By, Nancy Garrett, Ph.D., Chief Analytics Officer, Hennepin County Medical Center
When Minnesota decided to expand Medicaid to a poor, childless adult population in Hennepin County, the interested parties decided to take an innovative approach to ensure patients were receiving the kind of care they needed to be healthy. In essence, we built a Social Accountable Care Organization (ACO), a model wherein a group of healthcare partners (Hennepin Health) took on more risk and partnered with social services to care for this vulnerable population.
Hennepin Health was formed as a capitated Medicaid demonstration project by four organizations: Hennepin County Medical Center, NorthPoint Health and Wellness (a Federally Qualified Health Center), Metropolitan Health Plan and the county’s Human Services and Public Health Department (including Health Care for the Homeless, the county’s Mental Health Center and other social services). The providers bill the plan on a fee for service basis and split the gain (or loss) at the end of the year.
Together, we serve over 6,000 enrollees who face some stark health realities: 45 percent have chemical dependencies, 42 percent have mental health needs, 32 percent have unstable housing and 30 percent suffer from at least two chronic diseases. In total, the top 5 percent of the population’s healthcare utilizers demand 64 percent of the available healthcare dollars.
Clearly, the old system wasn’t working for these individuals. So, we built our model on the concepts of a primary care medical home with a strong continuum of care coordination paired with addressing the social determinants of health (housing, substance abuse, joblessness, etc.).
For this population, before you can even address the traditional health problems of a patient, you have to look at the social and behavioral issues present, which makes the partnership with the county’s social services so vital. For every patient, we try to meet them where they are and we’ve found that when we can get someone to a stable housing situation they are then able to start working on the prevailing health issues. Quickly, we decided to move mental health specialists directly into the clinic to provide easy access to care for the patient and consultation for primary care providers.
This approach has paid dividends to our bottom line and the health and wellbeing of all our patients. For one patient, who was a frequent utilizer of the emergency department, our model has improved his life dramatically. When we looked at his admission rates, we realized someone needed to coordinate the vast array of care he needed: he had many chronic conditions and the coordinator found the patient was also homeless.
So, the care coordinator called her partner social worker and together they found stable healthy housing. In that process, the coordinator discovered that the patient was interested in getting a job. We realized this was not unique to this individual so we used some of our savings to bring an employment counselor to the clinic to help people with behavioral problems learn how to get and keep a job. The counselor works to place them at a job and helps the patient for a year afterward, so they can retain their job.
Without the relationship with the care coordinator, we never would have had this patient applying for jobs and working on managing his chronic conditions. He has accessed primary care consistently and is much better health-wise. Even when this patient slipped and ended up in detox, his first call was to the care coordinator for help. This example demonstrates that there’s no easy fix with socially complex patients. There will be ups and downs, but if relationships exist and you can connect people with the appropriate social services, patients’ lives and health will improve. What could have been a complete substance abuse spiral ending in an emergency department visit became a simple call to a care coordinator who connected the patient with the appropriate services.
For our model to work this seamlessly all of the partners have to buy in. It was relatively easy for us since every partner is governed by the county and we serve the same populations. While we weren’t used to working with one another, through trial and error, we have found effective ways to collaborate.
It also doesn’t hurt that there are dollars at the table. If, collectively, we can treat the population for less, the money can be dispersed back to the partners and invested outside the conventional government boundaries into innovative ideas that better help those who we have spent our entire careers trying to help. We will finally focus on prevention.
Our early results are positive. We have seen an increase in primary care visits and non-billable phone and email visits as well as reduced medication costs. There have been increased connections of patients to social services (food assistance, transportation and financial assistance) and substance abuse and mental health services.
In our first year, Hennepin Health reduced emergency department visits by more than 20 percent. In fact, spending for some of the program’s top 200 users of medical services dropped. In total, the county has been able to reinvest more than $1 million in savings toward filling service gaps and providing even better, cost-saving, care.
We have used excess funds to pay for on-site behavioral health counselors and licensed alcohol and drug counselors, the employment counselor and expanding our complex care clinic. We plan on using future dollars to provide interim housing for people who are ready to leave the hospital but don’t have a stable housing situation.
We’ll also be building a sobering center. Looking at our data, a lot of the emergency department capacity has been used by people who are simply intoxicated. They didn’t need medical care, they needed somewhere to sober up. So, instead of using these valuable resources, we’ll build a separate center that can be minimally staffed and a lot less expensive than an emergency room visit.
Another beneficial aspect of this diverse, but dependent group of partners was the ability to share data. While it was time consuming and difficult to plan out the technical and legal aspects, we’ve built a data warehouse that includes claims from the plan, Epic information (one of the best, most integrated electronic health systems (EHR), and some social services data.
Bringing in the social services data and combining it with medical history provides as full a picture as possible of a current individual’s health and wellness. We have installed EHRs in a lot of social service agencies so they know what’s going on with medical care and medical providers will know what kind of social services a patient needs when they are treating them.
We can also use the warehouse as a sort of drug monitoring program. When we created the plan we really wanted to include dental. With the analytics, we can tell who is having a dental emergency versus who has been to the emergency room frequently for painkillers for various ailments. We can then track these individuals and get them into counseling.
There is always more we can do. Right now, we’re conducting a lifestyle survey to get information on health risk behaviors (smoking, exercise, access to healthy foods, etc.) to understand the determinants of health. We have only completed surveys of about 10 percent of our population, but, for those 10 percent, the data is coming into the warehouse and will be added to the record and accessed by social services and healthcare.
A successful health system must meet an individual’s basic needs before it can improve health. Experience has shown that social disparities often result in poor health management and costly revolving door care. Quite simply, by coordinating systems and services, Hennepin Health has improved health outcomes and reduced costs.
Success requires innovation, collaboration with non-traditional healthcare, adaptive and decisive leadership to force major systems changes and lean processing to streamline systems and reduce waste. By intentionally linking social services with healthcare, Hennepin Health is saving money and improving the health of individuals who are traditionally among the most costly and difficult to treat.
For more information on Hennepin Health, see:
Hennepin Health: People. Care. Respect. Presented at Trust for America’s Health Twin Pillars of Transforming a Sick Care System to a Health System: Delivery System Redesign and Payment for Prevention July 17 2013