HIMSSNicholas E. DaviesAward of ExcellenceCase StudiesAugust 1, 2018

• Four acute-care hospitals with 900 adult-

staffed beds

• One short-stay surgical hospital

• Three free-standing outpatient surgery

centers

• Over 140 outpatient service locations

• Over 150 physician practice locations

• Over 850 employed physicians

• Over 1,800 physicians on medical staff

• Over 12,000 employees

TriHealth At A Glance

TriHealth Awards for Clinical Quality, Technical Excellence and Employee

Engagement

TriHealth Awards for Clinical Quality, Technical Excellence and Employee

Engagement

Healthcare Information and Management System Society (HIMSS) Analytics Electronic Medical Record (EHR) Adoption Model Stage 7 Awarded to TriHealth July 2014

TriHealth successfully recertified as HIMSS Stage 7 in December 2017

Presented by:Lorraine Stephens, MD, Medical Director TPHOJoanna Sonnefeld, Application Architect, Applications Solution CenterH lli Kl k S l i L d D

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• TriHealth had over 200,000 covered lives in our valued based contracts with 50+ quality measures over multiple contracts.

• The payer Scorecards did not reflect the high level of care we felt we were providing.

• The organization’s leadership believed we were leaving dollars on the table for our value based contracts.

• There was no strategy to reconcile the payer’s care gap with the data that was in our EMR.

• Lack of data for the Managed Care team to use during negotiation to make the metrics achievable.

• All the data from the payers is retroactive and how do we become proactive. Data could be as old as 120 days.

• Not all the members are patients in our EMR.6

Source of Truth for Quality 

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Manual ProcessesGaps in Care and Membership list would be sent to the newly formed position, Contract Compliance Care Coordinator and the TPHO Medical Director. The Contract Compliance Care Coordinator would review the clinical data and send the necessary documents to the patient portals.The TPHO Medical Director would report to the practices the status of the measures.

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Where We StartedPayer Blinded -

Medicare

Advantage

2015 Quality Metric Performance

2015 Performance(%)

Breast Cancer Screening 65Colorectal Cancer Screening 41Adult BMI Assessment 11Metabolic Monitoring for CHF or Renal Failure NOT MEASUREDOsteoporosis Mgt for Women who had a Fracture 16Diabetes Eye Care 64Diabetes Kidney Disease Monitoring 96Rheumatoid Arthritis Management 76Diabetes Care Blood Sugar Controlled 0Annual wellness care NOT MEASUREDPlan All Cause Readmits 77Hospitalization for Potentially Preventable Complications 80Medication Adherence for Diabetes 77Medication Adherence for Hypertension 80Medication Adherence for Cholesterol 74

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Selection of Workflow and Solution Design

•Timeliness of payer files•Member attribution logic•Reconcile health maintenance with claims files

•Timeliness of payer files•Member attribution logic•Reconcile health maintenance with claims files

•Training team members•Start with quick wins and grow program•File import/clean up•Duplicate patient clean up

•Training team members•Start with quick wins and grow program•File import/clean up•Duplicate patient clean up

•Guiding principles to leverage core systems•Member and claims files from the payers•Scalable architecture•Discrete data for reporting quality and compliance

•Guiding principles to leverage core systems•Member and claims files from the payers•Scalable architecture•Discrete data for reporting quality and compliance

•Create a multi‐disciplinary team which included all stakeholders•Establish goals for the program•Determine what quality metrics to focus on –looking for quick wins

•Create a multi‐disciplinary team which included all stakeholders•Establish goals for the program•Determine what quality metrics to focus on –looking for quick wins

Governance  Solution Design

Barriers and ChallengesImplementation

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Workgroup & Governance

TPHO• Organize the team’s efforts and maintain momentum• Engage TPHO’s independent PCPs and equip them

with data to close care gaps

Managed Care• Obtain payer files (e.g., membership, gaps in care)• Manage financials for each contract• Serve as subject matter expert for each contract

