Preparing for Primary and Acute Care Systems: Learning from accountable care organisations

Transcription

1 Preparing fr Primary and Acute Care Systems: Learning frm accuntable care rganisatins Nvember 2014

2 INFORMATION DRIVES SOUND ANALYSIS, INSIGHT, AND ACTION. Preparing fr Primary and Acute Care Systems: Learning frm accuntable care rganisatins Infrm - Prblem Statement: challenges fr PACS Transfrm - Strategy, slutin and benefits Outperfrm - Case study Infrm Prblem Statement: challenges fr preparing fr Primary and Acute Care Systems (PACS) The NHS Five Year Frward View (Oct 2014) calls fr lcal health ecnmies t adpt new mdels f care centred n imprving ppulatin health and wellbeing, and increasing the quality f treatment. In this paper, we share sme learning, tls and experiences frm the develpment f accuntable care systems which might help health and scial care cmmunities cnsider hw they might mve frward. Fr thse wh need care, this will invlve redefining traditinal relatinships between patients and prfessinals and placing mre pwer and respnsibility with the patient. It will als require a new peratinal relatinship between the different prfessinals and prviders invlved in care delivery. The big prize is t re-fcus n the patient, imprve health and wellbeing, and imprve utcmes frm health and scial care delivery, whilst at the same time reducing cst pressures n the tax funded system. The prpsal t create Primary and Acute Care Systems is ne f a number f valuable initiatives included in the Five Year Frward View. It is likened t the mve t Accuntable Care Organisatins (ACO) internatinally. Preparing fr Primary and Acute Care Systems: Vertically integrated single rganisatins which at their mst radical wuld take accuntability fr the whle health needs f a registered list f patients, under a delegated capitated budget. -Five Year Frward View Accuntable Care Organisatins (ACOs): Grup f prviders held jintly accuntable fr achieving a set f utcmes fr a prspectively defined ppulatin ver a perid f time and fr an agreed cst. -McClellan et.al 1 There are a great many lessns t be learned frm the early adpters f ACO mdels nt least f which are: The central imprtance f the service user / patient as the real wner f their wn health and health utcmes and the need t invlve them at every level frm plicy t practice; The critical imprtance f sharing infrmatin between patient and prfessinal and acrss care prfessinals at the pint when treatment decisins are made; The need t rethink clinical gvernance and care prtcls acrss the entire care pathway; And the massive peratinal and cultural transfrmatin which is required if the system is t becme truly integrated frm the perspective f the patient. This is nt a quick fix. If it was, it wuld already be nrmal practice acrss healthcare systems acrss the wrld. Implementing these mdels will be difficult. Investment and time is required if the valuable benefits are t be realised and return n investment is t be achieved. This is nly the beginning f the jurney. True system innvatin will require cntinuus learning and imprvement if the new mdels f care in the NHS are t succeed. 1 McClellan, M., Kent, J., Beales, S.J., Chen, S.I.A., Macdnnel, M., Thumi, A., Abdulmalik, M., Darzi, A. (2014a), Accuntable Care Arund the Wrld: A Framewrk t Guide Refrm Strategies, Health Affairs, 33. n9. (2014):

