Prevention and Wellness Trust

Ch. 224 of the Acts of 2012

Prevention and Wellness Sustainability Committee

DPH Public Health Council Room

April 28th, 2016

Meeting Minutes

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Committee Members present: Jean Zotter, Maddie Ribble, Jeff Stone, Michael Powell, Abigail Armstrong

DPH Staff present: Carlene Pavlos, Laura Coe, Laura Nasuti, Liz Moniz, Susan Svencer, Santhi Hariprasad, Merry Yuan, Claudia Van Dusen, Alissa Caron, Durrell Fox (by phone),

Others present: Charles Deutsch, Peter Wilner, Barry Keppard, Carol Girard, Vaira Harik (by phone), Kim Kelly (by phone), Victor Shopov (by phone), Brenda Weis (by phone), Tracy Kennedy (by phone), Rob Schreiber (by phone), Sy (?Worcester), Janice Sullivan (by phone)

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Introductions and Overview of Agenda

Quorum established.

Review of Minutes

  • Ms. Zotter requests a motion to approve minutes.
  • Mr. Ribble - Motion to approve minutes.
  • Mr. Stone -Second.
  • All in favor, none opposed.

Mr. Ribble explains agenda item: review, discuss sustainability recommendations that he, Ms. Zotter developed.

  • Two committee meetings scheduled to review and refine these sustainability recommendations – today’s and meeting scheduled for May.
  • This document is a draft.

Review of Sustainability Recommendations Document Format

(SEE DOCUMENT CONTENT BELOW)

Ms. Zotter reviews 3 buckets of sustainability (discussed in this committee previously) (local sustainability, health care reform, legislative reauthorization). She also reminds audience:

  • This document is not final.
  • Input, questions welcome.
  • Recommendations will go to Prevention and Wellness Advisory Board (PWAB).

Ms. Zotter reviews format in which recommendations were written.

  • Overview – including overarching thoughts about the Trust.
  • Three Buckets of Prevention (traditional clinical prevention, innovative clinical prevention, total population/community-wide prevention),discussed further in recommendations.
  • Each section begins with context, then four types of entities involved in PWTF are highlighted:
  • State entities
  • Local entities
  • The legislature
  • Healthcare providers

Review of Sustainability Recommendations Document Introductory Content

Ms. Zotter reviews section that describes PWTF.

  • The document focuses on three areas of sustainability:
  • Interventions section focuses on the work that partnerships are doing to deliver evidence-based interventions.
  • The Model section focuses on linking clinical treatment and screening, making referral to community intervention, with relationship/feedback in between; can happen w/ 4 priority conditions but can happen with other conditions as well.
  • The Program section focuses on the program funded through Ch 224. Investment in public health Trust.
  • Why is this work important?
  • Talks to national significance of model.
  • First large effort to make community-clinical linkages.
  • Innovative, groundbreaking Trust.
  • Reaching 15% of MA population.
  • 6000 referrals in first year.
  • Designed to reach some of most vulnerable populations, highest risk.
  • Partnership between municipal, community, clinical leaders; governing board, joint decisionmaking
  • Why is it important from health care reform perspective?
  • Reduction of costs while improving health outcomes.
  • Healthcare reform doesn’t reach into community like PWTF does, doesn’t address social determinants of health regarding health outcomeslike PWTF can; PWTFaddresses health behaviors, but there is opportunity for Trust to also look at social determinants of health.

Mr. Ribble adds that PWTF is large scale effort, coordinated approach with other public health and health care reform goals. Not necessarily an active day-to-day coordination, but want to encourage people to see opportunities for coordination.

Ms. Zotter further describes connection between PWTF and Three Buckets of Prevention

  1. Bucket 1, Traditional clinical prevention: usually the realm of clinical care and includes preventive screenings
  2. Bucket 2, Innovative prevention for individual health outcomes in community: current PWTF lies here, seeking to improve health behaviors through communityprograms
  3. Bucket 3, Community-wide prevention: what factors in communitycan lead to poor health?
  • Asthma as an example: clinical service is management, but screening and home visit is Bucket 2; Bucket 3 is policies adopted by a housing authority to improve conditions for community that would impact child at risk of asthma and community more broadly

Ms. Zotter explains that recommendations considerwhat PWTF looks like now but alsowhat it might look like in future. She opens floor to questions.

