← Advancing Health
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- [00:00]
A
Welcome to Advancing Health. For many hospitals and health systems, a relatively small number of patients rely heavily on the emergency department for their care. Hear how University of Utah Health is taking a different approach, using intensive primary care to support patients navigating complex medical and social challenges.
- [00:22]
B
Hi, everyone. I'm Julia Resnick, senior director in the Division of Health Outcomes and Care Transformation here at the aha. Today, we're here to talk about care delivery transformation, particularly primary care transformation. I'm happy to be joined today by three outstanding leaders from University of Utah Health. Joining me are Dr. Peter Weir, Chief Population Health Officer, Dr. Erica Baden, Medical director of the intensive outpatient clinic, and Carrie Burns, Behavioral health Lead, also at the intensive outpatient clinic. Thanks to the three of you for joining me. Let's jump right in. I'd love to learn a little more about what led University of Utah Health to create the ioc. And what gap in traditional primary care were you trying to address? Peter, why don't you kick us off?
- [01:07]
C
So the way the concept started was we have at the University of Utah a internal insurance component to our health system, which is the University of Utah Health Plans. And you'll hear us refer to them as uuhp, University of Utah Health Plans. And they manage a Medicaid. It's called Medicaid aco, Accountable Care Organization for the state. So the state delegates a portion of the Medicaid population to our health systems insurance side to help manage that population. And so I went to them about nine, 10 years ago and said, do you have a small group of people within your Medicaid population that are really, really hard to care for because they appear to overutilize, go to the ER frequently, get admitted to the hospital frequently. And of course, like any group that manages a large population of people, there's always a small percent of people utilizing services at a really, really high rate. So it was pretty easy to identify who they were. And then the, the idea was it, was it possible to create a clinic and hire the right people to. To provide services to help address the issues that might be leading to the overutilization? And I say it that way in a way that has a little ambiguity to it because we didn't know how to do it or what we were doing honestly when we first got started. And there was a lot of lessons learned, but that was sort of the original conception of the idea and how it got started.
- [02:38]
B
So that makes a lot of sense. And I'm really curious about, you know, when you're intentionally designing primary care like that, what does it look like?
- [02:45]
C
Yeah. So initially we went into it with a very strong medical model, which is a very physician centric way of thinking, which is this is all medical. Right. In my head, I used to think this is going to be a medically fragile patient population, like people with heart failure that was really hard to treat and things like that. But as we began bringing people into the clinic, our social worker at the time said to me, the first 10 people we brought in, all 10 had had significant childhood abuse, both physical, verbal, like neglect, like a really, really rough childhood, lots of trauma. And I thought, this is what I said to her, actually, wow, what a coincidence. And she said, no, it's not a coincidence at all. And so what we realized by selecting for like high ER visits, what we were doing, we were beginning to select for a population of people that had needs that extended way beyond medical needs. They were social needs, they were behavioral health needs. They were in some cases substance use problems, in some cases precarious housing. But what really bound our patients together was this idea of having had significant trauma that led to like, difficult, challenging coping strategies and skills. And it led to this kind of frequent use of the er and hospital kind of stumbled into that. I honestly, we didn't foresee that. We had to slowly begin to hire the right people. And I want to have Carrie step in if I could, hiring people that could address those issues, which they're not like typical things a health system would address. It's not. This isn't a typical setup. It's quite customized to the needs of this population. Carrie, do you want to maybe expand on that?
- [04:30]
D
Yeah, I mean, I think we look at, not only do these folks have high medical needs, which causes a certain amount of trauma, but also their social situations, like Peter spoke about. So a lot of times we have them, their high medical needs. So they go to the ED because they don't have the right coping skills to say, what can I do? And what can I do not to go to the ed? What can I do to solve my problem without rushing to the ed? Because that's the only thing they know how to do. They just want it fixed. And with us working with them to improve their coping skills and improve resources in their lives, they can come up with better choices, hopefully after a certain amount of time, and then they can bring down their ED use and hopefully expand their coping skills and strategies and work through some of their trauma.
