Starting in September, the Portland metropolitan area’s largest private and public health care providers will forge a new way of delivering health care to some of the neediest and most vulnerable patients in the state, and they’ll do it in a way that seems impossible: by working together.
The organization the providers have created is called the Tri-County Medicaid Collaborative. It is one of dozens of coordinated care organizations, or CCOs, forming throughout Oregon to change how patients on the state’s Medicaid program, the Oregon Health Plan, receive health care.
Coordinated care organizations form the backbone of ambitious changes to the Oregon Health Plan pushed by Governor John Kitzhaber and bipartisan legislation the Oregon Legislature passed during the 2011 and 2012 sessions—an effort to not only provide higher quality care, but also to drastically reduce the state’s Medicaid expenditures by millions of dollars.
The Collaborative, like the rest of the state’s CCOs, does not have time to dally. CCOs are expected to save the state $239 million dollars in 2013 alone; if those savings are not made, it could be catastrophic for the state’s budget.
Regional umbrella organizations that bring together doctors, nurses, mental health and addictions providers, hospitals, counties, public health departments and other health care providers, CCOs are expected to integrate and coordinate the physical, mental and dental health care for the 650,000 Oregonians on the Oregon Health Plan.
The state’s first seven CCOs became operational on Aug. 1; by November, the transition to the new system is expected to be complete.
The Oregon Health Authority formally certified the Collaborative to become a CCO on July 31, and it will begin providing care to 180,000 Oregon Health Plan patients living in Multnomah, Washington and Clackamas counties on Sept. 1.
The Tri-County Medicaid Collaborative will, by far, be the largest CCO in Oregon. It is composed of every major health provider in Multnomah, Washington and Clackamas counties: Adventist Health, CareOregon, Central City Concern, Kaiser, Legacy Health, Oregon Health & Science University, Providence Health & Services, Tuality Healthcare, and representation from the three metro counties. Its annual budget is expected to be around $750 million dollars, and it will provide care for roughly a third of the state’s Oregon Health Plan patients.
Janet Meyer, the Collaborative’s interim CEO, says one of the biggest challenges is creating a coordinated system of care just as relevant and effective to patients living in St. Johns as it is to patients in Sherwood. “We have a huge area to cover,” she says.
Another is simply learning how to work together to make the new delivery model work. “We’re competitors, but … the reality is that we need to be collaborative and cooperate,” says George Brown, the CEO of Legacy Health and chairman of the Collaborative’s board of directors. “It is in our mutual best interest, and in the best interest of the community we serve.”
One of the first big tests the Collaborative will face is submitting an “implementation plan” to the Oregon Health Authority within 90 days. The plan will spell out exactly how the Collaborative will coordinate care, with estimations on how much emergency room and specialty care use decreases, how care improves, and most importantly, how much money the Collaborative expects to save.
And the federal government has its eye on CCOs: Earlier this summer, the Centers for Medicare and Medicaid Services (CMS), which regulates Medicare and Medicaid, brokered a deal with Kitzhaber to give the state $1.9 billion dollars over the next five years to help fund CCOs.
But there are strings attached to the money. In addition to clearly showing that preventive care is being utilized, the state must reduce Medicaid expenditures by 2 percent in two years.
The requirements demand that CCOs get moving, fast.
“We have to move quickly so that we can drive transformation, (but) not too quickly that we disrupt the system of care,” Meyer says. “This is a very vulnerable population.”
Ed Blackburn, a member of the Collaborative’s board of directors and executive director of the social service agency Central City Concern, thinks the savings are doable, but difficult.
“One of the things we must absolutely accomplish is the reduction in utilization in hospital beds, psychiatric units, and emergency departments,” Blackburn says. “We have to drive down those costs, not simply to help people, but get them into services that can intervene and prevent them from getting that far.”
He says the time has passed for the Collaborative, like the rest of CCOs, to do nothing. Medical costs continue to rise, exceeding national inflation rates, and the strain on state and city budgets means community services won’t be able to continue picking up the pieces of a failing health care system.
“We’ve got a few years to pull this off,” Blackburn says. “We’re all going to take big hits if this doesn’t work.”
