April SIMplify

Spotlight ▪ Save the Date ▪ Tools, Links and Resources ▪ Data Corner ▪ Pharmacy Corner ▪ Information Sharing

Volume 38 ▪ April 24, 2019

"The contradiction between objective and population health is subjective to ideals
that don’t even belong to the actual individual patient."
Adam Tabriz

As we reflect on the last four years of the State Innovation Model, there is a common goal that we can use to describe the incredible work undertaken throughout the state: population health. The building of community coalitions, the establishment of community-clinical care coordination, development of integrative health information technology, the targeting of prevention and improved management of diabetes and chronic disease and the active addressing of social determinants of health all serve to ensure the health and wellness improvement of individuals throughout the community. These individual efforts have a rippling effect, leading to improved outcomes and health not only for singular people but better health and quality of life for an entire population of people, spanning from small targeted populations to an entire community and beyond. This is population health.

These achievements towards population health were not accomplished on a whim. They were strategically designed and intentionally executed in a way that brought stakeholders and champions together through the community. Many of these strategies and actions were informed and guided by the principles and tactics outlined within our twelve Statewide Strategies. Within the Population Health Roadmap alone there are 15 individual tactics incorporated from four statewide strategies. These tactics exemplify the targeted, yet impact-building and cross-cutting strategies that lead to meaningful and systematic actions:

The tactics outlined above are just a sampling of the opportunities laid out within our statewide strategic plans. As we celebrate all that we have accomplished, we also look to the work we have yet to do. The opportunities to build on the momentum and foundations we’ve established are ripe. Through SIM we have honed skills, developed teams and implemented lasting impact. Whether you have been part of a designated C3 Community, have been doing this work for years, or are looking to get started, our Statewide Strategy Plans (link) and the Iowa Population Health Roadmap (PDF) offer the guidance and “community-applied, population-based” applications to continue to move us forward.

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Series to Enhance Cross-Continuum Readmissions Strategy
The Iowa Healthcare Collaborative (IHC) is hosting a five-part webinar series to help hospital readmission reduction work across the continuum. Webinars will be held from 11:00 AM – noon. Registration links below:

April 24 : Who is Doing What for Whom and Why? Event Registration (Link)
May 8: Working Smarter, Not Harder: Meeting Needs and Filling Gaps by Harnessing Available Resources Event Registration (Link)
May 29: Practical, Feasible Lessons from Accountable Care Organizations, Bundles and Patient Centered Medical Homes Event Registration (Link)
June 26: Practical, Feasible Lessons from the Multi-Visit Patient Method Event Registration (Link)
July 24: Practical, Feasible Lessons from Hospital Improvement Innovation Network Hospitals and Transforming Clinical Practice Initiatives Practices Event Registration (Link)

Iowa Association of Rural Health Clinics - Annual Meeting
May 7 – 8
Des Moines
Event Registration (Link)

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The Iowa State Innovation Model (SIM) is aimed at improving healthcare quality, effectiveness and efficiency through population-based, community-applied solutions. In pursuit of these aims, a portion of SIM funding and technical assistance is deployed at the local level to facilitate community health management initiatives.
More information (link) about SIM is located on our website.

American Lung Association West Des Moines LUNG FORCE EXPO
Designed for patients, caregivers and healthcare providers to learn more about trends resources and research.
May 10
West Des Moines
Event Registration (Link)

Iowa Pharmacy Association 2019 Annual Meeting – 20 Year Celebration
June 20 – 21
Cedar Rapids
Event Registration (Link)

Iowa CareGivers 2019 Conference
September 9 – 10
Altoona
Vendor and Exhibitor information (Link)
Registration upcoming at iowacaregivers.com (Link)

TOOLS, LINKS AND RESOURCES

Iowa Department of Transportation – Social Determinants of Health Resources

The Iowa Department of Transportation oversees 35 transit agencies statewide, while promoting and educating new and current riders about the availability of transit within their community. An important but lessor known role is that of Jeremy Miller, the statewide coordinator for the DOT. Miller networks with various agencies and organizations about Iowa DOT services and facilitates conversation to discover any barriers they might have, in this case accessing healthcare and/or healthy activities – and bringing the appropriate people together to the table. The roles public transportation can play for increasing the health of your community are within your reach for innovation and discussion. Clinics and communities can reach out to Jeremy today and start a conversation.

