Built-in Well being Companions (IHP) is a nonprofit, FQHC-controlled clinically built-in community, devoted to advancing value-based care and fee reform for historically underserved populations in San Diego and Riverside counties in California. Kristine Ortwine, IHP’s director of inhabitants well being IT and analytics, lately spoke with Healthcare Innovation about how the FQHCs are leveraging analytics to achieve value-based care preparations.
Established in 2015, IHP’s community spans 97 medical websites and works with six well being plans in Southern California.
Healthcare Innovation: Kristine, may you discuss how Built-in Well being Companions got here collectively initially, and whether or not it is grown considerably since then?
Ortwine: It has grown considerably. IHP started within the 2015-2016 timeframe. I joined the IHP crew in 2018. My function on the time was round serving to the community unify their knowledge to have the ability to help most of the initiatives that they have been attempting to execute on. In the end, IHP is a clinically built-in community. Their function actually was to assist federally certified well being facilities be part of collectively to undertake finest practices, to enhance affected person outreach, affected person care, affected person outcomes, and to assist help them as they ready for different fee fashions and value-based care initiatives. Once I began in 2018, we have been working with two well being plans and now we work instantly with six well being plans, and we have grown most likely 350% by way of our membership. We presently are at about 389,000 managed care lives. Once I began, it was most likely round 100,000.
HCI: Do the FQHC leaders function the board members and steer the course of initiatives?
Ortwine: Sure. IHP is admittedly working for the 9 well being facilities which are members. The board is led by the well being heart management and supported by the chief management and workers at IHP. However the well being facilities are the leaders, and so they decide the course of the community.
HCI: Are the well being plans Medi-Cal insurers? Or others as properly?
Ortwine: Our e book of enterprise is admittedly rising. We’re operating at about 97 to 98% Medi-Cal, which is California’s model of Medicaid. However we do have and proceed to develop different books of enterprise. We now have a small Medicare inhabitants. We even have new well being plans. We’re an FQ hub for SharpCare, and we’ve plans via SCMG [Sharp Community Medical Group]. We even have some industrial via Anthem. Our most up-to-date enterprise is with our ACO known as “My Alternative High quality Care Community.” That could be a new providing from CMS. It’s a Medicare Shared Financial savings Program that rolled out in 2025.
HCI: What are among the challenges that the FQHCs face once they’re working independently that being a part of IHP helps them enhance? Does it contain serving to them see their very own knowledge extra clearly, or does it contain aggregating knowledge throughout the FQHCs and pulling in knowledge from different sources?
Ortwine: I believe it’s all of that. FQs are resource-constrained normally. They serve a inhabitants of underinsured and uninsured people, and so they have an enormous footprint in the neighborhood. One in three persons are accessing main care via a federally certified well being heart. And what which means is that individuals go a lot of locations a lot of occasions. IHP has an open door coverage, so which means a patron can obtain care wherever they should. That is a variety of information in a variety of locations. So individually, these well being facilities are doing a extremely nice job delivering care, however it’s laborious when you’ll be able to see solely a partial image of that affected person.
The community provides help in a few methods. One is from the information aggregation perspective, and Arcadia is our associate there with our inhabitants well being software. If I stroll into Neighborhood Well being, for instance, and I am taking a look at this affected person, I can see that that she’s additionally been at Vista, and possibly she had a hospital discharge from one in all our hospital ADT companions — we’ve a feed with our native well being info alternate. Their capability to see that longitudinal affected person document actually helps them ship high quality care. It helps them perceive the general affected person standing, in order that they’ll goal and never duplicate providers.
Somebody who has very restricted workers in a single website now has the power, with the help of Arcadia and IHP, to take a look at how that affected person has moved via the community, and so they could not have had the sources to try this in any other case.
One other piece is round how we are able to help their medical, operational and coding workers that use the information. The place can we focus our sources? What does our monetary image appear to be in among the contracts that we’re engaged on? What are probably the most susceptible populations, by way of superior care administration that you simply need to have interaction? So it is not simply the technical piece that helps them jump-start merging all of this very fluid and disparate knowledge; it’s additionally the help piece to assist them operationalize utilizing that knowledge and improve and enhance their efficiency.
At IHP, we even have an enhanced care administration crew of 12 on the central stage that helps have interaction sufferers who qualify for enhanced care administration providers. We need to be certain that the neediest sufferers get the kind of care that finest serves them. That’s the kind of program that must be leveraged once you’re speaking about sufferers who’re both troublesome to achieve or are in very complicated conditions and are getting misplaced within the system.
HCI: Are these clinics on quite a lot of EHRs, and was that a part of the problem to start with — getting it arrange in order that the information flows backwards and forwards?
Ortwine: Sure, our well being facilities are all on totally different EHR distributors. And that is most likely the strongest purpose for having a pop well being associate: We now have a pair who’re on NextGen, simply for instance. Every of these well being facilities is an impartial entity that is leveraging that occasion of NextGen with their very own workflows and their very own knowledge inputs. So even you probably have them on the identical vendor, how they’re amassing knowledge, how that knowledge is being translated into the tables, after which how that knowledge is being built-in in Arcadia’s bigger knowledge lake is all very totally different. All of it must be mapped and optimized. So whereas every of the well being facilities does an awesome job inside their very own ecosystem, when you concentrate on inhabitants well being normally, you need to take a look at the totality of that affected person throughout a number of medical methods, throughout HIEs, throughout immunizations, throughout claims knowledge and enrollment. In order that’s the fantastic thing about them taking a look at knowledge in a brand new means. In the event that they have been attempting to do that by themselves, it might be time-intensive and far more pricey for a person well being heart.
