CMS Innovation Center Improving Care for Complex Patients

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1 CMS Innovation Center Improving Care for Complex Patients ECRI Institute Dr. Patrick Conway, M.D., MSc CMS Chief Medical Officer and Deputy Administrator for Innovation and Quality Director, Center for Medicare and Medicaid innovation Director, Center for Clinical Standards and Quality November 6, 2014

2 Delivery system and payment transformation Historical State Producer Centered Volume Driven Unsustainable Fragmented Care FFS Payment Systems PRIVATE SECTOR PUBLIC SECTOR Ideal Future State People Centered Outcomes Driven Sustainable Coordinated Care New Payment Systems and Policies (and more) Value based purchasing ACOs, Shared Savings Episode based payments Medical Homes and care mgmt Data Transparency 2

3 CMS Innovations Portfolio: Testing New Models to Improve Quality Accountable Care Organizations (ACOs) Medicare Shared Savings Program (Center for Medicare) Pioneer ACO Model Advance Payment ACO Model Comprehensive ERSD Care Initiative Primary Care Transformation Comprehensive Primary Care Initiative (CPC) Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration Independence at Home Demonstration Graduate Nurse Education Demonstration Bundled Payment for Care Improvement Model 1: Retrospective Acute Care Model 2: Retrospective Acute Care Episode & Post Acute Model 3: Retrospective Post Acute Care Model 4: Prospective Acute Care Capacity to Spread Innovation Partnership for Patients Community-Based Care Transitions Million Hearts Health Care Innovation Awards State Innovation Models Initiative Initiatives Focused on the Medicaid Population Medicaid Emergency Psychiatric Demonstration Medicaid Incentives for Prevention of Chronic Diseases Strong Start Initiative Medicare-Medicaid Enrollees Financial Alignment Initiative Initiative to Reduce Avoidable Hospitalizations of Nursing Facility Residents 3

4 Independence at Home GOAL: Testing the effectiveness of providing chronically ill beneficiaries with home based primary care. Medical practices provide chronically ill beneficiaries with homebased primary care. Practices must serve at least 200 targeted beneficiaries living with multiple chronic diseases to be eligible. Incentive payments for practices successful in: o meeting quality standards; and o reducing total expenditures. 14 independent practices and 1 consortia participating in IAH. October 2014

5 Pioneer Accountable Care Organizations (ACO) Policy and programmatic support for improving care for complex patients Full claims data + aggregate utilization metrics Accountability for overall cost and coordination of care Quality measure set 3 day SNF rule waiver Population based payment Shared learning among Pioneers reveals intense focus on: Patients with 3+ chronic conditions Patients with multiple medications and providers Patients with high spending and a high risk for admissions/readmissions and ED utilization Risk stratification data analytics Care coordination and management to bridge time and space between in person visits Post Acute Care transitions

6 Draft Integrated ACO Concept CMS is currently assessing the feasibility of a Medicare Medicaid Integrated ACO Model that would focus on dually eligible beneficiaries and require a 3 way agreement between CMS, state, and ACO Provider. Might Build on CMS Pioneer ACO Model and Shared Savings Program and early state Medicaid ACO experiences Full claims data + aggregate utilization metrics for both Medicare and Medicaid Accountability for overall costs in both programs and cost shifting between programs Encourage coordination of care, integration with LTSS/LTC and Behavioral Health Care Model Domains support duals, a complex and vulnerable population Provision of all Medicare and Medicaid benefits Patient centered care coordinated through care manager Interdisciplinary care teams Integration of behavioral health care Management of care transitions Management of long term supports and services Integration of community based supports and services Language translation services, culturally appropriate care EHR usage, including ability to extend EHR to community based providers

7 Comprehensive Primary Care initiative Risk Stratified Care Management for High Risk Patients: All CPC practices must demonstrate empanelment and risk stratification of the whole practice population, and care management of those at highest risk. Practices receive a care management fee in support of this work, plus support through shared learning. Progress by mid 2014: More than 95% of the 2.7 million patients active at CPC practices were empaneled to a provider or care team. All practices performed risk stratification, focusing on patients at highest risk for poor outcomes, patients with multiple chronic diseases and patients with recent hospitalizations/er visits. About 20% of all patients were identified as high risk. The average number of care managers per practice had increased from 1.35 to 2.5 since late 2012.

