# Presentation: 833865

## Return on Community Investment

- Building Financially Sustainable Healthcare Systems for the Uninsured and Underserved

- Intensive Workshop Session
- November 2005

## Today We Will Learn Together

- Identify your enterprise’s outcomes of value
- Figure out the deals to create this sense of value
- Develop a strategy for getting your community ready to make these deals
- Leave with a deal to go make

**The profound choice is to go and do this!**

## ROCI is

- A way to formulate the value received by complex sets of potential investors
- A method to measure value
- A process to achieve outcomes
- A way to act that builds trusting relationships
- A new strategic management discipline

***ROCI is easier to do than worry about!***

## Key Terms

*Enterprise*: The program, project, business unit or combination of critical activities that produces value for the collaborative
*Business case:* The compelling messages you give that result in investments
*Deal:* The terms of the business case. What the partners of the enterprise will do in exchange for an investment
*ROI:* The value proposition (benefits accrued to the organization minus the investment of the organization) for each investor
*ROCI:* The combined value proposition among partner organizations from a community view
*Gameplan:* An action-oriented strategy document that describes:
- The enterprise you intend to make sustainable
- The deals you envision making
- The community context and how to change it

## How to use the workbook (outline)

- Each Part is designed to help you develop elements of your gameplan and put it together
- Each case is named by the “key lesson” to take away
- Put yourself in the story ~ What’s your story around the case being presented?
- Exercises at the end of each case are to help you get started collecting and organizing information you’ll need
- Exercises at the end of each Part are to help you practice the conversations you’ll need to have

## The Social Entrepreneurial Role

- Somebody needs to do it
- Be it
- Hire it
- Create a deal team
- Support it (professional development)
- Which are you?
- Why are you passionate about this?

## ROCI Will Result in a Sustainability Game Plan

- There are three exponentially powerful stages of ROCI

## The Three Stages Of ROCI

## Implement your Game Plan in 7 Steps

**Define Your Enterprise**
**Find benchmark communities**
**Lay out your logic and measurement strategies**
**Craft the Deal**
**Make the return on investment business case**
**Move partners to a community-wide view of value**
**Create a community scorecard**
**Create the Readiness for Action**
**Generate greater community readiness**
**Promise and deliver accountability**

## ROCI Blueprint

**Return on Community Investment (ROCI)**

- Move each activity to sustainability
- Broker the big 100% Access deal

- Investment To Take The Portfolio To Scale For 100% Access

- $$$

- Pacing EventsSet Scale Of 100% Access Gap (# and $)

**Community Readiness:**

- Value To Investors

- Value To Investors

- Value To Investors

- Value To Investors

- Value To Investors

- Value To Investors

- Value To Investors

- Value To Investors

**Enterprise** Design & Benchmarking: *Best Practices*

**ROCI Blueprint**

**Return on Investment**

- Craft **Deal** Proposal Based On ROI Business Case

- Outcomes

- Outcomes

- Outcomes

- Outcomes

- Outcomes

- Outcomes

- Outcomes

- Outcomes

**Portfolio Of Critical Activities Necessary For 100% Access**

- Organize donated care

- Reduce inappropriate ER use

- Administer care coordination

- Leverage employer funds

- Enroll people in public programs

- Broker affordable prescription drugs

- Facilitate access to health services

- Automate enrollment and referrals

- $$$ savings reinvested

- Investment By Partners In An Activity (Based On ROI)

## Exercise

- What is the name and intent of my enterprise?
- What are the actual or envisioned critical activities of my enterprise?

| Organize volunteer safety-net providers for medical, dental and mental health services with coordinated specialty referrals |
| --- |
| Reduce inappropriate Emergency Department use through shared care plans and team approach for frequent users |
| Administer care coordination and disease management programs |
| Leverage public funds with local and private resources, including employer contributions |
| Perform outreach to find the low-income and uninsured and connect them to a medical home and facilitate access to health services |
| Partner with state agencies to enroll people in public and private programs for which they are eligible |
| Create common electronic referrals among local health and human services providers |
| Arrange for affordable prescription drugs on a community-wide basis |

