Health System Design to Impact Social Determinants...

11/23/2015

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Health System Design to Impact Social Determinants of Health

Cory Sevin, IHIJill Kemper; ICSI

Brigid McCaw, Kaiser Permanente

Beth Heinz, HealthPartners

Tom Blee

John Turnipseed,

L24This presenter has

nothing to disclose

December 6th 2015

1:00-4:30 ET

Orlando, FL

#27FORUM

Session Objectives

Describe how partnerships with community stakeholders

broaden the reach and impact of healthcare systems.

Identify how unique and impactful partnerships are

formed to impact a health issue.

Identify 3-5 ideas you can test in your own context.

P2

#27FORUM

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Agenda

Welcome and introductions

Health Care Meets People Where They Are - At

Court

Table Work-how does this apply to me?

LIFETeam: Breaking the Cycle of Violence

3:05-3:25 Break

Transforming Health Response to Domestic ViolenceTable Work-how does this apply to me?

4:30 Adjourn

P3

Health Care Meets People Where They

Are – In Court

December 6, 2015

IHI National Forum

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• Screening to identify people at risk for developing substance use disorders.

• Brief Intervention to raise awareness of risks and consequences, internal motivation for change, and help set healthier goals.

• Referral to Treatment to facilitate access to treatment and coordinate services between systems for people with higher risk and/or dependence.

SBIRT for Risky Substance Use

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What do we know?

MN/St. Louis County Data*

• 25,258 DWI arrests in MN (1037 in St. Louis County)

• 60% are first time violators

• Over the last 10 years, 71% of all DWI arrests were first time violators

• 2 out of 3 arrested for DWI never receive a second DWI

*MN Impaired Driving Facts 2014

SBIRT Research*

• Court ordered screening is coercive by nature.

• Target the time when is person most amenable to intervention.

• Design screening as part of brief intervention to increase insight, honesty and motivation.

*Lapham, 2004

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Hon. Shaun Floerke

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News clip from KBJR Duluth

Better Approach

"If somebody comes in and they're low risk/low need, and I treat them as though they're high risk/high need, I can actually harm them. I can make them worse.

You're not trying to make them criminalized. You're not trying to pull them deeper into the system.”

- Judge Shaun Floerke

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Distribution of Alcohol Use

Abstinent/Lo

w risk

Moderate risk High Risk

Primary PreventionBrief Intervention

Specialized Treatment

Disorder

40%35%

20%

5%

Target

Population

Target

Population

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Core Team– Hon. Shaun Floerke, 6th District Court

– Julie Seitz and Kim Davis, Center for Alcohol & Drug

Treatment

– Greg Anderson and Matt Johnson, St. Louis County

Health & Human Services

– Nicole Korby and Amy Turnquist, Court Administration

– John Walker and Heather Kussatz, Arrowhead Regional

Corrections

– Jill Eichenwald, Public Defense

– Capt. Steve Stromback, MN State Patrol

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Teamwork

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Process

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Key Improvements

• Locating interventionists in the courtroom

• Holding Bench meetings and keeping SBIRT

info out of client court file

• Having ARC, PHHS and CADT do the S & BI

• Reducing client fine by $50 when follow-up

appointments were completed

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24

75

117

175

257

367

14

46

68

110

168

236

716

33 39 4155

0

50

100

150

200

250

300

350

400

Week 1-10 Week 1-20 Week 1-30 Week 1-40 Week 1-50 Week 1-67

SBIRT Screens (data as of 9/17/15)

#Arrests Scheduled in Court

#Screened

#Potential Future Screens

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Client Comments

• “More time to process helps, this isn't just a parking

ticket…”

• “I’m not changing a lot, but I'm more aware of what I

should and shouldn’t do…”

• “This was amazing. I thought I could have 3 drinks and

still drive. This stuff should be taught in high school…”

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Follow Up

• 3-4 weeks after initial Screening/Brief

Intervention

• Discuss goals/progress

• -Audit- C

• Participation incentive/ reduction in fines

• Exploring alternative options for follow-up

including electronic means.

