Podcast Episode Transcript: Social determinants of health: The whole person model of care

With L. Gordon Moore, MD

Gordon Moore: Hello. This is the 3M Inside Angle Podcast, and I’m your host, Gordon Moore. With me today is Dr. Melissa Clarke. Dr. Clarke has worked on population health improvements and many other things. And some of the work that she’s done that caught my attention was thinking about and working on how to engage beyond just a typical health care delivery system when we think about meeting the needs of the people that we serve. So I wanted to have a conversation with Dr. Clarke about that work. Welcome, Dr. Clarke.

Dr. Melissa Clarke: Thanks, Gordon, for having me. I really appreciate being here.

Gordon: Yeah, I’m glad you could. First of all, start at the beginning of wherever you think the beginning is and how did you get into that work?

Dr. Clarke: Sure. Well, I am from the Greater Washington DC area, and I was doing a lot of work on a national level helping hospitals that were transitioning to becoming Accountable Care Organizations (ACOs), work on adopting population health measures as they formed the ACOs. And at the same time, I was on a volunteer basis working with a large federally qualified health center in my area as being part of their board. And I was chair of the Subcommittee on Quality of Care.

And I kept thinking to myself, wow, it would be great to be able to take all this work that I’m doing on a national level and really devote it right here in my backyard to helping primary care organizations like this federally qualified health center really get population health off the ground and apply a lot of the work that I’m doing nationally right here in my own community. And an opportunity came up to do so, and so I started doing that.

So there was an organization, the medical home comprehensive care that was starting up a group of clinics throughout the DC area, mainly in low-income neighborhoods with the idea of really increasing access to care that was integrated around primary care, behavioral health, and addiction medicine. And there was the opportunity to apply population health in that model. And so I joined the team working as the vice president for population health and provider contracting.

Gordon: Excellent. So then, take me to the next step. You saw this opportunity, you were working nationally, and seeing interesting moves, had a local footprint, and then this opportunity came up. So what did you do?

Dr. Clarke: Well, I joined the team and, together, we looked at really what were the problems and challenges that individuals who wanted to access care in DC faced. And so what we were able to discern from focus groups and talking with other community-based organizations and being familiar with the footprint of DC is that if you draw a line down the middle of DC running north to south, the communities on the east side of that line have traditionally faced higher levels of poverty, lower access to health care, more challenges with education, more challenges with transportation, more challenges with getting access to fresh food, more liquor stores and cigarette stores in their communities.

And so the challenges for optimal health care were greater. So, we really wanted to put together a model that addressed health equity. How could we try to level the playing field, not so that everybody had perfect health, but everybody had an equal chance of having optimal health? We put together a model around that. We actually first started working with a practice that was existing doing primarily addiction medicine, but they were located in the heart of the community where there were fewer providers.

And we built that into a patient-centered medical home and added other locations that served the pediatric population, that served families as well as providing not just addiction medicine care but primary care. And we were able to then grow that into about five different locations across the city.

Gordon: This is interesting. So you started with an addiction medicine practice. Why not start with a primary care practice if you’re looking at population health?

Dr. Clarke: Right. That’s a great question.  A couple of reasons. The first is that patients who have addictions and these individuals who had mainly opioid use disorder really have a tough time finding primary care, primarily because getting care for their addiction consumes so much time. And a lot of times, they’re behind the curve with issues such as transportation and also behind with basic health screenings.

The opioid use disorder population in DC is an aging one. The demographics mainly are, in DC specifically, African Americans over the age of 50, because they actually got caught up in the first wave of the opioid epidemic, which started in the 70s as opposed to the wave that we’re currently in. But they’re victims of the same lacing the opioid supply with fentanyl, and the death rates are very high.

And so we figured that that population was a population that was often overlooked for care. But they’re actually an extremely adherent population. They come for their visits in order to get office space, Suboxone, and buprenorphine. And so we wanted to build a model around that population because they were coming for their visits very religiously, either weekly, every two weeks or monthly. We could provide a lot of add-on services at that location or via telemedicine and telehealth, so that’s what we did.

Gordon: Interesting. So, you’ve got a very high-needs population. And I guess one of the things that occurs to me is that a typical primary care practice would have to build a lot of capacity to be able to take on addiction management in addition, if they were going to serve that same population. It might have been a lower threshold to think about the addiction medicine provider taking on broader aspects of care to cover primary care. Is that part of the mix?

Dr. Clarke: That’s absolutely right. So it was easier to add a primary care practitioner at that location and add a social worker at that location. And then via telemedicine, we had partnerships, a lot of community-based partnerships. One of which was with a psychiatric practice that had a psychiatrist, a psychologist and a case manager. So we were able to tie them in via telemedicine. We had relationships with a pharmacist, a local pharmacy as well as Howard University College of Pharmacy. And again, using telehealth, we were able to tie them in to do medication reconciliation.

