return of value: measuring the value of a complex care program€¦ · transforming life church of...

Return of Value: Measuring the Value of a Complex Care Program

November 2019Putting Care at the Center 2019

Randi Woods and Alice Bauman, presenting on work done by:Reverend Debra Hickman, Wil Torriente, Demetrius Frazier, Jessica Timmerman, Dorothy Sheu, Phoebe Rostov,

Melissa Sherry, and Lindsay Hebert

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The Story You Are About To Hear

CONTEXT QUEST JOURNEY

REFLECTION

TODAY

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CONTEXT

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Where Does the Story Take Place?

• 602,495 population• 62.8% African American

• $46,641 median household income (2017 dollars)

https://www.census.gov/quickfacts/fact/table/baltimorecitymaryland,US/PST045218

Baltimore City, Maryland

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Where: Baltimore City, Maryland

https://apps.urban.org/features/baltimore‐investment‐flows/

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When: Fiscal Year 2019

July 2018 – June 2019

Community Care Team

Neighborhood Navigators

Convalescent Care

Bridge Patient EngagementProgram JHOME

Johns Hopkins HealthCare LLCManagement Services Organization

Health Services Cost Review Commission

What is the Story About?Community Health Partnership of Baltimore*

7*Based on Fiscal Year 2019 data

Website: http://www.chpbaltimore.org/

What is the Community Care Team (CCT)?The Community Care Team’s goal is to help individuals develop a plan to address their individual needs in order to achieve their

best health.

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2 Community Health Workers

1 Care Manager

1 Health Behavior Specialist

Community Member(s)

Who Does the Community Care Team (CCT) Serve?

18+, receiving Medicare Fee‐for‐Service (FFS)

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Live in Baltimore City

Been hospitalized 2+ times in the past year(12 months)

Not in hospice, long term care facility, or taking part in a care management or accountable care organization (ACO).

*Based on Fiscal Year 2019 dataWebsite: http://www.chpbaltimore.org/

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QUEST

How do we know if the CCT is meeting its

goals?

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Does the CCT improve the quality

of care?

Are program participants changing their drivers of

healthcare?

Is the CCT addressing current gaps in our

regional system’s ability to coordinate care?

Does the community trust

the CCT?

Does the CCT strengthen connection of the community to

services addressing social determinants?

Does the CCT build on existing infrastructure in

a sustainable way?

So Many Questions

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The Quest

What is the Return of Value that Stakeholders Expect from the Community Care Team?

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Return of Value

Return on Investment

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JOURNEY

Public Learning

• How would you (or have you) begun to answer this question?

• What kind of value do you expect from efforts to address complex care and social need?

• How do you know the value? Do you see it or observe it? Hear about it?

• How do you share, communicate, and explore the value of programs, policies, or efforts?

• Is value different or the same as goals?

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Know Your Audience: Who is the Return of Value For?

HSCRC/Potential Future Funders

Hospital Partners

Sisters Together & Reaching (CBO)

Community Care Team

Johns Hopkins HealthCare (MSO)

Payers/Medicare

Centers for Medicare and Medicaid Services (CMMI)

Baltimore Community/Patients

Employers

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Allow Lots of Time…

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… for Consensus

Measurement Concepts

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• Community Relationship

• Patient Capacity & Engagement

• Patient & Community Health

• Cost Effectiveness and Return on Investment

• Workforce Creation

• Health System Optimization

Define & Redefine Your Measures:Seek Advise and Expertise

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Community Relationship

Patient Capacity & Engagement

Patient & CommunityHealth

Workforce Creation

Health System Optimization

Cost Effectiveness & ROI

• Determine 1‐2 Measures Per Category• Leverage in‐house experts to offer guidance on measurement

• Conduct Good, Better, Best analysis describing:• Measure• Resources Needed

Challenges With This Process• Data

• HIPAA compliance• Limited data availability (Medicare data, granularity of data, etc.)• Collection of data difficulty

• Resources• No budget for ‘Return on Value’ measurement and evaluation• Need for time from data & financial analyst

• Inclusion• Addressing and validating all stakeholders voices and needs• Management of many stakeholders priorities

