How Models Work: Care Coordination from an IT Perspective

Transcription

1 How Models Work: Care Coordination from an IT Perspective Steve Davis, DO Roberta Sniderman DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Conflict of Interest Disclosure Steve Davis, D.O. Roberta Sniderman Has no real or apparent conflicts of interest to report HIMSS

3 Today s Objective Identify the clinical care components of a successful ACO requiring IT support Identify the information technology components utilized to support the ACO Understand how IT can be utilized in real time clinical and analytical support of care coordination and financial strategies Identify and mitigate some of the roadblocks and obstacles that exist in technology based care coordination

4 California HealthCare Partners LLC HealthCare Partners Medical Group HealthCare Partners IPA Florida JSA Nevada Pinnacle Health Care Systems Summit Medical Group Fremont Medical Group Rainbow Medical Group In Patient Physician Network (IPN) HealthCare Partners Medical Group National Delivery System 4

5 Physician Led, Professionally Managed Global Capitation Predominates Centrally Coordinated Regionally Driven Strong Medical Management Infrastructure Robust Business Support Units Long history of technology support and leadership 5

6 Over 7,000 physicians Over 1,000,000 managed patients Over 175,000 Medicare Advantage 600,000 commercially insured full risk global capitation An unmeasured number of attributable private, FFS, and Medicare patients throughout our IPA networks 6

7 Our Vision : We will be the role model for integrated and coordinated care, leading the transformation of the national healthcare delivery system to assure quality, access, and affordable care for all.

8 We are altering the cost curve permanently in a positive direction. Zan Calhoun COO, Executive VP, CIO HealthCare Partners LLC

9 HCP ACO History Selected as one of the five organizations for Dartmouth-Brookings National Commercial ACO pilot Delegations in May of ,000+ Patients Selected as three of the 32 Medicare Pioneer ACO pilots including our Florida and Nevada divisions Pioneer program began January 1, ,000+ patients Received the Blue Cross Grant for ACO deployment 9

10 Current System Fragmentation Adversarial relationships Focus on doing One-to-one care Gatekeeper Perverse financial incentives Focus on volume/intensity ACO System Integration Cooperation Focus on managing a population Team-based care System management Aligned incentives Focus on quality and efficiency Source: Brookings-Dartmouth ACO Pilot Project 10

11 Capacity PatientsProcesesPhysicians HealthInformation HealthRisk ImprovedCare Aligned Technology Asesment Cordination Incentives ChronicDisease AcestoTimely Management Data PointofCare Reminder ReducedWaste Source Dartmouth Brookings 11

12 An Effective ACO: Three critical elements needed: 1. Better alignment of physician, hospital, and member incentives with desired results 2. Care management interventions to prevent medical problems from escalating 3. Robust technology to support care management interventions and incentive programs 12

13 Different Incentives from Current System 13

14 Size Matters: A small ship struggles in a big sea. 14

15 An ACO needs critical mass to be effective. 15

16 Proactive Population Management The continuous Virtuous Cycle of Improved care and outcomes is at the heart of HCP s proactive population management. Continuous improvement to drive: Better Care Better Quality Better Efficiency Better Patient Experience

17 The HCP Care Team Approach Interactive and collaborative teams of clinicians support HCP clinical programs. High Risk Programs: Home Care ESRD Comprehensive Care Center Post-Acute Comprehensive Care Disease Management Programs: Diabetes CAD CHF COPD Dementia

18 Care Management Interventions Hospitalist program Preventive care and health coaching Point-of-Care reminders Patient and physician education Care management for the chronically ill 18

19 Programs Overlap Health Support Care Support Outcome No or Low Claims Intense & Frequent Claims Risk Low High Healthy Lifestyle Issues Chronic Catastrophic Terminal Catastrophic Care Palliative Complex Care Management Disease Management Screening and Secondary Prevention Education and Information Sharing Health Promotion, Wellness, Primary Prevention Decision Support

20 Care Management Plans to avoid hospital readmission within 30 days Reduction in hospital admissions and length of stay utilizing Hospitalist programs Reduction in medication errors Reduction in duplicative testing Patient Self Management

22 Care Management Interventions Every system is perfectly designed to achieve exactly the results it achieves. If we want new results and we do we need a new system. -Donald Berwick Former Administrator, CMS 22

23 Technology ACOs must invest in the appropriate technology to enable economic incentives and care management interventions. We need systems for monitoring patients health and illness, and intervening before something catastrophic happens. 23

24 Chronic Care Model HCO Core Components Clinical information systems (electronic health records) Decision support information Delivery system design Self-management support Ed Wagner MD, MPH, Director, Improving Chronic Illness Care

