The ABCs of ACOs for MCH May 30, 2013€¦ · The ABCs of ACOs for MCH May 30, 2013 For assistance: Please contact [email protected]. or for web support 888-447-1119 option 2

The ABCs of ACOs for MCH May 30, 2013

For assistance: Please contact [email protected]

or for web support 888-447-1119 option 2

mailto:[email protected]

Brief Notes about Technology

A u d i o • Audio is available through your computer

speakers or earphones. • For assistance, contact [email protected]

or for web support 888-447-1119 option 2

2

Brief Notes about Technology Continued Q u e st i o n s • To submit questions at any time throughout

the webinar, type your question in the chat box at the lower left-hand side of your screen. – Send questions to the Chairperson (AMCHP) – Be sure to include to which

presenter/s you are addressing your question.

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Technology Notes Continued

Re c o rd i n g • Today’s webinar will be recorded

• The recording will be available in a week on the AMCHP

National Center for Health Reform Implementation

website at www.amchp.org • A PDF version of the presenters' slides will also be

available on the AMCHP website

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Objectives

Webinar attendees will: 1) Increase their knowledge of ACOs and ACOs that include MCH populations

2) Increase their understanding of how public health can play a role in ACOs

3) Will be able to identify strategies and resources to collaborate with, ACOs in their state

Evaluation Attendees will receive a link to a survey evaluation upon

completion of this webinar. Please take a few minutes to share your feedback.

Featuring: Colleen A. Kraft, M.D., FAAP, Carilion Clinic, VA Cate Wilcox, MPH, Maternal & Child Health Section

Manager, Public Health Division, Oregon Health Authority Don Ross, Policy & Planning Section Manager, Division of

Medical Assistance Programs, Oregon Health Authority Marilyn Hartzell, M.Ed., Director, Oregon Center for Children

and Youth with Special Needs

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The ABCs of ACOs: Making

Them Work for Maternal-Child Health

Colleen A. Kraft, M.D., FAAP

Family-Centered Medical Home

Child and Family

Developmental Services

Home-visiting network

Early Intervention

Child Care Resource & Referral Agency

Early HeadStart & HeadStart

Early Child Mental Health Services

Prevention, Building Health

Acute Care

Chronic Care

Developmental Services

Parenting Support

Lactation Support

Vulnerable children and

families

Medically Complex Children

Accountable Care Organizations

ACO

Hosp

PCP

Spec

Coordinates care for shared patients

Medicare, Medicaid Or private insurer

Financial bonus from savings

ACO Attributes • Coordinates care for shared population of patients with the goal of

meeting and improving on quality and cost benchmarks • Hires an administrator and establish a formal legal structure to work with

payers, monitor performance, and collect any shared savings • Receives a financial bonus that is divided among its participants

according to their agreement.

Traditional Medical Care and Financing “Un-accountable” care

Low Cost Care • Primary Care • Preventive Care—Screenings, Immunizations, Anticipatory Guidance • “Gatekeeper” • Health/Lifestyle counseling • Home-based care • Home visiting • Primary Care access for evenings and weekends

No Coordination of Care

• No incentive for communication and collaboration • No care coordinators • No measurement of outcomes • No comparative effectiveness Research • No focus on population health • No co-location of services • No self management services • No transportation

High Cost Care • Hospitalizations • Procedures • Duplication of labs, studies, procedures • Transportation = Ambulance • Complications of Chronic Disease • End of life care in an ICU

Low Cost Care Payment poor = No incentive

Transparency of Finances? Outcome Measures? Quality Reporting? Aligned incentives?