• Change Management• Not a large precedent for ‘Return of Value’ measurement or evaluation

• Need to adapt long standing processes and ways of thinking• Pioneering effort

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The Proposed Measures

A. CommunityRelationship

B. Patient Capacity & Engagement

C. Patient & Community Health

D. Workforce Creation

E. Health System Optimization

F. Cost effectiveness & ROI

Stories capturing how the CCT has influenced the community & Partner Hospitals (focus on health system level change)

Patient’s self efficacy to manage their own healthcare needs

Number and percentage of social needs of patients able to be addressed by CCT efforts

Number of self‐reported healthy days (CDC module)

Number of jobs created by the CCT

Count of ED visits, pre & post

Stories of patients experience with the health system pre & post CCT

Return on Investment of CCT

Cost effectiveness of CCT

Return of V

alue

CATEGORY MEASURE OUTCOME

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Acknowledging Resource Constraint & The Need To Prioritize

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Stories capturing how the CCT has influenced the community & Partner Hospitals (focus on health system level change)

Patient’s self efficacy to manage their own healthcare needs

Number and percentage of social needs of patients able to be addressed by CCT efforts

Number of self‐reported healthy days (CDC module)

Number of jobs created by the CCT

Count of ED visits, pre & post

Stories of patients experience with the health system pre & post CCT

Return on Investment of CCT

Cost effectiveness of CCT

Return of V

alue

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TODAY

This image cannot currently be displayed.

Return of Value (ROV) Measures

• Client Stories • Referrals to Services made & type

• Job Creation• Return on Investment (ROI)

CLIENT STORIESThis image cannot currently be displayed.

Stories capturing how the Community Care Team (CCT) has affected community members. Specifically what is a client’s narrative about their experience before and after engagement with the CCT.


Story 1This image cannot currently be displayed.

Recording

Theresa was referred to the Community Care Team program by the social worker at the hospital due to her chronic challenge with lice. Theresa notes “My problem was I couldn’t get them out.” Part of this was due to the fact that Theresa’s house had no electricity, no water, and minimal ability to move throughout the house due to clutter. Upon Demetrius’ engagement, he was able to contact Adult Protective Services to assess the house and identify supports that they could offer. Adult Protective Services delivered undesirable news –the house was condemned and Theresa could not live there. Theresa did not want to give up her house. Understanding that home is an important place, Demetrius emphasized that the priority was Theresa’s health. Through their consistent engagement –they eventually came to an understanding that it was best for Theresa to find a new place to live.


Story 2This image cannot currently be displayed.

Recording

Housing was a rollercoaster of emotion. There was lots of paper work, identifying the right place and time to turn it in, then waiting. Then the paperwork would expire because it couldn’t be processed in time by the housing authority or it would be misplaced and Ms. Jenkins would complete the paperwork again. Ms. Jenkins notes that it was very frustrating and how she leaned on Wil during this time. “I called you crying that I didn’t even want the place anymore and that I was just goingto find somewhere else to go. But you told me to just hang in there and let him do what you [Wil] do to get me into a home.” A year later, after Wil assisting Ms. Jenkins with acquiring the down payment, establishing utilities, and navigating the order of steps needed to be taken, she is sitting in her new apartment in a new development which she calls “awesome!”

REFERRALS TO SERVICES This image cannot currently be displayed.

Number of social needs that are able to be addressed by the Community Care Team.


CCT Total Referrals by Social Determinant of Health*


* Data is reflective of referrals from July 2018 to August 2019.

474 Referrals to 102 External Organizations


CHW Referrals by Social Determinant of Health*


423 Referrals to 70 External Organizations

* Data only reflects CHW referrals to resources/partners external to the CHPB from July 2018 to August 2019.


CHW Referrals by Social Determinant of Health*

Referral Type Count of patients receiving referral

Food 52

Housing 35

Housing Services: Eviction Assistance, Housing Repair, Occupational Adjustments, Rental Assistance

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Social Services 73

Transportation 248

Behavioral Health (Mental Health & Substance Use Disorder) & Treatment

4

Walk In Employment 2










* Data only reflects CHW referrals to resources/partners external to the CHPB from July 2018 to August 2019.


