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Competition Collaboration

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Simon Vision Consulting Team

Shabnam Popal

Project Manager

Mitchell Figueroa

Consultant

Corey Radzyminski

Consultant

Ann (HsinEn) Chi

Consultant

Philip Patyk

Consultant

Mengxi Li

Consultant

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Agenda

Problem Statement
Goal Overview
Barriers to Integration
Recommendations
Patient Roadmap
Q&A

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Problem Statement

Develop a strategic growth plan and processes to leverage the resources at East House, Compeer, and Trillium Health as a “one-stop shop” for Rochester community members to address their healthcare needs

Each company is co-located at 259 Monroe Avenue and would like to join forces to improve patient experience and serve the community collectively from affordable housing, to peer mentoring, to preventative/primary care

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Goal Overview

Implement "No Wrong Door" Policy

Enhance Cross-Functional Collaboration

Deliver Comprehensive Care Solutions for Low SES and At-Risk Patients

Restructure Organization for Seamless Operations - "No Walls"

Create the First Integrated Care Service Model in Rochester

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Barriers to Integration

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Barriers to Integration

The integration of East House, Trillium, and Compeer

Employee Connection

Transition of Service & Care

KPI Tracking

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Employee Level Barriers

Employee Connection

Mission and Vision Alignment

Organizational Cohesion

Competitive Environment

Corey

Mission & Vision Alignment – unclear messaging

Organizational cohesion – hesitant to share because of perception; lack of formal staff training

Talking Points:

Thanks Ann, I will now be drilling down into the three main areas we identified as barriers at the employee connection level
The last several months we have had the opportunity to learn more about each of your organizations. Being in the same physical building and understanding the Rochester community already puts you in a great position
Its now about taking it to the next step and based on our conversations we feel Mission and Vision Alignment, Organizational Cohesion and what is still a Competitive environment will be the hurdles to clear,

getting the mission and vision aligned across organizations is important and will ensure clear messaging that can be crafted by leadership and then shared to each organization.
For Organizational Cohesion – in our meetings we have talked about how employees across organizations do not know one another. By knowing one another and understanding what each other does moves that much closer to working well together
Finally it has been a competitive environment, last meeting we talked about competition over grants, how do we move to a more collaborative structure, determining ways to better support one another

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Transition of Care Barriers

Transition of Service & Care

Exclusive Services

Complications due to Insurance

Lack of Formal Closed-Loop Referrals

Lack of Cross-Functional Collaboration

Corey

Cross-functional collaboration - Lack of Formal Closed-Loop Referrals

Distinct Services - Patient's Lack of Awareness About Other Services They Require

Now getting into Transition of Service and Care

Each of your organizations offer different services which moving to an integrated model will have learnings and take time and collaboration to iron out how best to partner
Insurance providers in different patient scenarios is complicated and truly just the nature of healthcare
My Way Finder and Unite us were platforms we learned more about with the focus being closed loop referrals, a barrier definitely is how to operationalize one of those platforms and even improving how to walk a patient to a different organization
NEED Help here on what to potentially say on Cross functional collaboration

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Impact Measurement Barriers

KPI Tracking

Unidentified Metrics

Unclear Patient Outcomes

Workforce Shortage

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Fostering Synergy and Overcoming Barriers for Integrated Healthcare Advancement

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Recommendations

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Recommendations

Unifying Companies & Employees

Team Based Care Approach

KPI Tracking

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Driving Integration: Unifying Employees and Companies Through Purposeful Connections

Unify Companies & Employees

Opportunities for Employees to Meet

Establish values and goals

Boost Awareness of Services Provided by Organizations

Award successful patient outcomes and collective teamwork

Creating a shared mission and encouraging employee collaboration are essential for successful integration

Philip

Opportunities for Employees to Meet One Another

Shared room – with brochures from each organization so employees can become familiar with the services offered within the building
Joint office parties – for example with the holidays coming up you can do white elephant, pizza parties, etc to get employees excited for collaboration