3 In the USA, the basic tenets f ACOs supprt a healthcare delivery and finance mdel that: Ties prvider reimbursement t quality metrics and reductins in the ttal cst f care fr an attributed ppulatin f patients. Has a mechanism fr shared gvernance that prvides all ACO participants with apprpriate cntrl ver the ACO decisin making prcess. Fcuses n 5 quality dmains that frm the basis fr determining, benchmarking, rewarding, and imprving ACO quality perfrmance: 1. Patient Experience with Care 2. Care Crdinatin 3. Patient Safety 4. Preventive Health 5. At-Risk Ppulatin/Frail Elderly health Hwever, ACOs have prven t be cmplex mdels that take time and technical expertise t implement. Results fr ACOs have been mixed. Csts f rganizing and implementing the ACOs were higher than anticipated and care crdinatin via their clinically integrated netwrk prblematic. Nevertheless, there is cntinued interest in grwth f ACOs, which is driven by a greater appreciatin f placing the cnsumer at the centre f care delivery. With the benefit f a learning curve frm the US experience in implementing such systems, we have identified the fllwing challenges and barriers that the NHS faces in implementing an ACO mdel: 1. Wh is accuntable? By definitin, an ACO cmprises f three elements: Accuntable: Thse wh are accuntable fr the cst and quality f care fr a whle ppulatin will be incentivised t imprve care. Accuntability refers t bth clinical and financial accuntability. Care: An ACO delivers, rather than cmmissins, care. Organisatin: Accuntable prviders cme tgether in a frmal rganisatin structure t build apprpriate leadership team and gvernance structures. Currently, the NHS system cnsists f cmmissiners wh d nt deliver services and prviders wh are unwilling t share clinical and financial risks with ther prviders thrugh a legal structure. There is little incentive, legally r structurally, fr an rganizatin t mve twards adpting the status f an Accuntable Care Organisatin. Thus, a true ACO can nly be created when prviders wrk tgether under strng leadership that accepts accuntability. 2 This needs t be embedded thrugh rbust gvernance structures. 2. Prvider engagement Over the past three years the Department f Health has supprted pineers t cnsider new ways f cmmissining and Mnitr has stated that their lng-term aim is t develp a payment system that supprts delivery f gd quality care fr patients in a sustainable way. 3 All f these initiatives indicate that the current cntracting apprach is nt deemed t be fit fr purpse. Traditinal tariff-based structure des nt align financial incentives apprpriately between cmmissiner and prviders, r between prviders, t deliver the integratin f services that patients need r secure imprvements in utcmes. The gal f ACOs shuld be t develp payment systems that reward imprved perfrmance. T accmplish this gal, there are a wide variety f shared risk mdels that culd be emplyed. Episde payment and capitatin are examples f risk sharing arrangements. The chsen methds shuld aid the ACO in changing clinical behaviur and delivery f care. Fr all typical ACO cst sharing methdlgies, a spending benchmark shuld be established as a baseline using histrical data. If an ACO can maintain r imprve quality at less cst than the benchmark, it will receive a prtin f the savings. 2 See Welburn, D., Inman, L., Mallender, J. (2014), Accuntable Care Organisatins can prperly manage cmmissining risks, HSJ 3 2

4 3. Patient and service user engagement The Five Year Frward View advcates fr a radical upgrade in preventin and public health, which is a key part f delivery f an ACO. T this end, patients need t be encuraged t take an active rle in their care thrugh shared decisin-making and cmmunicatin abut selfmanagement, medicatins, and changes in lifestyle. Many wellness and health prmtin activities are patient driven and can be key cmpnents in prgrammes t prevent and treat active disease and t manage chrnic cnditins. Hwever, histrically, healthcare prviders have nt been particularly successful in engaging patients in their wn care, and patients have nt always shwn much interest in these respnsibilities. Mbilising patients t participate as partners in the delivery f accuntable care will be new territry fr mst health delivery rganisatins. Careful chices and pririty setting will be required t ensure that investments in patient engagement are cnsistent and can be leveraged t prmte accuntable care. 4. Health Infrmatin Technlgy Accuntable care requires the prvider t deliver patient care that is respnsive t immediate circumstances. Access t infrmatin abut the patients is required fr care crdinatin, which is at the centre f accuntable care capabilities. Within the UK, decisin making abut the adptin f technlgy resides with cmmissiners in health and scial care. At a lcal level, the decisin t purchase a particular technlgy may represent a significant investment, and therefre risk t decisin makers. Key barriers t adptin f technlgy include: Lack f availability f resurces; Technlgical innvatin mves faster than prcurement systems; Diversity f cre systems- technical interperability versus semantic interperability; Narrw decisin making prcess, such as sil budgeting; Lack f awareness f the benefits f technlgies amng decisin makers and few incentives t encurage rganisatins t invest in new technlgies; Lack f ecnmies f scale in purchasing; and Data security and ethics, including barriers such as infrmed cnsent t share infrmatin, gvernance n security, strage and access. 3

