1

Kings Fund Masterclass C

Session 4: Clinical and Quality

Programs

2

Objectives

• Provide overview of CMO clinical and quality programs

• Develop understanding of key role that clinical specialty

programs play in our PHM model

• Discuss how clinical and quality programs are integrated into the

overall PHM model

• Discuss development of Montefiore’s End-State Renal Disease

(ESRD) program as a key clinical program intervention (Case

Study)

3

Clinical Programs

4

Whole Person

Care Model

Clinical and

Quality

Programs

Network Care

Setting

Enabling

Technology

Population Health Management Foundational Architecture

PHM involves targeted approaches to manage medically complex patient conditions

• Focused clinical care and quality

programs designed to treat and monitor

advanced needs

• Cancer, Renal, Cardiac, Respiratory,

Transplant, etc.

5

Current Clinical Care Management Program Portfolio

Clinical Specialty

ESRD

Oncology

Diabetes

Post-Acute Care

Cardiac

Muscular-Skeletal

Respiratory

• Key goals are to reduce unnecessary

admissions and improve quality of life for

patients

• Programs are thoughtfully developed and

monitored leveraging consistent

framework:

o Objectives for Performance Period

o Processes / Workflows

o Clinical Pathways

o Patient Population / Profile

o Participating Providers

o IT Enablers

o Incentive Model, Benchmarks / Targets

o Outcomes (Clinical and Financial)

Transplant

Integrated

Behavioral

Health

6

Quality Programs

7

CMO

Behavioral Health

Care Management

Quality Administrative Services

• Population identification / stratification

• Whole-person care

• ED triage

• Care transitions

• Disease management

• Utilization management

• Behavioral health program

stratification

• Behavioral health co-management with accountable care manager

• Primary care and behavioral health integration

• Outcomes management

• HCC / CRG

• HEDIS stars

• CAHPS, NCQA support

• State, Federal quality measures

• Clinical documentation improvement

• Provider contracting

• Provider services

• Facility/ Provider Support Services

Our Core Services

Quality programs are key pillar of PHM infrastructure built to aggressively manage total cost of care and utilization

8

Key Performance Measures - High Impact domains

• Reduction in Preventable Inpatient

Admissions, Readmissions

• Reduction in Preventable ER Utilization

PQI / Inpatient Utilization

• Patient access

• Wait time in waiting room

• Ease of scheduling apt

• Staff helpfulness

Member satisfaction

• Well visits (Peds and Adults)

• Breast and Colorectal cancer screening

• Diabetes Care

• Med Adherence

• Behavioral Health Care

Preventive care/chronic

condition

9

Specialist Incentive Programs

Select specialists are eligible for specialty-specific incentive programs

Specialty to PCP responsibilities under specialist

incentive programs, include:

• Transitions of Care protocols, i.e. establishing

clinical guidelines for pre-referral work up

• Access standards, i.e. providing adequate visit

availability

• Care Management collaboration, i.e. Sending timely reports to PCP and visit summaries

Oncology

Behavioral Health

Specialties

Pulmonology

Cardiology

Nephrology

10

PPRs Lower than Expected for Diabetes, Heart Failure and Chronic Renal Failure

19

77

104

23

108

120

0

20

40

60

80

100

120

140

Diabetes Heart Failure Chronic RenalFailure

PPR - Actual

PPR - Expected

Source: Montefiore Internal ACO Data Analysis via 3M/Treo data

P

e

r

1

0

0

0

11

PPVs Lower than Expected for Diabetes, Heart Failure and Chronic Renal Failure

281

378 381

298

401 403

0

50

100

150

200

250

300

350

400

450

Diabetes Heart Failure Chronic RenalFailure

PPR - Actual

PPR - Expected

Source: Montefiore Internal ACO Data Analysis via 3M/Treo data

P

e

r

1

0

0

0

12

Case Study: ESRD Program

13

Kidney Care and End-Stage Renal Disease (ESRD)

Kidney care often is initiated later than is optimal for patient

Fragmented delivery system

Hospitals

Physicians

Dialysis

Providers

Care for ESRD

patients is poorly

coordinated and not

sufficiently robust

In-center dialysis

remains only option

for patients

CKD patients lack

sufficient

nephrology

services attention

Stakeholders Implications

• Lack of integration with

nephrology required for high-

quality, effective late-stage CKD

care

• Nephrologist and PCP integration

often weak

• Resource constraints (staff levels,

incentives) to manage multiple comorbidities

• Dialysis providers unable to

engage CKD patients early

• Lack of increased rates for home

dialysis, transplant

14

Program Guiding Principles

• Diagnostics and predictive analytics

• Proactive patient identification and education • Nephrology referral

Early Identification and Engagement

• Multidisciplinary care team supported by care extenders

• IT solutions to enable effective care management• Interventions to mitigate ED utilization

Integrated complex care

• Building strong relationships with patients

• Developing sense of ownership to be successful across multiple treatment modalities

Patient empowerment

15

Staffing

• Incremental Renal NPs and

RNs to supplement existing

CKD pods

• Expansion of nephrologist

network and affiliations

• Incremental resource support

for transplant prep and donor

advocacy

Technology

• Predictive analytics

• CKD registry

• EMR / Lab data integration

• Workflow platform

Key Program Elements

Services

• Transplant coordination

(transplant prep and living

donor advocacy)

• Home dialysis for pre-ESRD

management

• In-center dialysis

• Concierge-level services

16

Key Goals

Early Identification and Engagement

Integrated complex care

Patient empowerment

75% reduction in

unplanned dialysis starts

>50% reduction in

hospitalizations

>3.5x as many patients

receive a preemptive

transplant or home dialysis

17

Outcomes: ESRD Dashboard