- [05:28]
B
I imagine that to meet the medical and social and emotional needs of your patients at the ioc, you need to be very intentional. About how you're structuring your care teams. So can you talk a little bit about how you're thinking about that and who the different healthcare providers are that are on those teams and what that looks like? Erica, let's hear from you.
- [05:47]
E
In order to create this kind of team, we also have to understand that first it started with healthcare leaders and our health insurance plan, uhp, to have this innovative way of reframing how we care for this vulnerable population. And the team that we have is very integrated with medical support, behavioral health or therapists, care managers, our medical assistants and our front desk. Each of the people on this team have a way of building rapport, trust and care for these vulnerable patients that have very specific care seeking patterns that are leading to their utilization. What we found with this framework or method of delivering care for this population is that there's a lot of fear and uncertainty behind their utilization. And it takes the right people to sit and be patient and unpack all those layers that drove them to this utilization pattern. And so though we have people with different credentialing, there's something inherent within the team that we were able to hire and put together that has this beautiful and innate ability to just see people, and I mean see people through that surface, that utilization and really get to the heart of the matter.
- [07:08]
D
And if I could just add, we have a small team, but it's really important that we're all on the same page once we figure out what's driving our patients. For instance, Erica and I have a patient that we figured out not too far in after they came to the clinic that when she feels pain, her mental health declines. We had to come up with strategies to help her realize, yeah, I'm having pain, how do we deal with that? Because she would be in pain and then all of a sudden she was suicidal. So us all giving the same message, all helping her in the same ways is really important.
- [07:49]
B
What's it like working as a provider on this sort of interdisciplinary team?
- [07:54]
E
Medically, I don't know how to practice any other way without this interdisciplinary team. We learn how to lean into the skill sets of our different team members in order to see the whole person. Because if we're just seeing it from the lens of the medical condition, we're going to miss so much of what's really driving utilization for this particular person or what's that underlying concern that they have. Again, as Dr. Weir said, in the beginning it was very medical provider or medical centric, but we've moved towards this more holistic Patient centered, integrated approach.
- [08:31]
D
As a clinician, oh man, I know way more medical things than I ever wanted to know working in this field, in this clinic. But it's been nice to be able to see the correlation between medical issues and behavioral health issues.
- [08:46]
B
And for patients, what does it look like and feel like to receive care at the ioc? And do you have any patient stories that you can share that really illustrate what it's like to get care there?
- [08:57]
E
One of our patients who came from a history in a childhood of neglect, a parent with severe mental illness. A habit of picking partners that were not always kind to her, but she was always seeking to find her needs met, but not in ways that they were appropriately being met. And so one way that she coped was to use the emergency department because that was a time where she was alone, she didn't have to care for her kids, she had the attention that she needed. And in those few hours she was cared for, there was space held for her to get that rest, to get that care. But we've been able to work together in an integrated fashion to really understand and help her understand. When you feel this way, where is the best place to get your support or just to even acknowledge and validate? Yeah, we know this is hard. We know you're overwhelmed and sometimes it just takes that pause.
- [09:58]
B
Such a wonderful example of, you know, going from just realizing that they're a frequent utilizer of the ED to really understanding where that comes from and trying to get at it at the root of their what is clearly not just a medical issue but an emotional issue. And that's incredible that you have a clinic that is built just for people like that. Peter, can you talk about the operational and financial model for the clinic?
