Whole Person Care Los Angeles Clemens Hong MD

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Whole Person Care – Los Angeles Clemens Hong MD MPH July 12, 2017

Whole Person Care – Los Angeles Clemens Hong MD MPH July 12, 2017

Disclosure I do not have relevant financial relationships with commercial interests.

Disclosure I do not have relevant financial relationships with commercial interests.

Poll Question #1 What group do you represent? Hospital/Emergency Department Outpatient Specialty Provider Primary

Poll Question #1 What group do you represent? Hospital/Emergency Department Outpatient Specialty Provider Primary Care Provider Other Health Care Provider Social Services Provider/Community-based Organization Community Member Other

Sources: Cohen, Steven B. and Namrata Uberoi. 2013. “Differentials in the Concentration in the

Sources: Cohen, Steven B. and Namrata Uberoi. 2013. “Differentials in the Concentration in the Level of Health Expenditures across Population subgroups in the U. S. , 2010. ” Agency for Healthcare Research and Quality. http: //meps. ahrq. gov/mepsweb/data_files/publications/st 421/stat 421. shtml.

Using complex care management (CCM) teams to improve care & reduce costs One proposed

Using complex care management (CCM) teams to improve care & reduce costs One proposed solution to address healthcare cost problem Specially trained multidisciplinary, complex care management (CCM) teams

Challenges for CCM Programs: Drops in Potential opportunity Identification Engagement Finding opportunities for improvement

Challenges for CCM Programs: Drops in Potential opportunity Identification Engagement Finding opportunities for improvement Intervention Adapted from J Eisenberg JAMA. 2000 Realized improvement

Effective Targeting of Care Management Population Volume Healthy Area of Greatest Opportunity? Chronic Illnesses

Effective Targeting of Care Management Population Volume Healthy Area of Greatest Opportunity? Chronic Illnesses Medically Complex/ High Utilizers

Poll Question #2 Who believes that the Complex Care Management that you or your

Poll Question #2 Who believes that the Complex Care Management that you or your partner organizations deliver is effective for the highest risk Medi-Cal clients you work with? Yes No Don’t know

Whole Person Care – Los Angeles A Regional, Integrated Health Delivery Model for the

Whole Person Care – Los Angeles A Regional, Integrated Health Delivery Model for the sickest, most vulnerable LA County Residents

Los Angeles County Context • • Total Population – >10 million Geographic Area –

Los Angeles County Context • • Total Population – >10 million Geographic Area – 4084 square miles 88 Cities, 140 Unincorporated areas ~3 m Medicaid Beneficiaries - ~30% of CA Medicaid population • Health Agency – consists of 3 entities • Departments of Health Services, Mental Health, & Public Health (includes SAPC) • Department of Health Services (DHS) – County-run Healthcare Delivery system

What problem are we trying to solve? Engagement problem in health delivery COMMUNITY ORGANIZATIONS

What problem are we trying to solve? Engagement problem in health delivery COMMUNITY ORGANIZATIONS COMMUNITY MEMBERS

Ron’s Story Transitions Clinic CHW Ronald Sanders, “We adore Ron … Ron is the

Ron’s Story Transitions Clinic CHW Ronald Sanders, “We adore Ron … Ron is the man. Anytime I need anything from Southeast, I call Ron on his cell phone and he makes it happen for me. ” That’s a blessing to have people like that to come out and show you things you didn’t know about. He goes out of his way to try to help you out. ”

How do community health workers (CHWs) address this fundamental problem in health delivery? They

How do community health workers (CHWs) address this fundamental problem in health delivery? They deliver engagement; help the delivery system better understand the clients & the context in which they live; And help us better tailor our care

Poll Question #3 Do you work with community health workers (CHWs)? Yes No Don’t

Poll Question #3 Do you work with community health workers (CHWs)? Yes No Don’t know

Poll Question #4 Beyond client engagement support, which of the following is the most

Poll Question #4 Beyond client engagement support, which of the following is the most important role a CHW can play in complex care management for Medi-Cal beneficiaries? Social Support Administer Comprehensive Chronic Disease Support & Health Coaching Assessment Advising health delivery improvement Create & Manage a Care Plan Community–based Health System Navigation Organization engagement Care Transition Support Advanced Illness Management Community Resource Procurement Support

