ACO Operational Innovations Featuring the Winners of NAACOS Call for Innovation

Transcription

1 ACO Operational Innovations Featuring the Winners of NAACOS Call for Innovation January 14, 2014 Brian Silverstein, MD Managing Partner HC Wisdom April 24,2014

2 AGENDA INNOVATION OPPORTUNITIES FEATURED INNOVATIONS OPEN MIC GROUP SHARING

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4 Other Industries Have Many Examples of Innovation 4

5 Health Care Has Many Innovations 5

6 We Know Capitation Can Work. What Are Going To Be The ACO Innovations? - How do we engage beneficiaries without changing benefit design? - How do you manage with an attribution model (vs. enrollment)? - What is the best way to manage multiple populations with different needs (Commercial, Medicaid, Medicare)? - How do we coordinate care in an open network with different EHRs? - Can the shared savings model have a powerful enough incentive?

7 AGENDA INNOVATION OPPORTUNITIES FEATURED INNOVATIONS OPEN MIC GROUP SHARING

8 Amazing ACOs Innovations Young K. Joo Director of Pioneer ACO Steward Health Care Network Richard J. Lucibella CEO Accountable Care Options Kathy VanOsdol ACO Clinical Informatics Indiana Lakes Quality Partners ACO, LLC 8

9 National Association of ACOs 2014 Spring Conference April 24,

10 Who is Steward Health Care System? Largest integrated, communitybased system in New England 11 owned hospitals including 1 LTAC (NE Sinai) - 25% of acute hospital beds across eastern Massachusetts - Largest Inpatient Behavioral Health Provider in E Mass 2 affiliated hospitals Largest community physician network in New England Serving over 1,200,000 patients annually Approx. 4,000 on medical staff - 2,700 affiliated through Steward contracting network (SHCN) employed by Steward Medical Group Additional Key Elements: Steward Home Health & Hospice PET Imaging Company Steward Home Medical Equipment Innovative Insurance Products US Family Health Plan Steward Employees Steward Community Care Steward Community Choice 10

11 What is Steward Health Care Network? Integrated Community-Based Value Engine Value derived from increasing access to Cost Efficient, High Quality Community Based care Steward Health Care Network s Capabilities: What do we do: TME cost management Quality Improvement Expand Access to Community-based Care How do we do it: Community Based physician led governance Population Health Management Access Partnerships with key stakeholders: insurers, governments, employers Innovative Insurance Products Pioneer Performance: One of 23 participating Medicare Pioneer Accountable Care Organizations (ACO) and one of 13 original participants who successfully achieved 100% quality and generated savings in the first performance year for Medicare beneficiaries and the Medicare program. 11

12 Steward s Population Health Strategy has been key to delivering high quality, low cost, right site care Care Management Deployment Services Combined build efforts with outsourced support to expedite ramp up Care Management deployment and engagement with Members Emergency Department Redirection Clinical Integration Avoid costly delivery of services in the ER that are more appropriately delivered by PCP Patient Improve quality and prevention through clinical protocols and standardization Emergency Room Primary Care Clinic Readmission Prevention CHF Program Care Mgmt Plans for CHF patients with multiple comorbidities Inpatient Hospital Specialty Care Clinic Post Acute Home Complex & Chronic Patient Management Acute discharge planning, medication reconciliation and follow up visits. SNF Management (RAP) Nurses Targeted focus on SNF LOS reduction and discharge planning Risk Stratify to identify and manage the high risk/high cost members to prevent admission and generate medical cost savings 12 12

13 PHM Across the Continuum of Care Operational challenge: Identifying and coordinating care for Pioneer Medicare FFS beneficiaries who seek care from non-steward Providers and Facilities Inpatient Emergency Rooms Urgent Care Clinic Skilled Nursing Facility ( SNF ) Long-term Acute Hospital Psych Hospital/ Detox Units Inpatient Rehab Home Health 13

14 Options for identifying Pioneer Beneficiaries Beneficiary ID s oneself as associated with Steward s Pioneer ACO Five Pioneer ACOs in Massachusetts with high-turnover rate each performance year CMS/CMMI Issued Pioneer Beneficiary ID Card Design limitations applied to reduce confusion with official Medicare card Manual Look-Up of Pioneer Patient Rosters Steward s Pioneer ACO has >68,000 beneficiaries across eastern Massachusetts 14

15 Innovative solution for maximizing PHM efforts PatientPing allows Steward to: Extend the reach of population health management and minimize the administrative burden PatientPing allows Steward to work with any provider that sees our patients No contracts required between providers as PatientPing restricts data sharing to only common patients Instant onboarding for new providers Enhance collaboration with providers beyond Steward s network Post-acute facilities are collaborating more closely with our Care Management staff Data sharing to improve performance on quality and efficiency (i.e. admission/discharge info, LOS, etc.) 3. Send Pings to all members of a patient s provider care team (PCP, specialists, nurse navigators, etc) 4. Adapt to and integrate with care management workflows 5. Collect data and monitor performance 6. Checkboxes and ability to create to-do s for nurse managers Generate reports on SNF performance Maintain Data Security and HIPAA Compliance All technical, physical, and administrative safeguards in place Backed by data, security, and privacy insurance policy 15

16 How does Steward use PatientPing? Use 1 Help SNF identify our patients Use 2 Send SNF pertinent information on our patients Use 3 Get notified in real-time when SNF see our patients, regardless of referral source Use 4 Collect quality data from SNF Use 5 Notify SNF when patients are readmitted to our hospitals *Note: SNF is an example of out-of-network provider but PatientPing can be applied to any provider type 16

