Care Management Plus Program: Can This Innovation Be Scaled?

Welcome to the AHRQ Innovations Exchange Video Series
"Can This Innovation be Scaled?"
This video presents innovator and expert exchange on the
Care Management Plus Program.
The AHRQ Health Care Innovations Exchange works to accelerate the
uptake of innovations to improve health care quality and reduce disparities.
Speeding uptake was also the
focus of the Innovations Exchange
roundtable on scale-up and spread.
Innovators presented their innovations and plans for scaling
and spreading to experts on health care services.
The experts provided input on a number of topics,
which included how to develop an innovation,
how to assess its scalability and how to scale it.
This video will focus on how to develop an innovation
and how to scale it.
It features Dr. David Dorr, who led the development of
Care Management Plus.
Dr. Dorr is a member of the faculty of
Oregon Health and Science University.
Let's begin with a brief overview of this innovative program.
Care Management Plus offers comprehensive primary
care to seniors with multiple chronic illnesses.
A care manager helps each patient to manage his or her condition,
and coordinate care with specialists and community resources.
Care Management Plus also relies on health information technology to
track care and to provide reminders.
There are currently 170 clinical teams using Care Management Plus.
Evidence indicates that Care Management Plus helps patients to
live longer and reduces the number of
hospitalizations and other health care costs.
Patients also say they have a better experience in receiving health care.
Primary care clinics that adopt Care Management Plus have positive
returns on their investments, in the form
of lower costs and higher productivity.
Health care payers cover fewer hospitalizations and fewer
complications from illness.
Let's take a look as Dr. Dorr and experts talk about developing and
more widely scaling this innovation.
Consider how scaling will affect the innovation.
I'm real interested in hearing about your pilot
today when you have 70 people.
But I'm more interested in you telling me what it's going to look
like when you have 700.
What's the model going to look like,
what's the disruption going to look like?
What's your staffing?
What's the technology you're thinking about using?
You have 1,000 patients today.
What happens when you have 10,000?
The other thing particularly I would say for all this is,
and it's something we do in health care very well,
we have to have our top experts working on very,
very complex problems.
I push back to say think about the new workforce,
or what new technician could begin to emerge to take some of the cost
out, because we can't afford mid-level practitioner and doctor's
staffings on a one to -- 51 to 70 basis.
I mean that's just the reality.
So tell us what it will look like in the future,
because if you have a vision on what your scaled up model will look like,
that's more likely to sell me on future state of where we're headed.
If you can paint the picture of what we're going to look like down the
road, I might be much more interested in collaborating on that.
But if I get stuck in well, what's the start-up cost
for me to do how much today?
Yes.
There is the Clayton Christensen-Richard Bohmer model
about kind of moving the site of care,
how do we take things out of the hospital and put it into the clinic;
how we take things out of the clinic
and put them in a community-based service.
I would take things out of the community-based service and put it
in the home, and how do we work across a spectrum.
How do we go from a specialist to a general practitioner to a nurse
practitioner to a nurse, to a trained volunteer,
to the person doing it themselves.
As long as you're moving down those continuums,
you're making it simpler faster, faster cheaper,
and thinking that through as part of the vision for the future.
Innovators must turn into entrepreneurs.
You know, the first thing I thought about was,
you know, and I was trying to decide probably what the difference between
an innovator and an entrepreneur, and I think the difference is having
a clear goal that you're shooting for.
Nobody today really articulated their clear objective,
whether its sell five widgets or world domination,
whatever it is, you know.
It needs to be something that defines what are you trying to be
when you grow up, and how are you going
to know you got there measurably.
I think that's a really important thing to think about,
especially as you're starting to really spread.
What am I trying to do?
You know, you say 40 percent of the market is not fit.
So what?
There's 60 percent left, you know.
Decide that.
You know, that okay.
You have to decide what you're going to do and what you're going to be,
and that's real important.
The Hollywood model: Don't start unless you can scale.
Has anybody ever heard of something called the Hollywood model?
Okay.
So when somebody makes a movie in Hollywood,
that movie is not going to be released until they have twice the
monies to be able to do that broad scale dissemination of the movie.
It just, you know, it never would happen.
They won't even make the movie until that kind of securing of an
infrastructure, the plan, the communications plan,
the business plan.
Until all of that is established, they won't
even begin to commit to this.
Assess readiness of adopting organizations.
And it's too much work to try to put a new innovation into an old system
and not change the system first.
And so what I heard again and again was the need for readiness.
So having, and that's what we have gone to,
is a readiness score.
We're not even going to work with you until you're ready.
So I heard some of that.
But then it's the continued follow-up,
and implementation science would say it takes two to four years at least.
So we want that system changed, to be able to really accommodate
something that is known before we even do the training.
So there's a lot of pre-work that needs to happen.
Training then happens, and then
there's follow-up that needs to happen.
So just thinking of well what is the data system,
what are the metrics that are going to let us know whether or not we've
really been successful, and what is the model fidelity?
