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Founding Organization:
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Managed by the Network Builders Team (nbt) 2017
www.MoonshotCommunityCare.com
Health Care Leaders
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TABLE OF CONTENTS• Defining Moonshot
Why, How, What and Who
• Impacting Chronic Diseases
• Health Care Leaders Roadmap
• Moonshot National WorkforcePlatform
• Community Care Teams
• Community Care Teams Continuing Education
• Care Coordination Framework
• Turnkey Engagement Networks
• Community Data Evaluation
• Proposed Next StepsNetwork Builders Team
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Defining Moonshot The term ‘moonshot’ is derived from the Apollo 11 spaceflight project, which landed the first human on the moon in 1969.
‘Moonshot’ may also reference the earlier phrase “shoot for the moon” meaning aim for a lofty target. The Google definition of a moonshot is a project or proposal that:
1. Addresses a huge problem2. Proposes a radical solution3. Uses breakthrough technologies
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U.S. Healthcare’s Huge Problem
U.S. healthcare is the most expensive system in the world (almost by double) ranking a poor 11th in quality among the industrialized nations with a healthcare cost accounting for over 17% of the U.S. gross domestic product (GDP). Total healthcare costs are estimated to grow near 20% of GDP by 2020. Of those total U.S. costs, 86% are related to population groups with one or more chronic conditions.
Sources: National Healthcare Expenditure Projections, 2010-2020. Centers for Medicare and Medicaid Services, Office of the Actuary; and Multiple Chronic Conditions Chartbook: 2010 MEPS Data
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To slow, stop or even reverse the progression of non-communicable
chronic diseases
Radical Solution: The “Why”?
6Managed by the Network Builders Team (nbt) 2017
The “How”?
Building a Bridge of Trust to link Clinical Care with Community Care
7Managed by the Network Builders Team (nbt) 2017
The “What”? Community Care is that
ecosystem where healthcare organizations can reduce value-based care risks and costs by relying on a trained workforce of allied health professionals, community health workers, and volunteers as Community Care Teams delivering chronic disease care programs within a high value, yet lower cost network of safe and scalable point-of-care places.
Successful healthcare organizations are rooted in
the communities they serve.
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Breakthrough Technologies That:1) Analyzes population health management (PHM)
data to stratify chronic disease population groups;
2) Refines cohort profiles and readiness for change;
3) Optimizes recruiting, training, placing, and administrating Community Care Teams for quality controlled chronic disease care program delivery;
4) Supports patient chronic care program participation, human and digital engagement duration, frequency, and intensity;
5) Evaluates chronic disease self-care management process and outcome quality measures; and
6) Facilitates value-based care performance payments.
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B. Recruit a National Workforce of 50,000 allied health professionals (AHP), community health workers (CHW), and volunteers for credentialing, program training, specialty instruction, and annual compliances to fill the roles of Community Care Teams;
C. Recognize 20,000 Safe Care Places of community-based locations to host chronic disease care programs made accessible for all payer and community populations; and
D. Evaluate Community Data by analyzing Roadmap execution, Framework implementation, and Network accessibility along with program process, outcome and self-management metrics.
Moonshot Community Care Goals for 2020
A. Support 50 Health Systems to execute Community Care Roadmap alignment, implement a behavior change Framework, and build/manage turnkey engagement Networks;
Managed by the Network Builders Team (nbt) 2017 10
for Healthcare Organizations
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A Key Objective of Value-Based Care
Delivering intervention care programs to chronic disease population groups in lower cost community settings
is a key objective to value-based care success.
With 86% of U.S. healthcare costs attributable to chronic diseases, it is imperative that health systems identify, as early as possible, those ‘rising-risk’ patients with chronic diseases. This particular patient population is likely to increase utilization of medical services, incurring the most cost as they migrate toward ‘high-risk’. Payers (employers, insurers, Medicaid and Medicare), are most concerned with the escalating cost of care for chronically ill patients.
Source: World Economic Forum 2010
Risks and Behaviors Drive Chronic Conditions
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Uncover Root Causes
Assess the root causes of diagnosed chronic disease population groups to gain a better understanding of which
finite resources should the groups be referred that will actually make a difference in their risk rising to the high-risk level.
