Built-in Well being Companions (IHP) is a nonprofit, FQHC-controlled clinically built-in community, devoted to advancing value-based care and cost reform for historically underserved populations in San Diego and Riverside counties in California. Kristine Ortwine, IHP’s director of inhabitants well being IT and analytics, not too long ago spoke with Healthcare Innovation about how the FQHCs are leveraging analytics to reach value-based care preparations.
Established in 2015, IHP’s community spans 97 scientific websites and works with six well being plans in Southern California.
Healthcare Innovation: Kristine, might you speak about how Built-in Well being Companions got here collectively initially, and whether or not it is grown considerably since then?
Ortwine: It has grown considerably. IHP started within the 2015-2016 timeframe. I joined the IHP workforce in 2018. My function on the time was round serving to the community unify their knowledge to have the ability to assist most of the initiatives that they have been attempting to execute on. Finally, IHP is a clinically built-in community. Their function actually was to assist federally certified well being facilities be a part of collectively to undertake greatest practices, to enhance affected person outreach, affected person care, affected person outcomes, and to assist assist them as they ready for various cost fashions and value-based care initiatives. Once I began in 2018, we have been working with two well being plans and now we work instantly with six well being plans, and we have grown most likely 350% by way of our membership. We presently are at about 389,000 managed care lives. Once I began, it was most likely round 100,000.
HCI: Do the FQHC leaders function the board members and steer the course of initiatives?
Ortwine: Sure. IHP is de facto working for the 9 well being facilities which are individuals. The board is led by the well being middle management and supported by the manager management and workers at IHP. However the well being facilities are the leaders, and so they decide the course of the community.
HCI: Are the well being plans Medi-Cal insurers? Or others as properly?
Ortwine: Our ebook of enterprise is de facto rising. We’re operating at about 97 to 98% Medi-Cal, which is California’s model of Medicaid. However we do have and proceed to develop different books of enterprise. We’ve a small Medicare inhabitants. We even have new well being plans. We’re an FQ hub for SharpCare, and we’ve got plans via SCMG [Sharp Community Medical Group]. We even have some industrial via Anthem. Our most up-to-date enterprise is with our ACO referred to as “My Selection High quality Care Community.” That may be a new providing from CMS. It’s a Medicare Shared Financial savings Program that rolled out in 2025.
HCI: What are a number of the challenges that the FQHCs face once they’re working independently that being a part of IHP helps them enhance? Does it contain serving to them see their very own knowledge extra clearly, or does it contain aggregating knowledge throughout the FQHCs and pulling in knowledge from different sources?
Ortwine: I believe it’s all of that. FQs are resource-constrained usually. They serve a inhabitants of underinsured and uninsured people, and so they have an enormous footprint locally. One in three persons are accessing main care via a federally certified well being middle. And what meaning is that folks go plenty of locations plenty of instances. IHP has an open door coverage, so meaning a patron can obtain care wherever they should. That is a variety of information in a variety of locations. So individually, these well being facilities are doing a very nice job delivering care, however it’s exhausting when you may see solely a partial image of that affected person.
The community affords assist in a few methods. One is from the info aggregation perspective, and Arcadia is our companion there with our inhabitants well being software. If I stroll into Neighborhood Well being, for instance, and I am this affected person, I can see that that she’s additionally been at Vista, and perhaps she had a hospital discharge from one in every of our hospital ADT companions — we’ve got a feed with our native well being info alternate. Their capacity to see that longitudinal affected person report actually helps them ship high quality care. It helps them perceive the general affected person standing, in order that they’ll goal and never duplicate companies.
Somebody who has very restricted workers in a single website now has the power, with the assist of Arcadia and IHP, to take a look at how that affected person has moved via the community, and so they could not have had the assets to try this in any other case.
One other piece is round how we are able to assist their scientific, operational and coding workers that use the info. The place can we focus our assets? What does our monetary image seem like in a number of the contracts that we’re engaged on? What are essentially the most susceptible populations, by way of superior care administration that you simply need to interact? So it is not simply the technical piece that helps them jump-start merging all of this very fluid and disparate knowledge; it’s additionally the assist piece to assist them operationalize utilizing that knowledge and improve and enhance their efficiency.
At IHP, we even have an enhanced care administration workforce of 12 on the central stage that helps interact sufferers who qualify for enhanced care administration companies. We need to be sure that the neediest sufferers get the kind of care that greatest serves them. That’s the kind of program that must be leveraged whenever you’re speaking about sufferers who’re both troublesome to succeed in or are in very advanced conditions and are getting misplaced within the system.
HCI: Are these clinics on quite a lot of EHRs, and was that a part of the problem to start with — getting it arrange in order that the info flows backwards and forwards?
Ortwine: Sure, our well being facilities are all on completely different EHR distributors. And that is most likely the strongest purpose for having a pop well being companion: We’ve a pair who’re on NextGen, simply for instance. Every of these well being facilities is an unbiased entity that is leveraging that occasion of NextGen with their very own workflows and their very own knowledge inputs. So even when you have them on the identical vendor, how they’re amassing knowledge, how that knowledge is being translated into the tables, after which how that knowledge is being built-in in Arcadia’s bigger knowledge lake is all very completely different. All of it must be mapped and optimized. So whereas every of the well being facilities does an amazing job inside their very own ecosystem, when you concentrate on inhabitants well being usually, you need to take a look at the totality of that affected person throughout a number of scientific programs, throughout HIEs, throughout immunizations, throughout claims knowledge and enrollment. In order that’s the fantastic thing about them knowledge in a brand new means. In the event that they have been attempting to do that by themselves, it might be time-intensive and rather more pricey for a person well being middle.
