3/2/2015

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Integration for Populations:

Organizing the Mesosystem

Eugene C. Nelson, DSc, MPH

The Dartmouth Institute

Jonkoping International

Microsystem Festival

Block C7: 10:45 – 11:15

February 26, 2015 1

Mollie’s problems

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photo Chronic Back Pain Depression & Alcohol

Homeless

Sole Caregiver for

Elderly Mother

Unemployed

New to community … moved to take care of frail elderly mother

3/2/2015

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Mollie’s problems addressed

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photo

Shelter Job Assistance

Behavioral Health

Chronic Back Pain Depression & Alcohol

Homeless

Sole Caregiver for

Elderly Mother

Unemployed

Surgery

Iora Primary Care: Practice Team: MD, Coach, Nurse, Behavioral Health

Flow

1. The problem

2. Case examples

3. Integration

principles

4. Call to action

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1. Problem & Causes

• People are living longer

• Increase in chronic diseases

• Increase in multimorbidity &

complexity

• Traditions of siloed services &

payment systems that do not reward

integration

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We are living

Longer!

But increase in

chronic diseases &

in people with multiple

chronic diseases

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38 million of the 56 million global

deaths in 2012 were due

to chronic diseases

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45% of patients had more than one chronic condition

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Multimorbidity in

24% of population

accounts for ….

64% of spending

Basque Country

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20% of Medicare (older) patients

account for ….

80% of spending

United States

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Figure 1. Difference in average of adjusted annual cost (in euros) per patient, by number of

coexisting chronic diseases according to the presence of certain selected diseases.

Orueta JF, García-Álvarez A, García-Goñi M, Paolucci F, Nuño-Solinís R (2014) Prevalence and Costs of Multimorbidity by

Deprivation Levels in the Basque Country: A Population Based Study Using Health Administrative Databases. PLoS ONE 9(2):

e89787. doi:10.1371/journal.pone.0089787

http://127.0.0.1:8081/plosone/article?id=info:doi/10.1371/journal.pone.0089787

Service Siloes:

Social v Medical.

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Medical Center Social

Worker

Mental

Health GP

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US #1 in spending for health care

US #13 in spending for social

services & health care

Why does the US rank 38th

In the world in health status?

Implication?

Need to mobilize & integrate the

assets of individuals & families

& friends and formal social,

community & health services to

improve health and value for

individuals & subpopulations

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2. Case Examples

• Breast Cancer Center: Navigating

– Amy’s story

• Iora Health: Primary Care & Coaching

– Mollie’s story

• Spine Center: Interdisciplinary Team

– Brian’s story

• Auto Immune Soup: a facilitated network of peer patients

– Laura’s story

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Amy had navigator for integration

Biopsy on

10.27

Breast Care

Coordinator

(BCC)

MRI #1Shared

Decision

Making (SDM)

MRI #210.31 10.31 11.9 11.9 Surgeon11.9Med.

Oncologist11.9

Bone

Scan

CT Scan Lab work

11.11

Med.

OncologistWig

11.23

11.23 Infusion #111.2511.23 11.25Wig and

stylist

Wig-

stylistLab work

12.9

12.12

12.16 Lab work12.16

Breast

imaging

study

Breast

imaging

study

11.23

11:30—lab

workMRI

echocardio

gram

Lab

workLab work

Lab workMed.

Oncologist

1:29—infusion

#1 (scheduled

for 1:00)

1.27.06

2.16.06 2.17.06 2.17 2.17

2.17

2.24.06 2.24.06Infusion

#33.10.06

1.6Med.

Oncologist12.16

Infusion

#212.21 Infusion #3

Med.

Oncologist1.6.06

1.27.06

Med.

Oncologist2.16.06

Infusion #4

(end chemo

trx 1)2.16.06

Infusion #2 3.3.06Med.

Oncologist

Infusion #4

3.10.06

3.10.06

echocardio

gram11.25

Lab work 3.10.06

PharmacyGenetic

Testing

12:15-Lab

work

Breast

imaging

study

2:30-

Infusion #5-

check in

Infusion #53.17.06 3.17.06 3.17.06 3.17.06 3.17.06Lab

work

Infusion #6

3.24.06 3.24.06

3.24.06

1:45- Med.