## Part 1 ~ Design an Enterprise that Produces Outcomes

- Case A Lesson: Find Benchmark Communities

## Slide 13

| There are benchmark communities for each critical activity | Examples |
| --- | --- |
| Organize volunteer safety-net providers for medical, dental and mental health services with coordinated specialty referrals | Project Access, NC |
| Reduce inappropriate Emergency Department use through shared care plans and team approach for frequent users | Health Access Project, UT |
| Administer care coordination and disease management programs | Broward Regional Health Planning Council, FL |
| Leverage public funds with local and private resources, including employer contributions | Access Health (3-Share), MI |
| Perform outreach to find the low-income and uninsured and connect them to a medical home and facilitate access to health services | Regional Access Program, WA |
| Partner with state agencies to enroll people in public and private programs for which they are eligible | Pima County Access Program, AZ |
| Create common electronic referrals among local health and human services providers | Jesse Tree, TX |
| Arrange for affordable prescription drugs on a community-wide basis | Coordinated Care Network, PA |

## Organize volunteer safety net providers for medical, dental and mental health services coordinated with specialty referrals

- 33% reduction in direct care costs of enrollees
- 80% of physicians seeing uninsured and Medicaid
- $4 million a year in free care
- 45% reduction in hospital charity care
- Enrollee ER use dropped from 28% to 8%
- 80% of enrollees report improved health
***Could you achieve these results in your community?***

## Reduce inappropriate Emergency Department use through shared care plans and team approach for frequent users

- 25% fewer total ER visits among clients
- 42% higher compensated charges
- $400,000 in donated care a year
***Could you achieve bolder results in your community?***

## Administer care coordination and disease management programs

- 28% increase of patients in control of their disease
- Doubled the number of people with chronic disease who are participating in disease management programs
- 44% decrease in those severely out of control
- Cost of hospital care dropped by 24%
***Could you achieve these results in your community?***

## Leverage public funds with local and private resources, including employer contributions

- 97% of doctors participate
- Number of uninsured reduced by 1,500
- 38% of community businesses offer coverage
***Could you achieve these results in your community?***

## Perform outreach to find the low-income and uninsured and connect them to a medical home and facilitate access to health services

- Reduced hospital’s unpaid care by $2 million a year
- Reduced the uninsured by 3,000 a year (over eight years have cut the number of uninsured in half)
- Provided 980 free and reduced price prescription drugs to 455 people valued at over $125,000 a year
***Could you achieve these results in your community faster?***

## Creates a local infrastructure for 100% access

**Creates a local infrastructure for 100% access**

**Human service providers use a common web-based, highly leveraged community resource referral system**

**Organize care, acknowledge practitioners contribution and enhance well-being and access as a negotiable community asset**

**Incent small employers to**
**financially contribute for low-wage workers**

**Facilitate enrollment in programs and access to medical home, specialists and interpreting services**

## 3-Share Employer

**3-Share Employer**
** ****Coverage**

**Jesse Tree/ 211**

## Go to scale: Better Health Outcomes for More People at Less Cost

**Community Health Management Districts are the future of health care**

**Go to scale: ****Better**** Health Outcomes for ****More People at Less Cost**

- Combine Funding

- Capture Savings

- Achieve 100% Access

- Practice evidence-based treatment and reduce unnecessary procedures

- Invest in disease prevention and health management

- Invest fully in primary care and prevention and purchase risk protection for other services

- Pay providers using one common method

- Subsidize shared IS technology to improve productivity and patient satisfaction

