A Path to Risk: Critical Elements of a Structured Approach.

Value-based care arrangements have been the cornerstone of accountable care for decades. Risk arrangements with government and commercial insurance plans are ubiquitous, with most contracts focusing on upside risk only, meaning payers reward providers for good performance without punishing them for poor performance on quality and cost. However, payers are increasingly moving into downside risk arrangements, bringing to mind global capitation in the 1990s wherein several health systems failed. In this article, the authors focus on their framework for succeeding in value-based arrangements at University Hospitals Accountable Care Organization, including essential structural elements that provider organizations need to successfully assume downside risk in value-based arrangements. These elements include quality performance and reporting, risk adjustment, utilization management, care management and clinical services, network integrity, technology, and contracting and financial reconciliation. Each of these elements has an important place in the strategic roadmap to value, even if downside risk is not taken. This roadmap was developed through an applied approach and intends to fill the gap in published practical models of how provider organizations can maneuver value-based arrangements.

A Conceptual Framework for Building Individual and Team Capabilities to Provide Effective Longitudinal, Relationship-Based Clinical Case Management.

Individuals with complex, chronic diseases represent 5% of the population but consume 50% of the costs of care. These patients have complex lives, characterized by multiple chronic physical health conditions paired with a combination of behavioral health issues and/or unmet social needs. Unlike for most health problems, the problems faced by individuals with complex lives cannot be broken down into simpler parts to be solved independent from 1 another. In this article, the authors describe a 2-phase framework for improving outcomes in patients with complex lives, outline how the model works in more detail, and discuss lessons learned in this journey. In phase 1, a case manager carefully and deliberately focuses on building a relationship with the patient to first gain trust, and then identify, in partnership with the patient, how to best approach assisting the patient in improving their health. That pathway is often unknowable without a deep investment of time, a radical acceptance of the patient, faults and all, and an unwavering commitment to stay by their side, even when things are tough. Once the case manager and patient have established a trusting relationship, they enter phase 2-building a path toward wellness, including further emphasis on the relationship, solving prioritized issues, changing the health system approach, and engaging the patient in self-reflection and behavior change activities.

A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population.

Health care systems have made concerted efforts to improve value for individuals with complex and chronic disease. Despite these efforts, this population (and the Medicaid population in particular) has been historically difficult to impact as many members are disproportionately impacted by social determinants of health that interfere with their ability to engage the health care system effectively. Transactional, solutions-based interventions to resolve barriers to care have been ineffective at either improving outcomes or reducing cost in the long term. The authors identify 3 core barriers that prevent time-limited, transactional interventions from effectively solving complex health and social problems: trust, self-efficacy, and complexity. By evolving from a transactional framework to a relational framework, case managers can develop relationships with clients that will help overcome these barriers. More specifically, clinical case management can be utilized to resolve these barriers by implementing a long-term, relational approach with clients through 5 key principles: ensuring continuity of care, leveraging the case management relationship, titrating support and structure, engaging flexibility, and facilitating patient resourcefulness. This article discusses how these principles resolve the identified barriers and how such a model is currently being executed in University Hospital's system. RWJF Grant I.D Number is 98426.

The Unrecognized Impact of Anxiety in Complex and Costly Patients.

Strategies to reduce suffering and expense for complex and costly patients have met with limited success. This may be due to both the ongoing dependence on transactional relationships and the failure to recognize anxiety spectrum disorders as a primary driver of medical complexity. The authors describe an emerging current of thought regarding a universal approach to the conceptualization of anxiety disorders and extend it for application to medical complexity. Using 4 cases, they illustrate distinct anxiety-complexity patterns and describe how a relational intervention untangled and identified treatment targets within that process, with excellent results for patients, providers, and payors. They go on to propose future directions and implications of this intervention.

Redesigning Kidney Disease Care to Improve Value Delivery.