HCI: Are there some sources of information which are difficult to get, like lab knowledge or behavioral well being knowledge?
Ortwine: It’s not nearly having access to the information. So if I may reframe that, possibly it is about deciphering and stabilizing the information. I may have a want listing of all knowledge, however is that knowledge available? Is it being collected in an ordinary means? If we have been to speculate the power to construct a dwell connector or an everyday connector into Arcadia, will that knowledge be capable to be interpreted appropriately and joined with different knowledge that we’ve within the platform?
You simply referenced behavioral well being, and that may be a fantastic instance. In all probability high of thoughts with our group is closed-loop referrals knowledge. As a result of we’ve a powerful care administration program right here, oftentimes, as we should always, we refer sufferers out to community-based organizations to assist them handle issues which are exterior of a medical lens. Perhaps they’ve meals insecurity, housing insecurity, or employment points so we refer them out. However how do we all know that that referral really occurred, in order that we are able to perceive the way it impacts the affected person’s care? That is an awesome instance of an information supply that is troublesome to get our fingers on. However finally, I imagine the problem is admittedly round once we do have entry to knowledge, making certain that that knowledge stays wholesome and secure and can be utilized and interpreted appropriately throughout the community.
HCI: What about that social determinant knowledge you simply described — to determine sufferers who would possibly want transportation or housing or meals assist. Are the clinics themselves surveying their very own sufferers to collect that knowledge, or are there different sources of that knowledge?
Ortwine: It is type of a combined panorama proper now. Equitable entry to care is a driving power not just for our well being facilities, however it’s a pillar of IHP’s mission, so figuring out sufferers’ true wants throughout social drivers of well being is one thing that we’re investing in. However as you acknowledged, that sort of information isn’t solely troublesome to seize as a result of it is delicate in nature, it is troublesome to comply with all through a affected person’s lifetime of engagement with us. As with every different initiative, every well being heart is at a special place. Whereas everyone seems to be trying in numerous methods to gather that knowledge, how they retailer, preserve and leverage that knowledge may be totally different throughout the well being facilities within the state of California. We’re working throughout the state with Cal-AIM, which is a large initiative in California, and we help that initiative, and work alongside our DHCS [Department of Health Care Services] companions to find out how we are able to get that knowledge in an ordinary, coded means.
HCI: Do you even have robust well being info exchanges in your space you can rely on to get knowledge from and submit knowledge to?
Ortwine: Sure, we’ve San Diego Well being Join, San Diego County’s HIE. We established an ongoing feed with San Diego Well being Join’s ADT. We offer San Diego Well being Join with a month-to-month roster of lively sufferers, after which they supply us real-time messages of these ADT alerts. We’re talking with Manifest MedEx about the opportunity of establishing a really related feed in order that we are able to perceive in actual time inside the remainder of the aggregated knowledge exercise for these entities which are collaborating with Manifest MedEx.
I need to be clear, not one software solves every part; not one expertise works for everybody. However what we actually try to do as we help the well being facilities is restrict the variety of locations they need to go to get info. We do not need somebody who’s already strapped for time having to recollect this technique for this, and that system for that. So whereas every of those entities — San Diego Well being Join and Manifest MedEx — have elegant choices of their very own, or particular person portals that you can use, we’re attempting to restrict that boots-on-the-ground clinician or operational particular person having to try this. By how we deliver that info in, we wish them to have a one-stop store. Then as soon as we’ve that info, our capability to leverage our personal expertise sources to push that knowledge to them robotically turns into game-changing. And we do have packages which are constructed round these ADT messages for transition of care and enhanced care administration engagement.
HCI: Do you’re employed instantly with the payers on pay-for-performance contracts?
Ortwine: We do. We work instantly with the well being plans to assist be certain that gaps are being closed, be certain that the standard of the data and knowledge that is being supplied to the well being facilities is right and correct. We are able to comply with up and work via knowledge points, affected person assignments, and shut care gaps.
HCI: Are the well being facilities being profitable in a few of these different fee fashions?
Ortwine: Sure. I believe IHP is a good instance of how one can leverage this help on the community stage throughout these entities which are working in numerous geographies with totally different populations with totally different sources to push ahead with value-based fee. We now have two skilled threat contracts proper now, one with Anthem and one with Blue Defend Promise. That’s a brand new type of enterprise for our well being facilities, and I believe it might have been very troublesome for them to start out these sorts of relationships and people threat contracts with out overarching help, in order that that is an actual win. We now have alternative to enhance look after our sufferers and handle prices with these different value-based care fashions that may be new to them.
This new MSSP ACO product is a good instance of how we are able to band collectively and use the power of the community to help new forms of buildings for affected person engagement and care which may not have been possible. Everyone knows that these things is hard, however value-based care isn’t going anyplace. We’re going to have to repeatedly ship higher high quality of look after an affordable value and be sure that the affected person is not the one which pays in the long run. We wish the groups to ship the care and for us to offer the help they must be profitable.
HCI: Is there the rest I have not requested about that you simply’d need to stress in regards to the work with Arcadia, or different tasks you’re looking ahead to within the subsequent yr?
Ortwine: I’d say that for the well being facilities we work with, it requires effort and time to take part in these sorts of tasks. They need to have a major stage of engagement to make these initiatives profitable, so we’re appreciative of their help in these kind of packages to higher the lives of their sufferers.
On the opposite aspect of that, that is our sixth yr with Arcadia, and so they have been a stellar associate in adapting alongside our community. Our community has modified. How we leverage Arcadia has modified, and the way we help our well being facilities has grown and improved, in order that they have been a associate alongside us in dealing with the challenges on this swiftly altering atmosphere that all of us dwell in.