- Create a county coverage program with community prioritized service decisions

- Get new contributions from employers and community fundraising

- Count and factor in uncompensated care and what patients pay

- Combine government funds now spent through multiple programs

## Part 1 ~ Design an Enterprise that Produces Outcomes

- Case B Lesson: Lay out the logic and measurement strategies

## Lay Out the Logic and Measurement Strategies

- Define and measure both quantitative and qualitative outcomes to demonstrate the benefit of your enterprise.
- You may be able to measure all this in your community, but more general research also can be used to project outcomes in ways that could help attract investors.
- Collect baseline data before you start

## Logic Model Framework

| Resource
 | Activity | Output | Outcome | Impact |
| --- | --- | --- | --- | --- |
| Using these resources | enterprise will engage in these activities
 | to produce these results
 | which will yield these benefits
 | with this ultimate effect |
| RN Disease state managers | Disease 
management 
program 
implemented 
and used | Patients in 
compliance 
with baseline 
tests | Patient in 
control and 
self 
managing 
their chronic 
disease | Improve 
health status, 
reduce 
inappropriate 
health care 
cost |

## Defining measurements

- Decreased hospitalizations (hospital days) and associated costs.
- Decreased emergency department visits and associated costs.
- Decreased overall costs through patient enrollment in insurance programs.
- Increased Quality of Life as measured by nationally recognized scales.
- Improved clinical lab values (HbA1c, CD4& Viral Load)
- Increased patient satisfaction.
- Increased provider satisfaction.

## Approach and Outcomes

| Outputs | Measures | Baseline | Outcome | Actual Outcomes |
| --- | --- | --- | --- | --- |
| Program | #/% People Enrolled | 0 | 2000 (5%) | 1,680 |
| Health
Status | QOL Survey Results | 13% rated
fair to poor | Improve
status | 3% increase in SF 12 |
| Improve
Clinical
Values | Clinical lab values | Collected at 
first visit | Improve
from
baseline | 28% increase of 
those in control,44%
decrease in severe |
| Utilization | Hospital Bed days, 
Avg. Length of Stay 
(ALOS) Emergency 
Dept. Visits | 5.9 ALOS
204 ER 
visits | Reduce 
ALOS to 5 
days &
ED by 10%  | ALOS: 5.1 days
228 ER visits
(up10%) |
| Patients in 
Program | Current case
managers’ case load | 4% DMP | Double
enrollment | 8.4% in disease management program |
| Total 
Health 
Costs | Paid claims (hospital use and costs) | $2.9 million | Reduce 
costs 15% 
$435,000 | Reduced the cost of hospital care by $688,000 (24%) |

## Part 1 ~ Design an Enterprise that Produces Outcomes

- Case C Lesson: Assess the high potential benefits

## Premise:  Cost of coordinated care is less than cost of uncoordinated care

- Increase % of patients with a regular source of care
- Earlier access to specialists
- Decreased hospital acuity (less sick)
- Less wasted time for patients, doctors and nurses

## Define Benefits in Stages

| Fully Operational (FO) | Benefit |
| --- | --- |
| Facilitated enrollment & Screening | 33% reduction in direct care costs. Significant improvement in health status  |
| Expand safety-net to include Medicaid & small employers | 80% of physicians seeing uninsured and Medicaid.
Small employers voluntarily financially contribute. Reduced employee absenteeism and productivity increases |
| Early Operational (EO) | Benefit |
| Reduce inappropriate ER use | Immediate: Happier ER and on-call docs. Improved hospital through-put
Over-time: Costs the system less; Continuity of care; Better health outcomes |

## Have Early Traction Points

| Developmental (D) | Benefit |
| --- | --- |
| Organize physician’s donated care | Immediate: Renewal of the safety-net contract
Over-time: Donated care is defined as a negotiable community asset. Strong Medical society reducing the cost of direct care and expanding primary care capacity |
| Organize mental & dental health | Immediate: Renewal of the safety-net contract
Over-time: Treating the patient as a whole produces better health outcomes |
| Planning (P)  | Benefit |
| Administer disease management programs | Immediate: Communication flows among providers. Common treatment protocols,increase in compliance with base-line testing
Over-time: Improved quality of care and life, improved health outcomes and community health status |

## What to listen for

- What’s my strategy to make ROCI deals back home?

