Building an Accountable Care Organization. Jean Malouin, MD MPH University of Michigan Health System September 21, 2012

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1 Building an Accountable Care Organization Jean Malouin, MD MPH University of Michigan Health System September 21, 2012

2 Agenda UMHS overview PGP demo ACO precursor Current efforts underway Role of primary care

3 University of Michigan Health System 1.7 million ambulatory visits per year 46,000 hospital admissions per year 45 outpatient Health Centers 22,600 staff 2,800 faculty 1,075 house officers 695 medical students

4 Physician Group Practice (PGP) Medicare Demonstration The University of Michigan participated in the PGP Demonstration along with 9 other large physician groups from Prototype for ACO; Aimed at finding out whether care coordination interventions can generate overall Medicare savings for a population of Medicare patients Besides saving money, UM also had to achieve quality metrics Shared savings model; if UM saves money, we get money back. Amount based on both cost savings and quality. Cost/quality weighting: Year 1 = 70% / 30%; Year 2 = 60% / 40%; Years 3, 4, 5 = 50% / 50%

5 UMHS Results from Participation Successful each performance year in earning shared savings and achieving quality metrics One of 2 groups that achieved savings all 5 years Saved the Medicare Program over $46 million Earned shared savings of over $17.6 million Received an additional~$3 million for PQRS participation Annual per-member savings $1,155 (overall), $2,072 (dual-eligible patients) JAMA article 9/12/12: savings not due to risk-adjustment

6 Key Clinical Interventions Overall strategy: Decrease preventable admissions/readmissions, manage chronic conditions, coordinate care of complex/costly patients Transitional care interventions Call-Back Program for patients discharged from hospital and ED Transitional care clinics in Geriatrics, Cardiology and General Medicine Sub-acute nursing home program Home care Care coordination interventions for high risk/high cost patients Complex care coordination for frail elders, dual eligible Medicare Disease management program for heart failure and diabetes Palliative care consult service and hospice program for end of life care Year 4 Patient centered Medical Home (PCMH) implemented across primary care

7 UMHS Complex Care Management Program (CCMP) Centrally-based complex care coordination 4.5 FTE MSW/RN, 2.0 Patient Care Assistants 1.0 Director (Nurse), 0.2 Medical Director Target populations Medicare, Medicaid HMO, County insurance Functions Manage chronic conditions and coordinate care of complex and costly patients (Frail elderly, dual eligible, disabled/mental illness, ESRD, transplant) Work in collaboration with primary care physicians Success enhanced by emphasizing more local model 7

8 Lessons Learned: Population Health As an Academic Medical Center (AMC), UM has high risk, high cost patients Frail elders Dual eligibles Multiple diseases and disabilities Behavioral and social problems High risk/high cost patients have multiple providers and sites of care; many patients are co-managed Patients have better outcomes if they are within a system (but are probably less sick) ACO needs information about where patients get care and what care they receive

9 The next step: Pioneer ACO Demonstration began 1/1/2012; 3-5 years Shared savings model - ACOs are at risk for Medicare FFS expenditures and will move to partial capitation if successful Need to meet 33 quality metrics Patient/Caregiver experience Care coordination/patient safety Preventive health At risk populations (e.g., diabetes, hypertension, CAD, etc.) Beneficiaries are aligned based on primary care, geriatrics, and ambulatory specialties if no/little primary care UMHS is partnering with community physician group (Integrated Health Associates)

10 Pioneer ACO: UMHS Focus Areas Ongoing primary care redesign Increase involvement of specialists in ACO development Improve processes to decrease unnecessary admissions/ readmissions

11 Primary care redesign Based on MIPCT PCMH Demonstration Multi-payer; puts resources into primary care; aligned patients population is similar to Pioneer ACO Increase focus on patients in transition, high cost, and high risk patients Place Care Navigators in primary care, partner w/ccmp Strengthen clinical teams Improve access Navigate the medical neighborhood Provide feedback to clinics on quality and efficiency