- [10:23]
C
The first part of this that's key is having a payer partner who willing to do this work together. And we've had a great relationship with our own university, UT Health Plans. They've been a fantastic partner, extremely supportive, and without them none of this would exist. And you're exactly right. You need a novel payment mechanism to reward this type of work because it doesn't fit in a fee for service world. So if anyone's listening, like oh, this sounds really cool, I'm going to do it. You literally cannot do it in a fee for service manner. At least I can't figure out how you do it. We don't even come close to our fee for service reimbursement to cover our costs. So there has to be a value based payment or an alternative payment model or something Else to incentivize the care coordination, the mental health piece, we also do a lot of oral health integration, which we haven't talked about, but that's another key component is working with our school of Dentistry colleagues to aid in the oral health problems our patients suffer from, which is often frequent and significant. But I'll have to say, just if people are listening and curious about this, it isn't easy to find like the payment model to do this. It's, it's this negotiation, this back and forth. And then there's also this interesting thing where you can look at the data in different ways. So the data is the data, but then how you look at it and how you analyze it in terms of impact is also somewhat subjective in terms of how people want to do it and depends on their assumptions and things. So there's always a back and forth. But essentially what we do just to give people an idea, we do the fee for service billing to get as much of that part of it done as we can and we try to kind of optimize our billing side of things. And then there's incentives for like quality and HCC coding, which for all of you out there that are familiar with this world, that's kind of inherent. But there's also then money that goes towards the care coordination we provide, which we have to document in our medical record system in terms of time spent as well as an incentive to reduce ER rates and hospitalization rates. We've tried to look at the total cost of care, but our census is small. It's 150 people. And the variability year to year looking at total cost is like, it's, it's a mass, it's really hard to do. So it's easier looking at utilization patterns. And I'll, I'll say one more thing that's really complex that people wouldn't, might, they might not think of right away is sometimes the ER reduction doesn't happen until year two, doesn't, it doesn't happen in a 12 month cycle. And so insurance companies kind of look at the world through a 12 month window and we have to get them to think a little bit broader. And luckily we do have people in our health plans that have a clinical background such as nursing and are willing to have a broader view that this is more complicated and you have to look at it through a lens that incorporates a little bit longer timeframe than you would maybe in a traditional setting.
- [13:09]
B
You raise a really important point that, you know, we're talking about people who have a lifetime of trauma and medical conditions. You're not going to change all of that in one year. And it requires patience and ongoing engagement to get to that point. But to Carrie and Erica, you know, you're serving this patient with really complex medical and social needs. And so how do you measure impact? How do you know that you're on the right path?
- [13:33]
D
We have to look at, I call them like small wins. In the regular therapeutic community, you will see a patient for six to eight visits, and you give them coping skills and they have goals, and then they transition out of therapy. That's not how we look at things in our clinic. We look at things like, oh, they were hospitalized for suicidal ideations 10 times last year, and now they've only been hospitalized once.
- [14:05]
E
Erica it's about a movement through stability. When we first meet a patient, they're often in a state of maybe something is chaotic, there's several unmet needs, and it's just that longitudinal effort of moving them from one space of stability to another. And again, like Carrie said, it's the small wins that we look at every day. Did they show up for this appointment? Have they been able to build a community Even a lot of our patients are socially isolated, and that's something we don't get to talk much about in a typical healthcare setting. But they've been able to establish community. They find a space of safety outside of their home. Sometimes we become their point of contact when something significant happens or they become acutely destabilized and they find solace within our clinic walls. And so there's so many definitions. It's not typical, but it's what the patient needs at that time.
- [15:06]
C
One other small thing I think is a helpful framework to think about impact, which is the way over the years we've seen it work, typically is it starts with building trust and rapport, and then that slowly leads to engagement with their health and their health concerns. And then sort of last to move is the utilization. So, like, if you look at it just through a utilization lens, that's a blunt way of looking at it, and it's actually a late effect. It starts with trust. And like, the term that we use internally is trust is our currency. It's everything what we're doing, we look to the claims data is finding people and inviting them in, and they often start off very skittish. And like, they're testing us. They test a little bit at a time, and a little bit here, a little bit there's, like, is this thing for real? You guys really that interested and invested in me because they've been burned so many times and also retraumatized so many times. So we have this very trauma informed care model that really gently begins to build that trust back up again. And to me, like, that's how it all starts and you have to build off of that.
- [16:14]
B
That is profound and so important for everyone listening. So I want to thank all of you for being here, for the work that you do to serve patients in your community. It's truly inspiring and I hope that our listeners can pull out some tidbits from what you're doing to apply in their settings so that everyone can receive that kind of holistic, person centered primary care that your patients are able to. So thank you for all that you do and for sharing your expertise with us.
- [16:41]
C
Yeah, thank you very much for having us. It's really near and dear to us, so it really feels good to be able to share that with others. And, and if anyone is interested in connecting with us, we'd also be happy to connect. We're at the University of Utah and we're pretty easy to find online, so please look us up if there's a follow up.
- [16:59]
A
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