With a wide variety of value-based care experiences, St. Cloud, Minn.-based health system CentraCare has had particular success as a Medicaid accountable care organization. During the recent NAACOS spring conference, Rachael Lesch, R.N., M.B.A., executive director of population health and quality at CentraCare, discussed her team’s approach to value-based care in the Medicaid space.
Lesch said nine-hospital CentraCare’s Medicaid ACO has by far been its most successful value-based contract. “We have saved the State of Minnesota over $100 million over the last five years.”
One thing that they believe is a key driver with the Medicaid population is a very intentional patient engagement strategy. “We can't serve the patients that we're not seeing,” Lesch said. “I have a whole team of people — they're small but mighty — who do over 60,000 patient outreaches a month to ensure that we're seeing our patients for their care gaps and coding gaps if they're not connected to our primary care network. This is really big in the Medicaid population. Over 50 percent of our 50,000 Medicaid members are under the age of 18. So that wellness strategy for well-child visits is very important — making sure that we're getting relatively well patients and members in for visits but also making sure that we keep them attributed to our particular health system because there can be a higher level of churn in a Medicaid contract.”
Access to behavioral health and substance use treatment is also key, Lesch added. “We have a large behavioral health infrastructure within our health system, but we also connect with lots of behavioral health providers. Whoever is able to serve that patient first is the priority,” she explained. “We also know that this connects to a lot of social drivers. For example, patients in our ER who are being treated for substance use disorder, opioid disorder, overdoses — a third of that population is actually experiencing homelessness. They need connection to our community health improvement resources.”
CentraCare also has an integrated strategy with correctional medicine in some of its counties with high Medicaid populations, she said. “We manage their medical spend; we manage their conditions while they are in four different county jails. That is connected to specialized coordinated care resources, so after they come back into the community, we help with reintegration and social determinants of health, making sure that if they need to be on different medication for substance use disorders, because there's a high correlation there, that they have that support, both while they're in the jail environment as a patient, and then also when they come back into the community.”
Understanding the needs of the population is very important, and that requires data and analytics, Lesch said. “Six or seven years ago we decided to partner with Lightbeam. That has been excellent for us in understanding our population, understanding which patients would benefit from additional services.”
The community health improvement team has a couple of functions. They have an internal responsibility to serve clinicians and care teams around social drivers of health. They also work with patients individually around those drivers. They also work with over 100 different community partners outside of the actual health system.
All of this is driven by the Community Health Needs Assessment, Lesch explained. “This was a completely disconnected function within our health system until about six years ago. We had a group that had responsibility for this. I think they actually worked in marketing. They were doing this health assessment and then it went on our website. It was publicized, but the people who were doing the work were in a completely different part of our organization,” she said. “We fixed that.”
“The second really great strategy that I think brought us to the next level is we started to do that process as a community and not just as a health system,” Lesch added. “We work with schools, we work with public health, we work with higher education. We work with some of the social resources around transportation, around housing, around food security, and it has truly become our Community Health Plan, not the CentraCare Health Improvement Plan. For each region, we have an individual Community Health Improvement Plan (CHIP), which comes from that needs assessment. We boiled down our opportunities into three areas: health promotion, and prevention, connections and collaborations, and mental health and well-being.”
Health systems have a tendency to take charge of these initiatives. “I think at first, we felt like it was our role to work on everything and fix everything,” Lesch said. “We realized that actually was the wrong approach. Community health improvement is really about connections, the partnerships, the collaborations. We lead and convene a lot of the work within the community, but it's really about connecting to those resources. We don't have to do it all as healthcare.”
Screening for social drivers
CentraCare uses Epic as its EHR. “We decided to go big on our strategy around assessment for social drivers of health, Lesch said. “We screen all patients in the primary care environment every 180 days. We do that screening so it's more of a universal approach vs. just those patients who are in certain programs like care management, for example.
One of the big barriers to implementing this was that many clinicians were nervous about asking the questions and not necessarily having the resource or the information or the expertise within the exam room to know what to do next. Their standard practice became that things like tobacco cessation and intimate partner violence, the clinicians handle within the room just due to safety issues. “But my team follows up on all patients who have social gaps related to transferring transportation, food insecurity, housing insecurity, and financial stress,” Lesch said. “So those providers know that if those specific things come up, a culturally and linguistically aligned care team will be reaching out and making plans for all of those patients. They also do other things like connect to primary care, encourage the right level of service, ER utilization reduction, all those good things. We continue over time to analyze the data to see where we can establish deeper level fixes within the community and tie that back to our structured and collaborative community health improvement plan.”
Lesch said if you are thinking about getting involved in a Medicaid ACO, it is important to know your population. A lot of that can come from your SDOH data, your EHR data. Developing an intentional outreach strategy as well as an intentional attribution strategy is really important in a Medicaid population to manage that churn and to keep your population as stable as possible year over year. Developing a network of community partners is key, including in the dental sphere. “In our state, that's also a huge focus within quality measures, and we don't actually have dental, but my team spends lots of time ensuring that our patients have access to dental services, which also is a large avoidable ER driver,” she said.
Adapting models of care to the specific needs of the population is important, she said, as is using improvement science to help advance this work. “We all know that the outcomes are slow. We haven't necessarily reduced the level of disparities that we would like to,” Lesch said. “Minnesota's home to some of the largest disparities that I have seen and we know that we will not become a value-based care high performer until we can tackle equity. As I said, we went big with our primary care strategy with universal screening. We're expanding that to inpatient spaces and some of our specialty spaces like OB/GYN. We want to make sure that that moms that are newly pregnant have access to resources if they need them so that they can have a chance for a healthier pregnancy and outcome at birth. We're also developing systems to support our care teams, so that they feel comfortable having those conversations and that they feel supported and they know their role. Also, it was a breakthrough for us when we started to involve other community partners in the planning so we are truly growing together with our population health strategy.”