17 Use 1: ACO Patient Identification Note: Figures depict a test environment with no real patient data. PatientPing automatically collects data on admissions to SNF SNF identifies patient s ACO Patient Name: Jude Osmond ACO: Steward 17

18 Use 2: Send pertinent data to SNF Note: Figure depicts a test environment with no real patient data. Care Instructions Patient Name: David Hannan ACO Care Manager: Amy Gideon Phone: agideon@mail.com PCP: Dr. Grace Carver Preferred Hospice: Good Hope Center Preferred HHA: Steward Home Care At Discharge: Call ACO 24 hours prior Steward shares pertinent information with SNF 18

19 Use 3: Receive real-time Pings Note: Figure depicts a test environment with no real patient data. Track from any referral source Steward receives real-time notifications when patients are admitted to or discharged from SNFs, regardless of referral source 19

20 Use 4: Collect Quality & 3-Day SNF Waiver Data Note: Figure depicts a test environment with no real patient data. This image cannot currently be display ed. Quality First Name Last Name ACO LoS MBI FIM MOLS T? Jude Osmond Steward 14 days 35 NA Y Brian Hanan Steward 7 days NA 3 Nancy Millard Steward 25 days NA John Chao Steward 10 days Maggie Hill Steward 12 days Care plan within 48 hrs? Warm handoff? Discharge Disposition Y Y Home N N Y HHA 4 N Y Y Home 79 NA Y Y Y ER 95 NA Y Y N Deceased Steward securely collects any quality data they would like to receive from SNFs PatientPing will automatically aggregate most data fields 20

21 Use 5: Ping SNFs on (re)admissions back to Steward hospitals Note: Figure depicts a test environment with no real patient data. Morton SNFs can receive real-time notifications when patients (re)visit or are (re)admitted to Steward hospitals *Note: Requires hospital ADT data to PatientPing to facilitate 21

22 This image cannot currently be display ed. Richard J. Lucibella, C.E.O.

23 Company Profile: Florida based- Track One Operational Start- July 2012 Assigned Beneficiaries- 6,800 Participants- 35 Providers; 23 locations Primary Care Owned, Controlled and Exclusive Proudly For Profit Interim Year 1 Results- 11% Shared Savings

24 The Game Plan Defragment Patient Care Challenge Physicians to treat beyond the Chief Complaint Challenge Patients to truly partner in their care

25 Choose the Right Tool Defragment Patient Care Challenge Physicians to treat beyond the Chief Complaint Challenge Patients to truly partner in their care

26 Changing Practice Behaviors Walk before you run TMI The Transformation Killer HEDIS is NOT just a Quality Set

27 What We Did Q1: Preventive Measures: Staff eg: Mammograms, Colorectal screens, Vaccinations, Meds reconciliation, MU1, LDL control Q2: Chronic Disease Management: Physician eg: Meds Mgmt, A1C control, LDL control, BP control, Tobacco Cessation, Falls screen, Depression screen Q3: Patient Satisfaction: Team eg: Care Coordination, CAHPS Surveys, Patient Education, PCMH

28 How We Did It: Face to Face, physician to physician interactions Prospective and Retrospective chart review 7 Minute Miracle Videos: - Basic operations and paper flow - E&M - CHF - COPD - Meds Reconciliation - Diabetes - MRA Coding

29 What we didn t do Complex analytics Dictating specialist and hospital referral patterns Contracting Specialists and ancillary providers

30 Actionable Data to Accelerate Innovation Indiana Lakes ACO IU Health Goshen Kathy VanOsdol BSN, RN, Graduate Certificate in Clinical Informatics

31 Indiana Lakes MSSP ACO Indiana University Health Goshen January 1, 2013 Start 8,000 MSSP ACO lives 1,400 Medical Home Plan Health System Employed Colleagues 600 Medical Home Plan Commercially Insured Beneficiaries

32 The ACO Gerbil Wheel 33 Measures Data is in silos Free text charting Lack of standardization Disparate EMRs Patient and Provider Engagement

33 The Links Mapped clinical data from the EMRs of NextGen, eclinicalworks and emds across 24 ACO primary care practices. Integrating HIE data, claims, inpatient utilization reports, and patient survey responses into the same dashboard.

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42 Real Time Patient-Level Reporting Real Time PopulationLevel Reporting

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44 Actionable Data & Engagement Integrate survey innovations with algorithms of care. Automate ACO data capture & improve performance outcomes. New risk stratification opportunities; predictive power of health literacy and behavior change motivation.

45 Where To From Here? Pharma interest in funding the innovative survey tools in exchange for de-identified data. Opportunity to broaden this innovation at little or no cost to ACO s.

46 AGENDA INNOVATION OPPORTUNITIES FEATURED INNOVATIONS OPEN MIC GROUP SHARING

47 Open Mic Q & A Context - Do you have an innovation to share with the group? - Do you have a problem that you would like to see if someone has an innovation that would help you? Process - Ask question directly using a mic - Write question or statement on a piece of paper and hand to moderator Framing - Peer to peer sharing - ACO only questions and responses 47

48 Kathy VanOsdol BSN, RN Young Joo, Director of Pioneer ACO Richard J. Lucibella, CEO Brian Silverstein, MD Managing Partner Office: