''Serving the community" has always been a central mission of hospitals and health systems, and providing emergency and acute care services will always be a core part of that mission. However, in hopes of reducing overall costs of care, leading-edge hospitals and health systems are expanding their focus to include prevention and wellness. It is no longer just about serving the community, it's about improving the health of that community.
The two hospital systems profiled in this section have formed business savvy partnerships to help keep patients healthy and out of acute care facilities. By encouraging healthy lifestyles, cancer screenings, and chronic disease management, providers stand to benefit financially under risk-based payment arrangements. They are also building loyalty, reinforcing their positions as providers of choice among patients, payers, and employers.
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This past August, children enrolled at Kennedy and Chappell Elementary Schools in Green Bay, Wisc., were invited to drop by the school to pick up free school supplies-and receive a free dental checkup. The parents or guardians who brought them were encouraged to complete a health risk assessment.
As the school year progresses, students will take confidential online health assessments. They will see their teachers rushing to onsite Zumba® classes after school. The children can invite their grandparents for free blood pressure screenings on Grandparents Day. And they will grow microgardens and get a chance to sample the "veggie of the week" during lunch.
Improving health, decreasing costs. Front and center through all these healthy changes: Bellin Health System in Green Bay. The one-hospital system came to appreciate the power of population health initiatives after seeing the positive effects on its own workforce. Bellin experienced a 33 percent decrease in employee healthcare costs after introducing a comprehensive wellness program for employees, hiring a health coach, and offering free preventive services. The cost of employee health coverage has not increased since 2002-and Bellin estimates it has saved $10 million on employee health costs over a five-year period.
Convinced that improving population health is the key to solving America's healthcare cost crisis, Bellin Health is now launching special programs throughout Green Bay targeting three specific groups: employers, seniors, and children/families.
The overall goal of the school program-called Thrive™ to Be the Best You-is to encourage healthier habits at school and to help parents, students, and staff learn how to make healthier lifestyle choices. The program was developed by Bellin Health. "We're hoping to track these children and their families all the way into, and possibly through, high school," says Amy St. Laurent, Bellin's vice president of family programs and services. Bellin has similar programs for employers and seniors.
Building on a pilot project. Bellin piloted the Thrive™ program during the 2009-10 school year at Kennedy and Chappell Elementary Schools, both of which serve a high percentage of low-income families.
Children, families, and staff at the pilot schools were encouraged to complete confidential life health questionnaires and participate in biometric screenings, which include body mass index calculations and blood pressure/cholesterol readings. The data collected so far has provided insights into where Thrive programming needs to be targeted. "Weight and nutrition are the biggest problems for all groups in the two pilot schools, says Ann Barszcz, Kennedy Elementary's principal. "I was also surprised at the number of families that we have that smoke."
The pilot was also successful at engaging school staff and students. Kennedy Elementary staff members are highly motivated, says Barszcz. "One of our staff members lost 77 pounds as a direct result of her learning her biometrics and her body mass index," she says. "She said, 'I am done with this,' and she totally changed her lifestyle.'"
Based on the success of its two-school pilot, the Thrive program is now available to all 26 elementary schools in the district this school year. Bellin staff are working with school leaders to develop health improvement goals and tactics for the school community-teachers, students, and their families-based on data gathered during the pilots.
For example, last year's health risk assessments revealed that many children do not have regular dental care, so Bellin Health arranged for free dental checkups to be offered before the school year started. The health system also arranged for school supplies to be given away during these free checkups-after learning that parents and guardians are more likely to attend events when free items are provided.
Improving grades, too. Bellin and Kennedy officials are excited to advance their work together this year. Bellin nurses and other staff will be on hand for open houses, healthy Halloween parties, parent-teacher conferences, and other events in which they have an opportunity to connect with parents.
"It is the future for our school. That is how I look at it," says principal Barszcz. "There's so much research about how health and wellness and physical activity affect student learning. I look at this as an opportunity that really has no bounds."