This article describes the articulation, development, and deployment of a machine learning (ML) model-driven value solution for chronic kidney disease (CKD) in a health system. The ML model activated an electronic medical record (EMR) trigger that alerted CKD patients to seek primary care. Simultaneously, primary care physicians (PCPs) received an alert that a CKD patient needed an appointment. Using structured checklists, PCPs addressed and controlled comorbid conditions, reconciled drug dosing and choice to CKD stage, and ordered prespecified laboratory and imaging tests pertinent to CKD. After completion of checklist prescribed tasks, PCPs referred patients to nephrology. CKD patients had multiple comorbidities and ML recognition of CKD provided a facile insight into comorbid burden. Operational results of this program have exceeded expectations and the program is being expanded to the entire health system. This paradigm of ML-driven, checklist-enabled care can be used agnostic of EMR platform to deliver value in CKD through structured engagement of complexity in health systems.

Integrating primary care into a community mental health center.

Our initiation of a reverse-integration practice model revealed numerous advantages and rewards, as well as many challenges, for which we found solutions.

A Program to Increase the Appropriate Use of Long-Acting Injectable Antipsychotic Medications in Community Settings.

OBJECTIVE: The Multilevel Facilitation of Long-Acting Antipsychotic Medication Program (MAP) is a novel intervention to increase the appropriate use of long-acting injectable (LAI) antipsychotics in community mental health clinics. The authors investigated the feasibility of MAP, facilitators and barriers to use, and preliminary impact on LAI medication use. METHODS: Two clinics in Texas and two in Ohio serving 750 and 617 individuals with schizophrenia receiving oral antipsychotics, respectively, were asked to change clinical procedures for 1 year by using either the not receiving optimum benefit (NOB) checklist or the checklist plus MAP. Providers used the NOB checklist to identify individuals who could benefit from switching to LAI antipsychotics. MAP clinics used the NOB checklist plus nonbranded academic detailing for providers and a shared-decision-making video and tool for consumers. Use of MAP components was tracked, and barriers and facilitators were collected quarterly. Antipsychotic prescription counts were provided by participating clinics. RESULTS: Barriers to use of MAP included loss of local champions and administrators, difficulty with provider buy-in, limited availability of peer specialists, and a lack of infrastructural support to integrate MAP into clinic flow. Higher scores on the NOB checklist were associated with more provider LAI medication offers and greater patient acceptance of LAI antipsychotics. LAI medication use increased in clinics over time, but it is unclear whether this increase was due to MAP. CONCLUSIONS: Changing MAP components to fit local procedures and to circumvent unique barriers could aid implementation. Further research should investigate the potential impact of MAP components on LAI medication use.

Eliminating Defects in Behavioral Health Treatment.

To improve care, clinicians should seek to eliminate defects in behavioral health systems. The proposed framework to eliminate defects has three parts: designing a vision for defect-free care, designing analytics to guide care delivery, and identifying and alleviating defects that impede expected outcomes. To shepherd this process, psychiatrists need to embrace the role of systems engineer. An ideal system should work to not only help people recover (get better) from acute illness, but also manage chronic disease effectively (get well) and establish preventive care whenever possible (stay well).

Expanding the playing field: public and community psychiatry fellowship and beyond.

Fellowship training in public and community psychiatry has been shown to both extend career tenure and promote leadership attainment. While starting and sustaining a successful fellowship involves overcoming several hurdles, a successful fellowship can serve as a foundation for developing a viable academic division. Case Western Reserve University has redesigned and expanded its public and community psychiatry fellowship. At the same time, it has retained several fellowship graduates by developing a division of public and community psychiatry with a unique academic identity. This model could serve as a blueprint for other programs looking to establish or expand similar programs.

Public psychiatry fellowships: a developing network of public-academic collaborations.

In response to the expanding public behavioral health care system, a network of 15 public-community psychiatry fellowships has developed over the past six years. The fellowship directors meet yearly to sustain and develop fellowships to recruit and retain psychiatrists in the public sector. This column describes five types of public-academic collaborations on which the fellowships are based. The collaborations focus on structural and fiscal arrangements; recruitment and retention; program evaluation, program research, and policy; primary care integration; and career development. These collaborations serve to train psychiatrists who will play a key role in the rapidly evolving health care system.