Delivering High Value Care Through Clinical Integration Neorr a… · (H ost e d a t O ptum) IP CT II EMPI AD T, SI U , ORU, ORM H L 7 /ML L P C lin ica ls C SV/ SF T P EMPI C SV

Delivering High Value Care Through Clinical Integration

www.TriadHealthCareNetwork.com

AMGA 2013 ACO Collaborative Meeting

Bill Hensel, MD, Operating/Executive Committee Steve Neorr, Executive Director


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Greetings from Cone Health Greetings from Cone Health

The Moses H. Cone Memorial Hospital A Brief History


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• Trust established by Bertha Cone in 1911 to build a hospital as a memorial to her late husband, Moses Cone

• Construction begins in 1949 on The Moses H. Cone Memorial Hospital

• Hospital's first patient admitted in 1953

• Articles of Incorporation state: “No patient shall be refused admittance because of an inability to pay.”

Moses H. Cone

(1857 – 1908) Bertha L. Cone

(1858 – 1947)

Cone Health System Overview


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• Facilities

– 5 Hospitals - 1,035 Acute Care Beds – Awaiting final FTC approval to merge with Alamance

Regional Medical Center (238 beds; 2,100 employees)

– 2 Ambulatory Surgery Centers

– 1 Nursing Home – 92 Beds

– 2 Freestanding Ambulatory Care Campuses, Including a Freestanding ED

– 100+ Outpatient and MD Facilities, Including JVs in Imaging, Cardiovascular Services, and Oncology Services

Cone Health System Overview


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• People

– Over 8,600 Employees

– 1,000+ Medical Staff Members; 320+ Employed Physicians in Cone Health Medical Group

• Patient Care (FY 2012)

– 49,345 Discharges;

– 229,834 Inpatient Days; 4.68

– 509,619 Outpatient Visits; 197,050 ED Visits

• Finances

– Over $1 Billion Revenues; $1.9 Billion in Assets

– Financial Ratios At or Above AA Benchmarks

– $185 Million Charity/Uncompensated Care (at cost)

Cone Health System – Market Area


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Service Area Population

2011 2016

965,124 1,014,621

Inpatients Served = 50.4%

Source: ThomsonReuters Market Expert

Cone Health System Strategic Overview


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Strategic Target

Our Mission We serve our communities by preventing illness, restoring health and providing comfort, through exceptional people delivering exceptional care. Our Vision Cone Health will be a national leader in delivering measurably superior healthcare.

Triad HealthCare Network History and Overview

• Began as a 20-member physician-led steering committee in fall 2010

• Developed over eight months as collaboration between independent and employed community physicians and Cone Health

• Formed officially in 2011 as a Clinically Integrated Network serving the Piedmont Triad area

• Is an affiliate of the Cone Health System, but governance and operations is led by physicians

• Represents a new model of care – clinical integration - designed to align physicians and hospitals to improve access, improve quality and lower costs.


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Triad HealthCare Network Goals

• Allow physicians to have the opportunity to lead and have a voice in the necessary changes in healthcare versus simply being passive and have change dictated

• Engage physicians to develop new models of care and true “transformation” of the local healthcare delivery system

• Provide resources to physicians to meet the growing demands of accountability and transparency

• Create greater collaboration and trust among physicians, hospitals, patients and payers

• Be renowned as a national leader in delivering exceptional health care value in terms of cost, quality and service


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Triad HealthCare Network Structure and Governance

Board of Managers

Operating Committee

Nominating Committee

Contracting and Finance

Committee

Quality Committee

Credentialing Committee

Initial and ongoing membership criteria

Set clinical performance criteria and review member

performance

Look at 3rd-party agreements and determine potential

bonus distributions

Assist development of physician board

memberships

Oversees day-to-day operations


8 members: 3 Physicians (2 Ind./1 Emp.)

2 Cone Representatives 3 Community Representatives

21 members: 17 Physicians (9 Ind./8 Emp.)

3 Cone Representatives 1 Community Representative

MANAGEMENT Executive Medical Director

Thomas Wall, M.D.