5 Transfrm Strategy, slutin and benefit In light f the expected refrms, many prviders are shifting frm Shuld we becme an ACO? t What shuld we d t becme an ACO? Fr prviders wrking tgether t deliver a cntract fr a whle care pathway (r ppulatin), it requires changes at strategic, managerial and peratinal level. Prviders are rewarded t imprve peratinal efficiency and imprve utcmes. They face significant risks if they are unable t deliver the peratinal transfrmatin required at the pace determined by the cntract. Putting effective mechanisms in place as early as pssible is a prudent but ften-times verlked cmpnent f the mve twards acquiring ACO status. Belw we present tw tls t assist in the develpment f ACOs. Figure 1: Tls t assist develpment f ACOs 4

6 Assessing ACO Readiness There is n blueprint fr becming an ACO. Each rganisatin will vary in terms f the systems already in place, which will help t determine the steps that need t be taken and timescales required t mve twards becming an ACO. Varius readiness assessment tls have been emplyed by sme f the key advisrs in the US, where they have been subject t cnsiderable practical testing 4 t help answer Where are we nw? A synthesis f these tls, as well as ur in depth understanding f the UK health system, results in the fllwing key dmains fr ACO readiness. 5 Figure 2: ACO Readiness Dmains Cllectively, the 11 dmains reflect the full breadth f cnsideratins ver which the ptential ACO shuld be able t demnstrate cmpetence, capacity and capability required t deliver the triple aim f all healthcare transfrmatin high quality utcmes, excellent patient experience and increased value fr the taxpayer. This includes having a jint understanding f the aim, visin and values, including having a rbust gvernance system; an identified target ppulatin with active and invlved patients; jint planning and develpment f end-t-end prcedures; widespread adptin f evidence-infrmed clinical pathways; use f cmprehensive quality and perfrmance metrics; use f imprvement science t drive better utcmes and value; deep analytical capability with links between clinical and financial data; agreed plans fr gain-sharing as well as risk-sharing; trust between varius arms f the partnership; and rbust systems fr planning and management. Hwever, it is unlikely that rganisatins r grups f rganisatins seeking ACO status wuld be able t prvide a fully acceptable assessment against each f these dmains. Instead, the assessment will help them identify their current capability, whilst prviding a framewrk fr prductin and implementatin f develpmental plans. These plans fall under the fur brad pillars f peple, prcess, finance and technlgy. 4 See fr example American Institute fr Research Bundled Payment fr Care Imprvement: Readiness self assessment, American Medical Grup Assciatin ACO readiness assessment, Health Dimensins Grup Health care refrm readiness assessment, etc. 5 Fr mre details, see 5