Indeed, the connection between healthy lifestyles and student achievement is why the Green Bay school system jumped at the opportunity to have the Thrive program in its schools. "We are hoping that over time our data will show that it increases student attendance at school and parent involvement. Research shows that any time you have more parental involvement in your schools, students are more successful," says Kim Pahlow, the district's executive director of learning. For that reason, the program is tracking not just body mass index and fitness scores, but also reading and math proficiency scores and data about absenteeism and bullying. (See the exhibit below for the performance measures Bellin Health and the school district are tracking.)
A two-way investment. Bellin Health is the program's primary funder, while the principals at individual schools are bringing in business partners to provide incentives, such as free school supplies, that engage parents.
Both Bellin Health and the school district are also making significant time and energy investments. "It takes a commitment by each school's staff because they have to be willing to work with the kids, and they have to be willing to attend the family nights and be there when the parents come to school," says Pahlow. "Bellin's people are here in our district office and they're attending events as well. If there's a family night at Kennedy, at least two or three people from Bellin attend. It's definitely a collaborative activity, and if both sides weren't working hard, it would not work."
In addition to its commitment to improving population health, Bellin Health also has a business goal. The health system hopes to expand the Thrive program throughout the Green Bay area and, eventually, offer it to other districts in the state for a fee.
As it rolls out its school wellness program, Bellin Health is guided by the principles of the Triple Aim initiative, launched by the Institute of Healthcare Improvement in 2007 (see the exhibit below).
Bellin is one of 60 sites across the world participating in the Triple Aim initiative, which has three goals:
Fairview Health Services, a seven-hospital system in Minnesota, has goals that mirror Triple Aim. But it is using a different approach to achieve these ends. Fairview intends to become one of America's first accountable care organizations (ACOs). Its self-imposed deadline is 2012, and its transformation-which involves changing the delivery model, payment system, and patients' experience with the health system-is well under way (see the two exhibits below).
ACOs use legal partnerships between hospitals and physicians to improve the coordination, efficiency, and quality of patient care. Because the concept is still new, there is no established norm for how these partnerships are formed or exactly how they should work. The basic idea is that ACOs will accept accountability to improve the quality and reduce the cost of care for a defined population of patients-goals that promise to benefit the communities ACOs serve.
Becoming accountable goes hand in hand with taking on more financial risk. Fee-for-service arrangements with payers are typically replaced with capitated and/or pay-for-performance type arrangements. As discussed in detail in this case study, Fairview is in middle of a two-year, risk-based contract with Medica-one of the largest payers in the Minneapolis market. Fairview also intends to participate in the Medicare Shared Savings Program, which is scheduled to commence by Jan. 1, 2012. Under the Medicare program, qualified ACOs that meet specified quality performance standards will be eligible to receive a share of any savings achieved.
Fairview is well positioned to adopt the ACO model because it already offers a broad continuum of services and has put a number of structural components in place that help align the interests of physicians and hospitals. Fairview's integrated medical practice includes 450 employed physicians, including those who work at its 49 primary care clinics, and 550 affiliated academic physicians. Through a physician hospital organization, Fairview also works closely with Fairview Physician Associates, a network of 630 independent, closely aligned physicians. In addition, Fairview provides home care and senior services.
Starting with one payer. Two years ago, during routine contract negotiations, the top executives at Fairview and Medica decided there had to be a better approach to provider-payer relations than the standard adversarial dynamics.
An analysis of 2008 claims found that Medica members served by Fairview primary care clinics already had a total cost of care below the market average. Fairview leaders believed that they could drive costs even lower and improve the health of Medica members by redesigning the way care is delivered, says James M. Fox, Fairview's senior vice president and CFO.
In 2009, the two parties entered into a two-year contract that pays Fairview based on the achievement of defined outcomes for quality and total risk-adjusted cost of care-for all Medica members served by Fairview-employed primary care physicians. The contract includes pay-for-performance incentives based on Fairview's performance on certain diabetes and vascular care measures, as well as the health system's success in controlling the total cost of care for Medica members, as compared with communitywide data.