The idea of these types of opportunities is to make all three facilities feel like one unit, instead of competing organizations

Establish values and goals of working within teams

Initial meeting should address overarching KPIs to measure goals, outcomes, impact, vision, and success
Include a monthly in-person townhall for first 6 months, then can switch to quarterly/hybrid model once values and goals are established

In first town hall, establish formal process for warm-handoff referrals (in-person patients)

Leadership should encourage employees to be as vocal as possible in order to make adjustments to team-based approach
Implement mandatory, organization-wide UniteUs training to ease/streamline software implementation

Ideally, the training(s) should be organization-wide so employees from all three facilities learn and can provide feedback together and between one another (this also reinforces the continuous-learning environment)

Boost Awareness of Services Provided by Organizations

This starts with organizational-buy in from all facilities
Shared room will encourage/incentivize natural word-of-mouth support of integration strategy
Send newsletter or brochures to patients that contains content from all three facilities
Include easy-to-find links to the other facilities websites on each organization’s page for visibility

Recognition System

Awarding successful Patient Outcomes, and collective teamwork (e.g., putting a recognition/memory board in the shared room to document successes and continue to develop that shared culture)
Gift cards, included in newsletter to patients, etc.

Unify Companies & Employees

This point speaks for itself → staying consistent with above points/collective culture transition will inspire cohesion between the three facilities (can’t let your foot off the gas pedal here!)

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Optimizing Care: Unleashing Team Collaboration to Address Unmet Needs

Team-based care removes the barriers created by traditional care

Utilize Unite Us as Primary Referral & Communication Platform

Strong & Transparent Leadership

Total Health Screening

Improved Patient Satisfaction

Reduces Employee Burnout

Improves Time Management

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Measuring Success: Implementing Actionable KPIs for Realizing Patient and Integration Impact

Identifying key KPIs provides transparency on the overall success of the implementation and its impact on patient outcomes in team-based care

Number of Closed Cases on Unite Us

Patient Satisfaction Surveys

Unite Us Dashboards (Tracking Referrals)

Ann

Implementation

How many visits a month/quarter -- to see what services patients are using

Top diagnosis between the three organizations (E.g. from the metrics they shared with us)
What is the overlap of patients seen between three orgs

Using UniteUs to track the number of referrals sent, number of referrals completed, and patient outcome

With UU, you get access to Tableau dashboards
It is analytics built based on your actions, instead of spending time pulling reports
In townhalls, they use these dashboards to exhibit the numbers they were able to produce in X timeframe
These dashboards are customizable, and can tailor for all three companies as singular source of truth for impact (including screenshot of dashboard)

Patient outcomes

Did they achieve anticipated outcomes through this team-based model
Number of closed cases

Patient satisfaction

Anonymous surveys (what do you think of team-based approach versus original patient care workflow)

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Patient Roadmaps

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Patient Roadmap

East House

Private, nonprofit agency serving individuals with persistent mental illness and/or substance use disorder
Focuses on social determinants of health including but not limited to affordable housing, recovery and reintegration, care coordination, etc.

Compeer

Compeer serves as a bridge to better mental health and community integration
Focuses on social connections and mentoring programs for adults with mental health diagnoses, youth, children & family treatment and support services, family peer mentoring, “CORE”, etc.

Trillium Health

Provides full range of services including Primary Care, Pharmacy, Pathway Pediatrics, Center for Gynecological Care & Wellness, the MOCHA Center and Harm Reduction Services
Focusing on Support Service Department

Patient Entry Intake

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Patient Roadmap

Scenario: Patient comes to Trillium Health to treat depression

Clinical staff complete Patient Entry Intake
They discover patient is struggling with housing (not in crisis mode)
They have two options...

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Patient Roadmap

Option 1

Option 2

Scenario: Patient comes to Trillium Health to treat depression

Clinical staff complete Patient Entry Intake
They discover patient is struggling with housing (not in crisis mode)
Discuss eligibility criteria with patient
They have two options...

