The National Academies Press. doi: 10.17226/23635.

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

Example Implementation Strategy	Example Case Studies
Medical neighborhoods/accountable health communities	Colorado Regional Care Collaborative Organizations^a Hennepin Health^b Minnesota Accountable Communities for Health^a Oregon Coordinated Care Organizations^a
Care teams including non-medical professionals	Citywide Colon Cancer Control Coalition^c Hennepin Health^b Truman Medical Center^d
Open-access/same-day appointments for ambulatory care	The New York City Health and Hospitals Corporation^e Alaska Native Medical Center^f Denver Health^g
New technologies (e.g., teleconference, videoconference, and mobile screening units) that bring clinical care to patients	Montefiore Medical Center^h West County Health Centersⁱ Community Health Centers, Inc.^j Project ECHO^j
Regional collaborations with other health care providers	Western New York, West Central Michigan, Southern Arizona^k Health Share of Oregon^l Hennepin Health^m MetroHealth Care Plusⁿ
Involvement and collaboration with social service and public health agencies and community organizations	Colorado Coalition for the Homeless^l Hennepin Health^b Montefiore Medical Center^h Neighborhood Health Plan^p UPMC for You Cultivating Health for Success^q Denver Health^g

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 et al., 2014a.

^m Hostetter and Klein, 2015.

ⁿ Cebul et al, 2015.

^p Silow-Carroll and Rodin, 2013.

^q Lovelace, 2016.

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Suggested Citation:"BA: Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2017. Accounting for Social Risk Factors in Medicare Payment. Washington, DC: The National Academies Press. doi: 10.17226/23635.

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

Example Implementation Strategy	Example Case Studies
Coordinated care teams	Priority Health Tandem 365^a Kaiser Permanente Colorado PATHWAAY^b Fallon Health NaviCare and Summit ElderCare Programs^c Hennepin Health^d Denver Health^e Truman Medical Center^f
Case management by trained clinical or lay person care coordinators/patient navigators	Geisinger Health Plan Medically Complex Medical Home^g The New York City Health and Hospitals Corporation^h Health Care Homes in Minnesotaⁱ
New technologies (teleconference, videoconference, shared data) to coordinate care between clinical and social service providers	West County Health Centers^j
Collocating clinical, behavioral health, and social services	Priority Health Tandem 365^a Colorado Coalition for the Homeless^k Hennepin Health^d Cherokee Health Systems^l Truman Medical Center^f Eskenazi Hospital^m
Patient education about care transitions	Geisinger Health Plan Medically Complex Medical Home^g

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.

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Suggested Citation:"BA: Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2017. Accounting for Social Risk Factors in Medicare Payment. Washington, DC: The National Academies Press. doi: 10.17226/23635.

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TABLE BA-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 HealthWorks^a Cook County Health & Hospitals System^b
Culturally sensitive, targeted, and tailored patient education	New York City Citywide Colon Cancer Control Coalition^c UCare (UCare Response to CMS)^d Denver Health^e
Tailored care plans easily understood by patients	Geisinger Health Plan Medically Complex Medical Home^f Kaiser Permanente Colorado PATHWAAY^g
Clinician and non-clinician patient/health navigation	Best Babies Zone^h Genesys HealthWorks^a New York City Citywide Colon Cancer Control Coalition^c
New technologies (telephone consultation, videoconference, mobile screenings, smartphone apps, etc.) to promote healthy behaviors and reduce health risks	Columbus Regionalⁱ Genesys HealthWorks^a West County Health Centersⁱ
Reach patients through community centers, homeless shelters, religious organizations, schools	Best Babies Zone^h Health Plan of San Mateo^j Hennepin Healthⁱ Denver Health^e

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.

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Suggested Citation:"BA: Example Implementation Strategies and Case Studies." National Academies of Sciences, Engineering, and Medicine. 2017. Accounting for Social Risk Factors in Medicare Payment. Washington, DC: The National Academies Press. doi: 10.17226/23635.

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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.

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