Primary Care Leadership& Care Coordination

• Coordinate TPP efforts to close gaps in carebeyond the Contract Compliance Coordinator role

• Engage PCMH Coordinators in the practices

Contract Compliance Care Coordinator 

• Call Center: Review Health Maintenance and closecare gaps when patients call for GH appointments

• Contract Compliance: Call patients to close care gaps

Information Systems• Build payer‐specific registries for the Contract

Compliance Coordinators to work• Develop dashboards to set priorities/monitor progress

Revenue Cycle• Ensure that quality measures are coded and billed

appropriately to meet value‐based contractrequirements

TriHealth Team Role in OSP

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End User Involvement

Workflow Development Supported by IT

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•Add BMI diagnosis directly on the claim•Drop CPTII/HCPCS codes directly on the claims•Send Healthcare Effectiveness Data and Information Set (HEDIS) Supplemental data to the payers

•Send supplemental file to payers with all diagnosis codes per patients, per visit

Automation

•Identify the members per contract by measure•Show the payer care gaps along side of the clinical care gaps to see if there is a real care gap

•Dashboard to show the status of closing the care gaps so, the team members know which measure to focus on

•New Member Dashboard to quickly identify who our new members are

Information

•Tracking tool to help the team members manage their lists•Bulk ordering to tee up the orders for the providers to sign

•Smartset for the ease of orderingAction

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Workflow Development Supported by IT

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Intended Project Outcomes2016 Quality Goals – First VBC payer

Measures Goal

Quality Gate

Diabetes: A1C Monitoring 80%

Diabetes: Nephropathy Screening 85%

Metabolic Monitoring for CHF or Renal Failure 65%

Annual PCP Visit 75%

Quality Incentives

Breast Cancer Screening 75%

Colorectal Cancer Screening 77%

Adult BMI Assessment 96%

Osteoporosis Mgt (Women w/Fracture 56%

Diabetic Care:  Eye Exam 75%

Diabetic Care:  Kidney Disease Monitoring 94%

Diabetic Care: A1C<9 80%

Rheumatoid Arthritis Management 86%

Med Adherence

Diabetes 83%

Hypertension (RAS Antagonist) 76%

Cholesterol (Statins) 80%

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Gap In Care Workflow

Value Based Contract Quality Measures Dashboard

Payer/Metric Dashboard

Care Gap Report

Letters Activity

Ordering

Tracking Tools

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New Member Workflow

New Member Dashboard

Patient Tracking

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Closing Care Gaps

Care Gap Report

Letters Activity

Ordering

Tracking Tools

OSP VBC Dashboard – Quality Intervention

Value Based Contract Quality Measures Dashboard

payer/Metric Dashboard

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Closing Care Gaps

Value Based Contract Quality Measures Dashboard

payer/Metric Dashboard

Care Gap Report

Letters Activity

Ordering

Tracking Tools

payer Registry Reporting Dashboard

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Closing Care GapsCombining External and Internal Data 

payer Care GapFilter based on the 

columnsValue Based Contract Quality Measures Dashboard

payer/Metric Dashboard

Care Gap Report

Letters Activity

Ordering

Tracking Tools

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Closing Care GapsPatient Outreach

Value Based Contract Quality Measures Dashboard

payer/Metric Dashboard

Care Gap Report

Letters Activity

Ordering

Tracking Tools

Created tracking categories so the team member knows why and when to contact the patient.

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Closing Care Gaps

Patient Tracking Dates

Value Based Contract Quality Measures Dashboard

payer/Metric Dashboard

Care Gap Report

Letters Activity

Ordering

Tracking Tools

The tracking dates are displayed on the report which can be sorted or filtered on to give them a clean list to work.

