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
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 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.
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 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:
b Personal communication, Susan Knudson (HealthPartners) to Charles Baumgart (committee member), December 14, 2015.
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 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:
e Personal communication, Doug McCarthy (The Commonwealth Fund) to staff, January 12, 2016.
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 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:
d America’s Essential Hospitals, 2015.
TABLE BA-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:
f America’s Essential Hospitals, 2015.
l Personal communication, Doug McCarthy (The Commonwealth Fund) to staff, January 12, 2016.
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 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:
b America’s Essential Hospitals, 2014.
d Personal communication, Mark Hamelburg (America’s Health Insurance Plans) to Charles Baumgart (committee member), December 18, 2015.
j Personal communication, Doug McCarthy (The Commonwealth Fund) to staff, January 12, 2016.
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.
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/wp-content/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/report-Innovation_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-complex-patients (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 (Millwood) 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/fund-report/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/december-2014-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/october-november/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).
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-home-less-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/fund-reports/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/case-study/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 (Millwood) 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-partnershipsto-improve-care (accessed February 2, 2016).