## Part II: Figure Out the Deals to Make

- Case D ~ Catalog who benefits, know who benefits
- Case E ~ Engage potential investors

## Catalog collaborators by benefits they’ll accrue

| Type and Organization | What outcomes would benefit them? | Why they would value it? | What would they give in return? |
| --- | --- | --- | --- |
| “Mercy Me” Hospital | Enrolling uninsured in coverage | Increases reimbursements | $’s to pay for outreach and enrollment |
| “All Welcome” Community Health Center | Easy access to specialty referrals and affordable prescription drugs | Fewer unnecessary repeat primary care visits (more primary care capacity) | Community providers access to 340 (b) prescription drug prices |
| “Health R Us” County Health Department | Improved health status | Sustainable local public health infrastructure | A per capita tax to fund the portfolio management activities |
| “No More Free Care” physician office | Reduced fragmentation (the creation of a safety-net system) | Fewer admin costs and hassles | Agree to accept their fair share of low-income patients |
| “Can’t Pay More” State Medicaid program | Reduction in inappropriate ED use | Slows down the impact of medical inflation on budget | Medicaid admin match for local care coordination |

## Case F ~ Use Research

- Part II: Figure Out the Deals to Make

- Case G ~ Turn ROI into stakeholder value
- Case H ~Show the social return for the entire safety net

## ROCI Data

- Benefit
- Value
- Savings
- Interventions must be defined and “costed out” using the best available outcomes data and research
- Outcomes must be linked to dollar values that are credible to local investors

## Example of How to Use Formulas

**Benefit**

**$500,000 **

**additional **

**earnings **

**per100/yr**

- Earnings = 20%

- increase in

- average salary of

- $25,000

- Benefit = Annual earnings increase 10

- -

- 30%

- (Kaiser 2002). Sicker and Poorer:  The

- Consequences of Being Uninsured.

- Improved annual job

- earnings

- Enrollment of

- uninsured person

- into permanent

- health insurance

- Teaching health

- related self

- -

- management

- skills

- Assuring enrollee

- has permanent

- medical home

- (primary care)

**INTERVENTION**

**Savings**

**$75,000 per **

**100/yr **

- Savings = $750 x

- number of clients

- receiving self

- -

- management

- skills

- Savings = $750/yr (fewer hospitalizations) (

- Lorig

- et al. 1999) ‘Evidence suggesting that a chronic

- disease self

- -

- management program can improve

- health status while reducing hospitalization’.

*Medical Care *

- 37(1): 5

- -

- 14.

- Avoided

- hospitalizations and

- days for all

- enrollees

**Savings**

**$22,000 per **

**100/yr**

- Savings = cost

- per ED visit $600

- x .37 fewer visits

- = $222

- Savings = 37% less likely to have

- nonurgent

- ED

- visit (Petersen et al. 1998) ‘

- t

- Emergency Department Visits

- –

- The Effect of

- Having a Regular Doctor.’

*Medical Care *

- 36(8):1249

- -

- 55.

- Avoided ED Visits

- for all enrollees

**SAVINGS**

**-**

**BENEFITS per **

**100 enrolled **

**clients per year**

**MEASURE**

**-**

**MENT OF **

**COSTS**

**BENEFIT, VALUE, SAVINGS**

**TYPES OF **

**BENEFIT, VALUE, **

**SAVING**

**Benefit**

**$500,000 **

**additional **

**earnings **

**per100/yr**

- Earnings = 20%

- increase in

- average salary of

- $25,000

- Benefit = Annual earnings increase 10

- -

- 30%

- (Kaiser 2002). Sicker and Poorer:  The

- Consequences of Being Uninsured.

