As soon as the COVID pandemic started to ebb, the MaineHealth built-in well being system did a program analysis after which revised its advanced care administration framework. On the NAACOS spring assembly, Deborah McGill, affiliate vp for inhabitants well being administration on the MaineHealth Medical Group, described a few of the modifications.
MaineHealth features a Stage 1 trauma heart, eight extra hospitals, pediatric care companies, a behavioral well being care community, in addition to residence well being, hospice and senior care companies.
MaineHealth Medical Group unifies all MaineHealth suppliers on the system’s hospitals and medical facilities and greater than 230 specialty and first care practices in Maine and New Hampshire. Over 1,700 physicians work collectively by way of the MaineHealth ACO.
McGill stated that care administration generally is a important pressure on the subject of value-based care contracts, if it is accomplished effectively and if it is accomplished effectively. “We all know that historically care administration work with sufferers to enhance medical outcomes by working with them to assist perceive what’s the driver of the poor consequence.”
McGill defined that MaineHealth thought it had a fairly well-designed and well-established care administration program previous to the pandemic. It was primarily based on threat algorithms, segmenting sufferers, with multi-disciplinary care administration groups embedded within the major care practices. She stated that what occurred through the pandemic was that many extra sufferers wanted assist in some ways and care managers have been stretched skinny. Additionally, folks with completely different titles in several applications felt like their efforts have been overlapping considerably. “As a result of we have been taking all comers and we have been primarily specializing in social drivers of well being, our nurses have been doing the identical issues as our neighborhood well being staff, our well being coaches, and our social staff, so it made them really feel like they weren’t working to the highest of their license or certification,” McGill stated, including that they discovered that they had strayed away from their preliminary eligibility necessities.
Popping out of the pandemic, the well being system determined to do a complete care administration program analysis, together with business finest follow benchmarking.
“We discovered that if we have been going to be delivering advanced care administration, we would have liked to actually return to the inspiration of understanding our sufferers after which segmenting those which can be probably the most advanced, primarily based on information, and segmenting them right into a program that truly was designed to deal with a few of their points,” McGill stated. “We’ve applications and companies inside MaineHealth that deal with primarily social drivers of well being if there is not any different medical want or no avoidable utilization.”
McGill stated they determined to return to fundamentals. “We discovered that understanding our populations is basically vital, and designing the applications round them is equally vital. Once we seemed on the information, we weren’t seeing the outcomes that we might count on to see from a standard advanced care administration program when it got here to bettering medical outcomes,” she stated. “We did not see plenty of avoidable service utilization discount.”
MaineHealth got here up with a seven-part advanced care administration framework. It begins with proactive identification of the inhabitants —leveraging MaineHealth’s information to know who’re sufferers that it may possibly affect with conventional advanced care administration, and tips on how to establish sufferers who may benefit from different beneficial sources which can be out there. “We created a sequence of inhabitants well being screenings,” McGill stated. “Once we enroll a affected person into care administration, these screenings assist us to know what are the drivers of the poor outcomes that our sufferers are going through. How can we work finest with them by way of care administration? Is it extra behavioral well being? Is it extra social drivers? Is it extra medical? As soon as we perceive that, we create a posh plan of care in Epic for these sufferers.”
Beforehand that they had a posh care administration program known as “Lend a Hand,” which offers with social determinants of well being and includes neighborhood well being staff and social staff. It additionally had a transitions-of-care intervention. When discharged from a hospital, a affected person would get a one-time phone name from care transition to test in with them.
MaineHealth determined to create a number of completely different applications. They stored the Lend a Hand program, Additionally they have a posh illness care administration program the place they embedded distant nurses in major care practices.
MaineHealth additionally create a brand new program consistent with the strategic targets of the MaineHealth system, offering a greater care coordination for sufferers with end-stage persistent kidney illness, with nurses embedded within the nephrology practices. “The concept there may be to gradual the development of CKD by serving to to regulate plenty of the opposite co-morbidities, coordinating care, hoping to plan extra prematurely for dialysis or transplants and even finish of life,” she stated. “We additionally prolonged our transitions-of-care program to be extra of a 30-day help program.
This system analysis additionally discovered that care administration sources weren’t equally distributed throughout the medical group, so that they have labored to raised distribute them to extra rural components of the state.
Expertise is a large enabler, McGill pressured. Previous to the pandemic, that they had a selfmade complexity rating. “We did not actually name it a threat rating, as a result of it wasn’t predictive of something, however it was a conglomeration of various information that we use,” she stated. “We simply gained entry to the danger rating in Epic in October. We have been capable of goal our advanced sufferers with extra precision and get them enrolled.”
