Ohio Department of Medicaid

Infant Mortality: State Perspective Cincinnati

Mary Applegate, MD, FAAP, FACP, Medical Director, Ohio Department of Medicaid July 2015

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Perspective

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Prescription for Population Health: Working Together to Make A Difference

• We • Align

• Design • Develop

• Implement a PLAN • Focused on a population

• With specific measurement targets • Based on sound evidence of best clinical practice

• In the context of public health and sociopolitical systems

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Why Reducing Infant Mortality Is Important to Ohio

• A measure of the health of a nation, state, city… • We CARE about our smallest Ohioans

• Every life matters; every family matters

• The outcomes are SHOCKING, many potentially preventable • Especially for our African-American population

• There are several Disconnects: • Ohio is not the most impoverished state • Ohio has one of the nation’s richest medical education resource • Ohio is well represented among the nation’s best hospitals/NICUs • Ohio is spending more on health care, consuming relatively more

URGENCY

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

% OH births < 32 weeks gestation to women with with history of previous Preterm Birth (PTB)

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

% OH births < 37 weeks gestation to women with with history previous PTB

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Top 10 Medicaid Efforts to Improve Infant Mortality:

2013: Transition from projects/programs 2014: Building Systems Together 1. Presumptive Eligibility 1. Additional enrollment efforts in community

2. FP SPA 2. Availability of services through MCPs (DRG rebasing)

3. Medicaid Expansion 3. Continued support for longer term gain as a system

4. More timely identification of high risk 4. Enhanced MCP services based on risk status from vital stats link, direct connectivity to mom (txt4baby)

5. Health Equity language in MCP contracts 5. Meaningfully use of equity data in Performance Improvement Projects, Health Equity 17 P Workgroup, CM

6. NICU Discharge coordination efforts 6. Work into value-based purchasing efforts, measure, standardize home care for complex NICU graduates

7. All infants > 7 d NICU stay in high risk Care Mgmt 7. Tie to episodes of care and PCMH, harnessing IT

8. Social Determinants of Health effort: HUB 8. Targeted populations & “hot spots” for enhanced efforts in conjunction with community activation

9. Focused funding support (MEDTAPP): OPQC - Antenatal steroids, feeding of human milk, Early elective deliveries , +17P, Strong Start Ohio

9. Continued support for collaborative systems work: e.g.: OPQC MCP QI effort to take 17P to scale, focused neighborhood efforts planned: Design for outcome

10. CHIPRA: MOMS proposal, across systems 10. Large scale grants: State Innovation Model Implementation, value-based purchasing

2015: Taking It All To The Neighborhood

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Pyramid of Health

HIGHEST: Individual effort, Complexity, Cost LOWEST: Impact

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Social Stability

Education and Health Literacy

Physical Health

Mental Health

Building the Foundations

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Genetic predisposition

30%

Social circumstances

15%

Environmental exposure

5%

Health care 10%

Behavioral patterns

40%

What It Takes To Be Healthy

Shattuck Lecture, NEJM

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Social Environment

Physical Health

Driving Change: Improved Well-being

CHAN

GE

Change begins with

Broader, Stronger Foundations

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Population Perspective

Success

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Collaboration, Cooperation & Coordination

Leverage for improvement

Events: crises, anecdotes, problems, projects

Trends & Patterns: run charts, statistical analyses, trials

System Structure: pattern of interrelationship among key components: hierarchy, process flows, mental models, programs

Including alignment of Public Health, Medicaid & Clinical systems…

Adapted from The Fifth Discipline Fieldbook, p.97-103

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Shift to population- and episode-based payment

Most applicable for

▪ Primary prevention for healthy population

▪ Care for chronically ill (e.g., managing obesity, CHF)

▪ Acute procedures (e.g., CABG, hips, stent)

▪ Most inpatient stays including Newborn deliveries, post-acute care, readmissions

▪ Acute outpatient care (e.g., broken arm)

▪ Discrete services correlated with favorable outcomes or lower cost

Payment approach

Population-based: (PCMH, ACOs, capitation)

Episode-based

Fee-for-service (including pay for performance)

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Payment Models:

• PCMH Charter

• Episode Charter

• Overview Presentation

Ohio’s State Innovation Model (SIM) Test Grant Application:

• Population Health Plan • Delivery System Plan • Payment Models • Regulatory Plan • HIT Plan • Stakeholder Engagement • Quality Measurement

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Prescription for Population Health: Working Together to Make A Difference

• Align • Design

• Develop & Implement a PLAN • Focused on a population: Moms & Infants

• With specific measurement targets: Preterm Birth & Infant mortality rates • Based on sound evidence of best clinical practice: integrated, shared lifecourse view

• In the context of public health and sociopolitical systems: aligned in purpose, data & funding

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

• Affordable Care Act & Insurance Coverage Develop System

• Enrollment • Outreach

Get everyone in the system

•Timely identification of pregnancy •Non-pregnant high risk • (Pre- & Inter-conception populations)

Identify risk

• Pregnant • Non-pregnant (Pre- & Inter-

conception populations)

Provide Enhanced Services

•Community Health Workers •Centering, Integrated care models •Policy & value-based purchasing

Maintain & Support

lifecourse

Vital Statistics

Preterm birth

17-P Adolescent well checks

Safe Sleep

Tobacco Cessation EED

Post Partum

visits

Mental Health &

Substance Abuse

Chronic conditions

Ohio: Delivering the BEST BABY BUNDLE

Data sharing & feedback

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D Creating Systems to Improve Health Outcomes

Safety net services

Neighborhood

SIM

High risk maternity

Smart Data to Target Special Populations

Disparate Population

Neighborhood Filter

Health Care Coverage

Community Workforce

Community Coordination

PCMH

+ + + = Success

Innovation Data Support State and Agency Strategic Vision

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

State of Ohio Infant Mortality Plan: Designed to Address Disparities

Where? Use data for strategic focus:

Hamilton Hot spots**

Franklin Hot spots**

Cuyahoga Hot spots**

Butler Hot spots*

Montgomery Hot spots*

Lucas Hot spots*

Summit Hot spots*

Stark Hot spot*

Mahoning Hot spots*

Appalachian Hot spots

What to do? 1. Target neighborhoods with highest

preterm birth & low birth weight rates

2. Utilize Community Workers, maximizing opportunities to receive enhanced maternal care through Medicaid Managed Care

3. Invest in innovative care models 4. Link hospitals & clinicians to local

public health for community coordination & future sustainability

5. Leverage existing systems

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

Infant Mortality Density Map in Counties with >6/1000: Number Needed To Save for a 50% Improvement

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

What Can We Do To Improve Infant Outcomes?

• Work. • Together. • Differently. • With data. • And sharing.

• The Collaborative serves all the purposes

M a k i n g O h i o B e t t e r O H I O D E PA R T M E N T O F M E D I C A I D

mary.applegate@medicaid.ohio.gov And Medicaid family team

Creating Systems to Improve Infant Mortality Reliably. What else?

What can we do better together?

Thank you THANK YOU Thank you It’s hard work Thank you THANK YOU Thank you It’s not the way we normally work Thank you THANK YOU Thank you It’s frustrating work Thank you THANK YOU Thank you It’s slow work Thank you THANK YOU Thank you But It-will-save-a-life work Thank you THANK YOU Thank you