Woods Health and Disabilities Project

Tine Hansen-Turton, MGA, JD, FCPP, FAAN, is President and CEO of Woods Services, Inc. Throughout her twenty years of experience in health and human services senior management, executive leadership and consulting, she has founded and led several nationally recognized organizations and trade associations. Ms. Hansen-Turton is known for being an effective organizational change agent and policy and health and human services systems reform advocate. She got her start in public housing, where she conceptualized the idea of locating health centers within public housing, and advocated for new federal policies which made implementation possible across the country. Her experience and leadership in nurse-led care, including founding and leading the National Nurse-led Care Consortium, and the Convenient Care Association, have led to increased access to primary care for thousands of people across the U.S. and the expansion of the scope of practice for nurse practitioners to independently deliver primary care.

Woods’ model addresses significant barriers to health care and health disparities for people with intellectual disabilities through a population health approach which addresses the complex needs of people with intellectual disabilities, autism, brain injury and mental health disorders. Woods will expand its hub and spoke health care model through telehealth, which will reduce ER visits and hospitalizations, and fill the gap in access to care for people living in scattered group homes, with families or in rural areas. Woods’ providers have deep expertise serving this population, understanding their complex needs, and making accommodations for communication, mobility and behavioral challenges. Eight million people in the U.S. have intellectual disabilities, autism, or other issues requiring care across the lifespan. Woods’ model addresses a social justice issue of global importance by increasing access to care, reducing health disparities, and improving the health and well-being of a population who have complex medical conditions.

Despite the advances in medicine and the advancement of rights of people with disabilities to access care, the diverse population with intellectual or developmental disabilities (IDD) continues to experience significant barriers to care and health disparities in the U.S. and globally. About 15% of the world’s population lives with a disability – one billion people -- and rates of disability are steadily rising (WHO, 2018). About 22% of the eight million people with IDD in the U.S. have multiple co-occurring chronic conditions including psychiatric diagnoses requiring highly specialized and costly care (Braddock et al, 2017; Ervin et al, 2015).

However, healthcare providers in the community are not always prepared to serve this population, and are not well-versed in their specific needs. These issues persist today (Krahn & Fox, 2014). Care for people with IDD is administered through many systems and payers which remain fragmented and not well coordinated (2014). People with all types of disabilities are at greater risk of multiple chronic diseases (WHO, 2011), and yet these diseases may be undiagnosed or poorly managed when a person’s disability overshadows other health conditions (Krahn & Fox, 2014). In Woods’ model, care is holistic and coordinated across systems.  

Woods’ health care model will be expanded to reach more people across the U.S. with intellectual disabilities, autism and complex needs whose needs are often not met by mainstream providers. Many people with intellectual disabilities have co-occurring medical conditions, and they struggle to gain access to healthcare providers knowledgeable about their complex conditions, and who can accommodate communication or mobility barriers to care. Telehealth is a critical tool for expanding access to rural areas lacking primary care providers and specialists often needed to address complex medical conditions. Woods’ model entails team-based care driven by primary care providers who coordinate care across health care disciplines, focus on prevention and management of chronic diseases, and avoid unnecessary use of the ER or inpatient services. Woods’ providers are skilled in working with teams of direct care providers, including home health and personal care aides as well as nurses, who are typically providing 24/7 hands-on care in home or community settings. The COVID-19 pandemic has reinforced the urgency of implementing telehealth to reach more people while reducing risk of transmitting infectious diseases. This will be increasingly important as new waves of COVID-19 occur or other public health crises emerge in the future.

Woods’ health strategy reaches people with intellectual disability, autism, brain injury, mental health diagnoses, genetic disorders and other complex medical issues. More than 22% of people with intellectual disabilities or autism have co-occurring mental health disorders which contribute to poor health outcomes, including higher risk of uncontrolled chronic diseases, and disproportionate use of the ER and inpatient services, psychiatric and otherwise. The lives of people with intellectual disabilities and complex needs who require support 24/7 and who need specialized care could be vastly improved through the population health care model that Woods has developed over the last several years.  Team-based and comprehensive, Woods’ health care model deploys providers with years of expertise in treating patients with intellectual disabilities and other conditions. Woods’ providers treat the whole person, focusing on prevention and emergent health needs rather than the person’s disability. Woods seeks to reach more people with this model through telehealth, meeting several objectives at the same time: reducing use of the ER and hospitals and the traumatic experiences which can result, as well as reducing the potential for transmission of viruses such at COVID-19.

The Woods model is aligned with all of the dimensions of the Elevate Prize because integral to the approach is ensuring that people with intellectual disabilities, autism and complex medical conditions have equal access to health care. In theory everyone in the U.S. has equal rights to care, but in practice, this population does not have equal access or outcomes. Woods collaborates with schools of medicine to train more providers to serve people with disabilities, and advocates on a local, regional and national level to improve policies which drive better integration of systems and services for people with disabilities.  

