ACOs: Transforming Systems with New Payment Models & Community Integration · 2018-10-17 · ACOs: Transforming Systems with New Payment Models & Community Integration Sunnah Kim

ACOs: Transforming Systems with New Payment Models &

Community Integration

Sunnah Kim PNP (Moderator), American Academy of Pediatrics

Herbert Druilhet, RN, DNP, FNP-BC Lafayette General Medical Doctors

Michael P. Jeremiah, MD, FAAFP, Carilion Clinic

Todd Walker, MBA, Rainbow Babies & Children’s Hospital, University Hospitals

James Colbert, MD, Verisk Health

LafayetteGeneral.com

Lafayette General Health Journey in Population Health

Herbert Druilhet RN, DNP, FNP-BC



Where are we?

• Clinically Integrated Network

• Acadian Healthcare Alliance

• Patient Centered Medical Home

• Healthe Intent Population Health Platform

• Employee Health Management


Ochsner Health Network


Challenges

• Health Information Technology

• Practice Culture

• Physician Incentives


Steps to Success…...

Continue to refine

medical community

culture

Connecting the dots

PayorContracts

Expansion of PCMH best

practices into integrated

clinics


Keys to Success…...

Physician Collaboration

Payor Partnerships

Population Health Infrastructure

Clinical Care Delivery

Operational Improvements

Employee and Employer Solutions








Carilion Clinic

- efforts in population health

& accountable care

Michael P. Jeremiah, MD, FAAFP

Carilion Clinic1,026 Licensed Beds

49,000 Admissions877,000 Primary

Care office visits

40 Medical Homes

54,000 Urgent

Care visits

11,700 Employees 800 Employed Physicians $1.7B Net Revenue

180+ Primary Care Physicians

Background

• Strong primary care focus since 1996

– large primary care practice joined

• Implemented group-wide EMR in 2000

– Logician/Centricity

• Created internal scorecards in 2005

reviewing quality of care by provider

– Diabetes perfect care

– Hypertension control

Background

• 2007 - Carilion Health System became

• Increased physician leadership and a focus

on being an Accountable Care Organization

• 2008 - implemented EPIC system-wide

2010 - opened a medical school with

Virginia Tech

• 2013 - entered MSSP program

Clinic Transition Goals

• Broaden the number of specialties working at

Carilion

• Standardize our primary care model (PCMH)

• Optimize referrals within the physician group

• Fully utilize EMR to enhance communication

• Strengthen our patient-centered approach

Silos & Synergies

• Discovered other groups working in the system on similar

work

– Focused on specific P4P metrics

– Developing protocols and processes

– Somewhat in silos

– Opportunities existed for working together

• Proposal approved to link these efforts under one

“Accountable Care” umbrella

AQC

Care

Transitions

Group

SNF

Collaboration

Taskforce Extensivist

Clinic

Tele-Health

ED Case

Management

Pay 4

Performance

TeamAdvance

Care

Planning

CHF

Transitional

Visits

Employee

Health Plan

Accountable Care

Transition Team

CCMH

Central Care

Coordination

DOCTORS CONNECTED

Aligning Incentives

• List of Carilion 2016 approved metrics

available to choose for scorecards

Appropriate Testing for Children with Pharyngitis

Rheumatoid Arthritis Management

Breast Cancer Screening

Colorectal Cancer Screening

Diabetes A1c Screening

Diabetes A1c < 8.0

Diabetes Nephropathy Screening

Adult BMI Assessment

High Risk Medications in Elderly

Osteoporosis Management in Women with a Fracture

Annual Trends

Table 3.2 Impact on Preventive CareCarilion Clinic Medical Home Performance by Measure and Period

2009-2014

PREVENTIVE MEASURE

BASELINE

Year Prior

to

Transition

YR 1 YR 4

HEDIS

National

Mean (2013)

% CHANGE

Baseline to

YR 4

Breast Cancer ScreeningPercentage of women 40-69 years of age

with a mammogram in the past two years

41.6% 65.6% 60.5% 64.2% 45.4%

Pneumococcal VaccinationPercentage of patients >65 years of age

with a pneumococcal vaccination

67.6% 78.0% 80.0% 71.7% 18.3%

Tdap ImmunizationPercentage of patients 19-64 years of age

with a Tdap vaccination

55.9% 55.7% 57.2% U/A 2.3%

Data Source: Clinical Informatics and Analytics. Monthly Ambulatory Performance Reports. 2009-2014.

