Q&A · POLICY AND VALUE-BASED CARE
Is one of the things Equality Health brings to the table the technology to do predictive analytics to help providers identify where to deploy the resources and where the gaps are? Stephan: This gets at the fundamental difference for us. Yes, we have predic- tive analytics, but we don't bring analyt- ics to the practice. We bring actionable, bite-sized pieces of information, and help them then with work lists that are prioritized by who needs to be in your office and get this bit of work done today and tie it to workflows. Workflow is king in a primary care practice. It is the key to success. We don't just push data to them. It's really about actionable information, tied to workflows and specific role types in the office, so that the clinician can be a clinician. Really what we bring to them is practice transformation, and it benefits their entire panel, even though we're only a portion of their value-base book of business.
Let's talk about the new Equality Health at Home offering. Does it involve insurers paying specifically for home-based care or is it that in a capitated setting, this is the most effective place to spend the money — going into people's homes? Stephan: It's the latter. It really is part of our value-based agreement. There are patients, because of SDOH, language and health literacy barriers, who are not connected to a PCP. And they've been to hospital too much and they've got 10 specialists and 20 medications, but no one's really man- aging their care. They are falling into the emergency department on a regular basis. So it's that subset of the population that we prioritize. We say to the PCP: you do your work on the ones where we know you have an established relationship. We'll start at the other end of the work list with those who haven't seen anybody from a primary care perspective, and we'll meet in the middle. It is a short-term program to bridge them back, to repatriate them to a primary care setting. But as you can imagine, a lot of the people we're engaging are older and sicker, so about a third of them probably are eligible for palliative care. That is our current experience, so we also facilitate those discussions. We call it complex care. The average engagement is around 12 weeks.
For this effort, you're building teams of providers in each market. Who is on those teams? Stephan: The foundation of all of our high-risk management is the community health worker. They live in the commu- nity. They're field-based. They're very effective at finding these individuals and engaging them because they develop rapport quickly. If Spanish is your first language, it's going to be the community health worker’s first language as well. Trust is key. They address the social determinants of health. They address social isolation. Then they bring in the nurse practitioner. We don't lead with the medical stuff, even though it needs to be addressed. But that's not the driver of why the wheels came off. It's all those other elements, so we have to address that first. That's our philosophy, and that's our operation. Then the nurse practitioner comes in and helps you manage your diabetes and medication management and referrals or wound care — all these sorts of things that need to be stabilized and organized. We take the reins of care delivery in that sense. We stabilize them and repatriate them to a usual source of care. The third person on the team is the chaplain. They are very skilled at hav- ing leading discussions around family meetings and what's Dad's prognosis and palliative care. Behavioral health is another big factor. There's plenty of shame and guilt and misunderstanding about what a behavioral health diagnosis is, so the chaplains are facilitators, and they're advocates for people.
Was there anything that that you saw or learned in the pilot that made you make adjustments to the program went live with it? Stephan: Number one is we lead the engagement with the community health worker. Cold-calling people and saying, ‘I'm here to help you and I'd like to enter
your home’ is a tough sales pitch. The community health worker is for us much more effective and the engagement rate is higher. The trust is established early. And that's been a big learning. The other is we pivoted away from more traditional care management with licensed nurses and social workers. Because we found we had a lot of efficiency and effective- ness with the community health workers. They obviously cannot do everything that a nurse or a social worker can do, but the main barrier is not disease education as much as problem-solving, getting you needed resources. Programmatically we make referrals to the health plans’ care management, because they have care management for cancer, and high-risk pregnancy programs. We don't want to reproduce what health plans already do. We've decided our role is to stay close to the care delivery and the network and we find that that's where we're most effective and can drive better outcomes.
What kind of impact is the Medicaid redetermination issue having? Stephan: It is a challenge. And I don't think all of the repercussions have fully played out by any means, but we're managing.
Is there anything else you'd like to see CMS do differently? Stephan: Regarding the APM movement, there are many challenges there for sure, but what I guess I would say if the gov- ernment called me is, ‘Don't blink. Keep moving.’ It's hard. There's no doubt about it. It's not a magic wand. It's not going to be overnight, but it really allows an opportunity for primary care providers, who are the low end of the totem pole in a fee-for-service paradigm. This is one of their key opportunities to actually keep their practice alive, to be honest, because fee for service isn't bringing more clini- cians into primary care. HI
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