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How Does This Apply To Me?P21

#27FORUM

LIFE Team Helping Hurt People Who Hurt People

Dr. Tom Blee, John Turnipseed, & Beth Heinz

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Learning Objectives

Learn about the LIFE

Team program

What disparities do you see

in your community?

Apply learnings to improve the

health of your

community

Who We Are

• Beth Heinz

• Vice President of Operations, Regions Hospital

• Chief Quality Officer, Regions Hospital

• Thomas H. Blee, M.D.

• Assistant Professor of Surgery, University of Minnesota

• Trauma Surgeon, Regions Hospital

• John Turnipseed

• Vice President, Urban Ventures

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Health

planMedical

clinics

Dental

clinicsHospitals

Research

&

education

Nonprofit, consumer governed

HealthPartners Integrated Care

Who We Are: Regions Hospital

• Located in St. Paul, Minnesota

• Part of HealthPartners, the largest

consumer governed, nonprofit health

care organization in the nation

• Level 1 Adult and Pediatric Trauma

Center

• 800 Trauma team activations per year

90% Blunt

10% Penetrating

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Regions Hospital: Trauma Registry Data

• Average 340 admissions each year for “Assaults”

– 45% Assaults

– 32% Stabs

– 23% Gunshot Wounds

• 84% of patients are male

• 80% of patients are absent fathers

• Dr. Blee’s interaction with repeat

patients

LIFE Team History

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What is LIFE Team?Leadership Impacting the Family Environment

• At-risk individuals are identified, and

encouraged to participate in beginning a

positive life transformation

• Multiple intervention techniques focus

on stabilizing lives

– Physically

– Socially

– Economically

– Renewing each individual’s bond to the

community

LIFE Team Process

If the patient meets one or more of the following criteria, refer the

patient to LIFE Team:

• Gang involvement with a desire to get out

• History of perpetrating violence and a desire to change

• History of felonies/legal issues that are impacting ability to secure

employment

• Difficulty securing stable employment and are in a need for

training/interview skill teaching etc.

• History of lack of parental involvement/familial support resulting in

psychosocial issues and the patient could benefit from mentoring

• Need for parental skills training

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Community and Hospital Partnership

Case Study

• Surgical complexity

– 5 surgeries in a short period of time

• Stayed about one month on

trauma unit

• Couldn’t eat

• PTSD

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Case Study

• The Talk

– Grim discussion

– Needed a miracle

• The Solution: John Turnipseed and

Urban Ventures

• Hope

• Transformation

• Fixing a generational problem

• Health care costs

– Stopped future violence

related visits

Intervention Results

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• Direct interventions work best

– Consistency, keep showing up

– Train story

• Most powerful tools

– Rest

– Laughter

• Not every person ready to change

• Model is self perpetuating

Lessons Learned

Conclusions

• Hurt people hurt people

• Most effective when you stay in your strike zone

• Don’t reinvent the wheel, move your resources to

the problem

• The ultimate trauma prevention strategy is to fix

families

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Learning Objectives

Learn about the LIFE

Team program

What disparities do you see

in your community?

Apply learnings to improve the

health of your

community

Conclusions

Questions?

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Break-Return 3:25P39

Brigid McCaw, MD, MPH, MS, FACP

Medical Director, Family Violence Prevention Program

Kaiser Permanente

December 2015

Transforming the Health Care Response to

Family Violence

#27FORUM

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© 2015, The Permanente Medical Group, Inc. All rights reserved. Family Violence Prevention Program.

Objectives

� Learn about an innovative “systems model”

approach and quality improvement processes

that transformed a health care response to

family violence

� Learn about the critical role of linkages

between health care and community services

� Identify 2-3 opportunities to more effectively

address family violence in your setting.


