#Aim2Innovate. Share session insights and questions socially. UCLA Primary Care Innovation Model 6/13/2015. Mark S. Grossman, MD, MBA, FAAP, FACP

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1 UCLA Primary Care Innovation Model Mark S. Grossman, MD, MBA, FAAP, FACP Chief Medical Office, UCLA Community Physicians & Specialty Care Networks June 16, 2015 DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS. Share session insights and questions socially #Aim2Innovate 1

2 Disclosure of Conflicts of Interest None Learning Objectives Describe the UCLA Primary Care Innovation Model journey emphasizing the idea of Pilot to Scalability 2

3 Accountable Care: UCLA s History in Accountable Care UCLA Health has a 30-year History UCLA Medical Group Risk Contracts 1983*- Pay for Performance and Public Reporting Primary Care Innovation Model (PCIM) Design Team Medicare Shared Savings Plan ACO Commercial PPO ACOs Value Analytics Direct Employer- Provider Collaboration /Pre ACA/ /2010 ACA Passed/--/2012 ACA Upheld/------/Post ACA/ *Commercial HMO and Medicare Advantage 5 Accountable Care Populations at UCLA: Crossing the 50% for Primary Care 48.2% 9.8% 14.1% 4.3% 23.5% Medicare ACO (1/2013) PPO Based ACO Contracts (10/2013 1/2015) UCLA Medical Group Medicare Advantage HMO UCLA Medical Group Comercial HMO FFS Other Shared savings Pre-paid Neither Primary Care Population is ~300,000 An additional 200,000 patients see our specialists ACO Contracts: 3 PPO based, 1 HMO based 6 3

4 Population Focus: Distribution of Population H Geographic Distribution of UCLA Health PCP & Specialty Offices & Hospitals UCLA Patient Populations Index by Green Density H H H H Represents multiple care sites, PCP, Specialty, or both Community Hospital H H UCLA Hospital As of June 1, Population Focus: Care Coordination Patient Flow & Transitions Rehab/ SNF Home Hospital E R Advanced Urgent Care Physician Office Higher Cost Lower Cost 8 4

5 UCLA Primary Care Innovation Model (PCIM) UCLA Health Community Hospitals Primary Care Office Existing roles: 1. Physician 2. MA/LVN 3. Front Office 4. Manager New Roles: 1. Care Coordinator (License optional) 2. PharmD (My Meds) Behavioral Health Associates & Network Clinical Advisor Role (RN, LCSW) Palliative Care Coordinator for Advanced Care Planning & Home Palliative Multiple access points, including Patient Portal and Telemedicine IT Support 1. Registries and Care Gaps 2. Real-time discharge notification (ED & Acute Hospital) 3. EHR UCLA Employed Hospitalists Communitybased organizations (e.g. CCTP) Community resources, & family support Other Local Partners 9 PCIM: New Care Coordinator Role Problem: Complex high-risk patients had high rates of facility use; often related to social issues The Care Coordinator s role in the primary care office setting: Help to manage high-risk complex patients, post discharge calls Focuses on coordination of services, making sure care plans are executed, identification of barriers (e.g. transportation), linkage to case managers and pharmacists When Marjorie Crear, 66, left Ronald Reagan UCLA Medical Center after a stroke, she struggled to keep track of her medications and to remember her doctor appointments. [A newly] hired care manager [in her doctor s office], helped with those tasks and has also been trying to find public housing with a shower instead of a hard-tonavigate bathtub. 10 5

6 PCIM: Rapid Spread of Care Coordinators Timeline of Patient and PCP Growth sites Number of Patient Covered Number of PCPs included Patient count PCP count May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun sites 11 PCIM Results: Post-Acute Event Follow Up ED Visit Non-elective, non-l&d admit Ambulatory care-sensitive admit Facility Use (per 1,000 patient-yrs)* ED visits Non-elective, non-l&d admit Ambulatory care-sensitive admit With Care Coordinators 22.9% 32.7% 40.3% Without Care Coordinators 21.3% 27.5% 33.1% Day Readmission Rate 16.5% 18.4% Before and after PCIM in same office: Significant 20% reduction in ED visits 1185 less ED visits Total Cost of Care Savings on Reduction of ED visits alone*: $2.4 million For all 14 initial clinics with Care Coordination model: $13 million. CONFIDENTIAL NOT FOR FURTHER DISTRIBUTION Innovative Approach to Patient-Centered Care Coordination in Primary Care Practices Am J Managed Care, 2015 in press 12 6

7 MyMeds Ambulatory Pharmacist Program In Office and linkage with Home & SNF B. Post-acute hospital discharge HOME visit Home Meds Role: Health coach in home Pharm D Review of meds Identification of medication related problems Use of high risk discharge identification tool (LACE) Use of CME CCTP rules for Medicare FFS Home med list In office role: 1:1 access to MD EHR same as MD Focus on Adherence Targeted High Risk Groups A. MyMeds Clinical Pharmacist in Office Primary care physician Care coordinator Upon referral from SNFist: EHR same as MD Focus on medication reconciliation and avoidance of complications & adherence Assist with management C. Post-acute SNF 13 PCIM: Behavioral Health Associates Problem: Poor access to services, limitations of psych carve out plans 233,287 44,737 1, UCLA PCP Patients Patients with psychiatric illness Psychiatric emergency visits Psychiatric hospitalizations *Chronic anxiety and depression most common diagnoses 7

8 UCLA Adoption of IMPACT in its Behavioral Health Program Collaborative Care Patients may be seen by a psychiatrist first Referrals must come from the patient s PCP Primary Care Office (Physician & Comprehensive Care Coordinator) BHA Staff BHA Network Psychiatrist Licensed Clinical Social Worker Family Marriage Therapist A UCLA-developed FOCUS platform provides real-time data for stepped care decision-making at initial visit and week milestone Stepped Care Outcome Measurement Fully aligned with IMPACT Adapted from IMPACT 15 PCIM: Recent Approach to Increased Engagement HRA, Health & Biometric Screenings & Risk Assessment Health Coaching, System navigation. Coordination of care Choose a Primary Care Provider, Wellness Visit Patient Journey Triple Aim, & Maintained workforce PCP based System, Team care, Access, EHR and Patient Portal, Managed linkage to System and Community Chronic Condition Management, Care Ccoordinator, Pharma management & adherence Behavioral Health Access and Management Medical Home 1/22/2014 8

9 Multiple Access Points Same day appointments in all practices Patient Portal & Mobile Apps 24/7 nurse advice line with access to provider schedules Retail Clinic Affiliation (e.g. Minute Clinic) Fully integrated Advanced Urgent Care (ED alternative) on same EHR platform Asynchronous on demand diagnosis and treatment via mobile smartphone. Asynchronous follow-up with provider following office visits. Internet-based video communication for common conditions. 17 Questions? 9

10 Thank You Mark S. Grossman, MD, MBA, FAAP, FACP Clinical Professor of Medicine and Pediatrics CMO, UCLA Community Physicians & Specialty Care Networks

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