High Payment = Plenty of Incentive

Accountable Care Reduce Cost

of Care • Develop robust primary care access •.Streamline administrative tasks • Co-management between primary care and subspecialty to avoid hospitalization • Greater use of palliative care • Greater use of home care and home visiting • Patient/Family portals • Avoid duplication of care/HIT

Improve Coordination of Care--Investments

• HIT that promotes communication and interaction • Office Care Coordinators • Home Visiting/Home Care • Primary Care-Ancillary Health co-location, including therapists, dieticians, psychology • Electronic portal for patient communication/collaboration • Support for advanced primary care and Q/I initiatives • Data management infrastructure to evaluate processes and outcomes

Improve Quality of Care • Improving Scientific Basis of Healthcare Decisions • Based on Comparative Pediatric Effectiveness Research • Measurement of Outcomes • Longitudinal data collection and evaluation

• Payment Tied to Patient Outcomes • Based on Quality Measures

Fair Payment for Low Cost Care

Transparency of ACO Finances Patient/Family-Centered Investment in Infrastructure

Shared System Savings Aligned Incentives

Improved Outcomes

Accountable Care “Three-Part Aim”

Better Care

Better Health

Lower Cost

Pediatric Accountable Care

Prevention of Adult Disease

Optimize Health and Development

Reduce High Cost Care

Factors Affecting Child Health

SOURCE: Healthy People 2010, US Department of Health and Human Services, 2000.

Medical Services

10%

Environ-ment20%

Genetics20%

Health Behaviors

50%

Health Innovation can be funded through an ACO

• Extension of the Medical Home • In-home care management

– Early Childhood – Oral Health – Prenatal – Asthma – Development/Behavioral Health

Carilion Clinic-Aetna Partnership

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Carilion Clinic

ACO

Carilion Clinic

Physicians

Private Practice

Physicians

Update: 12/08/2011

Virginia Medicaid Regions

ACO System Savings

• Co-management between primary care and specialty

• Less duplication of services • Tracking of “high utilizers” with care

coordination to provide proactive care • Access to primary care, less use of ED and

hospitalization

CORE Predictive Modeling from Aetna

Mbrs who are Top 1%

Mbrs who are High Risk ED

Mbrs who are Medium/High

Risk IP

A Venn diagram, combining top 1% general risk with ED and IP risk, is used to help illustrate what risk groups a member falls into, and are they falling into multiple groups…

Members who are Top 1% AND high risk for an ED visit next 12 mos.

Members who are Top 1% , high risk for an ED visit, AND medium/high risk for IP admit next 12 mos.

Members who are top 1% general risk AND medium/high risk for IP admit next 12 mos.

Members who are high risk for an ED visit AND medium/high risk for IP admit next 12 mos.

Personalize the Profile for Medical Homes Increasing Medical and Behavioral Complexity

Group 3: •Ave age 33

•72% female

•PMPM $962

•5 ED visits, 0.2 admits

•32% asthma prevalence; 25% med adherence (asthma)

•85% MH prevalence

•58% co-occurring mental health and substance abuse

•52% with 5+ Rx classes

•5 Specialist visits

•10 PCP visits


•PMPM $3908

•2.6 admits

•12 IP bed days

•7 ED visits

•51% diabetes prevalence




•10 PCP visits


•PMPM $2425

•1.6 admits

•7 IP bed days

•6 ED visits

•Low medical disease prevalence


•62% co-occurring MH and SA


•9 PCP visits

3 6

4 Group 5: •Ave age 53

•PMPM $3202

•2 ED visits

•2 admits

•10 IP bed days

•56% diabetes prevalence



•19 Specialist Visits

•7 PCP visits

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ED Risk Only

ED Risk/IP Risk Only Top 1%/

ED Risk/IP Risk Top 1%/ IP Risk Only

Home Visiting Partner

• Child Health Investment Partnership of the Roanoke Valley

• Home Visiting with a Health Focus – Parents As Teachers – Oral Health – Asthma Management – Pregnant Moms – Behavioral Health

Home Visiting

• Pediatric Asth

Care Management Design

• Home Visiting Contract – Paid per member/per month

• “High Touch”, in-person, in-home • Data Collected in home

– HEDIS metrics – Health Outcomes – Reduced costs

Medical Home

Oral Health and Fluoride Varnish

• Begin with a Grin!