And then we had a social worker onsite who was able to help individuals after we did a comprehensive social determinants of health assessment to be able to help tie them in to social services through our other relationships with community-based organizations that looked at issues like food, housing, job security, et cetera.

Gordon: I’m really interested in a whole bunch of these and want to hear more. One in particular, let me start with, is the telemedicine that you’re doing. One of the problems that I’ve seen a lot in innovation and healthcare is that the policy and payment environment hasn’t caught up with advances in care, I mean, to the point that we’re decades behind what the medical literature says is good for people. And telemedicine is a terrific example of that.

So tell me how it is you overcame that and were able to use that terrific tool to support these people.

Dr. Clarke: Again, great question. You have your finger on the pulse of payment issues. So there was a demonstration project that was run by the Medicaid agency, District of Columbia Department of Health Care Finance. And we successfully applied to participate, and that made us eligible for some seed funding to be able to purchase equipment, integrate it with our existing electronic health records so that we already had the software to be able to do telehealth.

We got equipment for each of the locations and also each of our participating providers. We developed a curriculum where we trained a telepresenter at our location and also at the distant locations, as well as integrating our schedules with our consultants and training the consultants on the use of telehealth. And then, we were able to use that as a pilot to get things up and running.  At the same time, payment reform around telehealth had been a very active issue in DC so  we were able to get reimbursement for Medicaid patients who we provided these services to.

There’s still, I believe, a lag around Medicare and some of the other payers, but my understanding is that they’re coming onboard slowly but surely as telehealth models are showing their value in terms of decreasing admissions, increasing the value around chronic care management and decreasing readmissions.

Gordon: So for that telehealth you guys were providing, remind me again of what you were doing in that tele-environment that wasn’t face-to-face and its relative value compared to a face-to-face meeting. Was there a cost in terms of patient satisfaction or outcomes in doing that? So what was the breadth of it, and then what was the experience and outcomes of that?

Dr. Clarke: Sure. Internally, we used it to connect our social worker, who is at one location with patients at other locations. And we really didn’t track metrics around that. What we did track metrics around in terms of patient satisfaction was our  work with a pharmacist around medication reconciliation, which would happen every six months or as needed if a patient had a hospitalization. And we also used it to do telepsychiatry.

And again, the need for both of those services is because we had individuals at different locations. The pharmacist that we participated with was actually at a local pharmacy. So she would  take time out of her day to do the medication reconciliations for us. And it was just more convenient for her to be where she was with her medication reconciliation software, her right there, to be able to work with patients and also do education around their medications.

And the same for the psychiatrist, they were located in one quadrant of the city, and we had locations throughout the city, so it was easier, again, for patient convenience. And they really, they, meaning the patients, in terms of patient satisfaction, very much indicated that this was a service that they appreciated because many individuals face transportation difficulties. We had actually tried in the past just to give them a paper or electronic referral to a psychiatrist for mental health follow-up and it just wouldn’t happen for a variety of reasons.

But the adherence to getting those visits in from a patient standpoint increased by 60 percent once we started doing the telepsychiatry.

Gordon: Wow. That’s interesting. It’s the application of telepsychiatry, for instance, in a rural environment that seems pretty obvious in terms of the distances people have to drive. You would think in an urban environment with a reasonably robust transportation system, it wouldn’t be a problem. But that 60 percent increase makes me question whether or not I’m right.

Dr. Clarke: Yeah. And I think there’s the stigma of people just acknowledging that they have a mental health issue. So that takes one barrier away. If you’re coming in for a primary care visit or a visit around opioid use disorder and having your Suboxone renewed, if you’re doing that anyway, it just takes away that one additional tier of whatever it is, whether it’s stigma, whether it’s transportation, whether it’s just time in the day to be able to get that additional visit in. And so I think removing the barriers is really what helped the success.

Gordon: You mentioned getting that extra visit in. So one of the pillars of high-functioning primary care is the ability to deliver comprehensive services. And you started by describing a population with significant needs around addiction and, obviously, prevention and primary care in general. And so the ability to provide and bundle those services sounds like you were therefore able to reduce barriers.

But here’s another one of those “policy doesn’t keep up with care delivery” problems, when having more than one service in a day can sometimes trigger a nonpayment by an insurer who might think, hey, you’re trying to pack it in. Did you experience any of that?