Executive Director Steve Neorr

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Health Information Exchange (“HIE”)

Council

Management and oversight of the THN HIE

Triad HealthCare Network Quality Committee Structure


Family Medicine

Quality Committee Patrick Wright, M.D. – Chairman

Mary Jo Cagle, M.D. – Vice Chairman

Medicine CPC

Danielle Ray, MD John Bednar, MD

Primary Care CPC

Doug Shaw, MD Yvonne Lowne, DO

Heart and Vascular CPC

Ed Gerhardt, MD Tom Stuckey, MD

Surgery CPC

David Newman, MD John Hewitt, MD

Women’s and Children’s CPC

Kelly Leggett, MD Ron Young, MD

Hospital Clinical Services CPC Josh Kish, MD

Mark Shogry, MD

Internal Medicine

Hospital Medicine

Gastroenterology

Hem/Oncology

Infectious Disease

Nephrology

Rheumatology

Dermatology

Emergency Medicine

Endocrinology

Hospital Medicine

Pulmonology

Neurology

Neurosurgery

Cardiology

Cardiovascular Surg.

Vascular Surgery

Anesthesia

General Surgery

Orthopedics

Ophthalmology

ENT

Urology

Ob/Gyn

Neonatology

Pediatrics

Pathology

Radiology

Radiation Oncology

Practice Management Todd Pittman Misti Sellers

Community Practice

Administrators

Administrative Chair

Hospice /Palliative Care

Administrative Chair Administrative Chair Administrative Chair Administrative Chair Administrative Chair Administrative Chair

Psychiatry

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Triad HealthCare Network Structure and Membership (as of March 2013)

• Physician-led governance and committees composed of 50/50 split between PCPs and Specialists and employed and independent physicians

• 776 Affiliated physicians; 324 employed by Cone

– 55 groups; separate tax IDs

• 231 Primary Care Physicians across the community

– 180 Adult Medicine • 58 Unique clinic locations; 26 different EMR systems; 7 practices no EMR

– 51 Pediatricians

• 11 Unique clinic locations; 4 additional EMR systems


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Triad HealthCare Network Driving Care Transformation

• Deployment of advanced IT resources to support population management

• Care Management team to support practices

• Assistance to achieve Patient-Centered Medical Home recognition and practice transformation

• Facilitate care process redesign

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Triad HealthCare Network Key IT functions considered to transform delivery


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• Aggregate clinical data from disparate sources – EPIC, community EHRs, payer claims data, other hospitals, reference labs, radiology results, etc.

• Deliver “actionable” clinical data to physicians - at the point of care, disease registries, portals, faxes, etc.

• Proactively identify those at the highest risk – ability to make proactive interventions in disease progression

• Routinely report physician performance and compliance to national metrics, benchmarks and standards

• Report and manage cost efficiency among providers

Information Technology/Analytics Systems

• Reports performance to quality metrics • Provides clinical protocol engine; Clinical recommendations • Point-of-care reports • Patient disease registries

• Claims data integration

• Interfaces with community providers and aggregates clinical data • Hospitals • Physicians • Labs/Pharmacy/Radiology

• Master Patient Index (“MPI”) • Provides portal view to all providers

• Case Management module – care documentation, communication

• Patient stratification; Predictive risk

• Utilization and cost efficiency analytics

Clinical Performance Reporting System

Health Information Exchange (“HIE”)

Population analytics, utilization, case management module


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Triad HealthCare Network The challenge of aggregating data in a community


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Wellogic HIE (Amazon Cloud)

HIE CDR

EMPI Portal

Specialist Providers & Providers not in

CINA

EMR

ADT & Clinicals

HL7, CSV /

MLLP, SFTP, WS

Primary care providers

EMR

CINA Edge Server at Practice

Payers (CMS to begin

with)

Claims System

THN Server(CINA Datamart)

Aggregate Clinical

CDR

POC Report

Pop mgmt

Performance

Clinicals /

Procedures

ODBC/SQL

Direct

DB Replication

THN Quality

User Access

Population

Reports

OptumCare Suite

(Hosted at Optum)

IP CT II

EMPI

ADT, SIU,

ORU, ORM

HL7/MLLP

Clinicals

CSV/SFTP

EMPI

CSV/SFTP

Payer Data

(Future)

CSV/SFTP

LabCorp

Quest

Solastas

HL7/MLLP

HL7/WS

HL7 / MLLP

Providers

with no

EMR

Provider

Portal

EMR

EMR Lite

Hospitals

EPIC

ADT

(A01 - A08)

HL7/MLLP

THN Care Mgr User

Risk

StratificationClinicals: Encounter, Vitals

problems, Meds, Allergies,

immunization,

Procedures,

Social hist., Fam hist.