Vision To ensure the most vulnerable individuals living in Los Angeles County have the

Vision To ensure the most vulnerable individuals living in Los Angeles County have the resources and support they need to thrive Mission Build an integrated health system that delivers seamless, coordinated services to the highest risk LA County residents

WPC Overview Part of the 1115 Medicaid Waiver $1. 26 B (~$630 m Federal

WPC Overview Part of the 1115 Medicaid Waiver $1. 26 B (~$630 m Federal funding) between 2016 -2020 Builds countywide infrastructure & community capacity to improve care to sickest, most vulnerable Medi-Cal beneficiaries Focus on: Creating an integrated health delivery system Care coordination during high-risk times Addressing social & behavioral health needs Creating jobs for individuals with shared lived experience

Populations & General Approach WPC Homeless High -Risk* Justice-Involved High-Risk Mental Health High-Risk Perinatal

Populations & General Approach WPC Homeless High -Risk* Justice-Involved High-Risk Mental Health High-Risk Perinatal High. Risk SUD -Risk High Medical High -Risk Vulnerable population focus Regional Deployment with multiple entry points – “Any Door” Complex Care Management Foundation Behavioral Health & social needs focus Community Health Worker-driven social service teams Linkage to & Integration with the existing longitudinal providers

Populations & Programs WPC Homeless High -Risk* Justice-Involved High-Risk Mental Health High-Risk Perinatal High.

Populations & Programs WPC Homeless High -Risk* Justice-Involved High-Risk Mental Health High-Risk Perinatal High. Risk Homeless Care Support Service Re-entry Enhanced Care Coordination Intensive Service Recipients Mama’s Neighborhood Tenancy Support Services Communitybased Re-entry Residential and Bridging Care Other Services Recuperative Care Juvenile Aftercare Kin Through Peer Benefits Advocacy Sobering Center *Does not cover housing subsidy SUD -Risk High Engagement, Navigation & Support Medical Legal Partnership Medical High -Risk Transitions of Care

Central Program Structure WPC Hub Program Leadership Countywide Data/ Analytics Enabling IT & Support

Central Program Structure WPC Hub Program Leadership Countywide Data/ Analytics Enabling IT & Support Training Institute Performance Improvement WPC Leadership • Data Sharing/ • CHAMP – • Countywide • Management Integration Comprehensive Training Advisory • Health Plans, Health Collaborative Board/ HIE Accompaniment & to support Workgroups Management WPC training Platform • Evaluation & Learning Team _ Relentless pursuit • County Inputs • Improvement Advisors to support PI activities • Analytic support • Community • Develop Resource Platform curriculum & tools to support WPC

Regional Delivery Approach Regional Coordinating Centers WPC Programs RCC Director/Comm unity Liaison Outreach &

Regional Delivery Approach Regional Coordinating Centers WPC Programs RCC Director/Comm unity Liaison Outreach & Engagement Training/PI Support Community Engagement Regional Home & Staging Center for each program Outreach & engagement – real-time engagement at point of care Training & Performance Improvement activities • Case Conferences & Learning Collaboratives Community engagement to fill gaps, create capacity, & strengthen regional delivery system • Community Action Teams

Poll Question #4 Based on what you’ve heard today, would you recommend whole person

Poll Question #4 Based on what you’ve heard today, would you recommend whole person care services to a friend or family member? Yes No Don’t know

Opportunities to Engage with WPC-LA Work with WPC-LA to improve care delivery for your

Opportunities to Engage with WPC-LA Work with WPC-LA to improve care delivery for your sickest & most vulnerable clients Refer clients to WPC-LA – Referral Line, Direct Entry Co-Accompany clients & increase access to services for WPC-LA clients Take on longitudinal care management Support communication between care teams, including IT data integration Raise awareness of WPC-LA in the community Provide feedback through our website and help us improve WPC-LA Send talented people our way! Finally, help us solve our engagement problem in Health Delivery Join a Community Action Team or an WPC-LA Advisory group

Questions? WPC Information: wpc-la@dhs. lacounty. gov www. dhs. lacounty. gov/wps/portal/dhs/wpc Join our mailing list!

Questions? WPC Information: wpc-la@dhs. lacounty. gov www. dhs. lacounty. gov/wps/portal/dhs/wpc Join our mailing list!