Brief environmental scan Ti Triple AIM?...key elements Why the Plus One? How do we get there? What will be the advantage for us?

Transcription

1 The Current Environment Requires Progress On All Four Simultaneously! Bruce Bagley, MD President and CEO TransforMED Brief environmental scan Ti Triple AIM?...key elements Why the Plus One? How do we get there? What will be the advantage for us? 2 1

2 The Problem 3 People/Organizations/Integration/Work Technology and Connectedness Patient Engagement and Self-management Support Payment Reform and Incentives Community Involvement in design and execution of new models of care Patient Centered Medical Home Medical Neighborhood Accountable Care Organizations 4 2

3 1. The current path of medical cost growth and societal expenditure is not sustainable 2. How providers are paid makes a difference 3. Fee for service payment is one of the root causes of the problem and most now realize it must go 4. Clinical, financial and information technology integration is essential for efficiency 5. Value based purchasing requires performance data on metrics for service, cost and clinical quality 6. Distribution of resources will mirror value contribution More emphasis on wellness and prevention The importance of the community of care Access redefined as addressing patient s needs when and where they have the need rather than a conversation about appointment availability Strategic distribution of the work (team care) Consolidation, integration and market forces for greater efficiency and effectiveness Many practices and systems are already successful in making transformational change 6 3

4 Health care providers will work together with a true team approach and a focus on the best results for patients They will work in organizations that provide the required infrastructure support for optimal outcomes for patients Integration, coordinated care and seamless transitions from one point of care to another will be the norm There needs to be a strategic distribution of the work 7 We must apply the great technology we already enjoy in our everyday lives to health care delivery Knowledge management, communication and information exchange Electronic health records Patient portals Community wide Health Information Exchange (HIE) with patients and e-visits Video visits Systems for tracking, care management and care coordination Registries (chronic illness care, high risk patients, preventive services etc.) 8 4

5 Gretchen Hoyle, MD, Twin City Pediatrics, Winston Salem, NC 9 Eliminate non-compliant patient from our vocabulary Patient/Family/Caregiver engagement g Patient Self-management Support Patient activation Motivational interviewing Health coaching Shared goal setting Informed Medical Decision Making Home monitoring and between visit contact Care coordination across the medical neighborhood Home care as needed 10 5

6 11 Better individual care Quality of care-clinical performance measures Satisfaction with the experience of care Better population health Defined population within the practice Ability to aggregate individuals for quality assessment Lower per capita cost of care Total cost of care on a PMPM basis Proxies such as ER utilization, bed days/1000, ALOS 12 6

7 The Happy Triple Aim Providers need support and systems to help them provide excellent care to individuals and populations They must feel that their work is helping patients and they are not doing things that matter less. Staff satisfaction Rewarding and meaningful work that is valued Sense of team and contribution by all Positive work environment 13 Quality of care delivered as measured by the available clinical performance measures (starting place) Systems, protocols, reminders, registries, home monitoring and between visit follow up are necessary to do this well (required processes and infrastructure) Care management and care coordination, ideally risk stratified by need and complexity (pro-active approach) Patient self-management support to assist them in managing chronic conditions in their daily lives 14 7

8 Service orientation to build patient trust and loyalty Patient/family and care giver engagement g in helping to manage chronic conditions Access, broadly defined as the ability for patients to get what they need, when they need it without barriers, waits and delays Input from patients to help define and redesign what great service looks like (patient advisory panels) Patient satisfaction surveys to identify opportunities for improvement 15 Population management of a sub-group of patients in the practice vs. the health of the community Required to assess the quality of care delivered d to that t sub-group of patients ( N of 1 vs. valid assessment of systems and approach) Allows evaluation of systems for performance and outcomes for patients Provides useful information for comparison data and identification of optimal performance (best practices) Requires processes and systems such as registries, out-reach, between visit follow up and active care management 16 8

9 Reduce waste by eliminating tests and treatments that add no benefit to patients or have no chance of improving the outcomes of their care Pro-active care management and care coordination in the medical neighborhood Conversations and service agreements among providers to build a shared sense of responsibility for service, cost and quality Alignment, simplification and integration of finances, clinical quality and information technology 17 Better individual health Clinical performance measures based on EBM (IHA) Satisfaction surveys, retention, loyalty Better population health Aggregate of clinical performance measures for the subgroup that defines the population Must have levels, trends and comparison data Lower per capita cost of care Total cost of care calculated on a PMPM basis 18 9

