The Trinity Pioneer Story ACO SETTLERS THE PIONEER JOURNEY TO THE TRIPLE AIM. Sue Thompson Chief Executive Officer

Transcription

1 The Trinity Pioneer Story ACO SETTLERS THE PIONEER JOURNEY TO THE TRIPLE AIM Sue Thompson Chief Executive Officer

2 2

3 UnityPoint Health: Organizational Profile 3

4 4

5 UnityPoint Health Fort Dodge: Organizational Profile 5

6 Health Outcomes Ranking (out of 99 Iowa Counties) Population of County ,592 7,150 9,729 12,991 10,153 9,909 37,273 15, Sources: U.S. Census Bureau; County Health Rankings 6

7 Trinity Pioneer ACO: Demographics 13.7% Persons 65 years and over 15.3% 19.0% United States State of Iowa Trinity Pioneer ACO Service Area Source: U.S. Census Bureau, 2012 Estimates 7

8 Trinity Pioneer ACO: Demographics 8

9 Trinity Pioneer ACO: Demographics $54,000 $52,000 Average Household Income $51,637 $51,773 $50,000 $48,000 $46,997 $47,044 $47,677 Average Household Income $46,000 $44,000 $45,582 $45,780 National Average $42,444 $42,000 $40,000 Webster County Buena Vista County Pocahontas Sac County County Calhoun County Wright County Humboldt County Hamilton County State of Iowa Average Source: U.S. Census Bureau, 2012 Estimates 9

10 Attributed Lives Attribution of lives o PCP visits or plurality of visits with Trimark specialist 7,400 lives in ,744 remained after CMMI decedent methodology applied 9,900 in 2013 due to RHC s 1,761 from Year 1, not in Year 2 due to expired or change in PCP 10,600 lives in ,100 from Year 2, not in Year 3 10

11 Beneficiary Risk and Chronic Conditions: Number of high risk and priority risk beneficiaries: 1,709 (25.3% of total ACO population of 6,744) Patients with Diabetes: 1,725 (25.6% of total ACO population of 6,744) Patients with Congestive Heart Failure CHF: 244 (3.6% of total ACO population of 6,744) Patients with Coronary Artery Disease CAD: 1,115 (16.5% of total ACO population of 6,744) Patients with COPD: 510 (7.5% of total ACO population of 6,744) Total Patients with Claims over $100K in 2012: 26 ($3.56M in claims) 11

12 Trinity Pioneer ACO Achieving our Aim Secondary Drivers Primary Drivers AIM: Leverage every aspect of our community to achieve Best Outcome for Every Patient Every Time Primary Care Community Health-Risk Assessment Iowa s Healthiest State initiative Preventive screening Health Education and Literacy Wellness Program Patient access to PCP PCMH and IHH Common screening and assessment tools Single, patientcentric care plan Med Therapy Management Mental Health Action Team Care transitions Extended Care Facilities ICCDM all care settings Advanced Medical Team Telephonic- Telemonitoring Strategic Healthcare Partners Critical Access Hospitals Risk stratification Med Therapy Management Disease Management Coaching Strategic Community Partners Palliative Care: Inpatient Home-based Clinic Integration with PCP Hospice: Hospice Home Home-based Home/Neighborhood - Schools - Business - Healthcare Agencies - Government -Recreation - Church/Spiritual 12

13 Needs Based Teams and Work Programs Across the Continuum Palliative Care Health Risk Assessment My Care Profile Advanced Medical Team for High Risk Patients Care at Home to Support Transitions Telephonic Disease Management Pilot for Diabetes Care Long Term Care Collaborative Medication Therapy Management with Community Pharmacies Pediatric Partnership with Public Health Behavioral Health ACT Iowa Physician Order for Scope of Treatment to Honor End of Life Choices Our Common Language Across the Continuum Adaptive Design for Ideal Care Integrated Chronic Care Disease Management Teach-Back and Ask Me Three One Team 13

14 Trinity Pioneer ACO Why Palliative Care? Why Palliative Care? 78 Million Baby Boomers Are Reaching Their 65 th Birthday At The Rate Of 10,000 Per Day For The Next 19 years Population for States by Age Group: July 1, 2009 Selected Age Group United States Total (50 states + DC) 31.3% 24.2% 18.0% 12.9% 9.1% 6.1% 3.7% 1.8% Iowa 33.8% 26.6% 20.0% 14.8% 10.8% 7.6% 4.8% 2.5% Iowa - Ranked

15 Trinity Pioneer ACO Why Palliative Care? 15

16 Trinity Pioneer ACO Why Palliative Care? When we should have these conversations! Decline Usual Palliative Care Referral Crises Time 16

17 Trinity Pioneer ACO Triple Aim - Quality Triple Aim - Quality Hospitalizations Fort Dodge 292 UnityPoint Health patients consulted for Palliative Care Oct 2011-Sept 2012 Source: UnityPoint Health Internal EHR Oct 11 - Nov 12 - Dec 1 - Jan 2 - Feb 3 - Mar 4 - Apr 5 - May 6 - Jun 7 - Jul 8 - Aug 9 - Sep 0 (in months) (in months) PreConsult PostConsult 17

18 Trinity Pioneer ACO Triple Aim - Quality Triple Aim - Quality 18

19 Trinity Pioneer ACO Triple Aim - Quality Triple Aim - Quality Internal Palliative Care metrics capture a self-reported initial pain and dyspnea score followed by a recheck within hours using a 0 to 10 scale. Results show a 49% reduction in pain (5.3 to 2.7) and a 46% reduction in dyspnea (4.6 to 2.5) Palliative care metrics also track evidence of Advanced Plan Caring with a 99% outcome 19

20 Trinity Pioneer ACO Triple Aim - Cost Triple Aim - Cost $900,000 Claim Data - Dollars Acute claims only (CMS codes 60/61) 340 UnityPoint Health patients consulted for Palliative Care Oct Sept 2012 Source: MSSP/Pioneer claims data $800,000 $700,000 $600,000 $500,000 $400,000 $300,000 $200,000 $100,000 $ PreConsult CONSULT PostConsult 20

21 Trinity Pioneer ACO Triple Aim - Cost Triple Aim - Cost 21

22 Trinity Pioneer ACO Triple Aim Patient Satisfaction Triple Aim Patient Satisfaction Trinity Palliative Care All Sites 2013 Overall Patient Satisfaction Mean Score

23 Challenges o Data Analytics Timing from Medicare Turnaround time Lag time: Claims processing IT turnaround Analytical turnaround o Physician and community communication/engagement o Critical access hospital engagement o Risk based contracting experience in analytics Shifting risk of population management from insurance companies to providers 23

24 UnityPoint Health Fort Dodge Value-Based Payer Arrangements Iowa Medicaid ACO Medicare Pioneer ACO 10,600 9,900 7,400 UnityPoint Health Self-Insured Employee Health Plan 1,729 1, Wellmark ACO 10,615 9,714 10,883 TOTAL ATTRIBUTED PATIENTS 23,694 21,432 18,283 24