BUILT TO TRANSFORM
Nemours Value-Based Services Organization (VBSO) is taking steps to transform the current health system from a model that pays for sickness to a model that pays for health.
Nemours supports an expanded definition of children’s health as an investment in a healthier future for us all. Cultural and structural shifts within Nemours have led to a value-based model that leverages primary care, medical management, data analytics and technology, population health management and clinically integrated networks. By the end of 2019, the VBSO secured seven value-based contracts, covering commercial and Medicaid patients across Delaware and Pennsylvania, with a total of 32 metrics, and is participating in two additional value-based programs.
A “PAY FOR HEALTH” MODEL
While more than 400 Nemours VBSO associates are “on the ground” developing a value-based care model, the Nemours National Office of Policy & Prevention is working at state and federal levels to inform policies and promote funding that supports value-based principles for all children.
In 2019, a meeting co-hosted by Nemours and the Duke-Margolis Center for Health Policy in Washington, D.C. brought together leaders from across the U.S. to share insights on value-based payments and social determinants of health (SDOH).
Based on the meeting, teams from Nemours and Duke developed two issue briefs to spotlight accelerators, barriers, and policy and practice recommendations related to pediatric payment and delivery models that address SDOH.
To Address SDOH, You Must Assess Nonmedical Factors
Nearly two-thirds of U.S. parents of children under age 18 report nonmedical factors limit their family’s ability to live a healthy life. These factors, known as social determinants of health (SDOH), are a central focus for Nemours and include societal, community and economic factors that impact health over a lifetime.
In 2018, associates across the Nemours enterprise developed a standard SDOH screening tool to gather information on nonmedical patient needs in a variety of care settings. The development phase in 2018 and early 2019 focused primarily on the content of the screener, both in terms of phrasing and domains addressed. The pilot team also explored family and staff comfort discussing sensitive topics.
In late 2019, under the leadership of Nemours’ Population Health Management team, a version of the screener incorporating electronic health (EHR) records began a pilot phase at 11 Nemours locations in a variety of clinical settings. This phase is looking at the operational workflows of the survey instrument such as how often families should be screened and how to address new resource needs that are being revealed.
More recently, the screener has been operationalized across the 20 primary care practices in the Delaware Valley so Nemours Care Coordinators can consistently document the needs of families through their outreach and follow-up calls.
Identifying needs is imperative. However, even more important is ensuring the care coordination team can connect families to resources based upon those needs and have reliable follow-up to ensure they are received.
To advance the national conversation about the importance of addressing social and lifestyle factors among children, Nemours commissioned The Harris Poll to conduct a nationwide online survey of more than 1,000 U.S. parents of children under age 18.
THE KEY TO VALUE? DATA
From electronic health records data to disease process mapping, predictive modeling using machine learning transforms data into value for Nemours. Data modeling provides standardization, reduces variability and provides predictive analyses — lowering expenses and delivering higher quality care.
Predicting health outcomes, such as mapping complex disease, provides critical information used to personalize patient treatments, maximize health and minimize waste. Evaluating data using clinical risk groupings helps to reduce emergency department admissions and properly allocate resources to ensure that children with high risk factors receive timely, optimal care.
Data utilized in forecasting supplies, usage and expenditures further drives efficiencies enabling value-driven procurement. On the horizon, the ability to seamlessly merge clinical and operational data in large enough sets for artificial intelligence to observe and recommend ordering through seasonality or other factors that can further efficiencies and reduce waste and costs.
Journey To Value
- Shift Culture to Value
- Social Determinants of Health tools
- Innovative payment models
- Clinically Integrated Network
- Multidisciplinary Population Health Management Team with QI expertise
- Medical Management Team to support coordination, navigation and case management
- Data Analytics team to support population health and cost management with Healthy Planet
- Patient-Centered Medical Home designation across Nemours’ primary care networks
- NemoursOne: fully integrated Stage 7 EHR
Using Data to Identify Populations Who Can Benefit From Interventions
A community-based research study funded by the Institute of Education Sciences of the U.S. Department of Education has enabled a partnership among New Jersey’s Camden City School District, Nemours Children’s Health System and the Camden Coalition of Healthcare Providers to focus on an issue of shared importance: students experiencing homelessness. To date, the two-year grant has built capacity within the district and helped merge disparate data sources to better identify all families struggling with homelessness who could benefit from available resources.
Many students who experience homelessness go on to show resilience because families, schools, health care providers and social services keep children on track, even when adversity threatens development.
— J.J. Cutuli, PhD, Nemours senior research scientist
A $1.7 million NIH Environmental Influences on Child Health Outcomes (ECHO) grant is helping Nemours establish other connections in the community: advanced pediatric clinical research networks in rural and medically underserved areas. Nemours Pediatrics in Milford, Del. is one of the rural sites poised to bring clinical trial research direct to children who can benefit. The iAmHealthy Feasibility Trial, conducted by Thao-Ly Phan, MD, MPH, an expert in prevention and treatment of pediatric obesity, is designed to establish best practices for identification, recruitment and retention of children with obesity in rural clinics. To begin, data extracted from Nemours’ EHR greatly reduced the time to identify more than 300 children who met inclusion criteria. Enrolled trial participants (up to 32 children) will be provided with tablets so they can participate in a telehealth lifestyle intervention in their own homes.
Power In Numbers
Delaware Children’s Health Network (DCHN) is a physician-led, statewide, clinically integrated network of more than 24 Nemours and non-Nemours primary care practices that serve more than 70 percent of Delaware’s kids.
DCHN participant providers use evidence-based care methods, standardized clinical pathways and metrics collected in Healthy Planet — a population health management platform. Healthy Planet helps identify gaps and effectively target pediatric interventions.
Non-Nemours providers are playing a huge role in recruiting for the DCHN, saying, ‘you really need to be part of this, we’re collaborating to improve the health of pediatrics in our state’. — Jamie Clarke, Nemours’ Chief Value Officer
DCHN partners share best practices and agree to work on targeted initiatives to improve health such as:
- flu immunization rates
- well-child visits (age 0 to 15 months)
- pneumococcal 23 vaccination rates
Additional efforts to improve preventive health measures for Delaware’s children were put in place leveraging Nemours community health workers to reach out to families with children under age 15 months who are behind on vaccinations.
The DCHN will execute its first value-based payment contract as a clinically integrated network in 2020 and is planning on two additional contracts.
Read the Nemours Children’s Health System feature “LEADING TO HEALTH” from the Health Affairs series on Health System Transformation.
The Blueprint(s) to Address Persistent and Costly Health Inequities
By maintaining Moving Healthcare Upstream, Nemours continues to put a spotlight on hospitals and their community partners across the U.S. who are working to scale upstream health improvement strategies. These learnings are intended to inform the field and accelerate transformative practices. Recent contributions from Nemours include:
- Lived Experience: The Practice of Engagement in Policy, a brief Nemours compiled to synthesize the thought leadership of community organizers, parents, public sector, and organizational leaders committed to bringing the voice of experience to policy and practice decisions.
- Preliminary Findings on the Role of Health Care in Multi-Sector Networks for Population Health: Notes from the Field, a brief outlining Nemours’ understanding of the interplay of integrative roles and functions based on the scan and interviews the organization completed in 2019, as well as recommendations for the field and for the provision of technical assistance to health care partners that are seeking to strengthen their integrator role.
The 2020 Integrator Learning Lab will allow multi-sector population health networks to test these recommendations in the real world. Following the close of the 2020 Integrator Learning Lab, lessons, resources, and recommendations will be shared with the field as a follow up to this brief.