One recent development giving those closely watching the Collaborative’s development reason for encouragement is the composition of the Collaborative’s community advisory committee, which was announced in late July.
The committee is responsible for representing the perspectives of Oregon Health Plan patients and the larger community; in that regard, many view the advisory committee as an important source for holding CCOs accountable to their goals and mission. The committee is also responsible for developing a community health improvement plan, designed to address health disparities and improve population and public health that the Collaborative will implement.
The Collaborative’s advisory committee is made up of 17 people. Nine are current Oregon Health Plan patients. The other members include representation from a variety of agencies serving low-income and vulnerable people — including the Coalition of Community Health Clinics, the Housing Authority of Clackamas County and Multnomah County’s Department of Human Services.
Steve Weiss, an Oregon Health Plan patient and active consumer advocate, will serve as the committee’s chair. His chairmanship also makes him a voting member of the Collaborative’s board of directors.
The selection of committee chair and the committee’s composition, says Chris Bouneff, president of Oregon’s chapter of the National Alliance of Mental Illness says, shows the Collaborative is intent on engaging the community and taking its concerns seriously. “That’s a very impressive list,” he says. “They put some people on that committee who are strong advocates for better health care.”
Weiss, 69, has been an Oregon Health Plan patient since 1991. During that time, he has received dozens of notifications from the state telling him that certain health services would no longer be covered by the state. And he says the coordination between physical and mental health care has been “badly needed” for years.
He hopes he can help the Tri-County Medicaid Collaborative function as effectively as possible for the patients it will serve. He thinks the biggest challenge the Collaborative will face is being able to reduce costs, but still provide effective service.
He also worries that the Collaborative’s ability to clearly communicate with patients may be hampered by the sheer size of the Collaborative. “The greater number of middle men you have, the greater likelihood that you’re going to have complications,” he says.
Collaborative members and advocates alike do not expect the Collaborative to fully begin integrating and coordinating care in the short term.
The Centers for Medicare and Medicaid Services is allowing CCOs to be more flexible with how it spends its Medicaid dollars. Because of that, interim-CEO
Janet Meyer says the Collaborative, like the rest of the state’s CCOs, will be able invest some of its dollars in “flexible benefits” — methods to help patients maintain their health but not traditionally covered by insurance companies.
An example often used by Gov. Kitzhaber is that of an older person with congestive heart failure, living in an apartment that easily becomes hot during the summer. The hot, stuffy air exacerbates the person’s illness, which could easily be prevented if the apartment had an air conditioner.
While some details have yet to be ironed out, Meyer says buying air conditioners for the congestive heart failure patient, or vacuums for patients whose asthma flares up because of dust, will bring immediate benefit to Oregon Health Plan patients.
But what will fundamentally change a patient’s relationship with their provider and their health will be the Collaborative’s use across the tri-county area of a coordinated care model already proven to work: medical homes.
A “medical home” employs a team of multiple health providers, including doctors, nurses, physician assistants, mental health and addiction providers, and various support staff who track data and communicate with patients.
Each team member has specific responsibilities in relation to a patient’s health. If something is outside the realm of that person’s specialization, he or she communicates with the team member most qualified to address that issue. Patients interact with each team member to varying degrees, depending on the care they need.
“(Patients are) known and they have stronger relationships,” says David Labby, the Collaborative’s chief medical officer.
Labby is spearheading the Collaborative’s efforts to create medical homes, and says every Oregon Health Plan patient will eventually belong to one. Within a year, he says, the majority of the Collaborative’s medical homes should be operational.
“We have a lot of practices that are pretty advanced health home practices,” he says.
Creating a medical home depends on the providers thinking of their patients as a defined group of people for whom they are responsible. Identifying who their patients are and what their various health needs are determines the providers on the medical team. “You design the team around the group you’re taking care of,” Labby says.
Medical homes are touted for their responsiveness: If a patient needs to see their primary care doctor, they can within a couple weeks, if not days. Whether the Collaborative can make that sort of access possible remains to be seen.
“We need all the (health center) capacity as possible,” Blackburn says. “There is not enough access. That is a key issue.”