Ending family violence requires strong partnerships…

Religious

Leaders

Advocates Police

Employers

Health

Professionals

Educators

Friends

Policy Makers

Judges &

Legal

Professionals

…Healthcare has an essential role

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Kaiser Permanente’s Innovative Model

https://youtu.be/uocoMbCg9N8

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1,0221,663

2,354 2,550 2,8753,466 3,285 3,432

4,036

5,148

6,173 6,2037,106

8,347

12,862

16,062

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*

Nu

mb

er

of

Mem

bers

wit

h IP

V D

iag

no

sis

Members Diagnosed with Intimate Partner Violence, 2000-2015*(Women and Men)

*Note: 2015 estimate is based on data from 10/1/14 through 9/30/15

KP Northern California:

Sixteen-fold Increase in IPV Identification


0

2,000

4,000

6,000

8,000

10,000

12,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*

Nu

mb

er

of

Mem

bers

wit

h IP

V D

iag

no

sis

*Note: 2015 estimate is based on data from 10/1/14 through 9/30/15

KP Northern California:

Most Identification Occurs in Ambulatory Care

Members Diagnosed with Intimate Partner Violence by Dept Type

2000-2015*

1,022

16,062

{

{

Emergency Dept. & Urgent Care

Mental Health

Primary Care

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How to transform a health care system’s response to family violence:

Clear goal: DV inquiry and intervention is part of everyday work

Thinking in new ways: Systems-Model Approach

Implementation and dissemination plan

Quality improvement measures


Making the Case: Why is IPV an important

health care issue?

IPV is extremely common

The health effects are devastating

The health care costs are substantial

IPV impacts future generations

Health care interventions

make a difference

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Affordable Care Act

Screening and counseling for interpersonal and

domestic violence included as part of women’s

preventive health services

Recommends universal screening

for childbearing-age women

IPV screening and counseling

should be core part of women’s

health servicesWomen’s Preventive Health Care Services Committee


Comparison to other Important

Life-Threatening Conditions

that Affect Women

New cases of breast cancer[1] 211,000

Number of women dying from

cardiovascular disease[2]484,000

Women who are injured from IPV[3] 2,000,000

In the US, each year

1. Breast Cancer Facts & Figures. American Cancer Society: Atlanta, GA. 2005-2006.

2. Heart Disease and Stroke Statistics. American Heart Association: 2006.

3. Extent, Nature, and Consequences of Intimate Partner Violence. U.S. Department of Justice:

Washington, DC. NCJ 181867, 2000.

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IPV Associated with Many

Health Conditions

Most common cause of injury in women (18-44 yo)

� Headache, fatigue, insomnia, palpitations

� Chronic pain

� Depression, anxiety

� Obstetric and gynecologic conditions

� Poorly controlled chronic conditions


IPV and Chronic Health Problems

� 60% more likely to have asthma

� 70% more likely to have heart disease

� 80% more likely to have a stroke

� Twice as likely to be a current smoker

Center for Disease

Control (CDC)

Feb 2008

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Impact on

Future Generations

� Children who witness DV

� May also be victims of abuse

� Higher rates of

� Depression, anxiety

� Substance abuse

� Failure in school

� Becoming victim or

perpetrator

help happens here.


Intervention Makes a Difference!

Women who talked to their health care provider about the abuse

were nearly 4 times more likely to use an intervention

https://youtu.be/q2GDQMOGQ5E

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Most women end violent relationships

� It takes time: on average 3-5

attempts and about 7 years

� The majority of women do not

have recurrent abusive

relationships

� Clinical intervention helps







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Inquiry and

Referral

Supportive

Environment

Leadershipand

Oversight

On-siteServices

Community

Linkages

Member and employee IPV education materials

Ongoing work to establish and promote community

resources

Electronic Medical Record Tools

Clinician training modules

Builds on existing resources in behavioral health, social services,

mental health

Referral Protocols


Supportive EnvironmentAwareness and Information

What is it?

� Information: restrooms, exam rooms,

on-line, podcasts, health ed classes

� Posters: “Let us know, we can help”

� Reaching patients everywhere they

contact the health care system

� Engaged and informed workforce

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Rooming Alone

Rooming alone allows

for private discussions

of sensitive issues,

including relationship

violence.

Supportive Environment

Privacy Posters


Supportive EnvironmentEngaged and informed workforce

Stories of courage, survival, and hopekp.org/domestic violence

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Must Address Clinician AND

Patient Concerns

The doctor:� How do I ask about IPV?