Mr. Stone asks if recommendations address fact that PWTF is demonstration/pilot. Suggests that this has been framed as an important role for future, wonders if recommendations have language about scaling up.

  • Mr. Ribble responds that the question is a good one, should be bookmarked for discussion later.

Ms. Pavlos suggests that clarification should be made in overview that recommendations focus on grantee program aspect of PWTF only, not PWTF program as a whole(including worksite wellness). These recommendations focus on what legislature set up aslargest component of PWTF where 75% of funds are invested. Sustainability around worksite wellness will be considered elsewhere.

Ms. Harik comments that grantees are still in early innings of demonstrating that this model is efficacious, asks how that will be treated in recommendations if no outcomes yet.

  • Ms. Zotter replies that discussion might influence recommendations thatwill be discussedas they go through recommendations.

Ms. Coe asks where middle piece is in recommendations, of proving that model and impact on interventions has been effective to push for next phase. Evaluation of PWTF will play into this information.

  • Ms. Zotter responds that addressing the social determinants of health, having healthcare reform consider health behaviors has been demonstrated over time. We are using evidence-based interventions.PWTF is bringing this to a scale that has not been attempted. It is unclear what level of proof should be exacted from PWTF at this time, the state is moving toward an ACO model that is similarly unproven. As such, we are asking people to use same standards forthis public health effort as for that healthcare reform activity.
  • Ms. Pavlos asks if argument being put forward is that this is a dissemination effort, to bring to scale models that have only been on smaller scales, or a demonstration effort.
  • Ms. Zotter replies that these are interventions with demonstrated outcomes, PWTF is just bringing them to a scale that hasn’t been done. Do we need to exact same level of standard that evidence base already had if this project is based on evidence?
  • Mr. Deutsch adds that right terminology is important, as some terms are as much political as technical. Whether or not to use “pilot” is consideration about how legislature will consider it. Paragraph about model, when social determinants are discussed, using the term “systems change” maybe should be avoided. Missing from the model section is discussion around fact thatpartnerships needed to be built, took a lot of time to be built, put communities in a different place than they were when PWTF started.
  • Ms. Pavlos adds that partnerships are cornerstone of healthcare transformation.
  • Ms. Reddington-Wilde suggests that PWTF was not so much a “pilot” asan opportunity to work out kinks around how to bring this to a larger scale around these interventions.

Ms. Girard notes that a lot of evidenced-based practice is scripted, wonders how that fits in real world, asks if models need to be retrofitted.

  • Mr. Ribble responds that interventions are about specific activities in specific places, whereas program is much broader concept. He adds that consideration at hand is where we see this model infuture of healthcare delivery reform, and because we are at leading edge of that reform, have to figure this out based on evidence we have available to us, considerations of how this program can be most impactful. Program as it has been implemented with a specific set of interventions, communities, conditions were all implementation decisions, a task of DPH under legislative charge. There are major efforts in public, private sector to use healthcare money differently to get better outcomes. Much is happening around clinical services. What is role of community prevention, wellness there?
  • Mr. Wilner adds that, inintersection between what Health Policy Commission (HPC) is doingwith ACOs and what PWTF is doing, cost minimization is key. Link somehow has to be that this is targeted towards underserved populations that don’t typically have private insurance. How does keeping them well impact costs? Making that link will peak interests of legislature.

Review of Sustainability Recommendations Document Recommendations Content

Recommendations for Local Approaches (page 4)

Ms. Zotter explains that items1-3 are context for each recommendation. She adds that item 3.2 (philanthropy) is not a very sustainable option.

  • Mr. Ribble adds that while the Trust may continue, it may not operate same way in future.

Ms. Zotter notesit is not far stretch that some interventions might be picked up by ACOs down the line.