Clinical Measures: NCQA. State of Health Care Quality, 2012; approved for use by Ambulatory Quality Committee.

Baseline: Entries are means for all nine sites; snapshot taken 12 months prior to model transition.

Reporting Periods: Do not equate to calendar years because of staggered site transition starting dates.

HEDIS National Mean: NCQA. State of Health Care Quality, 2013; weighted per payment contribution within the nine sites; method approved by NCQA in 2010.

% Change: the per cent change from baseline to YR 4 result.

Medical Home Impact on ED Utilization(All Patients with 1 or more ED Visits before Medical Home Engagement)

n = 139229

153

103

0

50

100

150

200

250

One Year BeforeMedical HomeEngagement

One Year AfterMedical HomeEngagement

Two Years AfterMedical HomeEngagement

Nu

mb

er

of

ED V

isit

s

Changes in ED Utilization After Medical Home Engagement

(Year 1 vs. Baseline)

# Pt's Decreased Utilization 93 66.9%

# Pt's Increased Utilization 28 20.1%

# Pt's No Change 18 12.9%

Number of Patients 139

Changes in ED Utilization After Medical Home Engagement

(Year 2 vs. Baseline)

# Pt's Decreased Utilization 97 69.8%

# Pt's Increased Utilization 13 9.4%

# Pt's No Change 29 20.9%

Number of Patients 139

33%

55%








UH Rainbow Care Connection

Integration of Primary Care into a Pediatric ACO

Todd J. Walker MBABusiness Manager, Pediatric Clinical Integration and Accountable Care

Rainbow Babies & Children’s Hospital

© 2015 University Hospitals Health System, Inc.

Practice Integration Methods

• Medical Advisory Council

• Practice-tailored facilitation

• Clinical best practice toolkits

• CME and MOC events

• Integrated Behavioral Health Services

• Physician scorecards and practice rankings


UH RCC Provider Network• 161 Pediatric Providers• 60% UH, 40% Independent• 32 Practices• 51 Sites


Medical Advisory Council

• Early in the development of our ACO we created a Medical Advisory Council which supports physician involvement

• The council is comprised of one representative from each practice

• The council meets twice a year to offer feedback on our quality metrics

• We ask that the practices include their Office Managers in our meetings


Goal – Triple Aim Outcomes

Payer Partners

► Insurers

► Employers

► States

► CMS

• Improve health of the population• Enhance patient experience of care• Reduce / Control per capita cost of care


Practice Tailored Facilitation

• Practice facilitators

• Full office staff education

• Process re-design

• Performance feedback

• IT and data assistance

• Outreach and education


Practice Tailored Facilitation

0

80

3

78

52

99

0

100

PBF Baseline

PBF 4 month

BMI

All HEDIS

measures

% o

f elig

ible

child

ren r

eceiv

ing targ

ete

d s

erv

ices

Fluoride

Varnish

Lead

screening

50

0

80

3

78

52

99

0

100

PBF Baseline

PBF 4 month

BMI

All HEDIS

measures

% o

f elig

ible

child

ren r

eceiv

ing targ

ete

d s

erv

ices

Fluoride

Varnish

Lead

screening

50


Practice Tailored Facilitation:Quality

Fluoride Varnish Application

Lead Screening

Obesity

Asthma Management

Upper Respiratory Infection

Well Child Care (3-6)

Preferred Drug List Compliance

Well Child Care (13-18)

Pharyngitis

Adolescent Vaccine

ADHD

Literacy

Safe Sleep Habits

Maternal Depression

Early Childhood Education

Year

1

Year

2

Year

3

Year

4


Clinical Best Practices


Self-Monitoring Dashboards


CME & MOC Events

• Three times a year we release toolkits for the practices within our ACO on conditions such as :