� What do I do when the answer is “yes”?

� How can I offer an intervention that is caring, effective, and efficient?

The patient:� If I disclose, what will happen?

� Will I be able to access the next set of resources I need?

� How will this benefit my health?

Inquiry and ReferralMust address patient AND clinician concerns


Inquiry and Referral

What to do if the answer is “yes”?

Role of the clinician is clear and limited

� ASK

� AFFIRM

� ASSESS

� DOCUMENT

� REFER

“Making the right thing easier to do.”

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Website easily accessible from EHR

Clinical Care Path


Website easily accessible from EHR

Member Resources Available at Point of Care

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� Supporting clinicians:� Tools in electronic medical record

� Online clinician training

� Point-of-care online resources

� Engaging patients:� Online information for patients

� Advice Nurses in Call Center

� Apps: Circle of 6, 1 Love MyPlan

Inquiry and Referral

Using Technology to Improve Care


Comments from a KP Physician

https://youtu.be/KHWCZsXI8Rc

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Improvement in Member Satisfaction“How are things at home?”

0

10

20

30

40

50

60

70

80

90

100

18-34 35-44 45-64 65+

Asked about home life

Not asked

Percent of members rating satisfaction with physician as very good or

excellent (Member Patient Satisfaction Survey)


On-site IPV Response

� Triage for other mental health conditions

� Danger assessment

� Safety plan

� Support groups

� Referral to community resources

Social Services & Mental Health

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Customize using local resources

� Local DV agency provides

� on-site advocate

� on-call response to hospital or clinic

� In house DV-trained staff collaborate w/ DV agency

� Private place to access help via phone or on-line

On-site IPV Response

Options for HOW to do this


What are they?

� DV advocacy

� 24-hour crisis response, safety planning

� Emergency shelter; transitional housing

�Other services: counseling, legal services, court advocacy

� National DV Hotline, Online Chat, Love is Respect Mobile Texting

� Family Justice Centers

Community Linkages

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Family Justice Center Services

Counseling� Domestic violence and Sexual Assault counseling

� Safety planning

� Self-sufficiency program: computer skills, financial literacy, resume writing

and interviewing skills, ESL

Legal� Restraining orders

� Victims Compensation application assistance

Housing� Shelter and transitional housing assistance

Families� Parenting support

� Childcare while parent or guardian is receiving services onsite

Community LinkagesFamily Justice Center Services







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KP Quality Improvement (QI) Measures

� Uses automated database

� Makes sense clinically

� Actionable

� Linked with national standard

National Committee for Quality Assurance (NCQA):

“QI 11 – Demonstration of a health program showing

continuity and coordination between medical and

behavioral health care.”


Regional Identification Rate for IPV

5%7% 6% 7%

8%

10%

12% 11%

13%

16%

24%

28%

0%

5%

10%

15%

20%

25%

30%

Percent IPV+ Women Identified

Intimate Partner Violence Identification RateKPNC Women Age 18-652001-2015

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Matching the Performance of the Best

54%

37%

31%28%

27% 26%

20% 19%

15%

0%

10%

20%

30%

40%

50%

60%

A B C REG D E F G H

Intimate Partner Violence Identification Rate

by Medical Center (KPNC Women Age 18-65)

10/1/14 through 9/30/15


Culture Change

“No one is making you do anything you don’t want. I’m

just saying we’re all headed for Dodge City and we think

you should come along.”

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Rapidly Spreading What Works…

…and Sustaining It

� Infrastructure and sponsorship at each medical center

� Step-wise implementation

� Tools for implementation teams� Champion and Team roles

� Templates for referral pathway

� Clinician and patient education

� Regular communication with teams

� Quality improvement measures

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Phases of Implementation


Step-wise Implementation

Step 1� Form a local multi-disciplinary team with clinician champion

� Develop protocol for patients in urgent and non-urgent situations

� Identify community resources and develop partnerships

Step 2� Visible patient education materials

� Ensure that on-site services are in place

� Choose quality measures and annual goals

Stakeholder communication and engagement

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Step-wise Implementation

Step 3� Clinician training- brief, frequent. Include tools and stories.