25 HealthCare Partners Technology Systems Data Warehouse: Over 20 years of clinical and financial information Practice Management systems Multiple EMR systems Inpatient Tracking System Clinical Care Management(CCMIS) Referral Management System Claims Management System 25

26 HealthCare Partners Technology Systems Physician Information Portal HCC, P4P, Star measurement and support Patient and practice management information Care Guidelines and Educational Resources Patient Online Portal Clinical Information Viewer 26

27 IT/Operations 27

28 What do you need? Ability to Identify ACO Patients: Practice Management System (GE/IDX) Morphing system to make an ACO (Fee for Service or Medicare) patient look like HMO patient for triggering activity, reporting capabilities, and population management Utilizing our enrollment interface to load ACO patients Eligibility Member Benefits shell built for claim, DME coverage, office and specialist copay, etc. Modifying current system HMO requirements to fit ACO/PPO Model. I.e.: Paneling to PCP, security models for access, break glass, gate keeper concept, HIPAA violations, etc.

29 What do you need? Ability to Identify ACO Patients By Others: In-Patient Tracking System (Patient Keeper) Hospital admissions would be best if we can identify patient in the ambulance on the way to the hospital vs. 2 days later If our Hospitalist can meet the patient in the ER then we can potentially change care Hospitals need a way (and a reason) to identify an ACO patient and who is responsible for the patient (low tech stickers) to trigger ADT interface Attributed members show up in core hospital then hospitalist program kicks in if alerted by admitting provider Once identified, ADT HL7 Interfaces, document interfaces, faxes, required to communicate Unknown what will be available for Medicare Pioneer ACO patient

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31 What do you need? Ability to provide Discharge Planning for ACO Patients: InPatient Workflow System (K2) Route patient and activity Medication Reconciliation Admit activity Post Discharge Appointment Fax Routing IP Document Routing

32 What do you need? Ability to track post discharge: ICare (HCP) Ability to suggest another care setting Coordinate follow-up visits with PCP within 48 hours Order DME Phone call follow-ups Get the patient to the right specialists Enroll patients in High Risk Clinics Home Care Programs

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34 Referral Management HCP Inserting Preferred Provider Networks PCP Referral Specialist Suggesting Core Hospitals Managing Care Coordination Payor

35 What do you need? Manage Referral Process Referral Management System (HCP RMS) For tracking and managing medical management Hospital admissions attempt to encourage core hospital utilization, HCP surgeons, to obtain better outcomes Physician and facility contracting for in network access utilizing PPL flag at the ACO level System fed HMO Patients for attribution IPA docs will then know that this a ACO enrollment to PCP or Specialist

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37 What do you need? Provide Care Management Clinical Care Management (HCP CCMIS) Hospital data passed to in house system for chronic Care Management Manage transition of care upon discharge to establish action plan for SNF, Home Health Care, High Risk Clinics and Programs, DME Equipment, office visit, as required to avoid readmission

38 Complex Care Management and Disease Management Programs Care Manager History Goals & Actions Problems & Barriers Labs Assessments Tasks Pathways

39 Complex Care Management and Disease Management

40 Complex Care Management and Disease Management Appointment History Referral History Attachments Facility Visits / Inpatient Visits Claims

41 What do you need? Electronic Health Record Meeting Meaningful Use by 2012 EHR (Allscripts, Epic, NextGen) Ability to attest for Meaningful Use for 50% of all Primary Care Providers by the end of 2012 Capture elements for Quality Measure Reporting Requirements Provide clinical data for coordinated delivery of care amongst different clinical systems

42 What do you need? Clinical Data Capture Electronic Health Record (EHR) Reviewing and modifying to assure EHR (Allscripts, Epic, and NextGen) can capture Meaningful Use criteria Extract all Quality Measure Standards into a Data Warehouse for reporting to CMS and other ACOs 50% of Primary Care Providers Attest for Meaningful Use in 2012 Share clinical information amongst all patient care providers

43 What do you need? Collaboratively Share Clinical Content Clinical Data Sharing (HCP Clinical Viewer) Central repository of clinical content for all patients Collaboration for EHR (Allscripts, Epic, and NextGen) All Problems, Meds prescribed and filled, Allergies, Labs, Radiology, EKG s, Vitals, etc. Hospital data I.e.: Discharge Summary, H&P, ADT, Consultations, etc. Consult Notes, scanned documents, End of Life Wishes, etc. All encounter data: Procedures, referrals, diagnosis, etc.