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88% of U.S. healthcare dollars are spent on medical services. Medical care is only responsible for 10% of a person’s health while approximately 50% of an individual’s health is attributable to healthy behaviors. Yet healthcare only spends 4% of the nation’s total healthcare bill each year on promoting healthy behaviors.
The Lifestyle Behavior Impact
Why? Clinicians are not traditionally trained in health behavior change, and typically outpatient workflow constrains sufficient bandwidth for lifestyle behavior change counseling.
Community Care Teams are trained to deliver health behavior change care programs impacting lifestyles.
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Care Management
Intervention Care
Care Prevention
Wellness
5%
30%
35%
30%
HighRisk
Rising-Risk
Low-Risk
Healthy
Action
Initiate Action to Engage the ‘Rising-Risk’Add Community Care to slow, stop or even reverse the progress of chronic disease before migrating to ‘High-Risk’ Care Management
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Who are the ‘Rising-Risk’ Population Groups?
• Presence of one or more chronic diseases
• Utilization of hospital and emergency department visits are likely to increase
• Increasing chronic disease burden, treatment complexities, and total costs of care
• Escalating risk towards ‘high-risk’, high-cost care management on the care continuum
• Danger of potentially complex events and irreversible organ damage
• Continuing unhealthy keystone lifestyle habits that are the root causes of chronic diseases
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Healthy
Low-Risk
Rising-Risk
High-RiskHigh Cost
Diagnosed with one or more Chronic Diseases
Care Prevention
Chronic Disease Cost Concentration Care Continuum
Top 1% account for 21% of healthcare costsTop 5% account for 49% of healthcare costs
Top 10% account for 65% of healthcare costs
Upper 50% account for 97% of healthcare costs
Lower 50% account for 3% of healthcare costs
Care Management
Wellness
18Source: OPEN MINDS Daily Executive Briefing {internet}. Monica E. Oss. The IRS Turns Its Attention to ACO’s. April 12, 2016
Chronic Disease Risk
Intervention Firewall Progression
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I. Support Health Care Leaders in aligning Community Care Roadmap priorities and objectives
II. Recruit, educate, place and administrate a quality assured National Community Care Teams Workforce
III. Coordinate Clinical Care Teams and Community Care Teams to implement a behavior change Framework for Business Health
IV. Build and leverage turnkey engagement Networks of safe care places and high value resources to deliver chronic disease care
V. Evaluate Community Care data for Roadmap execution, Framework implementation, and Network accessibility along with program process, outcome and self-management metrics
Value Model
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ROADMAP PROCESS SYSTEM ALIGNMENT
Population Priorities • System Employees• Value-Based Care Payers• Patient Registries• Physician Referrals• Community Groups
Stratification Priorities • Chronic Diseases• Low-Risk• Rising-Risk• High-Risk• Health Determinants• Other Determinants
Coordination Priorities • Personal Preferences• Change Readiness• Change Counseling• Care Planning• Program Selection• Onboarding Transition
I. Support Health Care Leaders in Roadmap alignment (1)
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ROADMAP PROCESS SYSTEM ALIGNMENT
Continuum Priorities • Care Prevention (pre-diagnosed)• Intervention Care (diagnosed)• Self-Management Maintenance• Self-Management Sustainability• Care Management (complex)
Evaluation Priorities • Methodologies• Delivery Practices• Engagement Outcomes• Health Improvement• Self-Management Criteria• Aggregate Progression
Payment Models • Pilot/Demonstration Outcomes• Care Prevention Outcomes• Intervention Care Outcomes• Self-Management Maintenance• Self-Management Sustainability• Care Management Outcomes
I. Support Health Care Leaders in Roadmap alignment (2)
Community Care Teams
To help fill the patient lifestyle behavior change gap, Clinical Care Teams extend chronic care delivery access by
coordinating referrals with Community Care Teams that provide a lower cost, high engagement health behavior change Framework.
For health systems, the chronic diseasepoint-of-care burden is shifting to community.
II. Recruit a National Community Care Teams Workforce
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Moonshot National Workforce PlatformAn ‘Uber’ opportunity for healthcare by deploying
available community resources to meet the increasing clinical demand for non-clinical care prevention,
intervention care, and care management services.