7 Pillars f implementatin: 1. Peple The mve twards ACO usually requires several changes at rganisatin and gvernance levels. This may include changes t rganisatin structure (e.g. member requirements r physician requirements), legal structure (e.g. frming a special purpse vehicle), r gvernance mdel. Fr example, use f the Purpse and understanding dmain under the readiness tl may indicate a lw scre n identifying a rbust apprach t gvernance that recgnises clearly wh has authrity t make what decisins and hw accuntability will be held. This can translate int an implementatin strategy f launching an ACO rganisatinal structure by chartering a leadership steering cmmittee with shared accuntability acrss the partners. It is als essential t engage patients and public fr reasns that are twfld: first, t help patients and public manage health cnditins sustainably, and secnd, t becme a sustainable ACO. 2. Prcess Prcesses, bth clinical and peratinal, cncern rles and respnsibilities fr key prcesses including ACO applicatin, quality reprting, cst reprting, disease management, admissin diversin, readmissin reductin, utcmes imprvement, leading practices/clinicaleffectiveness, cmmunicatins and marketing, service lines, etc. The Clinical practice dmain f the Readiness Assessment tl asks fr agreed evidence-infrmed pathways acrss the cntinuum f care. In depth assessment f a ptential ACO may indicate misalignment between the service lines and the ACO mdel. This wuld call fr develping an end-t-end primary care inpatient/utpatient clinical pathway as a slutin. 3. Finance Gain sharing incentivises rganisatins t wrk tgether t achieve utcmes. Once utcmes are achieved and savings made, it is imprtant t knw hw these savings will be shared acrss the supply chain f rganisatins. Thus, establishing a clear gain sharing mdel is key t a successful ACO. Fr example, if the reimbursement mechanism that has been established with cmmissiners invlves bundled payments, the ACO will need t establish cst prjectins and budgets fr each cmpnent (such as primary, acute, cmmunity, etc), as well as develp an incentive prgram based n meeting cst targets, quality targets, and efficiencies. An imprtant cncmitant f this mechanism is cultural change- rganisatins may need t start thinking f themselves as expense rather than revenue centres. 4. Technlgy All successful examples f implementing integrated care thrugh ACO-style cntracts identify that the Health Infrmatin Technlgy (HIT) capability is fundamental t the ability t imprve c-rdinatin, achieve better utcmes and manage the gain sharing and cntracting arrangements. This includes implementing Integrated Data Reprting Systems, Advanced Care Management Systems, as well we patient accessibility prtals. Figure 3: Pillars f implementatin 6

8 Outperfrm Case study Leveraging the Readiness Tl and Pillars f Implementatin described previusly, Optimity Matrix has assisted ACOs r rganizatins seeking ACO status, t fcus their attentin and effrts n key requirements needed t build a successful, integrated mdel f care delivery. The tls aggregate best practice guidelines and enable Prviders t fcus n cre building blcks that include near-term financial incentives and lng-term peratinal transfrmatin. Belw we describe tw case studies fcused n rganisatins at different stages f becming an ACO. Case Study 1: Readiness Assessment fr ACO Status Client: A leading central Lndn NHS Fundatin Trust alng with partner rganisatins including the lcal Cmmunity Trust, Mental Health Trust as well as Scial Care and Public Health, was preparing a business case t becme an early adpter a Whle Systems Integrated Care Prgramme by frming an Accuntable Care Organisatin. The prgramme aims t encurage lcal brughs t develp and implement plans fr jined up care in rder t achieve the best pssible utcmes fr target ppulatins. Prblem statement: The partnership wanted t t assure itself that it was taking the necessary steps t prepare fr the new cntracting arrangements, the risks had been prperly assessed and mitigating actins identified, and pririties fr peratinal transfrmatin had been identified. Our slutin: Using ur Readiness tl, Optimity Matrix cnducted an Evidence and Self-Assessment wrkshp with participants frm acrss the partnership. This invlved presenting an verview f published infrmatin n ACO readiness, infrmatin that highlighted best practice and strategies used by ACOs internatinally t prepare fr taking n the lead prvider rle. Thereafter, the participants in grups discussed each f the dmains against a list f questins t facilitate the discussin, and scred the partnership s readiness against an established scale. The readiness rating is essentially a risk assessment f the ability t clse the gap between current capability and that required fr the perfect system. The utcme f the wrkshp helped priritise thse areas which needed further discussin and develpment. 7

