A New System of Care
Dr. Kraft is no stranger to harnessing the power of independent pediatricians to help rethink systems in the name of improved healthcare for children and families.
As medical director of the Health Network at Cincinnati Children’s (HNCC), she plays a key leadership role for a large and diverse organization modeling new ways to deliver health care.
Dr. Kraft calls HNCC our “innovation lab for value-based payment in Medicaid.” Negotiating a per-member, per-month capitated agreement with two of the Medicaid managed care organizations in Ohio has allowed the network to help providers deliver high quality primary care and meet population health goals. The 14 primary care practices in the network receive a per-member, per-month payment on top of what Medicaid provides.
“What we require them to do is really population health 101,” says Dr. Kraft, noting that the network provides some of the staff and resources that make this work possible. One important effort centers on attribution, or working with each practice to determine the children assigned to them by Medicaid who have been in and are getting regular care, and those who have never been in for an office visit. Once the practice has a handle on the kids who haven’t been in contact, they can work on getting them in.
“We are essentially finding these kids a medical home,” she says. “And helping our practices with the phone calls, the scheduling, again some of the things they don’t have the staff or the dollars to do.”
These efforts improve the practice’s Medicaid ranking, but more importantly they improve the health of children in Ohio who may otherwise have fallen through the cracks.
Another innovation — the network’s health management team – is key to the breadth of services available through the medical home.
“We’ve got teams of nurse care managers, social workers and community health workers that are available on the ground to meet with patients as they need,” she says.
This system means that pediatricians in the network have a mechanism to address underlying issues that may have a long-term impact on the health and well-being of kids. Do families have a roof over their heads? Are there co-occurring mental health issues or addiction issues in the family? Is there access to nutritious food? Transportation? Instead of asking the pediatric practices to assume all of the responsibility for answering these questions — or leaving them unanswered — HNCC provides the resources to tackle these complex needs.
Sometimes the answer to a medical problem turns out to be surprisingly simple, and HNCC leaves room to be nimble in its solutions thanks to an innovation called the Social Investment Fund. Dr. Kraft uses the example of a child suffering from asthma that is triggered by the heat. After a health management team assesses the situation, they are able to purchase the family an air conditioner, staving off rounds of emergency department visits and potential complications. By looking at a health problem from a perspective that encompasses more than a medical diagnosis, HNCC is able to reduce utilization and improve quality of life for kids and families. Next up: using telehealth to provide speech therapy for children and families who have difficulty traveling to appointments.
A more thoroughly integrated system means access to data, and Dr. Kraft points to the quality improvement initiatives made possible by the partnerships in the network as one of its most valuable assets.
One example: the problem of chronic constipation, common in pediatrics. Instead of an immediate referral to a gastroenterologist — which carries more cost and is more time intensive and stressful for a family — HNCC has a template they provide to primary care practices in the network. The template includes the questions and tests that the specialist would cover. If, after following the template, the problem still isn’t solved, then the referral happens. Often that referral isn’t necessary, as through this system Dr. Kraft says they’ve been able to improve care and cut costs, decreasing referrals for this problem by 84 percent in the last year.
High risk case management — identifying kids who need critical services and getting them that care — has also been a priority, and there’s been real improvement in this arena. HNCC now has upwards of 300 children, out of a population of about 32,000, in the high risk case management program, as compared to just one child who had been identified for this program prior to HNCC’s founding.
This had led to improvements in the health of these children, and it also has important implications for future health care costs.
“They can become high risk and high cost kids,” she says, “and we can prevent that if we know who they are.”
Has Dr. Kraft and HNCC landed on a model that can be more broadly applied, given the current healthcare landscape and its focus on controlling costs while ensuring more people have access to care? Dr. Kraft thinks so.
“Using the expertise of the independent practices is important,” she says. “Spreading and piloting this model in areas that may be receptive to it may be a good first step.”