FEATURE · POLICY & VALUE-BASED CARE
populations, she said. “We manage their medical spend; we manage their conditions while they are in four dif- ferent county jails. That is connected to specialized coordinated care resources, so after they come back into the com- munity, we help with reintegration and social determinants of health, making sure that if they need to be on different medication for substance use disorders, because there's a high correlation there, that they have that support, both while they're in the jail environment as a patient, and then also when they come back into the community.” Understanding the needs of the popula-
tion is very important, and that requires data and analytics, Lesch said. “Six or seven years ago we decided to partner with Lightbeam. That has been excellent for us in understanding our population, understanding which patients would benefit from additional services.” The community health improvement
team has a couple of functions. They have an internal responsibility to serve clinicians and care teams around social drivers of health. They also work with patients indi- vidually around those drivers. They also work with over 100 different community partners outside of the actual health system. All of this is driven by the Community
Health Needs Assessment, Lesch explained. “This was a completely dis- connected function within our health system until about six years ago. We had a group that had responsibility for this. I think they actually worked in marketing. They were doing this health assessment and then it went on our website. It was publicized, but the people who were doing the work were in a completely different part of our organization,” she said. “We fixed that.” “The second really great strategy that
I think brought us to the next level is we started to do that process as a community and not just as a health system,” Lesch added. “We work with schools, we work with public health, we work with higher education. We work with some of the social resources around transportation, around housing, around food security, and it has truly become our Community Health Plan, not the CentraCare Health Improvement Plan. For each region, we have an individual Community Health Improvement Plan (CHIP), which comes from that needs assessment. We boiled down our opportunities into three areas: health promotion, and prevention,
“We decided to go big on our strategy around assessment for social drivers of health. We screen all patients in the primary care environment every 180 days. We do that screening so it’s more of a universal approach vs. just those patients who are in certain programs like care management, for example.” — Rachael Lesch, R.N., M.B.A.
connections and collaborations, and men- tal health and well-being.” Health systems have a tendency to
take charge of these initiatives. “I think at first, we felt like it was our role to work on everything and fix everything,” Lesch said. “We realized that actually was the wrong approach. Community health improvement is really about connections, the partnerships, the collaborations. We lead and convene a lot of the work within the community, but it's really about con- necting to those resources. We don't have to do it all as healthcare.”
Screening for social drivers CentraCare uses Epic as its EHR. “We decided to go big on our strategy around assessment for social drivers of health, Lesch said. “We screen all patients in the primary care environment every 180 days. We do that screening so it's more of a universal approach vs. just those patients who are in certain programs like care management, for example. One of the big barriers to implement-
ing this was that many clinicians were nervous about asking the questions and not necessarily having the resource or the information or the expertise within the exam room to know what to do next. Their standard practice became that things like tobacco cessation and intimate partner violence, the clini- cians handle within the room just due to safety issues. “But my team follows up on all patients who have social gaps related to transferring transportation, food insecurity, housing insecurity, and financial stress,” Lesch said. “So
those providers know that if those spe- cific things come up, a culturally and linguistically aligned care team will be reaching out and making plans for all of those patients. They also do other things like connect to primary care, encourage the right level of service, ER utilization reduction, all those good things. We continue over time to analyze the data to see where we can establish deeper level fixes within the community and tie that back to our structured and collaborative community health improvement plan.” Lesch said if you are thinking about
getting involved in a Medicaid ACO, it is important to know your population. A lot of that can come from your SDOH data, your EHR data. Developing an intentional outreach strategy as well as an intentional attribution strategy is really important in a Medicaid popula- tion to manage that churn and to keep your population as stable as possible. Developing a network of community partners is key, including in the dental sphere. “In our state, that's also a huge focus within quality measures, and we don't actually have dental, but my team spends lots of time ensuring that our patients have access to dental services, which also is a large avoidable ER driver,” she said. Adapting models of care to the specific
needs of the population is important, she said, as is using improvement sci- ence to help advance this work. “We all know that the outcomes are slow. We haven't necessarily reduced the level of disparities that we would like to,” Lesch said. “Minnesota's home to some of the largest disparities that I have seen and we know that we will not become a value-based care high performer until we can tackle equity. As I said, we went big with our primary care strategy with universal screening. We're expanding that to inpatient spaces and some of our specialty spaces like OB/GYN. We want to make sure that that moms that are newly pregnant have access to resources if they need them so that they can have a chance for a healthier pregnancy and outcome at birth. We're also developing systems to support our care teams, so they feel comfortable having those con- versations and feel supported and know their role. Also, it was a breakthrough for us when we started to involve other community partners in the planning so we are truly growing together with our population health strategy.” HI
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