Dr. Clarke: So luckily, we didn’t for the most part. We had to really keep an eye on the patients—for the most part, that was not true of our Medicaid patients. A lot of them were participating in a program called Health Homes II, which is a national program for care coordination for patients with Medicaid. And so therefore, we actually had a capitated payment for those individuals. So it really didn’t become an issue around payment for those services. For patients—

Gordon: I’m just thinking there’s a payment model, if you have a payment that says, for a person with this kind of illness burden, here’s an adjusted payment to cover the expected medical resource utilization, then how you deliver services can be inventive and can actually maybe keep up with the medical evidence in the literature. So that sounds like the payment environment you were working in.

Dr. Clarke: And that’s exactly true. As I said before, unfortunately, we couldn’t extend those same privileges or service options to our entire panel, but we could definitely deliver it to individuals with Medicaid.

Gordon: Yeah. That sounds great. I bet you were going to go a different direction when I jumped in there?

Dr. Clarke: No. I was actually just going to make the point about Medicare. I think CMS has recently, in the past few months, announced that they want to do innovation around payment models and look at paying or providing reimbursement for practices that address social determinants of health. But that plan has not been well-defined or articulated yet from what I understand. But I know the industry is moving in that direction, such that practices that are taking the initiative to have models, such as the one that I’m describing, will be able to have better reimbursement and be reimbursed for what they do.

Gordon: I want to dig more into the social determinant aspects that you raised now, because I could just put a healthcare lens on what you’ve described so far. Tell me how it extends into social determinants, and what did you do there?

Dr. Clarke: We had a comprehensive assessment that we would do on intake of every patient or if they were already in the practice, doing that assessment, the social worker or nurse care manager would go over the assessment with them. It was electronic. So it automatically populated the EMR. And we looked at things like homelessness, health literacy, stress levels, transportation barriers,, depression screen, just to name a few to really be able to get an idea of the challenges that individuals face as I mentioned and leveling the playing field around optimal health.

Then we would match them to the appropriate services and that was the job of our social worker. We also have patient navigators that can help individuals make it to appointments, help them secure transportation if there were medications that were ordered for them, help them access those medications. And then we also had classes depending—we would look at cohorts with patients and decide what kinds of classes do we need to help increase health literacy.

So we added individual counseling around advance directives using the “Five Wishes.” We had a class called the Be Health Empowered class, which talked about how to effectively navigate the healthcare system. We partnered with our local QIO to do Diabetes Self-Management classes. And we partnered with another local community-based organization that had a food program for anyone who had food-related diseases, so very broad. It could be anything from obesity to osteoarthritis to hypertension.

And those individuals, if it was financially needs-based as well, if they qualified, they could get coupons to local farmer’s markets. And then it expanded to one of the large local supermarket chains. That was basically a prescription written by their doctor that they would take to the farmer’s market or to the supermarket. So we had a variety of programs to fit the needs of various cohorts of populations to, again, try to move the needle on health outcomes, taking into account their social determinants of health and the barriers to accessing care.

Gordon: How did you fund that work?

Dr. Clarke: A lot of it was grant-funded. As I mentioned, the QIO provided the education resources around diabetes self-management, the local nonprofit that had the Prescriptions Plus program. They provided the funding for that. We had our social worker funded under the Medicaid program that I mentioned, Health Homes II. And then we also had grant-funding. We’re very aggressive about finding grants to fund the classes and some of the other interventions that we did.

Gordon: The challenge for me as I think about grant-funding is that grants come and go, but these needs are probably relatively constant. So how do you sustain that?

Dr. Clarke: You’re absolutely right. And advocacy was a big part of what we did in terms of presenting results to payers, , especially to the Medicaid Health Care Finance division in the city to try to advocate for programs that would be sustainable and be put into their budget for the upcoming years, looking at Medicare Waiver programs as another way to fund it.

So again, a lot of what we did was getting grant-funding, proving results, taking that back to funders to try to put things in place that would be more sustainable or lead to payment reform.

Gordon: So in broad stroke, give me some of the results, if you can remember them.

Dr. Clarke: Sure. Around patient activation, which is a validated scale that basically looks at individual’s engagement in their health care. We looked at a cohort of 60 patients who participated in the Be Health Empowered program, for example. And we were able to raise the patient activation score, which is a five-point scale by two points or more for 75 percent of the participants. We were able to decrease hemoglobin A1cs among individuals who participated in the Prescriptions Plus program and the Diabetes Self-Management program.

We were able to decrease that for a cohort of about 120 patients by an average of a half a percentage point. And we also just looked at involvement in our childhood asthma project in terms of the number of patients that we were able to identify for the organization that we were working with called Breathe DC for home visits. We were able to increase that by 30 percent. So there were a number of, as I said, cohorts of patients that we did specific interventions for. And we’re able to definitely show a result.