Referrals to Partner Organization


Amazing Grace ChurchBaltimore Food RescueFranciscan CenterMeals on WheelsMoveable FeastMt. Pleasant Food Pick UpNew Life PantrySalvation ArmyThe DoorTransforming Life Church of God


300 N ApartmentsBaltimore Housing Light ProgramCatholic CharitiesDaniel Allen HousingHUBSLakewood TowersLight and Intake Assessment UnitMount ClareParkside Gardens ApartmentRenaissance at Reservoir HillRescue Element Assisted LivingRuscombe Gardens ApartmentSTAR internal program referralSHARP‐LeadenhallSkyline PropertiesThe Chateau and River ApartmentsWeinberg Center/St. Ambrose




Anne Arundel County Social ServicesAssurance WirelessBaltimore City Training CenterBenefit Data TrustBP TrustBrothers of BoazCaring Hands AMDCCenter for Urban FamiliesDepartment of Disability ServicesDetroit/Baltimore Water ProgramDepartment of Public WorksDepartment of Social ServicesEnergy AssistanceGoodwillHUBSLiving ClassroomsMaryland Partnership

Maryland Relay/Telecommunications AccessMTA MobilityNew Life PantrySNAP ApplicationsPayee ProgramQuit NowSafe Link Phone ApplicationSocial Security AdministrationSupplemental Insurance HelpThe Image Center of MarylandVeterans Affairs Pension OfficeWater Bill Reduction AssistanceZion Baptist Church Energy Services





MTA MobilityNew Life PantrySafe Ride

Cups CoffeeLiving Classrooms



This image cannot currently be displayed. 901 BroadwayPenn NorthUnlimited Bounds‐Placed


USA RehabAIDS Action of Baltimore CityBaltimore City CAP Rental Assistance ProgramFranciscan CenterSalvation Army




Health Behavior Specialist Referrals*


* Data only reflects HBS referrals to resources/partners external to the CHPB from September 2018 to July 2019.

51 Referrals to 32 External Organizations for Mental Health and/or Substance Use Support


Health Behavior Specialist Referrals


Apex Counseling CenterAspire WellnessBaltimore Crisis ResponseBaltimore Medical System HIghlandtownBayview Community Psychiatry ProgramBayview Chemical Dependency UnitBayview Intensive Outpatient Program (IOPA)Bridge TeamCenter for Addiction Medicine (CAM)Dundalk Counseling Epilepsy CenterFaith Health CenterFranklin Square Outpatient Mental Health ClinicGilchrestHarbor Outpatient Behavioral Health

Harbor Hospital Partial Hospital Program Harford Bel Air Community CenterHarford Bel Air OMHCJohns Hopkins Community Psychiatry ProgramJohns Hopkins Sickle Cell ClinicKey Point Health ServicesLincoln Trail Behavioral Health in KentuckyMosaicNational Pike CounselingPathways CounselingPeace of Mind CounselingPro Bono CounselingRoberta’s HouseTurning PointUnion Memorial Counseling CenterUniversity of MD1800‐Quit‐Now


JOB CREATIONThis image cannot currently be displayed.

Number of jobs created by the Community Care Team program. Types of trainings and skills acquired by staff of the CCT.


Jobs Created

Position Average Number of Positions

Community Health Worker

18.3

Community HealthWorker Supervisor

2.0

Community Health Worker Administrator

0.5

Community Health Worker Program Manager

1.0

Community Health Worker Director

0.4


Position Average Number of Positions

Care Manager 7.7

Care Manager Program Manager

1.0

Health Behavior Specialist 4.1

Health Behavior Specialist Lead

1.0

Senior Program Manager, Health Behavior Specialist

0.3

Medical Director 0.6

Clinical Nurse 0.3


Care Conference TopicsCare conferences featured 17 topics.

Staff identified topics and a task force of staff coordinated speakers.