Ms. Hansen-Turton has a long track-record of driving innovation in health care, which in her early career focused primarily on at-risk, low-income urban populations with little access to primary care. She ran a network of community health centers, was an early promoter of the integration of behavioral health and primary care, and helped to launch the nurse-led care movement which dramatically expanded primary care for vulnerable populations, including the homeless and those residing in public housing. Upon arriving at Woods, she realized that people with intellectual disabilities are often a hidden and overlooked population, and even more vulnerable. While not a large number of people, people with intellectual disabilities and complex medical needs require not just expert healthcare providers, but also thoughtful collaboration with the direct care workers who provide 24/7 hands-on care, and who are not typically part of the health care team. The past four years have been spent bolstering an existing medical center to transform it into a true population health model. It is not feasible to replicate the model through bricks and mortar medical centers. Thus the idea of telehealth was born, as a way to expand the model to more people in many settings.

At Woods we are all extremely passionate about reaching more people with intellectual disabilities, autism, mental health challenges and complex medical needs with the best possible healthcare. And we have in our one hundred years of experience had to be extremely creative to build services around this often-hidden population. Knowing that this population experiences health disparities and is at great risk for poorly-managed chronic disease, co-occurring conditions, and over-use of the ER, we knew that we needed to take our model which has been successful on a localized level and broaden it to areas where there are not enough providers in general, much less providers willing and equipped to serve people with complex needs. The field of intellectual disabilities has never been integrated with the health care system, and has been slow to adopt technology which could dramatically improve people’s lives. Woods has long-since utilized assistive technology, but with regulations governing telehealth changing, now is the time to use technology to bring healthcare to those who otherwise would not have access, or would have to travel great distances to see a provider. The people Woods serves require many specialists and these are even less available in rural areas.

Woods and its leadership team are uniquely-positioned to bring the telehealth project to fruition.  Ms. Hansen-Turton has spent the last four years bringing together a multi-disciplinary team of healthcare providers and experts in intellectual disabilities services, and strengthening the ability of the medical center to deliver team-based coordinated care. A patient-centered medical home pilot implemented two years ago resulted in a 39% reduction in hospitalizations and an 8.7% reduction in overall cost of care. The theory of change was that increasing primary care visits, improving coordination of care, and better managing chronic conditions would have positive results. This theory was borne out and telehealth will allow for expanding this model of care to others, improving quality of care while keeping costs down. The Woods leadership team understands the mechanisms of healthcare delivery, while being able to operate in a terribly fragmented set of systems that provide disparate aspects of care for people with intellectual disabilities. Maintaining the focus on coordination of care across providers, specialists and systems is key to success. Telehealth is an excellent mechanism to deliver care and to support coordination of care.

The story of healthcare is the story of chipping away at obstacles and barriers over a long period of time, while keeping an eye on the longterm goal of ensuring that everyone has access to healthcare. Ms. Hansen-Turton’s track record in health care of advocating for policy change resulting in expansion of primary care delivered by nurse practitioners, and systems focus, lends itself well to this project. In the on-going battle to expand the scope of practice for nurse practitioners, there have been many voices against changes that would allow nurse practitioners to practice independently, thereby significantly increasing the primary care workforce. Ms. Hansen-Turton has launched two national trade associations which have been a weighty force to winning small battles along the way. Barriers to telehealth are similarly many. Some of these have temporarily fallen away as a result of the pandemic. Woods has joined forces with national organizations advocating for regulatory changes governing telehealth to remain in place permanently. This will go a long way to supporting the implementation of this telehealth initiative.

Upon entering the intellectual disabilities sector, Ms. Hansen-Turton noted the lack of cohesion among large providers which serve the majority of people in the region with intellectual disability services, and the lack of integration with health care. She addressed this by proposing to a group of nine providers that they form a trade association which could better advocate for integrating services and systems, including the health care system. She co-founded a consortium with these providers two years ago, and has successfully advocated for numerous policy changes in Pennsylvania and New Jersey to the benefit of the populations served.  During the pandemic, the consortium became a conduit for all of the members, collectively serving tens of thousands of extremely frail and vulnerable people with disabilities, to acquire needed personal protective equipment (PPE), testing supplies, and also to successfully advocate for continued bridge funding for services while governmental shutdowns of programs occurred. Organizations were at risk of closing down entirely, which would have left a vulnerable population without any services following the pandemic. Now moving forward, there is a collective will to push for improved services and better integration of systems to benefit people with intellectual disabilities.  

