1. Community Linkages in Michigan
Carol Callaghan
June 11, 2012

2. Origin of Community Linkages Efforts in Michigan
Michigan is one of eight states implementing the Multi-payer Patient-Centered Medical Home (PCMH) Demo
410 primary care practices participating, serving >1 million Michigan residents
Built on 5 years of powerful PCMH investment by Blue Cross Blue Shield of Michigan
BUT… minimal attention to the social determinants of health that may have greater impact on the individual’s health status than does medical care

3. Innovation Driven US Health Care System Evolution Anthony Rodgers, CMMI
Health System Transformation and Evolution Critical Path
Community Integrated
Health Care System 3.0
Coordinated Seamless
Health Care System 2.0
Community
Integrated
Healthcare
Patient, Population, and Community-Centered
Community Health Resource Linked
Cost, Quality, and Population Health Outcome Transparency
Community Healthy Living Choices
Community Health Integrated networks capable of addressing psychosocial, economic and LTC needs
Right care, at right time, in right setting
Population-based reimbursement
Learning Organization: Capable of rapid
deployment of Best Practices
Community Health Integrated
Community Healthy Living Oriented
Community Health Capacity Builder
Community based support developer
Shared community health responsibility
E-health and tele-health capable
Wide use of remote monitoring and tele-health and e-health management
Health E-Learning resources, social networking, health literacy tools
Community
Integrated
Healthcare
Patient, Population, and Community-Centered
Community Health Resource Linked
Cost, Quality, and Population Health Outcome Transparency
Community Healthy Living Choices
Community Health Integrated networks capable of addressing psychosocial, economic and LTC needs
Right care, at right time, in right setting
Population-based reimbursement
Learning Organization: Capable of rapid
deployment of Best Practices
Community Health Integrated
Community Healthy Living Oriented
Community Health Capacity Builder
Community based support developer
Shared community health responsibility
E-health and tele-health capable
Wide use of remote monitoring and tele-health and e-health management
Health E-Learning resources, social networking, health literacy tools
Uncoordinated Health Care System 1.0
Efficient & Accountable Care
Episodic
Non Integrated
Care
Patient/Person Centered
Transparent Cost and Quality Performance
Results-oriented
Assures Access to Care
Improves Patient Experience
Accountable provider networks designed around the patient, including LTC needs
Shared Financial Risk
HIT integrated
Focus on care management and preventive care
Primary Care Medical Homes
Care management/ prevention focused
Shared Decision-Making and Patient Self-Management
Episodic Health Care
Sick care focus
Uncoordinated care
High use of Emergency Care
Multiple clinical records
Fragmentation of care
Lack integrated care networks
Lack of integration between acute and long-term care settings
Lack quality and cost performance
transparency
Poorly coordinated Chronic Care Management

4. Innovation Driven US Health Care System Evolution
Health Care System AND Community Care System: PARALLEL Evolutions & Critical Path
Coordinated Seamless
HEALTH CARE System 2.0
Uncoordinated
HEALTH CARE System 1.0
(Episodic Non Integrated Care)
(Efficient & Accountable Care)
Community Integrated
Health Care System 3.0
Uncoordinated
COMMUNITY CARE System 1.0
Coordinated Seamless
COMMUNITY CARE System 2.0
(Confused Consumers; Inefficient Care Delivery)
(Efficient, Accountable, Person-Centered Community Services)

5. Community Care System Evolution in MI
MDCH DRAFT of a Community Care System Critical Path
Community Integrated
Health Care System 3.0
Community
Integrated
Healthcare
Coordinated Seamless
Community Care System 2.0
Uncoordinated Community Care System 1.0
Organized, Accountable, Person-Centered Community Services
Confused Consumers; Inefficient Care Delivery
Patient, Population, and Community-Centered
Community Health Resource Linked
Cost, Quality, and Population Health Outcome Transparency
Community Healthy Living Choices
Community Health Integrated networks capable of addressing psychosocial, economic and LTC needs
Right care, at right time, in right setting
Population-based reimbursement
Learning organization: capable of rapid
deployment of Best Practices
Community Health Integrated
Community Healthy Living Oriented
Community Health Capacity Builder
Community based support developer
Shared community health responsibility
E-health and tele-health capable
Community service agencies ** in formal network
HUB with IT connectivity to all community service agencies and medical practices
Referral of high-risk clients to approp System
Coordinated care for moderate /low risk clients via screening, referral to appropriate agency/ service or assignment to CHW
Efficient, accountable care
Transparent cost / quality performance
Results-oriented, accountable agencies
Assured access to care
Improved consumer experience
Public reporting
** Agencies with services related to social & other determinants of health
Community agencies, each in own silo
Each with care managers
Each producing client care plans
Each producing client / family records
Fragmented care for individuals, families with multiple needs
Uncoordinated cross-agency care for individuals, families
Little or no cross-agency communication or data sharing
Little or no agency communication with medical care providers
No transparent quality/cost performance data
Inefficient, redundant (i.e., costly) services
Ever-shrinking public funding

6. The Pathways/Community HUB Model in Mansfield, OH
Focused efforts on high-risk, hard to reach pregnant teenagers to reduce very high rate of low birth weight infants
Created evidence-based Pathways: homelessness, domestic violence, school drop-out, unhealthy eating, undependable transportation, no health provider, depression, unemployment
Trained and incentivized Community Health Workers (CHW) to locate those in need and help resolve the many challenges faced by these adolescents

7. Results
In three years, low birth weight rates in target areas dropped from 16 per year to 1 per year – and rate was sustained
Millions of dollars saved by avoiding NICUs, Children’s Special Healthcare Services, Special Education services
Other examples of success with Pathways/ Community Care Coordination (

8. 22+ Pathways Defined Behavioral Health Housing Child Care
Income Support
Chronic Disease
Legal Services
Dental
Medical Debt
Depression
Pharmacy/Medications
Domestic Violence
Pregnancy
Education/GED
Medical Care
Employment
Social Isolation
Food Security
Substance Use/Abuse
Heat/Utilities
Transportation
Homelessness Prevention
Vision & Hearing

9. Strategies to address Social & Other Determinants of Health
Organize community service agencies into a formal resource network, including data sharing agreements
Promote use of evidence-based ‘Pathways’
Assure a trained workforce (‘lay’ CHWs plus health professionals) for efficient, accountable community-based care
Establish central data system with interconnectivity to all agencies (including medical practices)
Encourage positive outcomes with innovative payment systems for CHW’s (e.g., incentives) and community recognition for agencies

10. Roles of the Community HUB
Outreach: Searches out those at risk
Screens or briefly assesses client
Do you have any questions or concerns you would like to tell me about?
Do you need help with transportation? (to health care? job? school?)
Do you have problems with housing? (if yes, foreclosure? homeless?)
Do you have problems getting food? clothing? paying utilities?
Are you looking for a job? (if yes, need help searching? help with resume? need training? felony record?)
Enters data into Interconnected Central Data System
Identifies Evidence-Based ‘Pathway’ for each need

11. HUB Roles (continued)
Refers high-risk to appropriate System (MH, SA, LTC, AAA, HV, SEd)
Sends ‘Pathway’ along with referral to agency
Refers Low/Moderate Risk:
To appropriate service or
To CHW to implement Pathway(s) with client until resolution (including 3 mos. follow-up contact for assurance)
Reports sent back to referring provider or agency
Monitors/Evaluates (by client, provider, agency, community)
Reports to community and to policymakers
Accomplishments, Gaps, Costs – and Costs Averted