� Trend progress over time

� DV resources for employees

Step 4� Leadership training for champion and teams

� Link to other initiatives- electronic medical record, chronic conditions

� Sustain partnerships with community advocacy

� Highlight ‘promising practices’

Stakeholder communication and engagement


Implementation of IPV Services Underway in Every KP Region

Northern California

Northwest

Southern California

Colorado Mid-Atlantic

Georgia

Hawaii

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Transforming the Health Care

Response to Family Violence


Transforming the Community

Response to Family Violence

Looking ahead to the next decade…

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Contact Information

Brigid McCaw, MD, MS, MPH, FACPMedical Director, Family Violence Prevention Program

Kaiser Permanente

@BrigidMcCaw

[email protected]

kp.org/domesticviolence


Appendix

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Clinician Training Resources

How to Ask, How to Respond,

and How to Use HC Tools 14-min Online Training (2010)

Clinician Tipsheet“Communicating with Patients:

Intimate Partner Violence” (2012)

A Provider’s Handbook on

Culturally Competent CareChapter: “Intimate Partner Violence”

(2009)

Making a Difference6 min video (2013)

Abuse & Assault Link Video TipBrief Video Tour of Abuse and

Assault Website (2012)

Abuse and Assault Website Family Violence Prevention Program

Intranet Site

(2005-2014)


Descriptions of the

KP Systems-Model Approach

� "Using a Systems-Model Model approach to Improving IPV Services in a Large Health Care Organization". Institute of Medicine. 2011 http://www.iom.edu/Reports/2011/Preventing-Violence-Against-Women-and-Children-Workshop-Summary.aspx“

� “Developing a Health System Response to Intimate Partner Violence,” McCaw, B, and Kotz, K, Intimate Partner Violence: A Health-Based Perspective, C. Mitchell and D. Anglin ed., Oxford University Press 2009

� AHRQ Innovations Solution: “Family Violence Prevention Program significantly improves ability to identify and facilitate treatment for patients affected by domestic violence,” http://www.innovations.ahrq.gov/content.aspx?id=2343

� AHRQ Tool for Assessment of Health System Response http://www.ahrq.gov/research/domesticviol/

� Kaiser Permanente Domestic Violence website kp.org/domesticviolence

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KP Research Publications on DV

� “A Predictive Model to Help Identify Intimate Partner Violence Using Diagnoses and Phone Calls,” Barghava R, Temkin TL, Fireman BH, Eaton A, McCaw B, Kotz KJ, Amaral D. American Journal of Preventive Medicine, 2011.

� “Mental Health Service Referral and Utilization among Women Experiencing Intimate Partner Violence,” Ahmed A, McCaw B. Am J of Managed Care, 2010.

� “Intimate Partner Violence,” McCaw, B., A Provider’s Handbook on Culturally Competent Care: Women’s Health, Kaiser Permanente National Diversity Council and Office 2009

� “Domestic Violence and Abuse, Health Status, and Social Functioning,” McCaw B, Golding B, Farley, M, Minkoff J. Women and Health, 45(2), 2007.

� “Family Violence Prevention Program: Another Way to Save a Life,” McCaw B, Kotz K.The Permanente Journal 9(1), 2005.

� “Women Referred for On-site Domestic Violence Services in a Managed Care Organization,” McCaw B, Bauer H, Berman W, Mooney L, Holmberg M, Hunkeler E. Women and Health, 35(2-3), 2002.

� “Beyond Screening: A Systems Model Approach to Domestic Violence Services in a Managed Care Setting,” McCaw B, Berman B, Syme L, Hunkeler E. American Journal of Preventive Medicine, 21(3), 2001.


How Does This Apply To Me?P90

#27FORUM

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Thank You!

Links to online stories about these programs:

The LIFETeam: Breaking the Cycle of Violence Program

Translating care for substance abuse from the clinic to

the courtroom

Kaiser Permanente Domestic Violence Prevention

Program

Cory Sevin, RN, MSN

Director, IHI

[email protected]

P91

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