8 Primary Care for Complex Patients Draft thoughts for a new model to improve primary care for complex patients: Complexity defined by combination of high HCC scores, advanced age, disability, frailty, behavioral health issues, mental health diagnosis Covers broad range of medical, geographic, socio economic circumstances Requires engagement with community and social service resources Multi payer support Accountability for cost and quality Model development would focus on: Necessary practice infrastructure Possible waivers for regulatory barriers that interfere with care for this population Applicable, meaningful quality metrics Meet minimum complex patient numbers for participation

9 State Innovation Models Initiative States are developing mulitpayer approaches: Integrating behavioral health and primary care Developing strategies for improved care coordination Implementing Health Homes Working with communities on developing long term support services Developing state wide population health plans to address social determinant of health Round 2 state innovation model application resulted in 32 applications

10 Innovator Accelerator Program Offering states technical assistance in: Data analytics Quality measures Model development Disseminating best practices Rapid cycle evaluation Initial work will include changes in care delivery such as: Substance Use Disorder (SUD) Changes in care delivery Behavioral health Long term services and supports & community integration Superutilizers Perinatal

11 Health Care Innovation Awards (Round 1) Working with Complex Patients Awardee Brief Description University of The University of Texas Health Science Center at Houston program provides comprehensive care (CC) through a Texas- special high-risk children's medical home where both primary and specialty services are provided in the same clinic during the same visit. The program is targeting 290 complex pediatric children (<18 years old) with a >50% estimated Houston risk of hospitalization in the next year with usual care and has served 197 children to date. The comprehensive care (UTH) clinic is staffed by a diverse team of pediatricians and pediatric nurse practitioners who are highly trained and experienced and continuously accessible to treat these complex children. Through intensive integrated and coordinated care, the program reduces serious illnesses, emergency room visits, hospitalizations, pediatric ICU admissions, total hospital and ICU days, and total health care costs while improving the care, health, and quality of life for these fragile FirstVitals REMSA children. FirstVitals is targeting 600 patients with or at risk for diabetic peripheral neuropathy (DPN) and retinopathy by implementing early detection screenings (DPN and retinal exams) and a chronic disease management program that includes telehealth diabetes and blood pressure monitoring with the goals of improving glycemic control and preventing complications associated with DPN and retinopathy. Integrated Care coordinators train participants to use real time blood glucose and blood pressure meters, internet-connected tablets for health education and social supports, and proprietary home-based imaging and sensing devices to track key clinical information and facilitate easy communication with the patient. REMSA s Community Health Programs offer new care and referral pathways within the emergency medical services system. One of the 3 pilots being tested in this Health Care Innovation Award is the Community Paramedicine program, which uses specially trained paramedics to perform in-home delegated tasks to improve the continuity of care from hospital to home, perform point of care lab tests and improve care plan adherence. To date, the Community Paramedicine program has served over 430 beneficiaires, with many of these patients having CHF and COPD.

12 Health Care Innovation Awards (Round 2) Working with Complex Patients Awardee Four Seasons Compassion for Life Yale University Brief Description Palliative care focuses on improving quality of life for patients with advanced illness through relief of physical and emotional suffering (symptom management), communication, goal discussions around risks/benefits of medical intervention, and coordination of care among healthcare providers. Community-based palliative care (CPC), a new model, spans inpatient and outpatient settings and features interdisciplinary collaboration and integration of palliative care into the healthcare system, continuity of care across transitions, and longitudinal, individualized support for patients and families. Four Seasons (FS) will extend its FS CPC model from 4 to 14 NC counties and serve up to 10,000 beneficiaries with this model. The FS CPC care delivery model is anchored by a lead organization, that serves as the hub for local partners including hospitals, nursing homes, and assisted living facilities. Care is provided across settings, including patients' homes, by care teams: A "non physician" clinician (nurse practitioner [NP] or physician assistant [PA]) and/or physician provide clinical care; a social worker and chaplain (as needed) address psychosocial and spiritual well-being as well as relevant non-medical issues (e.g., paying for medications, transportation concerns). Yale s innovative program targets 7,000 elders and others with impaired mobility who contact for falls or lift assists but choose to remain at home. It trains EMS providers to perform enhanced evaluations during the initial call, and also train a new group of paramedics to make follow-up visits for detailed risk assessments, home medication reviews, and referrals to primary care doctors and skilled home services. A pilot study in one representative town confirmed that lift assist calls identify a patient population that is medically fragile and likely to incur substantial healthcare costs in the ensuing days or weeks. Because lift assist patients share many risk factors, such as advanced age, cognitive and physical disability, limited mobility, social isolation, and polypharmacy, with patients who fall, Yale s community interventions were modeled after previously proven fall prevention strategies.

13 Innovation Center 2015 Looking Forward We re Focused On Portfolio analysis and launch new models to round out portfolio Implementation of Models Monitoring & Optimization of Results Evaluation and Scaling Integrating Innovation across CMS 13

14 Contact Information Dr. Patrick Conway, M.D., M.Sc. CMS Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer

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