For our Health Homes II program, which was the care coordination for Medicaid beneficiaries, it’s too early to show the results because we’re looking at more macro level, long-term solutions around readmissions for that population. So that data is actually going to be coming out this year.

Gordon: Does it seem to be moving at all as far as you can tell, or is it too early to tell?

Dr. Clarke: It does seem to be moving. Again, with the addiction population that we serve, they’re one of the more challenging populations only because their addiction complicates everything around other chronic diseases. We do know that we have a 95 percent compliance rate with visits for Suboxone, and we’re able to roll in a lot of the other primary care and preventive screenings into that. So we’re expecting that that’s going to move the needle on readmissions and admissions as well.

Gordon: Just getting back to one of the first metrics you mentioned, the Patient Activation Measure. I recall from Judy Hibbard’s work on this, and she’s the OSCII researcher who developed that scores, that for each point increase, there’s a significant increase in the probability that somebody is successful at managing their condition and that cascades into reducing ED visits and all sorts of other more long-term outcomes.

Dr. Clarke: Yes, exactly. And ED visits is also another piece we’re tracking that we were checking for the Medicaid population in the Care Coordination Model that I described.

Gordon: Oh, that’s good. As I step back and think about the conversation that we’ve had so far, you had a focus population and experience at the national level in the work that you were doing and thinking about broad themes and outcomes and how that could apply to a population that was within your grasp because they’re close, you are working on the board of the FQHC. How long has this whole program been up and running at this point?

Dr. Clarke: Since 2013.

Gordon: That’s a good amount of time. And has it been able to sustain all the way until 2019?

Dr. Clarke: Yes. You’re talking about the integrated behavioral health in primary care, correct?

Gordon: Yeah.

Dr. Clarke: The first clinic actually opened in 2015. And so this is the fourth year now. The Care Coordination program started in 2017. So we are now just coming up on the end of the second year of that in terms of data, which is why I was saying this is the first year from 2018 into 2019 that there’s accountability outcomes around ED visits and readmissions, because the first year of the program was more ramping up and getting the interventions in place.

Gordon: I so admire the nature of that program. One of the things that always struck me as odd was the idea that we treat a person’s head and their body as separate things with entirely different healthcare systems and behavioral health organizations and substance abuse clinics, and then for their body health care, they go off somewhere else. And even with all good intent, there’s usually poor coordination and communication across those two spheres. To see it come together for people with very high needs under the auspices of an addiction medicine clinic just makes a lot of sense.

So I have high hopes and expectations that that actually should pay off quite handsomely in terms of better outcomes for the individuals and reduced unnecessary expenditure because you’re helping them avoid bad outcomes.

Dr. Clarke: Absolutely. I mean, I think there’s so many systems in health care that are set up in silos. Many cities have it such that the Department of Health is different than the Department of Behavioral Health. And from there, the problem starts. All the programs and interventions that emanate from each of those departments never get integrated with each other.

And so when you’re trying to put together a comprehensive program, it can be challenging because you’re really dealing with two different agencies. And wouldn’t it be great if we as physicians and public health experts in the field really got together and brainstormed, “how can we set up frameworks and infrastructures in cities to make it easy for this integration of health to take place?” Because, really, we are body, mind and spirit.

Gordon: Yeah. I had a conversation recently with another colleague who reminded me that, in health care, one of our organizing principles is, first, do no harm and we’re here to help people. We could be engaged in so many different types of enterprise, but this is, first and foremost, about the people that we serve and hold that paramount. And therefore, organizing care around the person is a critical way to do that, which means we have to overcome budget silos, delivery silos, disease silos, and all these different silos that try to divide people up into artificially distinct buckets that may have had reasonable origin but I think are now really getting in the way of delivering care that people need.

Dr. Clarke: You’re absolutely right. Actually, what we call our model of care was the whole person model of care. And it’s reflective of those very principles that you mentioned. One of the bright spots was really the relationships that we were able to develop with community-based organizations, actually, faith-based organizations throughout the city, one that was a consortium of 70 churches. And they provided patient navigators for us. They also put us in touch with different churches that had community outreach, so food banks and clothing banks and some had mental health resources that we were also able to refer individuals to.

And the other good partnership was actually with the Medicaid managed care organizations, because they were, again, being held for accountable for that individual’s entire care, they got it in terms of being able to work successfully with practices to really be able to help to close gaps in care that their individual beneficiaries, who were our patients, were having.

Gordon: Well, Dr. Melissa Clarke, I want to thank you so much for your time and your thoughts today.

Dr. Clarke: You’re welcome. Thanks for having me, Gordon. I appreciate it.

Gordon: For Inside Angle, this is Gordon Moore. You can find more podcast episodes at www.3mhisinsideangle.com.

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