Asthma Case Management

• Assess environment, modifications

• Smoking cessation • Observe inhaler use • Asthma control

assessment • Asthma action plan and

education • Transportation to visit

Behavioral Health

• Prenatal to age 7 • Perinatal/postpartum

depression screening • Connection to services

for parents and children at-risk and diagnosed

• Transportation to visits

Results

In-Home Screening

Ready for School?

Pediatric Asthma

Home Visiting Intervention Pilot

Home Visiting = In-Home Prenatal Care Management

IDEA • Poverty is a risk factor for

poor maternal and newborn outcomes.

• What if every mother with Medicaid had a Home Visitor to provide support, education, transportation?

• How would this impact health of the next generation?

AIM STATEMENT • Reduce the number of

infants born at <37 weeks gestation and low birth weight (<2500 grams) by 30% by December 2012 utilizing home visitors as in-home case managers.

National Benchmark=March of Dimes

Virginia • “C” grade for premature

birth • Total prematurity = 11.3% • Late preterm (34-36 wk) =

8% • Uninsured = 17.2% • Maternal smoking = 15.2%

Roanoke/Allegheny • Metrics worse for this

region • Prematurity = 12.2% • Late preterm (34-36 wk) =

10.1% • Uninsured =15.6% • Maternal smoking = 24.4%

Measures Measure Health Care Cost

Percent of infants born at < 37 weeks gestation O

Percent of infants born between 34 and 36 weeks gestation (late preterm) O

Birth weight term infants <2500 grams O

Percent of Pregnant Moms participants who smoke that stopped smoking O

Percent of Pregnant Moms participants who start prenatal care in the first trimester P

Percent of Pregnant Moms participants who attend all the recommended prenatal visits P

Percent of Pregnant Moms participants who are uninsured P

Percent of Pregnant Moms participants identified with depression P

Percent of Pregnant Moms participants connected to treatment for depression P

Cost of Care C

1st Trimester—Goal =90%

Percent Goal = 90%

All Visits-Goal = 60%

Percent Goal = 60%

Reduce Maternal Smoking by 1/3

Percent Goal = 16%

Perinatal Depression

Reduce Percentage of Infants born <37 weeks by 30%

<37wk 34-36 wk

Goal

Reduce Percentage of Term Infants born < 2500g by 30%

Cost of Care

Note: One premature infant March 19-May 10

Next Steps • Continue current project, data analysis • Continue Home Visiting Contract after birth • Expand Asthma and Behavioral Health HV models • Assess

– HEDIS measures – Compliance with Asthma guidelines, ER and hospital

admissions, missed school and work days – Co-locate HV teams in OB and Pediatric practices – Feasibility of project replication as ACO expands – Development and school readiness of birth cohort

Other Outcomes

• 92% of children with asthma are well controlled with minimal inhaler use

• 90% of all pregnant mothers attended all their prenatal visits, starting in first trimester

• 57% of pregnant moms who smoked were able to stop smoking

• 100% of children with behavioral health problems improved on PECFAS

Care Connection for Children

Special Families

Special Families

• 42 families with successful IEP meetings • 10 families connected with waiver services • 10 hospitalizations avoided due to connection

to home health services • 8 support group meetings • Special Families facebook page • Respite program

Accountable Care

• Health of a population – Pregnancy outcomes? – Decrease in hospitalizations and ED visits? – School attendance, grades? – Parental education and employment – Function and performance of the Medical Home

CONCLUSION:

It is easier to build strong children than to repair broken men.

Frederick Douglass

Don Ross Oregon Division of Medical Assistance Programs

Cate Wilcox Oregon Public Health Division

Marilyn Hartzell Oregon Child Development and Rehabilitation Center, OHSU

Coordinated Care Organizations

Health System Transformation and Opportunities for Preconception Health

What we’ll talk about today

Basics of Coordinated Care Organizations Public Health Role in CCOs (ACOs) MCH Metrics Preconception Health (One Key Question)

Opportunities for Children and Youth with Special Health Care Needs to work with CCOs (ACOs)

www.health.oregon.gov

Oregon Health Plan

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Triple Aim: A new vision for Oregon