The Collaborative might have been off to a slow start, were it not a three-year, $17.3 million grant from the Center for Medicare and Medicaid Innovation (CMMI), an offshoot of the Centers for Medicare and Medicaid Services that funds projects throughout the nation designed to provide more effective health care at a lower cost.
The money will fund five pilot projects to be launched by September.
The first pilot program will embed up to 15 community health workers in existing medical home practices. Community health workers don’t have medical training, and are similar to outreach workers — they work closely with a caseload of up to 30 patients with multiple illnesses and barriers to accessing care.
“(Patients). are going to be seeing a lot more of those people in their lives,” Meyer says.
The workers visit patients at their homes, and communicate with them by e-mail, text messages, and phone calls to make sure, for instance, that the patient does not forget about an upcoming doctor visit and that they’re taking medication regularly. Home visits can also reveal whether a patient is experiencing other issues, such as social isolation or nutrition problems that can impact their health.
“In a standard office visit, those things aren’t apparent,” Labby says.
Similarly, the second pilot program will place outreach workers in the emergency departments of three hospitals in an effort to decrease the number of patients using the emergency department. The workers will help people in the emergency room connect with a primary care doctor, possibly that same day.
The third pilot program will create three teams that will work in three separate hospitals to identify people at risk of quickly destabilizing and becoming unhealthy again once they are discharged. The team will work intensively with the patient to appropriate follow up care and related services.
The fourth pilot program will create a standardized method of discharging a patient from a hospital. Often, Labby says, primary care doctors may not know for months, if ever, that one of their patients went to the hospital for emergency or specialty care. A standardized “transition document,” to be used by all the Collaborative’s providers, will be created to record each hospital visit.
When a patient leaves the hospital, the document is sent to the patient’s primary care provider. The communication between hospital and primary care doctor, via paper trail, will ensure that the doctor is able to “reliably follow up” with the patient in a “timely fashion,” Labby says.
The fifth pilot program will embed outreach workers in hospital psychiatric units who will work with patients with acute mental illnesses who can destabilize easily, and help them enter behavioral health treatment and stabilize.
The Collaborative expects to save $32.5 million dollars over the three years the pilot programs will be tested, simply by virtue of coordinating care, focusing on prevention, communicating more effectively and often with patients, and focusing more compassionately on their health care.
Although the pilot programs are funded by the grant for three years, the Collaborative can decide to fund, expand and standardize a program across the Collaborative before then, if any or all of them prove effective.
Connecting the Collaborative’s partners will be a new information sharing system. A digital database containing information about a particular patient — where their medical home is, what physical or mental conditions they have, and a record of care they’ve received. All the Collaborative’s providers will be able to use the database and add information to it.
If a patient living in Portland somehow ends up in a Beaverton hospital and is cared for by a doctor who has never met that person before, that doctor will easily be able to access the patient’s information and, for instance, not prescribe medication they may be allergic to, or conflict with other medication they already take. And that doctor can enter information about the visit into the database, which the patient’s primary care doctor can later access.
The Collaborative’s success won’t be measured simply by seeing an improvement in Oregon Health Plan patient’s physical health, but will also rely on whether other problems or issues that can impact health are dealt with.
Central City Concern’s Blackburn has been using his membership on the
Collaborative’s board of directors to help educate others about the importance of developing partnerships with service providers not necessarily related to health, including housing and employment services.
He has helped form an informal association of 35 mental health and addiction treatment service providers, all of which could possibly contract with the
Collaborative. Blackburn is also working to create a group of housing agencies, which is expected to begin meeting in the next couple weeks.
“There’s a lot of people who depend on housing services, social services, employment services,” Labby says. “Those things are really important for people’s health.”
“We need to recognize (those services) as part of the care team and intentionally engage with them,” Meyer says
But Brown says it is unlikely that the Collaborative will contract directly with social service providers to help Oregon Health Plan patients get housing if they are homeless, for example. The reason, he says, is that the Collaborative would not be able to use its budget — made up of Medicaid dollars, the use of which is regulated by the Centers for Medicare and Medicaid Services — to pay for services not strictly health related.
“But within our scope is to find those agencies that do have the dollars … so that we can achieve the desired end,” Brown says.
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