12 Michigan Primary Care Transformation Project Advancing Population Management 12 PCMH Services PCMH Infrastructure Complex Care Management Functional Tier 4 Care Management Functional Tier 3 Transition Care Functional Tier 2 Navigating the Medical Neighborhood Functional Tier 1 All Tier services plus: Home care team Comprehensive care plan Palliative and end-of life care All Tier 1-2 services plus: Planned visits to optimize chronic conditions Self-management support Patient education Advance directives All Tier 1 services plus: Notification of admit/discharge PCP and/or specialist follow-up Medication reconciliation Optimize relationships with specialists and hospitals Coordinate referrals and tests Link to community resources Health IT - Registry / EHR registry functionality * - Care management documentation * - E-prescribing (optional) - Patient portal (advanced/optional) - Community portal/hie (adv/optional) - Home monitoring (advanced/optional) Patient Access - 24/7 access to decision-maker * - 30% open access slots * - Extended hours * - Group visits (advanced/optional) - Electronic visits (advanced/optional) Infrastructure Support - PO/PHO and practice determine optimal balance of shared support - Patient risk assessment - Population stratification - Clinical metrics reporting Prepared Proactive Healthcare Team Engaging, Informing and Activating Patients P O P U L A T I O N M A N A G E M E N T *denotes requirement by end of year 1

13 Increase Specialist Involvement in Pioneer ACO Goals Specialists are involved with appropriateness of care Specialists and primary care physicians need to strengthen coordination and communication, or improve The Medical Neighborhood Specialists need to decide how much responsibility they will take for which patients Some patients may need a Specialty Medical Home Some patients should be managed in primary care with specialty support When are specialists involved in transitions of care? Specialists must engage with quality measurement and performance improvement

14 Improve Processes to Decrease Unnecessary Admissions and Readmissions Minimize unnecessary Emergency Department use Clinic access, hot-spotters program, better care coordination, develop urgent primary care Develop resources so ED can send people home safely: rapid clinic access, home visits, direct SNF admission Improve ED coordination with non-umhs providers Increase institutional focus on transitions of care

15 PCMH as the Foundation for ACO Population Management Source: Premier Healthcare Alliance 15

16 Family Medicine: Phased Approach To PCMH Implementation Phase 1: Team development, role definition (2005) Phase 2: Point-of-care population management Phase 3: Population management and care coordination, access improvement (2009)

17 Primary Care Delivery System Redesign Define and expand team member roles Physicians - NP/PA Medical Assistants - Social Worker Outpatient Office Assistant - Dietician Pharmacists - Data Manager Nurses - Patients/Families Redesign the work appropriate to level of training/professionalism of the team member 17

18 Managing Populations: Tiered approach to care management IV. Most complex (e.g., Homeless, Schizophrenia) III. Complex Complex illness Multiple Chronic Disease Other issues (cognitive, frail elderly, social, financial) II. Mild-moderate illness Well-compensated multiple diseases Single disease I. Healthy Population <1% of population Caseload % of population Caseload % of population Caseload~1000

19 Our Philosophy: Stratify Risk, Maximize Health of ALL Patients Tiers 3 and 4 Patients with multiple co-morbidities, high risk Goal: Focused intense interventions to minimize complications and unnecessary utilization, maximize function and quality of life Tier 2 Patients with one or more chronic, stable conditions Goal: Self-management, improve intermediate outcomes, prevent long-term complications from disease Tier 1 Healthy patients, no chronic conditions Goal: Keep them healthy!

20 Resident Role: Family Medicine Key to involve residents in daily PCMH work THE WAY WE PROVIDE CARE! Learn by doing Teach teamwork and team model of care Role of non-physicians in care model Team meetings (At UMHS, held monthly and carved out of patient care time) Learn/practice philosophy that more is not always better when it comes to patient care

21 In Summary Population management is a team sport!

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