Telehealth itself is not new.  However, utilizing this technology in the context of a holistic population health model that brings together health care with other services needed throughout the life span for people with significant disabilities creates a new dimension of performance. Woods’ health care model has already had successful results, as a recent pilot has shown. People with intellectual disabilities, autism, mental health disorders and other co-occurring conditions require care throughout their lives, and care which adapts to changing needs throughout life.  Woods’ model encompasses expert providers who understand the range of needs, treat the individual needs of a person rather focusing on the disability.Providers  bring together and coordinate specialty care when this is needed. Telehealth is a useful tool for delivering care and also for coordinating care.  This project will allow many more people with disabilities to access care – and for many for whom travel is a barrier, for whom sensory or behavioral challenges make going to a medical visit in person uncomfortable, telehealth can be a preferable medium by which the right care can be accessed. Woods’ model has already been proven to improve care and reduce costs – as well as reduce the incidence of ER visits and hospitalizations, which in themselves can be traumatic. Telehealth can help to avoid ER and hospital usage even more.

The theory of change of the Woods model is that increasing access to care, particularly primary care, which has its focus on prevention and managing chronic disease, will reduce the need for higher levels of care such as ER visits and hospitalizations.  These are also the most expensive levels of care, and their use does not always translate into better care or better outcomes. The patient-centered medical home pilot that Woods conducted over the past two years yielded promising results in exactly these areas. Primary care visits increased 400%, as anticipated, while ER visits and inpatient hospitalizations were dramatically reduced, overall cost of care was reduced, and quality of care improved.  Telehealth is a new component of Woods’ existing health care model, and will operate under a similar theory of change.  Telehealth visits will be used selectively where appropriate and feasible, and we anticipate a significant reduction of ER usage and hospitalizations resulting from ER visits especially during off-hours when the medical center is closed. Crises can occur at any time, and having a provider available via telehealth to address problems, answer questions and triage for the need for emergent care will increase access to care and improve quality of care.  All of this combined will help achieve the goals of reducing barriers to care, and reducing health disparities for people with disabilities.

Currently Woods serves 600 people within close proximity of its main location in Pennsylvania. The telehealth project is being piloted now at its headquarters, and will expand over the next several months to an additional 100 people living in group homes managed by an affiliate of Woods throughout the Southeastern Pennsylvania region. Woods and its affiliate organizations collectively serve 18,000 people across Pennsylvania and New Jersey, who have many complex needs including mental health and drug and alcohol abuse disorders. In addition, Woods and its Consortium partners serve 20,000 more people regionally that this project has the potential to expand to. We anticipate having a meaningful impact of the telehealth project on 700 people in the next year, and 5,000 people by year five.

There are two main goals of this project, the first of which is to increase access to care for people with intellectual disabilities who experience barriers to care. Barriers result from a lack of providers who have the expertise or who are willing to make the modifications needed to provide care, or the fact that in some medically-underserved areas everyone experiences difficulty finding a provider within a reasonable distance.  Another barrier experienced by this population is one that is common to many – transportation, either as a result of poor transportation systems or economic barriers that prevent being able to afford a car or public transportation.  The second goal is to reduce the unnecessary use of the ER or inpatient hospital services, whether psychiatric or otherwise.  Telehealth allow for access to providers who can be anywhere, or access at times when medical practices are typically closed. Many of the people Woods and its affiliate organizations serve experience mental health crises which are unpredictable and occur 24/7.  Regulations governing publicly-funded services for people with intellectual disabilities also carry with them many rules which require immediate access to medical care when certain kinds of incidents occur. If these occur after hours, usually the next step is an ER visit.  Many of these visits could be avoided by accessing a provider through telehealth.

Major barriers include the existing regulatory environment for telehealth, which in the past has either prevented services from being delivered this way, or prevented sufficient reimbursement for these services. This is a disincentive for providers to invest in the technology needed to provide telehealth. While advocacy organizations have for many years been pressing for rules to be relaxed so that providers can provide care across state lines, or be reimbursed adequately, only recently has there been a dramatic change.  The COVID-19 pandemic has accelerated change, if only temporarily.  Reimbursements for telehealth visits are for now on par with in-person visits and such visits are being actively encouraged at all levels of health care systems and governmental agencies.  Work will need to continue to advocate for these new rules to remain in place.  In addition, there are not enough primary care or mental health providers in many areas of the United States—and there are not enough providers who are knowledgeable about this population.

To address the problem of regulatory barriers to utilizing telehealth, Woods has joined with several national organizations which advocate for improved services and systems for people with intellectual disabilities. Woods has lent its voice to these advocacy efforts, and is a national leader in the field in its own right. Woods is also continually building partnerships with schools of nursing and medicine to help train future generations of providers equipped to provide care to complex populations. Students from these schools, as well as other allied health professionals, conduct internships and residencies at Woods to learn skills needed to provide the highest level of care for people with complex needs.  Additionally, Woods and its leadership continue to press for the expansion of scope of practice in all states for nurse practitioners, which is an additional solution for increasing access to primary care as we face a shortage of primary care physicians. This is an effort that has been going on under the leadership of Ms. Hansen-Turton for the past 20 years.