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Closing Care Gaps

Value Based Contract Quality Measures Dashboard

payer/Metric Dashboard

Care Gap Report

Letters Activity

Ordering

Tracking Tools

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Closing Care Gaps

Value Based Contract Quality Measures Dashboard

payer/Metric Dashboard

Care Gap Report

Letters Activity

Ordering

Tracking Tools

Bulk ordering allows the end user to place an order on multiple patients with a couple clicks

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Closing Care Gaps

Value Based Contract Quality Measures Dashboard

payer/Metric Dashboard

Care Gap Report

Letters Activity

Ordering

Tracking Tools

Created a smartset to make it easy for the Call Center to place the orders

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New Member Dashboard

New Member Dashboard

Patient Tracking

The New Member Dashboard shows who are new patients

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New Member Tracking

New Member Dashboard

Patient Tracking

Created tracking categories so the team member knows the number of times they have contacted the patient so, they have the appropriate documentation

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Contract Coordinator Use of the OSP Tools

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Project OutcomesPayer Blinded -

Medicare

Advantage

2016 & 2017 Quality Performance Compared to 2015 Base Year – First

VBC payer

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Project OutcomesPayer Blinded -

Medicare

Advantage

Column1 2016 2017* Grand Total

Sum of Total Year Available $ 1,993,404 $ 3,058,273 $ 5,051,677

Sum of CY Earned $ 2,354,458 $ 3,825,554 $ 6,180,012

*2017 CY Earning projected. $2.04MM received. Shared Savings not yet applied. – est. ~1.7MM

2016 & 2017 Incentive Performance First VBC Payer

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Project Outcomes

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Project Outcomes

*Projected FY17 Incentive Payments

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Impact of Quality Workflow Colorectal Cancer Screening• Offered Fit DNA testing as alternatives if the patient

refused a Colonoscopy• 2 patients lives were saved! • These patients may not otherwise have been screened• Practices were educated Summer of 2017

National Cancer Institute. Cancer Prevalence and Cost Care Projections. Annualized Mean Net Costs of Care.https://costprojections.cancer.gov/annual.costs.html.

$149,574

5 year Cost Avoidance of Colon

Cancer$149,574

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Impact of Quality WorkflowBreast Cancer Screening• Allowed Contract Coordinators to schedule

mammograms• Engaged Central Scheduling in the same workflow

to do outreach for those patients that are overdue for mammograms

• 712 additional patients had their screening mammograms scheduled thereby reducing this population’s risk of undiagnosed breast cancer

050

100150200250300350400450500

July Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun

Scheduled Mammograms

FY17

FY18$34,113

5 year Cost Avoidance of Breast

Cancer$34,113

National Cancer Institute. Cancer Prevalence and Cost Care Projections. Annualized Mean Net Costs of Care.https://costprojections.cancer.gov/annual.costs.html.

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Impact of Quality Workflow

Month Total Pts % ScheduledJuly 2017 90 68.89%

August 65 67.69%

September 123 68.29%

October 193 69.43%

November 389 50.39%

December 276 57.61%

January 2018 349 70.49%

February 239 61.92%

March 230 46.09%

April 207 43.47%

May 266 41%

June 216 Not yet available

Grand Total 2,643 58.66% average, not including June

Diabetic Eye Exam• Developed a close relationship

with CEI and Apex Eye• They will do the outreach to

our patients once they receive our referrals

• The results will interface directly into our EMR and route directly to the providers

• 12 patients were found to have retinopathy who may not have been identified with screening without outreach5 year Cost Avoidance of Diabetic Care Management

$576,060

Economic Costs of Diabetes in the U.S. in 2017 American Diabetes Association http://www.diabetes.org/advocacy/news‐events/cost‐of‐diabetes.html

ROI for OSPIncreased Incentive Payments*

$ 6,180,012

Reduced Costs for Manual Processes

$78,000

Cost Avoidance Diabetic Care Management

(5yr)

$576,060

Colon Cancer Cost Avoidance

(5 yr)

$149,574

Breast Cancer Cost Avoidance

(5 yr)

$34,113

Total ROI

$7,017,759

• We were able to take on more value based contracts in a shorter timeframe than originally projected.