• ADHD

• Asthma

• Headache

• Concussion

• We provide MOC credit for QA participation

• Evening CME events on best practices


Integrated Behavioral Health

• Office-based psychiatric SW

• PCP psychiatric telephone consults

• Access and referral programs

• ED crisis intervention SW


Physician Scorecards & Practice Rankings









Insights from Case Studies of Primary Care Transformation within ACOs

James Colbert, MD

Senior Medical Director, Verisk Health

Consultant, ACO Learning Network, Brookings Instition

Instructor in Medicine, Harvard Medical School

Physician-Led ACOs – Current Issues

Very little literature exists on implementation efforts leading to the success of physician-led ACOs

A study released recently revealed common gaps in readiness of organizations to become successful ACOs:

• Lack of human and fiscal resources

• Few care management tools

• Underutilization of health information technology

• Communication challenges

• Lack of knowledge regarding quality performance measures

37

Source: Steckler, Feldman and Watts. A Physician-led Accountable Care Organization: From Award to

Implementation. American Journal of Managed Care September 24, 2015

Focus on Primary Care Transformation

Primary care is central to the identity of a physician-led ACO

Primary care + ACO = Success

• Mixed results from studies of financial return on investment for PCMH

• Yet, data suggest tying medical home to shared savings model may be a winning combination

Brookings Institution Partnership with Patient-Centered Primary Care Collaborative

• PCPCC participated as reviewer for 2014 Brookings Institution ACO Implementation Guide

• Resulting discussions led to the idea of a collaboration between the ACO Learning Network and PCPCC

38

Primary Care Transformation within ACOs

39

Building on work done for the physician-led ACO toolkit, the Brookings Institution’s ACO Learning

Network delved deeper into how ACOs are engaged in advancing primary care to identify best

practices and lessons learned.

Purpose

• To showcase examples of primary care transformation efforts that are taking place within accountable care

arrangements

Methods

• Stakeholder interviews

• Literature reviews

Outcome

• A series of five case studies highlighting how ACOs are using advanced primary care approaches to achieve the

goals of improved quality and reduced costs

Five Highlighted Organizations

40

Adirondacks ACO - Northern New York

Anne Arundel Medical Center - Eastern Maryland

Bon Secours Medical Group - Virginia

Hennepin County Medical Center – Minnesota

WellSpan - Pennsylvania

Common Themes

41

Organizational Commitment to Primary Care Transformation:

• All five organizations had core commitment from leadership to support primary care innovation

• Many partnered with commercial payer to fund incentives for PCPs to improve quality

Staffing Changes to Support Team-Based Primary Care:

• Medical assistants

• Data Analysts

• Dedicated RN Care Managers

• Health Coaches

• Pharmacists

• Behavioral Health Professionals

Development of Care Management Programs:

• Models included embedded CM, home visits, call centers

• Assist with disease management, coordination of care, connections with community resources

Common Themes

42

Implementing Transitions-of-Care Programs

• Successful discharge plan involves coordination of care between inpatient medical

team and patient-centered medical home

• Elements include patient education, post-discharge phone call, visit with PCP

• Strategic use of Medicare TCM codes

Provider Engagement Initiatives

• Importance of physician champions

• Helping clinicians to realize the value of care managers and physician extenders

• Collaborating around quality initiatives

• Gaining support of hospital partners and treating them as colleagues

Common Themes

43

Engaging the Entire Team

• While strong physician leadership is necessary, it is not sufficient to truly transform care. Practice office staff support is integral.

Building Health IT Infrastructure

• All organizations cited the need for improved health IT to enable population health management

• While many organizations initially used internal funds to improve health IT and data analytic capabilities, some also took advantage of external grants.

Governance that Involves Clinicians, Patients, and Families

• Primary care clinicians as essential members of central leadership

• Patients and families should be active participants in governance

Policy Implications

44

How should primary care delivery reform be funded?

• Commercial payers

• Large healthcare systems

• CMS

Rethinking incentives for primary care practitioners

• Motivating providers to change practice patterns, implement team-based care

• How do we attract primary care team leaders?

Support for primary care health IT and analytics

• Managing data is key to successful primary care and population health

How best to integrate specialty care into the ACO

• Medical home neighborhood model

• Distributing shared savings to specialists








Documents

ACOs: Transforming Systems with New Payment Models & Community Integration · 2018-10-17 · ACOs: Transforming Systems with New Payment Models & Community Integration Sunnah Kim