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45 What do you need? Patient Engagement and Patient Experience Patient Portal (HCP) Need to have patient feel they Won the Lottery by becoming an ACO member Secure with provider and/or office Lab views Appointment scheduling, Bill Payment Patient Education and Demographic Updates emobile connectivity Request prescription refill

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47 What do you need? Communication, Communication, Communication Physician Information ( Ability to provide information on overview of an ACO Q&A s for providers State specific regulations and guidelines How to contact key resources Telecommunication additions for direct dialing access to ACO questions for providers, hospitals, and patient: ACO

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50 Real Time Clinical Clinical data sharing when patient presents with relevant clinical data in a useable format Real time notification for hospital admissions Real time Referral and Authorization for routing patients in network Patient identification and communication of changing care delivery models Real time data feed from CMS or payor to chase sick patients

51 Analytical Support Analysis of the provision and financing of health care services Episodic Treatment Groups (Ingenix ETG) Measuring and comparing healthcare providers based on the cost of treating patient episodes Measuring health care demand, including the prevalence of clinical conditions and the services and costs involved in their treatment Establishing disease management strategies, including tracking organizational performance and trends around specific diseases and episodes

52 Predictive Modeling and Risk Stratification Data Analysis Analytical Support Identify sickest portion of patient population to enroll them into appropriate care programs Identify likely events ER visit, clinical event, drug change Utilizing CMS Hierarchical Condition Coding (HCC) Risk Adjust Factor (RAF) scores to identify patients at risk

53 Disease Management Analytical Support Analytics (HCP Reporting Services) All systems pass information to Data Warehouse for Analytics and Decision Support Reporting Disease Registries populated to identify who falls into which programs proactively Determination of who should you touch with limited resources Web based, Self Service

54 Clinical Data, Clinical Tools Disease Registries for every HCP physician to better understand the make up of his or her patient panel Web-based, Self-Serve, Disease Registries: Diabetes COPD CHF CKD Dementia CAD Asthma Depression

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56 Custom Registries Based on Specific Interventions

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58 Analytical Support Quality Measures Reporting CMS 2012 Program Analysis - ACO Quality Measures 33 required quality measures that are part of the quality performance standard Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience survey measures Claims-based measures Electronic Health Record (EHR) Incentive Program measure Group Practice Reporting Option (GPRO) web interface quality measures that are required for purposes of ACO participants earning a Physician Quality Reporting System (PQRS) incentive under the Medicare Shared Savings Program.

59 Analytical Support Quality Care and Patient Management Physician Information Portal (HCP PiP) Ability to provide intervention reports by HCC Category, HCC Physician Pursuit List, High Risk Pursuit List, P4P Category, STAR Measures, etc. to assure quality outcomes Performance Measures for each physician for HCC summary, recapture rate, P4P scores, STAR Scores, etc. Patient Management: lists, schedules, panels, etc. Care Guidelines and Patient Education Material

60 Needed Interventions

61 Example of Point-of-Care Reminder 61

62 Example of P4P Scores Report 62

64 source gigglemed.com

65 Outside Health IT Control: CMS has no way to alert when an ACO patient is in the hospital Medicare card does not identify ACO patient or belonging to HCP ACO patients can go anywhere they want, to any provider they want, any specialist, any hospital Hospitals have no incentive to alert HCP of PPO ACO patient Providers have little incentive to request referral authorization for PPO patient Patients can opt out of data sharing completely

66 Under Health IT Control: Systems are not setup for every potential Referred To provider HCP does not have all claims and clinical data on ACO creating a dependency on data dumps from CMS or provider Stale data for analyzing and identifying key patients to target intervention programs is difficult to operationalize Clinical System Vendors are not to a point of collaboration with each other System requirements not well defined due to daily learning

67 Sometimes the worker bees just have to go flower to flower Sometimes low-tech is OK: When cost of system modifications are greater than potential earnings Anthem real time referral system modification estimated at $1million Low tech solution for $150k to meet the 10 referrals / day Live communication with patients shown to be more effective. Sometimes people just need to communicate to people

68 The Pretty Please Method Pretty please provider, can we see your patient? Pretty please patient, will you share your data, see our providers, and use our hospitals instead of yours?

69 The Pretty Please Method We have really good data that shows when you take patients and you really inform them about their choices, patients make more frugal choices. They pick more efficient choices than the healthcare system does. -Donald Berwick Former Administrator, CMS 69

70 Off on the wrong foot! Identify the problem and own it organization wide Address it rapidly Direct communication Restore trust

71 + + = Aligned Incentives Care Management Interventions Robust Technology Keys To ACO Success 71

72 Steve Davis, D.O Roberta Sniderman