Kim Olmedo, LCSW, CCM CSW-G Social Work Manager, Silverback Care Management

Transcription

1 Kim Olmedo, LCSW, CCM CSW-G Social Work Manager, Silverback Care Management

2 According to AARP, about 8000 people turn 65 every day The Medicare Trustees have estimated that Medicare will run out of money in 2026 The good news : this date is 2 years later than anticipated, in part due to slowed spending, primarily for skilled nursing care

3 Creation of the CMS Center for Innovation in 2009 Accountable Care Organizations (ACOs) A platform for doctors, hospitals and other health care providers to come together to decide what is best for the Medicare beneficiaries they serve

4 The Challenge Medicare has significant challenges in program management and sustainability Our Opportunity To be a part of the solution to come together to help shape the future of Medicare The Model Pioneer ACO Health care organizations and providers that are already experienced in coordinating care for patients across care settings

5 Texas Health Resources and North Texas Specialty Physicians submitted an application to CMS in August 2011 Pioneer ACO status was granted in October 2011 Plus became operational January 1, 2012

6 Patients 41,000 traditional Medicare beneficiaries Primarily in Tarrant, Johnson, Parker, Dallas, and Collin counties Patients are aligned based on the physicians who provide the plurality of their care Physicians 600 NTSP physicians; about 200 are PCPs 140 Texas Health Physicians Group (THPG) PCPs and 40 THPG physician extenders

7 Save Medicare dollars Provide quality health care

8 All ACOs must adhere to 32 quality metrics mandated by CMS

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10 Managing a previously unmanaged population Care management plays an integral role in the ACO model

11 CMS shared claims data with Plus This allowed Plus to see where Plus beneficiaries were getting their care, and the type of care they were getting

12 In 2012, UM services were provided by Gordian. All providers were asked to notify Gordian of services being provided to Plus members, including hospital admissions (acute care, LTAC and Rehab), home health services, skilled nursing admissions and DME requests In April 2013 this service was brought back under the auspices of NTSP through a new company, Silverback Care Management

13 Plus members are still traditional Medicare beneficiaries They still have the choice to use any health care provider, even providers not on the Plus Preferred Provider list We still ask all providers to notify Silverback, so that we know the services our members receive, and so our case managers can assist when needed

14 Developed preferred providers These providers go through a formal process that looks not only at costs based on claims data, but that also looks at a variety of quality measures Costs are weighted based on RAF scores, which is a risk adjustment index

15 Care management team was gradually implemented during 2012 Initially there were 2 nurses doing a Discharge Transitions program from THFW One nurse embedded in THFW Emergency Department on the weekends to do ED Diversion 2 social workers by the end of the year, monitoring patients at THSW and assisting with discharge planning, as well as providing community case management

16 Nurses identified patients in the hospital who were at the highest risk of being rehospitalized within 30 days Following discharge, the patient received at least weekly phone calls from the nurse

17 Nurse embedded in ED By identifying Plus patients in the ED, she was able to prevent some admissions by identifying other services, such as SNF placement when qualified, or direct admission to inpatient rehab

18 This team now includes 7 social work case managers and 3 RN case managers We can do: Home visits Referrals to community services Provide services across the care continuum Coordinate care between health care providers Assist discharge planners in hospitals and skilled nursing facilities

19 A three-tiered predictive modeling system helps us identify patients who might be in need of care management services

20 These are healthy patients, or those with a stable chronic disease state Patients are engaged, and receive most care at the primary care level Patients with more PCP visits than ED visits No hospitalizations in the past 12 months

21 These patients are at risk for moderate to serious health issues Have had between 2-5 ED visits in the past 12 months More ED visits than PCP visits At least one hospitalization in the past 12 months

22 These patients have established disease states and/or may be in the terminal stages of chronic illnesses 5 or more ED visits in the past 12 months More than 2 acute care admissions in the past 12 months Multiple system of care contacts

23 Plus is on pace to save $10 million annually in Medicare spending Plus is meeting all quality metrics

24 At this time, Plus has notified CMS of our intent to withdraw from the Pioneer ACO program, due to possible substantial penalties At this time, we are still a Pioneer ACO, and as recently as Friday we were still in talks with CMS on how we might remain in the Pioneer ACO program

25 It is very likely that traditional Medicare will have some level of management There are still 23 Pioneer ACOs, and more and more shared savings ACOs are being created Medicare supplement products are attempting to manage their members, and United Healthcare is demonstrating savings with this population in 5 cities across the country