Mr. Ribble explains that materials are being drafted for the PWTF partnerships to start promoting work.

  • Ms. Zotter adds that materials may be updated to include evaluation findings.

Ms. Zotter describes some funding collaborations that have been explored.

  • Opportunity for funding from Centers for Medicare and Medicaid Services (CMS) about Accountable Health Communities (AHC) not as well suited to PWTF as we thought it would be.
  • DPH is allowing grantees to use some resources to hire grant writers as needed.
  • PWTF has discuss with MassHealth their ability to provide support to ACOs around purchasing services currently provided in PWTF, or prevention-like services, technical assistance. Idea is to“buy, not build”, as PWTF would like to see that resources in community are supported.

Ms. Zotter notes that, at this point, there are no recommendations to legislature or statewide organizations around local approaches to sustainability.

Ms. Zotter notes that recommendations to healthcare providers should consider how ACOs can support what is out in community.

Ms. Zotter opens floor to questions.

Mr. Wilner reemphasizes how PWTF reduces costs, rather than reinventing wheel.

Mr. Keppard reiterates fact that this bill came out of a cost control effort, adds that public health and cost control don’t have to be the same thing. Asks what driving factor of recommendations is:adopting a public health model or adopting cost control on care we are delivering?

  • Mr. Ribble replies that, when it comes to interventions, working withMassHealth, ACOs, there are big goals and limitations, it depends on who we are asking to sustain which level of this work.
  • Ms. Zotter adds that standard of ROI is that insurers will cover cost effective interventions sometimes, soROI standard isn’t always needed. If good outcomes, cost effectiveness can be demonstrated, don’t always need dollar-for-dollar improvement.
  • Ms. Pavlos suggests that assumptions made that insurers are looking for interventions that make people better, are cost effective, but insurers aren’t looking at community interventions at all. Posits that one important aspect about recommendations is fact that whole system is saying that we have expectationsin health care transformation of all insurers, ACOsthat they will pick up these interventions. Don’t have to build them, they just have to buy them.
  • Mr. Deutsch adds that it’s not just insurers that fall under those considerations, also doctors, who write referrals. He suggests we should not underestimate how different it is from their perspective.
  • Ms. Reddington-Wilde adds that healthcare/healthcare finance world very different from community. ForACOs that will be cominginto being, a strength is to be able to say that PWTF has already created really important community systems in 15% of MA. Linkages are key. ACOs don’t have that communication system, need it desperately.

Ms. Girard notes that if a point is reached where ACOs are picking up some of these services and they see that housing, infrastructure are causing problems, they are big enough to create pressure to address environmental work, influence policies and systems.

  • Mr. Deutsch agrees with Ms. Girard but notes that, in immediate term, how many plans are made without people on the ground involved?He suggests that ifpeople involved in ACO redesign actually had to do this work, they would see howPWTF partnerships established those methods.

Mr. Stone comments on importance of annual report as informational material.

Mr. Ribble notes that role of legislature to help local partnerships may not be significant.

Ms. Coe notes that recommendations around local approach to sustainability seem to be focused on interventions, not about the PWTF model of linkages, partnership. She adds that the evaluation will likely show thatthat is a key success of PWTF. If ACOs pick up interventions, linkages aspect should get lost.

  • Ms. Zotter replies that that issue is discussed more in health systems section, but it should be in local health systems section as well.

Mr. Schreiber emphasizes importance of cost effectiveness in demonstrating value to ACOs. Adds that focus of ACOs hasn’t been on community, community health, but on how to survive, develop payment methodologies, hit quality metrics. Adds that a lot of provider groups want to do right thing, problem is operationalization of models, getting people into programs, getting information back to them, determining outcomes. Suggests that DPH, legislature recommend that linkages occur, support development of quality metrics that represent number of patients referred to community interventions, impact on individuals’ engagement. Further suggests that other quality metrics could be proxy measures to demonstrate linkages.

