Delivery of Care

Population health in RI takes a big step forward

New federal award of $3.9 million for Care New England to build an Accountable Health Community places it in the national vanguard

Photo courtesy of Care New England

Dr. James Fanale, left, executive vice president and chief clinical officer for Care New England, and chief clinical officer for Integra, and Garry Bliss, program director, for the Integra Medicaid Accountable Entity.

By Richard Asinof
Posted 4/17/17
A new $3.9 million federal grant by the Centers for Medicare and Medicaid Services to establish an Accountable Health Community model delivery program in Rhode Island was awarded to Care New England, one of 32 health systems nationwide to receive the grant and one of only three such awards made in New England.
The new program will screen and connect high-risk Medicaid and Medicare patients with services, including navigators, to help them access resources, addressing issues of health equity and social and health disparities.
Will the new program provide Care New England with a competitive advantage as the business model for health delivery changes? As health systems take on more risk in managing the continuum of care for patients, how will that change the relationship between hospitals and health insurers? What are the lessons that the state Medicaid office can learn from the development of the new Accountable Health Community model in changing its road map around accountable entities? How will the current population health databases be rewired to interface with the screening tool being developed by CMS?
As the recent Aging 2.0 event in Providence demonstrated, the role of the patient is changing, from accepting direction by the health care industry to becoming a more demanding customer. That change is reflected in the development of new communications tools, including social media and wearable devices – and in what customers desire in becoming participants in that conversation.
Access to resources, new screening tools, and recognizing the needs of patients most at risk are the beginning of a major change in the delivery of health care: there are new kinds of engaged communities that are recognizing how to give voice to their needs within the political process.
The longer that Congress and President Trump remain tone-deaf and dismissive of those emerging forces, the greater their own future political risk.
An ACO, or Accountable Care Organization, is the term used by federal agencies to describe an entity created by a hospital or group of providers that uses a reimbursement strategy that puts the financial risks and rewards on providers to attain better health outcomes that promote value over volume. The initial focus was on Medicare patients.

An AE, or Accountable Entity, is the term used by the R.I. Medicaid office to describe an organization – whether it be a health system, a group of providers, or a community health center or centers – that puts the financial risks and rewards on the organization to better coordinate the care of its managed Medicaid members to achieve better outcomes and lower costs. Under the Reinvention of Medicaid state law, some 80 percent of all managed Medicaid members must become part of an accountable entity by 2018.

A HEZ, or Health Equity Zone, is a community-based effort led by the R.I. Department of Health to create 10 HEZs in Rhode Island communities that emphasize finding solutions to health care needs outside of the health care delivery system.

A Neighborhood Health Station is a concept championed by Dr. Michael, the former director of the R.I. Department of Health, to develop a collaborative approach to health care needs by designing care around the needs of the community. Two have already been established in Rhode Island, one in Scituate and one in Central Falls.

PROVIDENCE – With all the noise created last week when Dr. Timothy Babineau inexplicably “shared” with The Providence Journal that Lifespan had made, in his words, a “compelling” bid to merge with Care New England, a far more significant development may have gotten lost in the hubbub: the announcement that Care New England had been selected by the Centers for Medicare and Medicaid as one of 32 Accountable Health Communities model grants in the nation.

The initial $3.9 million award as part of a five-year program positions Care New England to be in the national vanguard of health systems focused on population health, creating collaborative strategies to address health equity and the social determinants of health.

Care New England was one of only three winning health systems chosen in New England; the other two were Danbury Hospital and Yale-New Haven Hospital in Connecticut.

In winning the award for the “alignment” track, which focuses on ensuring that high-risk Medicare and Medicaid patients have access to high-quality health care services, using a system of navigators and a screening system to be developed by CMS, Care New England had apparently been selected over a rival bid from Lifespan.

Validation
The award validates, in many ways, the path toward population health that Care New England has chosen to invest in as its future business model of health care delivery.

In 2015, Care New England created Integra, a system-wide accountable care organization. [See links to ConvergenceRI stories below.]

In 2014, it invested, in partnership with Blue Cross & Blue Shield of Rhode Island, to create a new, for-profit division of The Providence Center known as Continuum, which provides wrap-around mental health services for patients within the commercial insurance market under a program known as HealthPath. [See links to ConvergenceRI stories below.]

Beginning on Jan. 1, 2017, Integra began its participation in the Next Generation ACO for Medicare beneficiaries, under the direction of CMS. It had been participating in the previous Medicare Shared Savings Program.

Currently, Care New England’s operating budget is awash with red ink, caused in large part by the ongoing losses at Memorial Hospital; a sale is reported to be imminent.

Care New England is also seeking a new health system partner, following the demise of a planned partnership with Southcoast Health headquartered in New Bedford, Mass.

[The likelihood that Lifespan is a potential winning suitor was diminished by Babineau’s announcement that Lifespan has submitted a bid, given that negotiations are being conducted in private.]

If and when the proposed sale of Memorial Hospital is concluded and approved by state regulators, and further, if and when a new health system partner is announced and approved by state regulators, Care New England’s calculated choice to invest in a business model that aligns with bundled reimbursements, population health and a continuum of care may prove to be a winning bet.

Bridging the gap
The newly launched Accountable Health Community initiative seeks to address “the health-related social needs of Medicare and Medicaid beneficiaries by bridging the gap between clinical and community service providers,” according to the CMS news release.

Further, CMS defined “social needs” to include: housing instability, food insecurity, utility needs, interpersonal violence and transportation.