• We extended the program to all value based contracts.

• Managed care has been able to use data from the VBC Dashboard to drive negotiation discussion.

• We are now able to properly identify our attributed population due to ingestion of membership files from the payers allowing us to manage the correct patient population for our at risk

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Expanding OSP Processes

Due to the initial success with our first payer, TriHealth was able to expand OSP generating the following successes:

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Expanding OSP Processes

Column1 2016 2017* Grand Total

Sum of Total Year Available $                             201,492.00  $     1,478,525.00 $   1,680,017.00

Sum of CY Earned $                             341,815.00 $     1,133,872.00 $  1,475,687

2016 & 2017 Incentive Performance Payer# 2 MA

Column1 2016 2017* Grand Total

Sum of Total Year Available $      2,280,503.00  $             10,325,750.00  $           12,606,253.00 

Sum of CY Earned $      4,290,489.00 $             15,041,499.00  $           19,461,788.00 

2016 & 2017 Incentive Performance Payer# 2 Commercial

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Project Outcomes

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Project Outcomes

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Keys to Success

Keys to Success

Culture of Partnership

We Work Better

Together

Quick Wins

Information Systems is part of the Care Team

Workgroups should include all departments in the life cycle of a measure. Team members who call the patients, revenue cycle as well as physicians are all critical team members on the team

At TriHealth, there is a strong culture of partnership between all team members. The ability to work successfully in complex multi-disciplinary teams by valuing everyone’s contribution is critical to the success our initiatives

At TriHealth, Information System is considered part of the care team. There is a close relationship between IT and Clinical Operations

Focus on elements of the process that are quick wins and celebrate successes. Start with changes that are transparent to the user but move the needle on meeting measures.

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Lessons Learned• Stay focused on your “why” and communicate it often to the

project team as well as end users• Involve physicians in the process. Help the providers

understand why what we are asking is important. Need to have them part of the team earlier in the process.

• Payer are challenging to work with so it is critical to partner with them as much as possible.

• Managed Care would negotiate and expect operations to execute. Now Managed Care and operations are partnered to make sure the contracts reflection operationalize the performance. We can’t have contracting get the in way of performance. Safeguards in the contracts to get the data we need. Better partnership

• Fully examine quality measures and determine where you should focus efforts. Maximize operational efforts to maximize results and outcomes for our patients.

• Revenue cycle is a key stakeholder - not included early enough in the process

• Different and disparate information from payers is a challenge. Architecture (ETL processes) to standardize the payer information and run it through various quality checks before it was in Epic and actionable was key.

• Don’t get comfortable - every year we are dealing with new measures, new contracts etc...need to be flexible and agile and

What’s Next

Epic Optimization• Roster Management• Claims directly loaded into Caboodle• Cost Utilization Dashboard

OSP has been elevated to the organization’s Population Health Quality Committee

Moving to Daily Practice Operations• Begin engaging the practices more into the utilizing the tools as part of their daily operations.

Cincinnati’s Largest Payer named TriHealth

#2 Top Performing Commercial ACO in the nation

#1 in the state of Ohio

OSP Recognition & Wins

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Wrap Up

Problem

Left incentive dollars on the table

Missed quality metrics with payers

Incomplete data for managed care negotiations

Design

Leverage core systems

Ingest payer files for claimsIngest payer files for member

attributionRegistries

Strong multi-disciplinary

governance

IT Tools

Clinical data warehouse ingestion

Custom patient attribution engine

Registries/bulk ordering/health maintenance

Standardized & discrete documentation

Reporting dashboard for

compliance monitoring

Value

Met all quality metrics x 2 years

Increased incentive payments

Increased patients receiving colo-rectal screening

Increased screening mammogramsIncreased diabetic eye exams with community partnership

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