Claims Data

CSV / SFTP

Practice

Care Mgr

User

Incremental

Clinical Data

(POC records

PDF)

(Care Plan

PDF)

GSO radiology/ CanopyHL7 / MLLP

Practice CDR

ClaimsDB

CINA Point of Care Report


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• Improving Care Delivery to Patients

– Guides decision making at the Point of Care

– Drives consistent care delivery across providers / practices / THN

– Promotes team based care delivery

– Integrates data beyond the EMR – claims, hospital, community

• Encouraging Patient Responsibility

– Provides easily accessible tool for Patient Engagement

– Encourages “talking points” between the patient and care team

• Benefiting Practice Management

– Enhances current / new revenue generation

– Highlights ACO required metrics for reporting

Sample Clinical Decision Support at the Point-of-Care


Practice Performance Feedback

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Diagnoses and Meds are prioritized to highlight chronic conditions

Action Items and Goals are highlighted for quick reference and visibility

Targeted reminders for nursing staff allow better leverage of provider time and more efficient workflow

Labs, Calculations and Diagnostic Procedures pertinent to the Action Items are displayed for easy reference

Wellogic Health Information Exchange


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• Connects healthcare information systems and devices across the continuum of care:

– Primary care physician & specialist offices

– Hospitals

– Long term care facilities

– Laboratories

– Imaging Centers

– Pharmacies

– Payers

• Creates “one patient one record” across all venues of care

• Delivers tests, reports, alerts, and decision support recommendations wherever necessary

Wellogic Health Information Exchange – Screen Shots

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Presents longitudinal view of patient in the

community

Wellogic Health Information Exchange – Screen Shots

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Click on Lab Value for Full

Panel

Optum Population Management/Analytics


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• Overall impact of Optum

– Risk stratification and interventions • Who should THN Care Management help manage?

– Severity of illness determination

– Utilization, cost efficiency • PCPs, SCPs, Episode Treatment Groups (ETGs)

• Effect on day to day PCP activities

– Communication with THN Care Management


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SERVICES METHODS WHAT THIS MEANS RESULTProvider Collaboration Goal Collaboration

Team Collaboration of Barriers

Consistent Message to Patients One Multifaceted Plan for

Quality Outcomes

High-Risk Community CM Relationship Building

Health Belief Model Utilized

Evidenced-Based Education

Advanced Directive Planning

Patients Assessed at Home

Holistic Plans Implemented

Patient and Family Engagement

Improved Self-Monitoring

Reduced Emergency Room

Visits Reduced 30-Day

Readmissions Advanced

Directive Goals

Care Transition Coordination of Serivces

Assessment within 24-72 hours

Post-acute

Standardized Assessment Call

Early Identification of Barriers

Plans to Remove Barriers

Improved Quality of Life

Reduced 30-Day Readmissions

Disease Management Health Promotion Model Utilized

Evidenced-based Education

Engage Members in Goal Setting

Educate Toward Self-Management

Improved Self-Management

Treatment Goals Achieved

Improved Outcomes

Community Resource

Referral

Eligibility Determination

Payer Collaboration

Members Connected With Services

Reduces Barriers to Treatment

Reduces Barriers to Quality of Life

Coordinated Services

Improved Quality of Life

Med Adherence Program Medication Box Fills

Pharmaceutical Engagement

Reduced Confusion of Timing Meds

Improved Adherence to Meds

Treatment Goals Achieved

Consistent Med Optimization

24-hour Nurse Access Line Timely Access for Questions Reduced Anxiety about Unknown Reduced Emergency Room

Visits

Impacting Health and Wellness Outcomes for All

THN Care Management

Triad HealthCare Network Care Management Team Supports Practices


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Rhonda Rumple, RN, MSN, CCM - Program Director

RN Care Managers (16)

Licensed Clinical Social Workers (3)

RN Hospital Liaisons (2)

Care Management Assistants (2)

Geriatric Nurse Practitioner (1)