HCI: Are there some sources of information which are difficult to get, like lab knowledge or behavioral well being knowledge?
Ortwine: It’s not nearly having access to the info. So if I might reframe that, perhaps it is about decoding and stabilizing the info. I might have a want record of all knowledge, however is that knowledge available? Is it being collected in a regular means? If we have been to take a position the power to construct a stay connector or a daily connector into Arcadia, will that knowledge have the ability to be interpreted appropriately and joined with different knowledge that we’ve got within the platform?
You simply referenced behavioral well being, and that could be a fantastic instance. In all probability prime of thoughts with our group is closed-loop referrals knowledge. As a result of we’ve got a robust care administration program right here, oftentimes, as we must always, we refer sufferers out to community-based organizations to assist them deal with issues which are exterior of a scientific lens. Possibly they’ve meals insecurity, housing insecurity, or employment points so we refer them out. However how do we all know that that referral truly occurred, in order that we are able to perceive the way it impacts the affected person’s care? That is an amazing instance of an information supply that is troublesome to get our arms on. However in the end, I consider the problem is de facto round once we do have entry to knowledge, guaranteeing that that knowledge stays wholesome and steady and can be utilized and interpreted appropriately throughout the community.
HCI: What about that social determinant knowledge you simply described — to establish sufferers who may want transportation or housing or meals assist. Are the clinics themselves surveying their very own sufferers to assemble that knowledge, or are there different sources of that knowledge?
Ortwine: It is form of a combined panorama proper now. Equitable entry to care is a driving drive not just for our well being facilities, however it’s a pillar of IHP’s mission, so figuring out sufferers’ true wants throughout social drivers of well being is one thing that we’re investing in. However as you acknowledged, that sort of information will not be solely troublesome to seize as a result of it is delicate in nature, it is troublesome to observe all through a affected person’s lifetime of engagement with us. As with every different initiative, every well being middle is at a distinct place. Whereas everyone seems to be making an attempt in several methods to gather that knowledge, how they retailer, maintain and leverage that knowledge is perhaps completely different throughout the well being facilities within the state of California. We’re working throughout the state with Cal-AIM, which is a big initiative in California, and we assist that initiative, and work alongside our DHCS [Department of Health Care Services] companions to find out how we are able to get that knowledge in a regular, coded means.
HCI: Do you even have robust well being info exchanges in your space that you would be able to rely on to get knowledge from and submit knowledge to?
Ortwine: Sure, we’ve got San Diego Well being Join, San Diego County’s HIE. We established an ongoing feed with San Diego Well being Join’s ADT. We offer San Diego Well being Join with a month-to-month roster of energetic sufferers, after which they supply us real-time messages of these ADT alerts. We’re talking with Manifest MedEx about the potential for establishing a really related feed in order that we are able to perceive in actual time inside the remainder of the aggregated knowledge exercise for these entities which are collaborating with Manifest MedEx.
I need to be clear, not one software solves every little thing; not one know-how works for everybody. However what we actually try to do as we assist the well being facilities is restrict the variety of locations they should go to get info. We do not need somebody who’s already strapped for time having to recollect this method for this, and that system for that. So whereas every of those entities — San Diego Well being Join and Manifest MedEx — have elegant choices of their very own, or particular person portals that you could possibly use, we’re attempting to restrict that boots-on-the-ground clinician or operational particular person having to try this. By how we deliver that info in, we wish them to have a one-stop store. Then as soon as we’ve got that info, our capacity to leverage our personal know-how assets to push that knowledge to them mechanically turns into game-changing. And we do have applications which are constructed round these ADT messages for transition of care and enhanced care administration engagement.
HCI: Do you’re employed instantly with the payers on pay-for-performance contracts?
Ortwine: We do. We work instantly with the well being plans to assist be sure that gaps are being closed, be sure that the standard of the knowledge and knowledge that is being offered to the well being facilities is appropriate and correct. We are able to observe up and work via knowledge points, affected person assignments, and shut care gaps.
HCI: Are the well being facilities being profitable in a few of these various cost fashions?
Ortwine: Sure. I believe IHP is a superb instance of how one can leverage this assist on the community stage throughout these entities which are working in several geographies with completely different populations with completely different assets to push ahead with value-based cost. We’ve two skilled threat contracts proper now, one with Anthem and one with Blue Defend Promise. That’s a brand new form of enterprise for our well being facilities, and I believe it might have been very troublesome for them to start out these sorts of relationships and people threat contracts with out overarching assist, in order that that is an actual win. We’ve alternative to enhance take care of our sufferers and handle prices with these various value-based care fashions that is perhaps new to them.
This new MSSP ACO product is a superb instance of how we are able to band collectively and use the power of the community to assist new varieties of buildings for affected person engagement and care which may not have been possible. Everyone knows that these things is difficult, however value-based care will not be going wherever. We’re going to have to repeatedly ship higher high quality of take care of an affordable value and be sure that the affected person is not the one which pays ultimately. We would like the groups to ship the care and for us to supply the assist they must be profitable.
HCI: Is there anything I have not requested about that you simply’d need to stress concerning the work with Arcadia, or different tasks you’re looking ahead to within the subsequent yr?
Ortwine: I might say that for the well being facilities we work with, it requires effort and time to take part in these sorts of tasks. They should have a major stage of engagement to make these initiatives profitable, so we’re appreciative of their assist in these kind of applications to raised the lives of their sufferers.
On the opposite facet of that, that is our sixth yr with Arcadia, and so they have been a stellar companion in adapting alongside our community. Our community has modified. How we leverage Arcadia has modified, and the way we assist our well being facilities has grown and improved, in order that they have been a companion alongside us in dealing with the challenges on this swiftly altering setting that all of us stay in.