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Needs assessment

Medicaid/ Medicare

Diabetes/ CVD

Housing Dental Safety EPIC Crisis response

Pharmacy

Mobile clinic

“The Spot”

Team building

Mercy Patient

Sinai Patient

MedStar Franklin Sq

Patient

MedStar Harbor Patient

JHH Patient

JHBMC Patient



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RETURN ON INVESTMENT This image cannot currently be displayed.

Return on Investment in terms of cost for funders.


ROI Calculation: Assumptions

1. Pre Utilization Charges – Post Utilization Charges = Annual Savings2. Total Program Cost (i.e. program expenses) for Fiscal Year 193. Variable Savings Factor of 50%; 50% of savings attributed to CCT4. Client Total =

1. Version 1: Total Number Clients with Available Pre/Post Data2. Version 2: Total Number Clients Enrolled in CCT During Fiscal Year 20193. Version 3: Total Number Clients if CCT was At Capacity



ROI CalculationThis image cannot currently be displayed.

Per Member Per Year Savings* x Number of Clients = Annual SavingsAnnual Savings x Variable Savings Factor = Annual Net Savings

Annual Net Savings‐ Total Program Cost**/Total Program Cost = ROI

*Estimated PMPY Savings based on Pre‐Post change for CCT clients enrolled for 6 months during FY2019.

**Total Program Cost based on FY2019 CCT Budget.


Cost*: OutreachThis image cannot currently be displayed.

Assumptions:‐ 50% of Administrative Staff time dedicated to Outreach‐ 50% of CHPB Program Supplies dedicated to Outreach‐ 15% of HBS time dedicated to Outreach‐ 30% of CHW time dedicated to Outreach‐ 50% of CHW Team Lead time dedicated to Outreach‐ 25% of CHW Manager/Supervisor time dedicated to Outreach

Total Cost of Outreach

Total Number of Clients Outreached

$ Cost Per Client for Outreach

* Cost based on FY19 budget. FY19 budget used to assess personnel and salaries.


Cost: EnrolledThis image cannot currently be displayed.

Assumptions:‐ 50% of Administrative Staff time dedicated to ‐ 50% of CHPB Program Supplies dedicated to Outreach‐ 85% of HBS time dedicated to Outreach‐ 70% of CHW time dedicated to Outreach‐ 50% of CHW Team Lead time dedicated to Outreach‐ 75% of CHW Manager/Supervisor time dedicated to Outreach

Total Cost of Outreach

Total Number of Clients Enrolled

$Cost Per Client for Enrollment

* Cost based on FY19 budget. FY19 budget used to assess personnel and salaries.


Hopefully, you felt that we…

• Explored the concept of Return of Value of complex care and social needs programs

• Got you thinking about how, for your own program, you would define what the Return of Value is

• Learned from our journey. We’d love to hear about yours!

CONVERSATION. Questions?Feedback?Insights?Tips?

THANK YOU.

APPENDIXRETURN OF VALUE CATEGORY DEFINITIONS

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A. Cost Effectiveness/Returnon Investment

This category looks to capture a qualitative perspective of the value the CCT presents to stakeholders through understanding the power of the resource investment on patients health outcomes.

B. Patient Capacity & Engagement

This category addresses soft skills and mentorship that the CCT provides to patients and identifies the impact these services ‐ soft skills and mentorship ‐provide.

C. Workforce Creation & Optimization

This category documents the need, creation of, and sustainment of a new workforce to address the challenges and gaps in the healthcare system that the CCT strives to address.

D. Patient & Community Health

This category looks at health outcomes and health system use behavior of individuals ‐ patients ‐ and the community as a result of their (individual and community) interaction with the CCT.

E. Health SystemOptimization

This category looks to understand the value that the CCT provides as a partner in health care delivery; meaning that it assesses the skills, gap filling properties, and system functions that the CCT performs (referral network, partnership building, finding patients who otherwise are not found, etc.).

F. Community Relationship

This category highlights the value of the relationship of the hospital partners with the community and the community with the hospital partners from a macro level and looks to identify the characteristics that define a positive relationship and how the CCT promotes that relationship.

return of value: measuring the value of a complex care program€¦ · transforming life church of...

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