Option 1: Send referral to East House, if they are eligible for resources, then walk them over to their office to discuss next steps

Option 2: With the assumption that an MOU agreement is in place – Submit referral and have EH employee come to patient's room

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Patient Roadmap

Regardless of choice, staff have many routes to integrated care through Team-Based Model and enforces notion of "No Wrong Door" policy and "No Walls" between organizations

Option 1: Send referral to East House, if they are eligible for resources, then walk them over to their office to discuss next steps

Option 2: With the assumption that an MOU agreement is in place – Submit referral and have EH employee come to patient's room

Option 1

Option 2

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Executive Summary

Unifying Companies & Employees

Team Based Care Approach

Measuring impact

Competition -> Collaboration

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Thank You! Questions?

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Appendix

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Team Based Care Diagram

Rosen MA, DiazGranados D, Dietz AS, Benishek LE, Thompson D, Pronovost PJ, Weaver SJ. Teamwork in healthcare: Key discoveries enabling safer, high-quality care. Am Psychol. 2018 May-Jun;73(4):433-450.

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Team Based Care Statistics

TBC Data/Evidence
Higher rates of

Active Depression Screening (46.1% vs. 24.1%)
Adherence to a Diabetes Care Bundle (24.6% vs. 19.5%)
Documentation of Self-care Plans (48.4% vs. 8.7%)
Lower proportion of patients with controlled Hypertension (85% vs. 97.7%)

Healthcare Utilization rates lower for:

Emergency Department visits (18.1 vs. 23.5)
Hospital Admissions (9.5 vs. 10.6)
Ambulatory Care-sensitive Visits & Admissions (3.3 vs. 4.3)
Primary Care Physician Encounters (232.8 vs. 250.4)
Lower costs for Delivery System ($3,400.62 vs. $3515.71)
Investment Costs were lower to implement for TBC model

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Diagnosis Patterns Roadmap

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Recommendations

Breaking Down Silos: Strategies for Overcoming Organization Integration Barriers

Collective/Shared Values

Must be agreed upon by Trillium, East House, and Compeer
Establishes integration validity/mission/vision/goals
Guides cross-functional collaboration
Drives employee expectations/perspectives

Strong Leadership

Encourages/enforces sustainable change
Communicates overall integration objectives
Incentivize continuous-learning environment
TBC Data/Evidence

Higher rates of

Active Depression Screening (46.1% vs. 24.1%)
Adherence to a Diabetes Care Bundle (24.6% vs. 19.5%)
Documentation of Self-care Plans (48.4% vs. 8.7%)
Lower proportion of patients with controlled Hypertension (85% vs. 97.7%)
Healthcare Utilization rates lower for:

Emergency Department visits (18.1 vs. 23.5)
Hospital Admissions (9.5 vs. 10.6)
Ambulatory Care-sensitive Visits & Admissions (3.3 vs. 4.3)
Primary Care Physician Encounters (232.8 vs. 250.4)
Lower costs for Delivery System ($3,400.62 vs. $3515.71)
Investment Costs were lower to implement for TBC model

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Team Based Care Risks

KPI tracking may not be possible because of different platforms being used
Operating with significantly less staff may be what hinders the success of the integration
Patient’s may not be motivated to seek out or receive care from multiple places in the same day
Employee’s lose sight of vision and goal of the integration plan

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Why Unite Us?

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Unite Us – Customized Data Visualizations Dashboards

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Unite Us – Provider Interface

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Why Unite Us?

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Why Unite Us?

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Why Unite Us?

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Future Areas of Focus

Internal Communications: Integration Messaging, KPI Transparency
Developing Cross-Company Events for Improving Employee Connection
Developing Cross Team Mock Situations for Team Based Care
Community Marketing
Talent Acquisition Marketing
Talent Sourcing and Creating Talent Pipelines through Universities