Jeremy Johnson-Miller
Statewide Mobility Coordinator, Office of Public Transit (Link)
Iowa DOT
515-239-1765
jeremy.johnson-miller@iowadot.us

Population Health Successes in Iowa Communities

At the March State Innovation Model (SIM) Learning Event, seven Community and Clinical Care (C3) (link) SIM awarded initiatives shared their success stories. The three contributors of success focused on person-centered care, coordinating the coordinators and integrated data.

Person-centered care includes the following steps: using existing data to identify a small group of patients at high risk of sub-optimal health, using a care coordinator to build rapport with these patients, identifying and addressing unique healthcare and social needs of these patients and conduct ing intensive interventions (home visits, follow up phone calls and arranging healthcare or social service on behave of the patients). Please note that patients may become attached to the care coordinator. A transition plan can be beneficial if a change of care coordinator is expected. For instance, the leaving coordinator may introduce the new coordinator to patients and help them get connected. Otherwise, patients may simply leave the program upon the leave of the care coordinator.

Coordinating the coordinators means it is vital to have an integrator that aligns various existing efforts. Multiple agencies in the community are committed to improve the well-being of community members, such as local public health departments, healthcare system, social services, religious organizations and other community alliance. Without proper collaboration, there can be duplicated services as well as service gaps. The integrator can engage and invite all stakeholders to the table, map out existing resources and efforts, help align and declare roles and facilitate group decisions and communications. When the stakeholders are working as a team, a person can seek help from any involved agency and get connected with all relevant resources, which increases accessibility to services and improves health, social and economical outcomes. The teamwork will also promote ownership, accountability and job satisfaction of stakeholders, while reducing unnecessary competitions for funding or waste of resources. For chronic disease management, collaborations with the local pharmacy is very valuable and necessary.

Integrated data can include standardized or streamlined data and closed-loop communication. Data is needed to define baseline status, identify unmet social needs and monitor and track improvements. Standardized or streamlined data can help stakeholders speak the same language, allowing data to be comparable across settings and regions. Establishing partnership and actively engaging stakeholders from the very beginning can help identify the most appropriate data collection and communication approaches, making data integration and related changes less challenging. Please note that data includes both numbers and stories. When it comes to managing complex healthcare and social needs, stories may speak louder than numbers. Last but not the least, closed-loop communication means referrals/initiations will be followed up, ‘patients and partners’ feedback will be collected and addressed. Closed-loop communication can reduce service gap, error and delay.

Though many creative approaches have been uncovered, person-centered care, coordinating the coordinators and integrated data have emerged repeatedly in the Accountable Health Communities Model at local and national levels. Revisiting and reviewing progress towards these themes periodically may help the C3 initiates stay focused and on track to success.

The pharmacist’s role in population health continues to grow in Iowa and across the country as these efforts are intended to improve care, promote wellness, contain costs and help community vitality. A growing body of evidence promotes the benefit of local and national pharmacy involvement in population health activities and as part of health systems population health high-risk management initiatives.

The Patient Centered Medical Home (PCMH) initiative, adapted by health systems and clinical practices across the nation, integrated medication management and safety with population health efforts. Pharmacists play a leadership role in the development and execution of personalized medication care plans, coaching, medication reconciliation and promotion activities. (Source: American Journal of Health System Pharmacy TM - Volume 74, Issue 18)

Population health management can segment based on the needs of the community and growing health concerns. The need for increased mental health responses at the community level prompted the Iowa Pharmacy Association (link) to host Mental Health First Aid (PDF) courses across the state of Iowa to position pharmacists, pharmacy technicians and students to better serve the mental health needs in their communities. In addition, pharmacists continue to assist providers in helping patients achieve their mental health goals by regularly conducting PHQ-9 assessment to help monitor the effectiveness of anti-depressant medication therapy.

INFORMATION SHARING

The Iowa State Innovation Model (SIM-IA) is supported by grant # 1G1CMS331400-01-00 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or any of its agencies.

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