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Changing health care delivery


Benefits & services are integrated and coordinated

Physical health, behavioral health, dental health Get better outcomes: Health equity Prevention Social determinants of health: education, employment

MH: Supported Employment Community health workers/non-traditional health

workers Collaborate and Integrate with other health and

human services (e.g. long term care; public health; schools)


Global budget

Current system MCO/MHO/DCO/FFS Payments based on actions No incentives for health outcomes

CCO global budget One budget Accountable to health outcomes/metrics Local vision, shared accountability, shared savings Flexibility to pay for the things that keep people healthy


CCOs: governed locally

State law says governance must include: Major components of health care delivery system Entities or organizations that share in financial risk At least two health care providers in active practice Primary care physician or nurse practitioner Mental health or chemical dependency treatment

provider

At least two community members At least one member of Community Advisory Council


ACOs vs CCOs-What’s Different?

ACOs have distinct features: ACOs developing around health systems, not payers ACOs in the ACA are aimed primarily at Medicare savings Providers in ACOs share in Medicare savings in:

Medicare Shared Savings Model Advance Payment ACO Model Pioneer ACO Model

CCOs are accountable to the state, and local community Medicaid enrollment in CCOs is required


Community Advisory Council

Majority of members must be consumers. Must include representative from each county government in

service area. Duties include Community Health Improvement Plan and

reporting on progress.

CCOs and public health Variety of requirements in statute:

o State shall require and approve agreements between CCOs and publicly funded providers for payment for certain services (immunizations, STIs and other communicable diseases)

o State shall allow CCO enrollees to receive family planning and HIV and AIDS-related services from fee-for-service providers, as well as maternity case management if CCO cannot do it

o State shall encourage and approve agreements between the two entities for authorization and payment of other services including maternity case management, prenatal care, school-based clinics, services provided through schools and Head Start programs, screening services for early detection of health problems in vulnerable populations


CCOs and public health (2) Variety of requirements in contract:

o Collaborate with local public health authority, local mental health authority, community based organizations and hospital systems for community health assessment and development of community health improvement plan

o Actively promote screenings with A or B grades from USPSTF, or recommended in Bright Futures guidelines

o Contribute to implementation of state’s plans for physical activity, healthy nutrition, tobacco prevention, suicide prevention, and local public health and health promotion planning efforts

o Partner with local public health and culturally, linguistically and demographically diverse community partners to address the causes of health disparities. www.health.oregon.gov

Accountability Metrics for CCO’s Reduction of disparities - report all other metrics by race and

ethnicity

Member/patient Experience of care

Health and Functional Status among CCO enrollees

Rate of tobacco use

Obesity rate

Outpatient and ED utilization

Potentially avoidable ED visits

Ambulatory care sensitive hospital admissions

Medication reconciliation post discharge

All-cause readmissions

Alcohol misuse – SBIRT

Initiation & engagement in alcohol and drug treatment


Accountability Metrics for CCO’s

Mental health assessment for children in DHS custody

Follow-up after hospitalization for mental illness

Effective contraceptive use among women who do not desire pregnancy

Low birth weight

Developmental Screening by 36 months

Planning for end of life care

Screening for clinical depression and follow-up

Timely transmission of transition record

Care plan for members with Medicaid-funded long-term care benefits

www.health.oregon.gov Metrics in bold can be applied to Preconception Health

Initial Metrics Designed to achieve quick return on investment to

meet the federal requirements Maternal and Child Health is imbedded in many, but

not necessarily called out


Second Phase of Metrics

Important to be at the table—we have a lot to offer! MCH brings the sustainability factor MCH brings the lifelong wellness factor


Possible MCH metrics

Look at a broad range of standards of care/practice HP2020, Bright Futures, USPSTF, Title V priorities

Include Adolescent measures Look for means of coding/tracking the measure


Possible MCH metrics

Targeted measures for MCAH populations Oral Health Positive Parenting Sleep hygiene Positive Youth Development Family violence prevention Safety/Injury prevention Pregnancy intendedness


Example: One Key Question

Do you plan on getting pregnant in the next 12 months?