The readiness is important.
The experience that we've had with our member organizations is that the
readiness assessment is going to play a key role into how successful
the integration is going to be.
If the practice isn't ready, the care coordinator ends up doing a lot
of the work that the office staff would normally do.
They're just caught in the hamster wheel of the primary care practice.
So making sure that that can get implemented and you're not wasting
that expensive care coordinator resource in an office function type
of role is very important.
Assess innovation readiness for spread.
I think there's been a lot of talk today about readiness from the end
user, the adopting organization side,
but not as much, and I think it's echoed in a lot of the comments here
in terms of a readiness checklist on behalf of the innovators,
in terms of is your innovation ready for scale up and spread.
Which would include things like have you thought about reimbursement,
a board perhaps?
Is it sustainable?
What are the incentives, the costs, the evidence?
Is it efficient marketing impact, dissemination,
distribution channels?
You know, to what extent do you need to go to spread in order to get a
return on investment?
How many people need to be reached?
So I think maybe moving forward, I guess kind of one of the objectives
is to make some recommendations to AHRQ,
in terms of, you know, maybe providing a checklist so innovators
can see okay where on this readiness scale is my innovation for scale-up
and spread, and what do I need to do in order to move myself to be able
to get that end point?
Address multi-payer issues.
In thinking about sort of your more typical situations out in the
country, where each practice is funded by six or more different
payers, it's very difficult for an individual payer to fund the costs
of all of -- of a whole care coordinator.
I know our member organizations look for,
you know, maybe 50, 60 percent of the dollars coming into that
practice are associated with their plan,
and they're willing to say that there's some free riders,
you know, or some other people will pick up on these benefits.
But it gets below that, and it's more difficult to have one payer
sort of bear the brunt of the cost
of those additional care coordinators.
So I think if there's a community engagement approach,
where you can get multiple payers together in a more collaborative
environment, to say okay let's, can we together fund parts of this,
in a way that makes sense, so you don't end up with the free rider
problem of one payer funding this, you know,
out of a more altruistic type of outcome,
because that's not sustainable over the long term.
Think not only about primary costs, but think about secondary costs as
well, because your financers are thinking about those things.
So it's not just the cost of your programs,
but what are the costs that are going to happen in the health care
system because of your program, and what are those going to be,
because that's what the payer's
thinking in the back of their head too?
It's not your program sitting by itself;
it's in the system as a whole.
So I think that's very important, and you know,
health care costs are unsustainable and payers know that,
and there's going to be less willingness to throw a lot of money
at something up front.
Payers have been burned a lot in the past in investing up front with
savings that will come down the line,
that never really materialize.
So thinking about maybe is there shared risk mechanisms or other
financing mechanisms that allow you to -- so the risk isn't all on the
person who isn't doing the implementation,
because when you have the person who is paying and taking all the risk,
and the person who is implementing not -- at no financial risk because
someone else is paying for it, you could end up with some adverse
incentives going both ways.
Ensure fidelity to the model.
What is in place to make sure all those places that have a CM Plus are
actually doing and are replicating reliably
what you have as far as your program?
The way that we feel comfortable about that is we send them a survey
later, and then for the ones who we've really partnered with,
we actually follow them for a couple of years,
and we ask them about all the components we taught them,
and whether they do that, whether they do those components.
Our survey rate is about 70 percent of them,
they've least tried those in the first six months,
and we're still getting the data for the longer periods.
So a lot of people have done this.
Innovators must market to different stakeholders.
Who is your target population,
and then if you have a plan for how to reach them?
So in looking at your map, I'm just curious about how you happen to
connect with all these, you know,
sort of disparate folks all over the country?
Are there mechanisms that you're using?
Have you thought about that, you know?
What's your thinking on that?
So one of the ways that we've really approached this marketing is we look
at regions where they're doing a lot of health care reforms.
So in Oregon, we're doing patient-center primary care home.
That's funded by the legislature.
There's an opportunity there.
A lot of practices are sort of interested,
but they don't know how to go about engaging in it.
They're worried, and they don't want to take the risk.
We actually help them.
We adopted our program only slightly,
so that in the readiness assessment we point them to this reimbursement
and talk about what it would take for them to do this,
and then try and teach them the ways
that will help them to be successful.
So we go to health plans and say who
are the practices you work most with?
Can you help embed or change the payments for them,
so that care managers can go in their clinics?
So we go out to payers and purchasers,
as well as going to, reaching out
to clinics who are interested in reform.
It's kind of surprising, and maybe I shouldn't have been,
by the incredible fear of marketing that I observed,
you know, and as a person who by background is actually a marketing
person, you know, it's safe to try, you know.
It's not a dirty word?
It won't kill.
It may be a dirty word, but it's not a deadly word,
and you know, I think understanding -- if you don't know how to do it,
that's okay.
I mean you saw it where you came from,
but go find somebody who does, because there are people out there
that that's what they love to do, and pair up with them,
you know, and think about how you can use them.