10 Better individual health Registries, protocols, reminders and pro-active outreach People and training to do patient engagement, selfmanagement support, care coordination etc. Better population health Disease registries, ability to analyze data in near real time Quality improvement strategy Comparison data and awareness of optimal performance Lower per capita costs Must have reliable cost data from payers for all care in the community (at least a valid sample) 19 Increasing quality and cost transparency will allow much better assessment of relative performance on the Triple Aim Even before you have all the numbers there are some systems that are known to work better for patients and should be installed Payers must begin to recognize and reward all aspects of the Triple Aim Your entire team will realize that the redesigned practice works better than the old way and that patients are getting better care and better service 20 10

11 Primary care infrastructure cannot be solely funded from visit based fee for service revenue Care management fees (transition strategy) Community wide support for IT and care coordination Global payments, bundled payments and capitation Resources must flow to the people and practices in relation to the value added for patients and measured by the progress on the Triple Aim 21 NCQA is useful but not sufficient Real organizational development required Leadership and decision making Systems thinking Metrics and improvement strategies built in Team approach to care Strategic distribution of the work Cost data needed down to the NPI Remove barriers to change 22 11

12 PCMH-Nothing less than an extreme make-over for primary care practices to make them: More Service Oriented for patients More Effective for better patient outcomes More Efficient for better profit More Fun to go to work for all 23 True team approach to care and change Quality measures and a culture of improvement Patient and family engagement with patient selfmanagement support Care management and care coordination IT enabled for the core business, clinical, education and communication functions 24 12

13 Practice and Payment Redesign in the CPC initiative Creating a Shared Sense of Responsibility for Service, Cost and Quality 26 13

14 Care Plan Home Care PCMH Mental Health Clinical Information Specialist Patient Hospital Facilitated Access Imaging Center Surgery Center Family and Caregiver Support Pharmacy 27 Shared responsibility for service, cost and quality Willingness to discuss process and interactions Efficient transfer of clinical information Multi-level accessibility Commit to a high level of service The patient is always the central focus 28 14

15 A three-year project funded by a CMS, Center for Medicare and Medicaid Innovation (CMMI) - Health Care Innovation Award (HCIA) Expands the Patient-Centered Medical Home to a Medical Neighborhood connecting Primary Care to: acute-care hospitals specialists community health resources increasingly assists patients manage their health proactively Avera Health, O'Neill, Neb. Charleston Area Medical Center, Charleston, W.Va. Columbus Regional, Columbus, Ind. Greater Baltimore Medical Center, Baltimore, Md. Huntsville Hospital, Huntsville, Ala. INTEGRIS Health, Oklahoma City, Okla. Marquette General Health, Marquette, Mich. Northeast Georgia Health System, Gainesville, Ga. North Mississippi Health Services, Tupelo, Miss. North Shore Physicians Group, Salem, Mass. Novant Health, Winston Salem, NC Ol Orlando Health, Orlando, Fla. Owensboro Medical Health System, Owensboro, Ky. Via Christi Health, Wichita, Kan. Western Connecticut Health Network, Danbury, Conn. **90 total primary care practices 15

16 Phytel offers Insight and Coordinate solutions for automating population health management delivering advanced care coordination, patient engagement, and quality-based analytical tools for PCMH-N. VHA Inc. is a network of not-for-profit hospitals that work together to improve their clinical and economic performance. VHA includes more than 1,400 not-for-profit hospitals and 25,500+ nonacute health care organizations. Provides consultation ti and 12 blueprints around PCMH-N leading practices. Cobalt Talon helps healthcare companies transform data into a strategic asset by providing high-performance analytic and data management products and services designed to solve the complex issues facing the industry. Reduce the Total Cost of Health Care for Medicare and Medicaid Beneficiaries by $49.5 Million Improve Health of Eligible Population Demonstrated by an Average of 15% with at least 3% Improvement in Each Selected Quality Measure A 25% Improvement in Patient Experience Demonstrate Ability to Scale to Additional Practices within Each Community 16

17 High needs/high cost patients require special attention Risk stratified care management and care coordination Care plan, registry, team approach, clinical integration Patient/family/care giver engagement and support The community footprint is real and requires leadership and comparison data to change Quality data Cost of care data, down to the NPI level Shared sense of responsibility for service, cost and quality New tools required Population health management and RSCM support Collaborative agreements or service contracts Development of a supportive community of care 33 If We Build It They Will Come Field of Dreams -Christine Bechtel National Partnership for Women and Families 34 17

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