Oncologist

12:45-Lab

work

3:00-

Infusion #73.31.06 3.31.06 3.31.06

12:10-Lab

work

SDM- p/u

video

1:15-

Infusion #84.7.06 4.7.06 4.7.06

6 months, 14 different microsystems, 21 visits

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Care Support Tools and Mechanisms:

• Daily Huddle and Review of Worry List Patients

• Custom Built Electronic Health Record for Longitudinal

Care

• Systematic and Repeated Health Assessments Using

Patient Reported Measures

• Post-visit Patient Experience Survey

• Patient advisory Group Quarterly Meetings

Mollie had a coach

Person and

Family

• Mollie

• Mental Health

• Orthopedics

• Homeless

Shelter

• Pet Shelter

• Employment

• Resources

Community Resources

Primary Care Team

• Physician

• Coach • Behavioral Health Specialist

• Office Staff

18 18 © 2000, Trustees of Dartmouth College, Batalden, Nelson, Wasson

Referral or Visit Request

Orientation &

PROMs

Initial Work Up

Plan of Care

Functional Restoration

Chronic Care Management

Acute Care

Management

Disease Status

Expectations For Good Care

Sunk Costs

Functional & Risk Status

Disease Status

Experience Against

Need

Incremental Costs

Functional & Risk Status

Palliative Care

People with healthcare needs

People with healthcare needs met

Feed Forward

Feedback

Brian had a solution shop with

integrated team & information

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Laura X, MD

with auto immune “soup”

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“I learned more from my Yahoo chat

group than I learned from the

doctors at Dartmouth, or Mass

General or Johns Hopkins”

Laura had a facilitated network

that she started herself

3. Integration Principles

1. Assume: Self-care is the new principal care &

align incentives to promote better value

2. Improve: Use co-design to map, mobilize and

redesign the mesosystem for & with

subpopulations to integrate services

3. Innovate: Leverage and combine all 3 ways to

create value: shop, chain, network

4. Communicate: Feed forward data to make and

update care plans & track outcomes

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Think “Co”

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Co-Design

Co-Produce Co-Evaluate

Health

&

Value

Assume: Self-care is the new principal care

& align incentives to promote better value

“Assume doctors and hospitals are the last resort.” Don Berwick

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Upshift in Health Care Payments

Old Cost Stream:

Illness Pays

Patient exits home when sick

Primary Care

Specialty Care

Hospital Care

Quaternary Care

New Value Stream:

Health Pays

Person healthy doing self-care

Primary Care

Specialty Care

Hospital Care

Quaternary Care

$$$$$$

$$$$$$

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Systems Inside Systems

Self-

care

system

Individual

care-giver

& patient

system

Microsystem

Mesosystem

Macrosystem

Market /

Geopolitical

system

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Improve: Map, mobilize and redesign the

mesosystem for and with subpopulations

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Lind Family

Mesosystem

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Innovate: Leverage and combine

all 3 ways to create value

• Solution shop

• Value chain

• Facilitated network

Solution Shops

Mayo Clinic just opened a “cough clinic” bringing together all

of the specialties for the first time for this subpopulation

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Value Chains

Aravind cataract surgery India & Frenesis renal dialysis centers in the US

Mission: to eliminate

needless blindness

Facilitated Networks

Welcome to Wikipedia, The free encyclopedia that anyone can edit.

4,605,853 articles in English

Cystic Life “Real. Positive. Community”

7763 members and counting

“PatientsLikeMe Is Building A

Self-Learning Healthcare System” Paul Wicks, Medical Architect 3/1/13

1000+ CF Patients

3/2/2015

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Value Creation Models &

Level of Complexity

1. Solution shops: complex problems

2. Value chains: simple or complicated

3. Facilitated networks: simple or complicated or

complex

“In future, in a well designed system, shops and

chains may become nodes in the network.”

P. Batalden 9/19/14

Information: Feed forward data to make

and update care plans & track outcomes

Feed Forward PRO Data

Feed Forward Clinical Data

Learning Health System For More Effective Action by Patients, Providers, and Researchers

Partnership for Co-production

Patient & Family

Provider & Care Team

Optimal Health and High Value Care for Patients and Populations

© 2014 Trustees of Dartmouth College and Karolinska Institutet 32

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4. Call to action: Integration

• Start by organizing & activating the mesosystem

• Continuously feed forward information to assess the

individual’s health, assets changing needs and preferences

• Identify the resources that can be mobilized

• Develop a personalized care plan that takes advantage of

the assets of the person, family & friends, peers,

community, social and health services to co-produce health

& high value services – “doctors & hospitals are the last

resort”

• Integrate shops & chains & networks to support high need

populations (e.g., frail elderly, children with special needs,

complex multi-morbidity)

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