9 Figure 4: Readiness self-assessment- findings frm wrkshp Evidence wrkshp Resilience Cultural readiness Partnerships Health infrmatin Quality imprvement Care c-rdinatin Clinical practice Transparency f perfrmance Ppulatin and patient fcus Scpe Nt discussed Purpse and understanding Scale: 1- far frm ready 6- fully ready Accrdingly, an in-depth Readiness Review f the partnership s capacity and capabilities was undertaken. This review invlved infrmatin gathering frm key players acrss the partnership, t develp a plan f actin t strengthen the partnership s psitin t be cmmissined as an Accuntable Care Organisatin. Financial, clinical, peratinal and technlgy-specific interviews were cnducted with key peple frm the Acute, Cmmunity and Mental Health Trusts. This helped t take stck f where each rganisatin within thepartnership currently std, and what actins needed t be taken t mve twards ACO status. The way frward: The findings frm the review, including interviews utcmes and emerging prpsals fr a Business Intelligence tl will be presented t the Prject Bard. These findings will take the frm f a rute map, setting ut what key milestnes need t be delivered befre the rganisatin is ready fr ACO status. 8

10 Case Study 2: Implementatin Plan fr ACO Client: A US based partnership between a Private Payer, Hspital and Physician Netwrk recgnized the need t evlve their care delivery and financial perating mdels and get ahead f the current market shift twards accuntable care. Prblem Statement: The client was challenged by varying degrees f understanding ACO peratins and a legacy culture which did nt supprt a mve twards a truly integrated care delivery mdel. Our slutin: Optimity assessed business and clinical cmpetencies f the hspital and physician netwrk seeking t transitin t an Accuntable Care Organizatinal (ACO) mdel. As part f the assessment, Optimity assessed and develped recmmendatins arund rganisatin, prcess (clinical and peratins), technlgy, and financial areas, prviding pprtunities fr the hspital and physician system t evlve int a quality and cstbased integrated care delivery mdel. In their first year as an ACO, the client has been rated as ne f the tp perfrming ACOs in the US with significant savings and imprvements in quality. Example recmmendatins and cre cmpetencies identified as part f the assessment are prvided belw: Figure 5: ACO cre cmpetencies Peple Prcess Technlgy Financial Catastrphic patient management Cmmunicatin Organizatinal/Gvernance Structure Human Capital Management Recruitment Physician Incentive Plan Perfrmance Mnitring Training/Develpment Culture Change Management Enterprise Quality Reprting Cntracting/Netwrk Management Reimbursement Cmpliance Marketing and Prduct Develpment Value Based Benefits Meaningful Use: Fcused Gals Admissin Diversin Readmissin Reductin Disease Management Case Management Utilizatin Management Health & Wellness Prgrams Decisin Supprt Guidelines Expanding Primary Care Services Nutritinist Health Infrmatin Technlgy Electrnic Medical Recrds Integrated Data Reprting Systems Advanced Care Management Systems Care Transitin Electrnic Plans/Mnitring Decisin Supprt Predictive Mdeling Wrkflw/Autmated Triggers Patient Accessibility (Prtals) Patient Health Recrd Patient caching/guidance Supplementary health cmmunicatins Cst Reprting Actuary Gains Sharing/Revenue Mdel Capital Budget Planning Pay-fr-Perfrmance Mdeling Cmpetitive Cst Benchmarking Care Crdinatrs Nurse Practitiners 9

11 Table 1: Example recmmendatins Peple Challenges: Legacy prviders d nt buy int the ACO culture. Cnsumers are nt aware f apprpriate utilisatin. Recmmendatins: All prvider grups in the ACO are represented in leadership/executive cmmittee with shared accuntability. Cnsumers are empwered and incentivized t be accuntable fr apprpriate services. Prcess Challenges: Histrical referral patterns d nt align with ACO financial, delivery and reprting bjectives. Recmmendatins: Incentive mdel must accunt fr gegraphic variability and demgraphic risk. Care Delivery mdel must integrate services frm Health & Wellness t Disease/Case Management. Technlgy Challenges: Current system capabilities are nt able t integrate data frm disparate surces. Patient clinical and financial data are nt integrated t supprt hlistic reprting and enterprise peratins. Recmmendatins: Data strategy and infrmatin sharing is wned by all participants Enterprise Reprting addresses individual & ppulatin and financial & clinical data 10