I think one of the most important things,
again about that great leadership, is finding team members to augment
your skill set.
Get professional buy-in.
You know, in addition to the Triple Aim,
I always like to include a fourth piece,
which is the professional experience.
So you know again, if you're making an innovation on the backs of the
doctors and nurses that have to deliver the care,
the long-term staying power is somewhat reduced.
So thinking about that, and then finally,
and this is a piece that I'm very curious about,
because it directly impacts our innovation and is very similar to
yours, is what -- This seems like it's sort of out of the usual care
experience, that we're really sort of moving those patients.
How does that resonate with the physicians and the other health
professionals, you know, with sort of losing those patients or losing
some of the ability of those patients?
The provider experience, by the way, is excellent.
I mean they love the program, and part of that is due to our approach
to the question you asked, which is that
we try to make it as seamless as possible.
We introduce the care manager as part of the team.
Where possible, they're co-located.
Different clinic sizes sometimes make that a partial co-location.
But they're co-located in the clinic,
and we train the team to actually have the provider,
somebody with the relationship to the patient,
introduce the care manager for, you know,
this is part of my team.
They're going to work with you.
So that's been very positive, that patients especially,
are a little nervous about, for instance,
getting a call from somebody they don't know.
But they're much more willing,
when introduced in a warm way by the provider.
Assist systems with limited resources.
What experience do you have thus far in providing the IT infrastructure
to clinics that are serving vulnerable populations,
and are not nested within highly resourced and very sophisticated
systems like IHC?
One of the things that we provide that's a little different is some
pretty intensive on the ground practice support to the clinics that
might have fewer resources as part of this,
and there's been a number
of initiatives that have really helped us.
AHRQ funding, for instance, has allowed us to do that,
and I think there's many more that are coming as the health reform
affects those particular clinics, especially they're really hungry to
get this, and with the right practice support,
I think that they're really ready to serve it as well.
So a lot of rural, a lot of safety net type clinics.
Differentiate your innovation from competitors.
Everywhere I go, I see case management programs proliferating,
and consulting groups that come in and know exactly how to do this,
exactly how to do this, and I'm wondering how you're approaching
that, given the number of people in the marketplace that are doing this,
and the number of health systems that are doing this internally,
or bringing in external consultants,
and sort of how you handle running into those.
Understanding how your idea competes,
even if it's not competing in a business sense,
it's competing with other people who have other ideas.
I think you made the point earlier on,
Janell, that yeah, that's a great idea,
but how does that compete for my time and energy and priorities among
the 15 other things that are supposed to be high priority items
for my health system?
So your idea is always competing with someone,
understanding your competition, and understanding what you're offering
that's different than your competition
is another piece of the puzzle.
So there's lots of eye-opening that has to,
it would seem, would have to happen.
Spread is a new world.
So actually doing the innovation and making it happen is a difficult
task, but at least you kind of kind of know the world you're in.
You're dealing with other frontline clinicians;
you're dealing with other clinical groups.
You're making it happen in your own place or
in places that have invited you in.
I guess what I'm hearing from this is that the scale-up and the spread
is yet another difficult, complex thing.
But in addition to that, typical innovators in health care don't even
know the world that they've stepped into.
There's a whole new language.
They've been dropped in the middle of South America somewhere and
they're trying to find their way back home.
Decide who will lead the scaling effort.
You're not going to invest unless you know who's leading that show,
because most of success comes through subjectivity of the force
and the charisma and the mental clarity of the driver,
and I didn't hear who the driver was in any three of your scenarios.
Good idea with a great leader always
beats a great idea with a good leader.
Yeah.
Always, every time.
I mean you see it in every industry.
So being able to articulate the importance and qualities and
qualifications of your team is really important.
Learn how to create a business plan.
You know, your passion for your root purpose will always be the major
driver of the investment.
Don't ever forget that.
But also get thick-skinned and change your vernacular,
change your mind set, change your approach in whatever way you have
to, to help other people understand what you're doing in their terms.
So the big thing with you all is, you know,
the vernacular changes.
In health care provider groups, business plan means the budget,
the dollars, and that sounds cold.
When you're dealing with anybody but providers who has money,
with the exception of foundations, business plan means your total plan.
It's your target market, it's your purpose.
It's your target market; it's your geographic penetration.
It's all of it, that has to be not only articulated,
but forecasted and timelined out.
That's a business plan, and you need,
all of you are in various stages of end readiness.
But on a real good track towards it, and I would encourage you to get the
outside resources that you need.
The big thing that you've got to have in that business plan that I
didn't hear at all today is because bottom line,
whoever's going to invest in you, even if your numbers look good,
your appropriation already is impressive and all that sort of
thing, it's who's going to be running the show on the
appropriations side of things, in the dissemination side,
and who's going to be running the show.
For more information on this and other health care innovations,
please visit the AHRQ Innovations Exchange website at
www.innovations.ahrq.gov.