- Improved annual job

- earnings

- Enrollment of

- uninsured person

- into permanent

- health insurance

- Teaching health

- related self

- -

- management

- skills

- Assuring enrollee

- has permanent

- medical home

- (primary care)

**INTERVENTION**

**Savings**

**$75,000 per **

**100/yr **

- Savings = $750 x

- number of clients

- receiving self

- -

- management

- skills

- Savings = $750/yr (fewer hospitalizations) (

- Lorig

- et al. 1999) ‘Evidence suggesting that a chronic

- disease self

- -

- management program can improve

- health status while reducing hospitalization’.

*Medical Care *

- 37(1): 5

- -

- 14.

- Avoided

- hospitalizations and

- days for all

- enrollees

**Savings**

**$22,000 per **

**100/yr**

- Savings = cost

- per ED visit $600

- x .37 fewer visits

- = $222

- Savings = 37% less likely to have

- nonurgent

- ED

- visit (Petersen et al. 1998) ‘

- Non-urgent

- Emergency Department Visits

- –

- The Effect of

- Having a Regular Doctor.’

*Medical Care *

- 36(8):1249

- -

- 55.

- Avoided ED Visits

- for all enrollees

**SAVINGS**

**-**

**BENEFITS per **

**100 enrolled **

**clients per year**

**MEASURE**

**-**

**MENT OF **

**COSTS**

**BENEFIT, VALUE, SAVINGS**

**TYPES OF **

**BENEFIT, VALUE, **

**SAVING**

## Roll-up Institution ROI to Stakeholder ROI

- Show the cost of doing nothing (or not having the enterprise)
- By type of stakeholder
- Hospital
- Primary care
- Public health
- Subtract investment from benefit to get value equation
- Compare institution ROI within stakeholder types

## Exercise

- What are the deals you will make to achieve sustainability?
- My potential investors are?
- My “deal team” is?
- The kind and amount of value I will offer to deliver is?
- What I will ask in return is?

## Part III What to listen for

- How can I keep creating greater levels of community readiness to do bolder change over time?

## Part III: Make the Community Deal Ready

- Case I ~ What readiness is present and where readiness has to be created

- Case J ~ Harness readiness and create more

## Map Stakeholders 

- Key: Unless they are on board it won’t happen
- Important: Could happen without them, but it will happen faster and easier with them
- Helpful: Have energy to put into enterprise or activity but lack influence
- Assign a starting point:
- Champion (will die on their sword to make it happen)
- Supporter
- Fence sitter
- Detractor

## Work It!

| Type | Leader | Priority | Starting Position | Position Today | ?’s and concerns | Personal/ Org interest |
| --- | --- | --- | --- | --- | --- | --- |
| Hospital | Charles Stewart | Key | Fence sitter |  | What does this have to do with hospitals? | Better relationship with medical staff |
| Physician | Brian Branson | Important | Supporter |  | Dr.’s don’t have the time to work on this | Recognition |
| County Government | Comm. Sharon Lord | Key | Detractor |  | Puts unfunded mandates on local government | More public health funding |
| Employer | Arnie Johnson | Helpful | Supporter |  | Employers don’t want to be taxed | Chamber recruitment |
| Faith Leader | Skip Bjornson | Helpful | Champion |  | Different faiths don’t work together | Social justice for the indigent |
| State Government | Sen. Sandra Sharpe | Important | Fence sitter |  | Communities will make poor decisions | Re-election |
| Health Plan  | Ann Faulk | Important | Detractor |  | Don’t interfere with provider contract negotiations | Adequate provider network |

## Exercise

- New Ideas For Creating Greater Community Readiness

## Learning Communities and Recognition

- Who inspired you today and why?
- What is one of the most exciting things you learned today?
- What steps do you feel confident to take?
- How can CJA help?
***Stand up if you’re confident you will take action to make your deal when you get back home***