Clinical Pharmacist Manager (1)

Access Data Base Specialist (1)


• Engaged TransforMED to lead PCMH initiative

– Train the trainer model

• Teamed with local Area Health Education Center (AHEC) to provide “boots on the ground”

– Funding one AHEC FTE dedicated to THN PCMH initiative

• Identified 24 initial practices expressing interest to go through process

– Wave 1: 5 practices; Late March 2013

– Wave 2: 13 practices; June 2013

– Wave 3: 4 practices; September 2013

– Wave 4: 2 practices; January 2014

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Triad HealthCare Network PCMH Assistance


• Readmissions - System-wide breakthrough project

– CHF

– COPD

– Pneumonia

– High ED use/Past Admissions

• Care Transitions – Hand offs, access

• Chronic disease management

– CHF

– Diabetes – Sanofi support

– Hypertension

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Triad HealthCare Network Facilitating Care Process Redesign

Triad HealthCare Network Contracting Approach

• Initial focus on quality, not joint FFS, contracting

• Practice maintains control of billing and collection

• Practice makes claims and EMR information available

– Goal to create community Clinical Data Repository (CDR)

• Focus on incentive-based contracts based on quality and cost control initiatives

– P4P, shared savings, gain sharing

• THN negotiates a “Savings/Bonus Pool” with the payers – government, insurance companies and employers

• THN is responsible for managing / distributing bonus payments


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Triad HealthCare Network Business Model


Continue Current

Fee-For-Service

Claims & Payment

Structure

Quality

Bonus Payout

Based On THN

Goals and

Performance

Measures

Insurers and

Employers

Negotiated

Incentive-Based

Contracts

Physicians Claims and EMR Data

POC, Registry, Performance Data

P4P Shared

Savings

Gain

Sharing

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• Affiliated with over 750 community physicians – over 50% independent

• Developed physician-led infrastructure

• Identified 129 quality metrics across all major specialties

• Approved to participate in Medicare Shared Savings Program as ACO – Over 40,000 Medicare beneficiaries

• Identified and begun deployment of Clinical Performance Reporting System, Health Information Exchange (“HIE”), and population analytics, utilization, case management modules

• Identification and hiring of case management “team”

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Triad HealthCare Network First Year Accomplishments


• PCP alignment/attribution is difficult

– Not prepared for initial MSSP list

• Underestimated time and effort to send letters to 40,000 patients

• Interfacing and connecting practices takes longer than anyone will tell you

• Vendors are all learning too

• EMR data is not structured and standardized and time consuming to validate

• Clinical data is difficult to aggregate and report – must standardize

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Triad HealthCare Network Lessons Learned – Administrative Perspective


• Need a plan to educate and train multiple clinics (physicians and staff)

• Should have required EMR use to participate

• Develop a model to distribute “maybe money’ earlier versus later

• Plan well ahead for care management and analytics

• Have a plan to manage your population assuming you do not have much data initially

• Limit your initiatives and focus on key areas

– “You can have a lot of ammunition and never get a shot off.”

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Triad HealthCare Network Lessons Learned - Administrative Perspective


• Take the time to develop understanding, unity and buy-in from your core physician leaders.

• Physician culture is one of skepticism. Don’t expect full buy in from all physicians at first.

• Physicians witnessing the health system committing resources based on the potential is very influential.

• ACO leadership needs a balance of internal and external representation – old and new.

• Physician engagement is key. Provide many opportunities for involvement.

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Triad HealthCare Network Lessons Learned – Physician Perspective


• Be cognizant of and transparent about hot button topics – money, employed vs. independent, PCP vs specialists; MEC

• Focus on Primary Care.

• Need to expand physician definition of professionalism to include a vision of a team and bigger picture.

• Be aware and sensitive to ‘change overload.’

• Don’t expect too much help from the government

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Triad HealthCare Network Lessons Learned – Physician Perspective

Questions?

For further information, please visit www.TriadHealthCareNetwork.com


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http://www.triadhealthcarenetwork.com/

Documents

Delivering High Value Care Through Clinical Integration Neorr a… · (H ost e d a t O ptum) IP CT II EMPI AD T, SI U , ORU, ORM H L 7 /ML L P C lin ica ls C SV/ SF T P EMPI C SV