Under the Care New England program, participants will also be screened in the areas of substance use/addiction and independent living/caregiving.

The Integra Community Care Network, an accountable care organization comprised of Care New England, Rhode Island Primary Care Physicians Corporation and South County Health, will serve as the bridge organization for the Integra Accountable Health Communities Partnership, according to the news release put out by Care New England.

The network will be working in collaboration with a broad, statewide network of clinical providers, community service organizations, academic institutions and governmental partners.

Clinical sites will include: Memorial Hospital; Women & Infants Hospital; Butler Hospital; South County Health; The Providence Center; CODAC Behavioral Health; and CCAP Health Center.

In turn, alignment and integration of community resources will be led by a Community Services Council of major statewide organizations representing the core social determinant areas, including: Rhode Island Coalition for the Homeless, Childhood Lead Action Project, R.I. Community Food Bank, Rhode Island Public Transit Authority, R.I. Coalition Against Domestic Violence, Rhode Island Community Action Coalition, among others.

ConvergenceRI talked last week with Dr. James Fanale, executive vice president and chief clinical officer for Care New England, and chief clinical officer for Integra, and with Garry Bliss, program director, for the Integra Medicaid Accountable Entity. Here is the interview.

ConvergenceRI: Can you break down how the new Accountable Healthy Communities grant will be implemented?
FANALE:
It is a five-year grant. We will seek to fulfill the requirements of the grant. The first year is the planning year, and it has certain milestones and requirements.

ConvergenceRI: What are some of those milestones?
FANALE:
It will not just be focused on clinical outcomes. The expectation is that we would screen a certain number of Rhode Islanders annually for social determinants of health and then link them to community agencies working with those issues.

We will be screening people in five broad areas of social issues: housing insecurity, [including risk of homelessness, housing quality]; transportation; food insecurity; interpersonal violence; and utilities.

ConvergenceRI: How will they be screened?
FANALE:
The screening tool is being developed by CMS and will be, as we understand it, used by all of the sites that [have been selected] under this grant to identify the needs of patients.

We will then populate a database using local resources and the United Way 211 [information referral system], because they are tops in monitoring the network of services provided in Rhode Island.

Patients would then be provided with information about where they can go for services [to address] their health needs, as identified through the screening tool.

Depending upon the severity of their needs, the patients would be hooked up with a navigator to work with them – to go to a food pantry, to find a domestic violence advocate, to apply for food stamps or WIC benefits.

ConvergenceRI: Where exactly is the funding coming from within CMS?
FANALE:
The Centers for Medicare and Medicaid Innovation division.

ConvergenceRI: Is there any concern that funding could be curtailed under the Trump administration budget?
BLISS:
Like with any federal grant, it is contingent upon federal resources. We need to move forward [with plans] that the funding as promised will be there.

ConvergenceRI: What do you see as the strengths of the approach, from a population health perspective?
FANALE:
We did a lot of preliminary work connecting with the communities, agencies and families – and with URI, to engage with them to evaluate the needs in Rhode Island.

Quite frankly, one of the strengths of Rhode Island is that there are statewide resources to connect patients with.

BLISS: We are building upon strong Rhode Island assets that we already have, such as the United Way 211 resources statewide. [The people who call there] are people that are self-identifying their needs. United Way has an excellent database and training program.

Rather than invest in creating a duplicate of what this capacity is, we will build upon it.

ConvergenceRI: As I recall, one of the initial requirements of the grant when it was first announced by CMS in January of 2016 was the program need to serve 75,000 lives.
FANALE:
Yes, I believe it was 75,000 lives, in that range. The only other application that I know about was one that I heard that Lifespan was putting together.

ConvergenceRI: Where will the navigators come from? Will you be hiring them?
BLISS:
We will be working with both Brown University and with URI to recruit navigators, who will be highly trained and carefully supervised college students, on a health or public health track.

Those navigators would be a rotating, revolving group from year to year.

We will also be recruiting other folks who will be more established in their careers, and who would endure beyond the boundaries of the academic year.

ConvergenceRI: How does this position Integra and Care New England with the efforts by the state Medicaid office to develop accountable entities for its managed Mediciad population?
BLISS:
We have increased experience in the area of addressing social determinants of health. This grant positions Integra to have a very robust capacity for identifying and addressing those needs.

As part of the planning stage for this grant, we are eager to see the screening tool that is being developed by CMS, and how that platform will interact with [existing] databases of resources, matching the needs with resources, and who are the folks who should be directed and connected to a navigator.

ConvergenceRI: How does this new award position Care New England to be in the vanguard nationally?
FANALE:
All along, we’ve envisioned ourselves as being in the vanguard, to do more in population health. With Integra, with the Next Generation program, we’ve been very forward thinking.

When we began to look at applying for this grant, we recognized that, looking at the populations served by the Accountable Healthy Communities program, this work could make a major impact, set us ahead of the vanguard in developing the right way to deliver health care for this population.

The impacts will be far-reaching, because it will touch the lives of so many Rhode Islanders and connect them with services, improve their lives and reduce health care costs.

ConvergenceRI: Have you reached out to those communities involved with developing health equity zones? Do you anticipate potential collaboration with Neighborhood Health Stations in Central Falls and Scituate?
FANALE:
We have already actively engaged with some of the health equity zones, including the one in South County. We will look to deepen that engagement.

Now that we have been awarded the grant, we will begin to have those conversations on a deeper level.

[In regard to Neighborhood Health Stations], we know that they’re there. There are a number of local initiatives that may cross over each other. We don’t want to duplicate services; we don’t want to confuse people.

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