Return on Community Investment

1
Return on Community Investment

• Building Financially Sustainable Healthcare
  Systems for the Uninsured and Underserved

Intensive Workshop Session November 2005
2
Today We Will Learn Together

• Identify your enterprises 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!
3
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!
4
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

5
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 Whats your story
  around the case being presented?
• Exercises at the end of each case are to help you
  get started collecting and organizing information
  youll need
• Exercises at the end of each Part are to help you
  practice the conversations youll need to have

6
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?

7
ROCI Will Result in a Sustainability Game Plan

• There are three exponentially powerful stages of
  ROCI

8
The Three Stages Of ROCI
9
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

10
ROCI Blueprint
Enterprise Design Benchmarking Best Practices
Craft Deal Proposal Based On ROI Business Case
Community Readiness
Pacing EventsSet Scale Of 100 Access Gap ( and
)
Return on Investment
Portfolio Of Critical Activities Necessary For
100 Access
Organize donated care
Outcomes
Value To Investors
Reduce inappropriate ER use
Outcomes
Value To Investors
Return on Community Investment (ROCI)
Administer care coordination
Value To Investors
Outcomes
Leverage employer funds
Outcomes
Value To Investors
Facilitate access to health services
Outcomes
Move each activity to sustainability Broker the
big 100 Access deal
Value To Investors
Enroll people in public programs
Value To Investors
Outcomes
Automate enrollment and referrals
Outcomes
Value To Investors
Broker affordable prescription drugs
Value To Investors
Outcomes

Investment By Partners In An Activity (Based On
ROI)
Investment To Take The Portfolio To Scale For
100 Access
savings reinvested

11
Exercise

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

12
Part 1 Design an Enterprise that Produces
Outcomes

• Case A Lesson Find Benchmark Communities

13
(No Transcript)
14
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?

15
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?

16
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?

17
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?

18
Perform outreach to find the low-income and
uninsured and connect them to a medical home and
facilitate access to health services

• Reduced hospitals 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?

19
Organize care, acknowledge practitioners
contribution and enhance well-being and access as
a negotiable community asset
Creates a local infrastructure for 100 access
Human service providers use a common web-based,
highly leveraged community resource referral
system
Incent small employers to financially contribute
for low-wage workers
Facilitate enrollment in programs and access to
medical home, specialists and interpreting
services
20
Jesse Tree/ 211
3-Share Employer Coverage
21
Go to scale Better Health Outcomes for More
People at Less Cost
Community Health Management Districts are the
future of health care
Capture Savings
Achieve 100 Access
Combine Funding
Subsidize shared IS technology to improve
productivity and patient satisfaction
Create a county coverage program with community
prioritized service decisions
Combine government funds now spent through
multiple programs
Invest fully in primary care and prevention and
purchase risk protection for other services
Practice evidence-based treatment and reduce
unnecessary procedures
Count and factor in uncompensated care and what
patients pay
Get new contributions from employers and
community fundraising
Invest in disease prevention and health
management
Pay providers using one common method
22
Part 1 Design an Enterprise that Produces
Outcomes

• Case B Lesson Lay out the logic and measurement
  strategies

23
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

24
Logic Model Framework
25
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.

26
Approach and Outcomes


27
Part 1 Design an Enterprise that Produces
Outcomes

• Case C Lesson Assess the high potential benefits

28
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

29
Define Benefits in Stages
30
Have Early Traction Points
31
What to listen for

• Whats my strategy to make ROCI deals back home?

32
Part II Figure Out the Deals to Make

• Case D Catalog who benefits, know who benefits
• Case E Engage potential investors

33
Catalog collaborators by benefits theyll accrue
34
Part II Figure Out the Deals to Make

• Case F Use Research

Case G Turn ROI into stakeholder value Case H
Show the social return for the entire safety net
35
ROCI Data

• Return on Community Investment (ROCI) must show
• 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

36
Example of How to Use Formulas
INTERVENTION
SAVINGS
-
MEASURE
-
BENEFIT, VALUE, SAVINGS
TYPES OF
INTERVENTION
SAVINGS
-
MEASURE
-
BENEFIT, VALUE, SAVINGS
TYPES OF
BENEFITS per
MENT OF
BENEFIT, VALUE,
BENEFITS per
MENT OF
BENEFIT, VALUE,
100 enrolled
COSTS
SAVING
100 enrolled
COSTS
SAVING
clients per year
clients per year
Savings
Savings
Assuring enrollee
Savings cost
Savings 37 less likely to have
nonurgent
ED
Avoided ED Visits
Assuring enrollee
Savings cost
Savings 37 less likely to have
nonurgent
ED
Avoided ED Visits
has permanent
per ED visit 600
visit (Petersen et al. 1998)
t
has permanent
per ED visit 600
visit (Petersen et al. 1998)
Non-urgent
22,000 per
22,000 per
for all enrollees
for all enrollees
medical home
x .37 fewer visits
Emergency Department Visits

The Effect of
medical home
x .37 fewer visits
Emergency Department Visits

The Effect of
100/yr
100/yr
(primary care)
222
Having a Regular Doctor.
Medical Care
(primary care)
222
Having a Regular Doctor.
Medical Care
36(8)1249
-
55.
36(8)1249
-
55.
Benefit
Earnings 20
Benefit Annual earnings increase 10
-
30
Improved annual job
Enrollment of
Benefit
Earnings 20
Benefit Annual earnings increase 10
-
30
Improved annual job
Enrollment of
increase in
(Kaiser 2002). Sicker and Poorer The
earnings
uninsured person
increase in
(Kaiser 2002). Sicker and Poorer The
earnings
uninsured person
500,000
500,000
average salary of
Consequences of Being Uninsured.
into permanent
average salary of
Consequences of Being Uninsured.
into permanent
additional
additional
25,000
health insurance
25,000
health insurance
earnings
earnings
per100/yr
per100/yr
Savings
Savings
Teaching health
Savings 750 x
Savings 750/yr (fewer hospitalizations) (
Lorig
Avoided
Teaching health
Savings 750 x
Savings 750/yr (fewer hospitalizations) (
Lorig
Avoided
related self
-
number of clients
et al. 1999) Evidence suggesting that a chronic
hospitalizations and
related self
-
number of clients
et al. 1999) Evidence suggesting that a chronic
hospitalizations and
75,000 per
75,000 per
management
receiving self
-
disease self
-
management program can improve
days for all
management
receiving self
-
disease self
-
management program can improve
days for all
100/yr
100/yr
skills
management
health status while reducing hospitalization.
enrollees
skills
management
health status while reducing hospitalization.
enrollees
skills
Medical Care
37(1) 5
-
14.
skills
Medical Care
37(1) 5
-
14.
37
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

38
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?

39
Part III What to listen for

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

40
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
41
Map Stakeholders

• Key Unless they are on board it wont 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

42
Work It!
43
Exercise

• New Ideas For Creating Greater Community Readiness

44
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 youre confident you will take action
  to make your deal when you get back home