Community Care Teams
Register National
Workforce
Select Role & Prerequisites
Complete Training
Role Pool
Role Placement
Teams Active
Find
Verify
Engage
Manage
PayRate
Professionals, Workers and Volunteers
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Allied health professionals (AHP), community health workers (CHW), and volunteers for role credentialing, program training, specialty instruction,
and annual compliances to fill the roles of Community Care Teams
• Health fitness• First responders• Social workers• Dieticians• Nutritionists• Occupational therapists• Physical therapists• Health educators• Wellness coaches
Community Care Teams Roles and Education
AHP and CHW included, but are not limited to:
Teams continuing education provided by, but not limited to:
Creating healthcare jobs that reduce healthcare costs, increase healthcare access, and improves the healthcare experience!
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Chronic Disease Care ProgramsCommunity Care Teams qualified to deliver:
• Care Prevention programs for the low-risk or pre-diagnosed chronic disease cohorts
• Intervention Care programs for the rising-risk diagnosed chronic disease onset, early progression, or late progression cohorts
• Care management programs for the high-risk chronic disease cohorts
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One or More Chronic Diseases and Aging Populations
Chronic Disease Care Programs
Overweight and Obesity Classes I, II and III
Diabetes
Hypertension
Non-communicable Chronic Disease Clusters
Extended Care
Arthritis All Others
Lipid Disorders
Cardiovascular Disease
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III. Health Behavior Change Framework for Business Health
RoadmapAlignmentSystem LeadershipPHM Execs &TeamsCommunity Care TeamsChange FrameworkChronic Care ProgramsTurnkey NetworkSelf-Care OutcomesValue-Based Payments
• Active cohort care management
• Community Care Teams deliver chronic disease care designed for cohort
• Community touch points• Digital touch points• Engagement duration,
frequency and intensity• Targeted education• Self-care management
progress tracked
PROCESS
• Criteria to achieve self-management graduation
• Analyze process quality measures
• Evaluate community and digital engagement
• Re-enroll patients as needed
• Continue to maintenance phase
• Sustainability options
OUTCOMES
• Care coordinators share care pathway decisions
• Outline care plan• Not health activation
ready referred to readiness counseling
• Transition to Community Care Teams for program enrollment and onboarding
• Revise care plans as needed
TRANSITION• Screen stratified
population groups for risk drivers
• Analyze level of support needed
• Evaluated patient activation based on physical and motivational readiness along with personal preferences to reveal participation barriers
READINESS
• Appearance on chronic disease patient registry
• Payer populations health management risk identification triggers for stratified population groups requiring value-based care payer contracted chronic disease care services by health systems
REFERRALS
Stratified
Team Coordinate Care Pathways Care Plans Onboard
Referrals Readiness Refined
Chronic Disease Care Programs Methodologies Engagements Management
Community Care Datasets for Change Framework Process & Outcome Quality Measurements
Rollout Date
ChangeElements
Framework Implementation
2. Change Readiness
3. Change Transition
4. Change Process
5. Change Outcomes
Sessions Start
1. Change Referrals
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Community Care Teams in coordination with Clinical Care Teams use this Framework to implement care pathways, care plans and chronic disease care programs.
Community Care Roadmap
Health Behavior Change Framework
Bridge of Trust
Community Care Teams
Leveraging Turnkey Engagement NetworksCommunity Care Teams delivering multiple chronic disease care programs in safe and accessible lower cost community settings
withClinical Care Teams
to implement a
sustained by
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IV. Leveraging Turnkey Engagement Networks
PlacesDesignated safe and
conveniently accessible point-of-care locations that meet the criteria for hosting
group sessions to deliver chronic disease care programs for health behavior change
ProgramsChronic disease care
cohort specific assembled with health behavior change
methodologies and high-touch engagement strategies to slow,
stop or even reverse chronic disease progression
Community Care
TeamsCredentialed, program
trained, specialty instruction, and annual compliances to
deliver chronic diseasecare programs
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Turnkey Engagement Networks
Chronic Care Programs
Community Care Team Roles
Designated Safe Care Places
• Pathway Navigators• Readiness Counselors• Care Plan Directors• Community Connectors• Program Preventionists• Program Interventionists• Program Care Managers• Program Assistants• Maintenance Monitors• Sustainability Monitors
• Care Prevention• Intervention Care• Care Management
• Medical Fitness • Hospital Wellness• Municipal Community• Park & Recreational• YMCA Branches• Public Libraries • Commercial Clubs• School Facilities• Corporate Health• Other Safe Spaces
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Claims Clinical Community
Community Data Acquisition Sources
Wearables
Observation
Mobile Apps
Self-Report
Surveys
Aggregated
Actionable Data for Health
Behavior Change
Community Process and Outcome Analysis
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V. Evaluate Community Care Data
Referred Refined Onboarded Engaged Self-Managed
PHM Stratification of Physician Registries and Payer Populations
The “Who”? Paying Community Care Teams and thecosts to administrate Turnkey Engagement Networks?