12 Cntributrs: Vikas Arya Vikas is a Manager at Optimity Advisrs. He has ver twelve years f Healthcare leadership experience in the areas f Prgram Research and Design, Plicy Analysis, Infrmatin Systems Management, Enterprise Sftware Sales and Higher Educatin. Over the curse f his career, Vikas has prvided thught leadership and strategic guidance t Prviders, Cmmercial Payrs, Gvernment- Civilian Agencies, and Cnsumers in slving their challenges t share infrmatin acrss the cntinuum f care and in imprving patient experience and utcmes. Jacque Mallender Jacqueline is the funder and a partner at Optimity Matrix. She is a respected internatinal ecnmist specialising in the fields f health, justice and educatin. Jacque has extensive NHS experience acrss all clinical areas, and all care settings. Her experience includes: resurce allcatin; priritisatin; ecnmic appraisal; service review and audit; ecnmic evaluatin. She has wrked at a natinal level fr DH, NICE, NIHR, NHSII and ther agencies, and in all NHS regins at a strategic level and within health cmmunities. Jacque is als a funding Ccnvenr f the jint Campbell and Cchrane Ecnmics Methds Grup. Dris Stein Dris is a partner at Optimity Advisrs. She has 25 years f cnsulting and industry experience with functinal expertise in prgram management, strategic visining, business prcess re-engineering, system migratins, prcess imprvement, and team facilitatin. She leads the U.S. Gvernment prgrams area, and has extensive experience with integrated health prgrams and rganizatins. She has previusly cnducted an assessment fr a large hspital and physician system seeking t becme an Accuntable Care Organizatin (ACO). This invlved develping rganizatinal, financial, and peratinal recmmendatins t evlve int a quality and cst-based revenue and delivery mdel. Aarushi Jain Aarushi is a Cnsultant at Optimity Matrix. She supprts the cnsultancy team in carrying ut evaluatins, impact assessments and data analysis, and wrks n prjects fcussed primarily n the UK health sectr. Her prject experience cvers innvative frms f cmmissining and cntracting, including develping an utcme based cmmissining apprach fr a leading Clinical Cmmissining Grup, as well as assessing the readiness f a grup f prviders in Central Lndn t achieve Accuntable Care Organisatin Status. Fr further infrmatin cntact: Dr Niamh Lennx-Chhugani, NHS and Lcal Gvernment Lead, E: niamh.lennx-chhugani@ptimityadvisrs.cm, T: +44 (0)

13 Matrix Knwledge frmally jined the glbal cnsultancy grup Optimity Advisrs in September As its Eurpean arm, the newly cmbined business trades as Optimity Matrix t run the public plicy arm f Optimity Advisrs glbal peratins. Fr mre inf g t: Optimity Matrix and Matrix Knwledge are trading names f TMKG Limited (registered in England and Wales under registratin number ) and its subsidiaries: Matrix Decisins Limited (registered in England and Wales under registratin number ); Matrix Insight Limited (registered in England and Wales under registratin number ); Matrix Evidence Limited (registered in England and Wales under registratin number ); Matrix Observatins Limited (registered in England and Wales under registratin number ); and Matrix Knwledge Grup Internatinal Inc. (registered in Maryland, USA under registratin number D ). Disclaimer: In keeping with ur values f integrity and excellence, Optimity Matrix has taken reasnable prfessinal care in the preparatin f this dcument. Althugh Optimity Matrix has made reasnable effrts, we cannt guarantee abslute accuracy r cmpleteness f infrmatin/data submitted, nr d we accept respnsibility fr recmmendatins that may have been mitted due t particular r exceptinal cnditins and circumstances. Cnfidentiality: This dcument cntains infrmatin which is prprietary t Optimity Matrix and may nt be disclsed t third parties withut prir agreement. Except where permitted under the prvisins f cnfidentiality abve, this dcument may nt be reprduced, retained r stred beynd the perid f validity, r transmitted in whle, r in part, withut Optimity Matrix s prir, written permissin. TMKG Ltd, 2014

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