It is too early to share results from the new contract. But neither Medica nor Fairview shies away from expressing their optimism about this new way of doing business. "It's safe to say that Fairview is doing a very nice job of bending the cost curve compared to what it would have been in a traditional fee-for-service environment," says Charles Fazio, MD, Medica's chief medical officer.
The relationship has increased transparency between the two partners, giving Fairview access to information that is vital to improving the health status of Medica-insured patients. "The biggest value Medica is bringing to Fairview in the current phase of our relationship is information about Medica members who are in the Fairview system," says Fazio. "Who would we predict, based on our analytics, is about to get sicker and benefit from some kind of outreach? Which members with chronic diseases do we predict could be healthier and, therefore, have a lesser need for services?"
Fairview's experience to date suggests that the ACO model can be good news for health systems, says Fox. "In the long term, I expect we will be more profitable than under fee-for-service medicine."
Redesigning care. Reorganizing to become an ACO requires a total cultural transformation, says Fox. Toward that end, Fairview has assigned four primary care clinics to take the lead in designing new care processes for the system. These beta-site clinics are focused on four goals:
Each of the four beta sites has reorganized its workforce into teams, which include a physician, a nurse practitioner, nurses, medical assistants, and schedulers. Team members "huddle" at least once each day to discuss issues about individual patients, as well as ways to improve patient flow and care processes. Patients choose their own physician-led team, assuming the team has capacity, and each team is responsible for a panel of patients.
Reassigning duties within the teams has improved patient access to care and overall efficiency. In one clinic, primary care physicians saw their end-of-day duties-patient messages, lab result review, and charting-decrease from an average of 90 minutes to zero because other team members are now handling that work. In another clinic, the percentage of patient messages that required a physician's response fell from 30 percent to 3 percent, as other team members were empowered to address patient needs themselves.
Meanwhile, the beta sites are also developing new ways to serve patients, including nurse-only visits, group appointments, and virtual care visits via e-mail and phone conversations. In the traditional model, a patient being monitored for high blood pressure was routinely scheduled to see a physician; now hyper-tension patients can be seen by a registered nurse if clinically appropriate.
Preliminary data indicates that these clinics have, on average, reduced their total cost of care growth rate by more than 5 percent, says Fox. In addition, clinical quality is improving. Fairview Eagan Clinic, which is one of the beta sites, documented improvements in the percentage of patients obtaining needed immunizations and screenings within five months of launching the new team-based approach (see the exhibit below).
Patient satisfaction is mixed, as is the increase in number of patients cared for, but the transformation is just getting under way so it is too early to evaluate. There were some initial costs involved in the primary care transformation. The cost of hiring additional staff members for the physician-led teams in the clinics and the short-term drop in productivity increased the cost-per-patient in these clinics by more than 15 percent during the transition to the new care delivery model. Medica agreed to help pay for some of the changes in care delivery at two Fairview clinics.
"These costs are necessary funding requirements needed to create care model changes to better manage the outcomes represented in our four goals," says Fox.
Spreading the improvements. Meanwhile, Fairview is using a rapid-iteration innovation model to spread improvements across the health system-and speed clinical transformation. Using this approach, all of Fairview's 40 primary care clinics are expected to adopt the new processes piloted at the four innovation sites by the end of 2010.
Fairview is using several strategies to hasten the systemwide changes needed to succeed as an ACO. More than 100 physician leaders have been trained at the Fairview Leadership Academy, where they learn principles of adaptive leadership and skills needed to inspire culture change. Additionally, more than 1,200 physicians, nurses, and other staff members have participated in simulations designed to foster teamwork and behavior changes.
Changing physician compensation. Hand in hand with redesigning the primary care delivery model is a redesign of physician compensation. Fairview-employed physicians are being paid to manage the total healthcare costs of a panel of patients. By receiving a base salary with incentives for their performance on quality and cost measures, the physicians are aligned with the ACO model, says Fox.
Even as Fairview moves aggressively to become an ACO, Fox does not expect all payers to embrace the concept quickly. "I expect we will live with fee- for-service, ACO, and bundled payments for the next few years," he says.
Related Sidebar: IHI's Triple Aim Initiative
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