Value-based care contracted payers: Employers, Insurers, Medicaid, Medicare, the Military, and Intermediaries
From value-based carerisk bearing contracted services with payers, Community Care Teams and Network delivery costs for chronic care services are paid to the Network Administrator
Network Administrator receives invoices for each role member of the Community Care Teams and pays based on the agreed upon chronic disease care services and quality assured performance
Community Care Teams of professional and workers
paid as independent contractors by the
Network Administrator$
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Starts with Health
Systems and Payers
Contracted Services
Performance
Bridge of Trust GraphLe
vel o
f Tr
ust
Moonshot Community Care
Health Care Leaders execute Roadmap alignment
Community Care Teams trained and ready for
Framework and/or Network placement
Clinical Care Teams linked to trustedCommunity Care Teams for referrals by
Care Coordinators from the stratified and readiness refined population groups
Health behavior change Frameworkimplemented (care pathways, care plans
and replicable care programs)
Turnkey Engagement
Networkoperationalized
Evaluate process and outcome data for engagement and self-management
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Healthcare Organization Proposed Next Steps
• Align the Moonshot Roadmap with health system priorities and objectives
• With the Roadmap alignment complete, the behavior change Frameworkimplementation plan can be presented
• With an approved Framework plan, a Master Services Agreement (MSA) can be submitted to support the implementation of the Framework
• As part of the MSA, a Statement of Work (SOW) will be submitted to demonstrate the chronic disease care program(s) for evaluation
• Once the pilot satisfies evaluation requirements, an additional SOW will be submitted to build a turnkey engagement Network for chronic disease care prevention, intervention care, and care management programs
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Exercise is Medicine® (EIM) is the Founding Organization for Moonshot Community Care. EIM is managed by the American College of Sports Medicine (ACSM), the largest sports medicine and exercise science organization in the world. More than 50,000 international, national and regional members and certified professionals are dedicated to advancing and integrating scientific research to provide educational and practical applications of exercise science and sports medicine.
For more EIM information visit: www.exerciseismedicine.orgFor more ACSM information, visit www.acsm.org
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Led by Exercise is Medicine® (EIM) advisory board member, Dr Felipe Lobelo, the director of the EIM Global Research and Collaboration Center (EIM-GRCC) housed within the Global Diabetes Research Center at Emory’s Hubert Department of Global Health and the Rollins School of Public Health.
EIM-GRCC leverages the expertise of leading researchers at Emory University and the global network of ACSM/EIM members to achieve its overall goal of evaluating the real-life effectiveness of EIM implementation via standardized clinical care and community care linkages to prevent, manage or even reverse the progression of chronic diseases.
Network Builders Team (nbt) manages the Moonshot Community Care initiative for awareness, discussion, education, advocacy, and funding to solve the infrastructural, technical, logistical, analytical and financial challenges of establishing Community Care.
The nbt provides the support for:• Health Care Leaders executing Roadmap alignment of priorities and goals• Recruiting, training, placing and administrating a Moonshot National
Community Care Teams Workforce• Implementing a behavior change Framework for chronic disease care• Building/managing turnkey engagement Networks of chronic disease programs• Collecting data to Evaluate processes, outcomes and self-management criteria• Negotiating risk bearing payment methods for chronic disease care services
Network Builders Team
40www.NetworkBuildersTeam.com
Network Builders Team
For more information contact:Phil TrotterMoonshot Community CareExercise is Medicine® (EIM)Network Builders Team (nbt)Email: [email protected]: (317) 710-5031
Managed by the Network Builders Team (nbt) 2017 41