The goal of tomorrow’s meeting is to develop actionable innovations to improve population health with sustainable funding mechanisms. This important objective of the federal grant under the ACA must be addressed in conjunction with the consensus recommendations for delivery system and payment reform developed by the health plans and providers that have met since April. We will be discussing population and community health goals and how they can be initiated with changes in the delivery system.
Here is the section that relates to integrated care, developmental disabilities and other special populations:
1) Commitment to creating comprehensive, community-based, integrated care for special populations such as developmentally disabled, frail elderly, seriously mentally ill, patients in the justice system, homeless, HIV, end of life and substance abuse without other risk factors.
· Create and test comprehensive, community-based, integrated delivery system (CCIDS) innovations, designed for specific populations, with accompanying funding mechanisms using the following five guiding principles. The population-specific CCIDS may be part of a larger CCIDS or a newly formed population-specific CCIDS with appropriate relationships and governance structures. Several population-specific CCIDs will be chosen to test, refine and prove value of innovations package and then devise communications plan to garner support that will be needed for broad implementation. These innovations would have the following characteristics:
– Meet special populations where they are and on their time schedule. Special populations need convenient, timely and robust primary, preventive, social and specialized services that are located in places where they live their daily lives. Examples include co-location of medical homes in day-sites, group homes and nursing homes, embedding comprehensive resources in community health clinics, setting up 24-hour call support, training families to care for patients and allowing corrections facilities to communicate release dates to enrollment systems to improve timely access after release.
– Create the capability to form flexible and innovative partnerships thataddress the needs of specific populations and integrate expertise while reducing redundancies. Delineate the roles and responsibilities of all types of providers, plans and payers for specific populations. Special populations have broader challenges than medical needs. Often, more basic needs must be met before any type of medical treatment can be effective. The care team for special populations needs to be the most comprehensive, community-based and integrated. Responsibility for comprehensive care coordination needs careful consideration since it might not reside with traditional primary care. Examples include the assignment of care coordination to a community-based-organization instead of a medical PCP, the creation of one holistic care plan that is customized for the patient and includes medical, functional, environmental, financial, social, and psychological services/supports such as housing, job training, nutrition and violence prevention.
– Create robust training, technical assistance & knowledge-integration methods for all stakeholders, including patients. The community responsible for the care of special populations is made up of many types of healthcare workers, agencies, organizations, payers and plans, each having significantly diverse expertise, backgrounds, experience, training and ways of working. A common language and understanding is necessary for the comprehensive community to work together positively and productively, leading ultimately to integration. Proactive formal and informal training and communication efforts are needed to help patients to work productively with the system. Examples include the development of communication processes for all stakeholders involved with a patient including the patient and her family, training and workshops to ensure that all stakeholders have a better understanding of each other and how best to work together and methods of collaboration.
– Connect all stakeholders through technology. Because many “providers” in multiple settings render services to patients, technology is needed for communication among all stakeholders. Examples include technology solutions such as common care plans and real-time data alerts that help all types of providers/CBOs/payers/plans to use the experience/expertise/perspective of all disciplines delivering care to populations, including doctors, psychologists, care coordinators, social workers, and community outreach workers.
– Create a flow of money that aligns funding with social determinants of health as well as health care itself. Funding and financial incentives should be used to drive the organization and transformation of disparate care, supports and services provided to special populations. Examples include the adoption of a global budget that includes all medical, behavioral and social service funding, leveraging health home potential, creating multi-payer opportunities that align incentives and create critical mass.
Tony Paulauski Executive Director
The Arc of Illinois
20901 S. LaGrange Rd. Suite 209
Frankfort, IL 60423