Woods partners with many organizations and government entities.  For example, as described above, Woods partners with universities and schools of medicine and nursing to establish relationships for bringing in specialists as needed, as well as to establish internships which allow Woods to serve as a training ground for health care providers.  Local county health officials have been a strong partner to Woods over many years, and particularly during the current pandemic in which Woods’ role in keeping vulnerable people out of the hospital has been recognized and celebrated. Woods has also founded a trade association which is the first of its kind in the nation among intellectual disability providers, whose goal is to improve services and systems for this population by designing models of integrated services and partnerships with managed care organizations which will improve outcomes and reduce costs of care. Woods also is a member of numerous national provider advocacy organizations and through these organizations lends its voice to important policy issues relating to health care, telehealth, and intellectual disability services.  For this project, all of these partnerships will play a role.

This project is fully integrated into our business model for our health services, which are billable services. Woods has provided healthcare for decades; the last several years were spent reorganizing the health center at Woods to become an umbrella for coordinating all health services, including round-the-clock nursing care, and specialty care.  Now the majority of health care services provided under the umbrella of the Medical Center at Woods are billable, which has created the foundation for sustainability. Woods launched a patient-centered medical home pilot two years ago, in partnership with Pennsylvania’s largest Medicaid insurer, and the results from this pilot have formed the basis of a number of initiatives which are designed to improve quality and reduce costs. Reimbursement rates for primary care in this model are higher than typical Medicaid rates, allowing for increased primary and preventive care, and chronic disease management.  The model led to dramatic lowering of ER visits and hospitalizations, thereby lowering cost of care overall. Health care services are a critical component of the whole-person care which Woods provides. Typically intellectual disabilities service providers do not provide healthcare, and yet they are held responsible by regulators for outcomes relating to health and wellness.  Woods’ model is holistic and coordinates across these systems and payers, so that outcomes are improved and reimbursement rates can be more effectively negotiated. 

The services Woods provides for people with intellectual disabilities are reimbursed through contractual agreements with governmental agencies that span departments of health, child welfare, education and services for people with intellectual disabilities, autism, brain injury or mental health disorders.  Health services are reimbursed through health insurance, whether public (Medicaid or Medicare) or private. Services reimbursed through public funds are increasingly delivered and managed through managed care organizations, which are increasingly demanding value and quality in return for reimbursements. Woods’ model has already shown results in quality for lower cost, and telehealth will fit into this on-going effort.

Woods has raised initial funds to pilot the telehealth initiative with a group of patients, and has an on-going arrangement with a Medicaid insurer to reimburse for primary care visits and in the new initiative, for telehealth visits. The health center generates revenue by billing for services provided and this model will extend to telehealth once it is fully implemented.

Woods is seeking $1,000,000 in additional dollars through grants and contracts to purchase additional equipment needed to deliver telehealth services, to pay for costs associated with integrating and upgrading the electronic health and medical records systems which are critical for documentation of services, billing and quality improvement functions, and to support a portion of new nurse practitioners hired to deliver telehealth services until they are able to start billing.

The budget for this project will be approximately $1.5M, which includes costs for health care providers, electronic health record, telehealth equipment and devices and performance and quality improvement.  The costs for telehealth equipment will increase as more people are served. Health care providers will bill for services, which over time will lead towards financial sustainability. Some services will never be able to be reimbursed, or will not be reimbursed at a rate which covers some of the costs of providing the services. Additional funding will need to be raised to cover some of these costs.

Woods is applying for the Elevate Prize for several reasons.  The funds that would be awarded as part of the prize would go a long way towards providing tangible support for the purchase of telehealth equipment and other expenses. In addition, non-monetary support will be very welcome in the form of additional partners which can help increase provider capacity, consulting on improving data systems and analytics which are critical to a robust quality improvement system, and help advocate for systems and policy change related to telehealth regulations and health care reimbursement models. These partners could be in the form of national organizations, policy organizations, or consultants. The network that will be available as part of the Prize would be very helpful to the implementation of this project.

Woods already has developed many strong partnerships on the local, regional and national levels, but is always looking for additional partnerships which can strengthen our work and serve as mechanisms for disseminating the model. National organizations which provide technical assistance and advocacy for telehealth services would likely be very helpful, and additional partnerships with universities – schools of medicine and nursing, hospitals and health systems will always be helpful in terms of expanding our ability to expand our providers and serve as a training ground for the next generation of providers.