If yes, preconception health care If no, contraceptive health care


ACA, Public Health, & Data

Pay attention to Electronic Health Record requirements in the ACA The concept of “Meaningful Use” introduces more complex

reporting to public health by Electronic Health Record users.

Public health needs to be ready to be able to receive data from providers.

Public health needs to be ready to be able to provide data to providers.


Opportunities for Children and Youth with Special Health Care Needs to work

with CCOs (ACOs) Join the conversation – get to know the ACOs/CCOs Educate ACOs about the population of children with

special health care needs Who are CYSHN?

Complex Broad and inclusive definition Commonalities of needs across the population of indivduals

Educate ACOs about how to identify CYSHN within a system of care

Screeners Complexity Scales


Opportunities for Children and Youth with Special Health Care Needs to work with

CCOs (ACOs) …and their families

Family-Professional Partnerships

Patient Engagement is not Family-Professional Partnership Family Professional Partnerships involve: Shared knowledge and expertise Mutual respect Collaborative problem solving



with CCOs (ACOs) Advocacy and Education

Encourage family leaders, F2F HICs, community leaders to join the Advisory Committees

Support family leaders in their work with ACOs The Family Voice

#1: Nothing about us without us! #2: Decisions made under Parent/professional

partnership involves compromise for both! #3: Please listen to our concerns.



with CCOs (ACOs)

Effective Systems of Care for CYSHN Family Centered Care Early and continuous screening Medical home with care coordination Ease of Use of Community-based services Youth Transition to adult health care (think specialty

care too!) Health care finance

Be a resource to ACOs



with CCOs (ACOs)

Public health programs support ACO aims & metrics Immunizations Flu vaccination Annual well-child visits Annual dental visits Reduced ER usage

Build partnership with ACO to help achieve the 3 aims Remember – there are 3 aims!


Opportunities for CYSHN to work with CCOs (ACOs) - An expanded model for statewide care coordination

Tertiary-based Care Coordination Team

CYSHN are assigned to when they are identified through the hospital or clinics CC Team serves as single point of contact for families in the targeted group

of children CC Team nursing, social work, family navigator, psychology – according

to the needs of the child and family Regional Unit of Care Coordination (Senior Nurse Coordinator)

Regionally based senior nurse coordinator (expert nurse with CYSHN) Child/family referred to/through back into community-based care Links family with PCP and community-based care coordination as needed Senior Nurse Coordinator provides connections between the tertiary care

coordinators, PCPs and the community public health services Community-based Care Coordination

Child identified within the community through public health nursing or primary care settings; goals identified by PHN and/or PCP

Linked to Senior Nurse Consultant for input, and behavioral specialist when needed

For More Information: Don Ross, Manager Policy and Program Unit Division of Medical Assistance Programs Oregon Health Authority [email protected] 503-945-6084


Marilyn Hartzell Director, OCCYSHN OCCYSHN / Oregon Center for Children and Youth with Special Health Needs Institute on Development and Disability (IDD) at OHSU [email protected] 503-494-6961

Cate Wilcox, Manager Maternal and Child Health Section Public Health Division Oregon Health Authority [email protected] 971-673-0299




Question & Answer

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•Please submit questions through the chat feature and direct them to the chairperson

Thank you for attending “The ABCs of ACOs for MCH”

Colleen A. Kraft, M.D., FAAP, Carilion Clinic, VA Cate Wilcox, MPH, Maternal & Child Health Section Manager, Public Health Division, Oregon Health Authority Don Ross, Policy & Planning Section Manager, Division of Medical Assistance Programs, Oregon Health Authority Marilyn Hartzell, M.Ed., Director, Oregon Center for Children and Youth with Special Needs

The recording will be posted on www.amchp.org

http://www.amchp.org/

Documents

The ABCs of ACOs for MCH May 30, 2013€¦ · The ABCs of ACOs for MCH May 30, 2013 For assistance: Please contact [email protected]. or for web support 888-447-1119 option 2