INTRO TO THE MICHIGAN PIONEER ACO 101: THE BASICS. Karen Unholz, RN, BSN

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1 INTRO TO THE MICHIGAN PIONEER ACO 101: THE BASICS Karen Unholz, RN, BSN

2 Origins of the Accountable Care Organization ACOs originated from the Patient Protection and Affordable Care Act (Healthcare Reform) which was signed into law on March 23, One of the goals of healthcare reform was to find ways to deliver care that resulted in better quality at lower costs. The Centers for Medicare & Medicaid Services (CMS) was the first to pilot ACOs with the Pioneer ACO program. 2

3 What is an Accountable Care Organization (ACO)? Groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. Goal: coordinated care is to ensure that patients, especially the chronically ill, get THE RIGHT CARE AT THE RIGHT TIME, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

4 Different Types of ACOs Medicare Shared Savings Program (MSSP) Advance Payment ACO Model Pioneer ACO Model

5 Pioneer ACO Calculation of Shared Savings/Losses Performance year expenditures < applicable benchmark in a given year AND quality performance metrics are met = ACO will share in portion of savings Performance year expenditures > applicable benchmark in a given year = ACO required to pay back a portion of the losses Potential gains/losses are greater for Pioneer ACOs than ALL other Medicare Shared Savings program options

6 History of the Michigan Pioneer ACO Selected as one of only 32 original Pioneer Accountable Care Organizations nationwide start date January 1, Only 19 remaining Pioneer ACOs in the nation as of Historically, our attributed Medicare FFS population is one of the highest in the country - roughly $18,000 Per Member Per Year (PMPY) the national average is $10,000 Our mission is to provide high quality healthcare services that improve the health of the population and the communities we serve.

7 Who is the Michigan Pioneer ACO? Over 180 Primary Care Physician Members Comprised of Private Physicians, Wayne State University Physician Group and DMC Physicians Approximately 18,000 Aligned Medicare Fee-For- Service Beneficiaries Patient Populated Located Wayne, Oakland and Macomb Counties

8 ACOs: Focused on the Triple Aim There are 3 main goals of an ACO, often referred to as the Triple Aim: 1. Better health for the population 2. Higher-quality care 3. Lower costs of care

9 Quality Measures Quality is an important piece in the ACO. There are 33 quality metrics that CMS uses to rate the quality of care the ACO is providing to patients. If the ACO does not meet certain quality metrics, it cannot receive shared savings. The quality metrics are distributed across 4 domains: Patient/Caregiver Experience (CAPHS/patient satisfaction survey) Care Coordination/Patient Safety (includes Meaningful Use Attestation) Preventative Health At-Risk Populations (specifically: CHF, CAD, DM, Ischemic Vascular Disease, Depression)

10 Changes in Care Delivery To meet the goals of an ACO, we must change the way we deliver and provide care. Because patients can still go anywhere for care, ACO providers and facilities must work together to help coordinate care for the patients we serve.

11 How do we traverse the care continuum? Medical Management: Registered Nurses, trained Care Coordinators Post-Hospitalization calls Transportation support Support alignment between PCP and patient Focus on PCP appointment within 7 days of hospital discharge Referral for Home Care Services Early Intervention Programs Focus on patients with ambulatory sensitive conditions that may benefit from additional support in the home to assist in self management Collaboration with PCP and specific Home Health Agencies

12 How do we traverse the care continuum? Personalized Advanced illness management program for the most chronically ill patients. Multidisciplinary Care planning approach Provide services that are not currently available to Medicare beneficiaries 24 hour nurse response program Program is funded by the MI Pioneer ACO and patient must meet criteria for admission into the program

13 How do we traverse the care continuum? Skilled Nursing Facility (SNF) Follow up Follow MI Pioneer ACO patients who are transferred to a SNF at discharge from the hospital Focus on establishing a continuum for the patient that includes the PCP Preserve the patient s benefit Ensure appropriate services are in place prior to the patient discharge Continued follow up after discharge for support

14 How do we traverse the care continuum? 3 Day Waiver Program Allows MI Pioneer ACO patients to be admitted directly to a SNF without the required 3 day inpatient hospital stay CMS approved facilities are partners in the program Ambassador Nursing Center Medilodge Of Milford Oakpointe Senior Living Center Regency Heights Nursing and Rehab Center Sanctuary at White Lake

15 Michigan Pioneer ACO 2014 Results The Top Performing Pioneer Accountable Care Nationwide First Two Years of Performance resulting in nearly $24 Million in Medicare Savings Continuous Quality Improvement Year-Over-Year Nationally Recognized Post Acute Quality Initiatives

16 Why is the Michigan Pioneer ACO good for your patients? Quality-focused Cost-effective Optimizes communication Creates a continuum of coordinated, integrated care

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