  • Mr. Stone adds that, given praise integrated care, coordination of care have received for some time, valuable to recognize that that is what this program is doing.
  • Ms. Harisprasad adds that this is valid point to bring to insurers.

Mr. Keppard comments on possible capacity issue that exists given that programs are run through municipalities. Capacity can be built but doesn’t exist everywhere.

  • Ms. Coe adds that there is a question of who will support infrastructure ofpartnerships
  • Mr. Schreiber notes that there are grant opportunities to cover continuation of infrastructure of some conditions, using Healthy Living Center of Excellence (HCLE) pursuit of grants for falls and chronic disease self-management as examples. Could be opportunities to continuePWTF programs for 1-2 years, until legislature, ACOs, other insurers are willing to pick up interventions. Adds that this isn’t answer for all the need but is a piece of puzzle that could be leveraged.

Ms. Zotter asks Ms. Coe, Ms. Pavlos what recommendations they have based on their comments that discussion of the infrastructure of the PWTF partnerships is missing from the recommendations.

  • Ms. Coe suggests focusing on success of linkage strategies – including around eReferrals and CHWs. Adds that state has invested in connection because there has never been a strong connection, and that language in recommendations needs to emphasize sustaining linkages, interventions, partnerships etc.
  • Ms. Pavlos adds that education with local hospitals, ACOs should also include centrality of partnerships to make model work.
  • Ms. Zotter notes that, regarding infrastructure, recommendations consider what could happen in healthcare system and whether or not changes would support this kind of partnership model. We have recommendations to ensure that management of partnerships has community representative.
  • Ms. Nasuti adds that municipalities, community organizations can play a role.
  • Mr. Keppard replies that this would also influence who drives policy priorities.
  • Mr. Ribble notes that that speaks todifference of doing this purely at local level and adds that it may be worth highlighting this as a challenge so that policy makers won’t just expect local entities to pick up program and fundraise for it.
  • Ms. Reddington-Wilde suggests also that ACOs become an active part of local partnerships so that they then understand the realities of what’s going on.

Recommendations for Insurer/ACO Approaches

Mr. Ribble suggests that this section might be retitled“health care system”.

Mr. Ribble describes healthcare transformation as focusing on paying for value.

Mr. Ribble discusses recommendations to state agencies around insurer/ACO approaches.

  • He explains that work that MassHealth, HPC are undertaking is different than that of PWTF but trying to get at same goals, so they are included in this discussion. He suggests that ways should be found to support MassHealth, HPC to turn these promises into reality.
  • He explains that HPC committee voted yesterday to advance certification standards for ACOs. One item on list of things ACOs must do to receive certificationwas developing a data collection strategy and stratifying the risk for patient populations.
  • Ms. Pavlos adds that this is an increasing responsibility of public health to do this community by community. She would demand that DPH do this as well.
  • Mr. Ribble notes that difference between the two is population: forACOs, its covered lives, whereas DPH is on regional, community level.
  • Mr. Deutsch notes that data warehouse was originally part of PWTF conversation.
  • Mr. Ribble explains that regarding ACO investment in community-based programs, partnerships, this is something that ACOs simply aren’t used to doing and that, at a minimum and on level of principle, this investment should be from insurers.
  • Ms. Reddington-Wilde adds that community benefits are key, that actually having community benefitpayments being used in community programs (DON funding) is valuable.
  • Mr. Keppard asks what is meant by “community expertise” in recommendations.
  • Ms. Zotter replies that goal is to make sure ACOs have community involvement in decision making. It is unclear who that would be but felt it was important to include, in addition to including a consumer/patient.

Mr. Ribble adds that the principles discussed in this section of recommendations are generally agreed upon.

Mr. Schreiber suggests that is these concepts could be more transparent, accepted by medical providers, communities if they were made available publically. He also asks if there is an opportunity for some community benefit money to go to evidence-based programs focusing on social determinants of health.

  • Mr. Ribble responds that hospital community benefits and DON are important but different consideration.

Ms. Pavlossuggests that recommendation that MassHealth provide upfront TA maybe be off-base, as that is not MassHealth’s area of expertise.