The Evolution of Managed Care as the Foundation for Health Reform ACO s as the Vehicle for Integration and Coordination of Care for All Patients Stuart Levine MD MHA Corporate/ Regional Medical Dir., Asst. Prof. IM/ Psych UCLA
Our Vision for the Future: We will be the role model for integrated and coordinated care, leading the transformation for the national healthcare delivery system to assure quality, access, and affordable care for all. Our Mission Every Day: We will partner with our patients to live life to the fullest by providing outstanding healthcare and supporting our physician to excel in the healing arts. 2
Currently providing healthcare in California, Florida and Nevada to over 800,000 patients 170,000 Medicare Advantage 450,000 commercially insured members Physician-owned and Managed Staff / Group Model- 45% of patients in California, 65% of patients in other states 600 Full time employed Physicians IPA- Independent Physician Association- 55% of patients in California, 35% of patients in other states Over 4000 PCP s, over 1500 Specialists 3
Sustaining Commitment to quality Hub and Spoke Approach (Group and IPA) to drive enrollment and profitability Managed care administrative functions, including contracting, claims, and eligibility Evidence based, coordinated care and disease management. Risk stratification to identify high acuity Patients. Expertise for care of commercial and senior populations 4
Hospice/Palliative Care Home Care Program Provides in-home medical and palliative care management. Physicians, Nurse Practitioners, Care Management, Social Workers Chronically frail Patients Physical, mental, social, financial limitations in accessing outpatient care Level 4 Home Care Program $250 $260 $220 $200 Comprehensive Care and Post Discharge Clinics Intensive one-on-one Physician /Patient care Case management for the highest risk, most complex Patients. When stable, Patient is upgraded to Level 2. Complex Care Management / Disease Management Provide long-term enhanced care oversight. Multidisciplinary team approach for complex, high acuity Patients; Diabetes, COPD, CHF, CKD, Depression, Dementia Primary Care Physician Motivate, educate and engage Patients to get involved in their care and self-management with their PCP and Care Team. Level 3 Comprehensive Care Clinic/ Post Discharge Clinic Level 2 Complex Care and Disease Management $ 50 $100 Level 1 Primary Care Physician Patient Self-Management & Health Education
Health Support Care Support Outcome No or Low Claims Intense & Frequent Claims Risk Low High Healthy Lifestyle Issues Chronic Catastrophic Terminal Palliative Catastrophic Care Complex Care Management Disease Management Screening and Secondary Prevention Education and Information Sharing Health Promotion, Wellness, Primary Prevention Decision Support 6
HOME CARE COMPLEX CARE/ DISEASE MGMT (CHF, COPD, DM, CKD) HOSPITALIST PROGRAM ESRD PROGRAM PATIENT Patient URGENT CARE CENTER PRIMARY/ SPECIALTY CARE HIGH RISK CLINIC SNF PROGRAM
TEAM CARE- PHYSICIANS, NURSE PRACTITIONES, CARE MANAGERS AND SOCIAL WORKER HomeCare- Patient & Family Centered Care At Home for the Most Frail with a focus on Palliative Care Comprehensive Care Centers- Post-hospitalization stabilization/ Care Transitions and Chronic Care Clinics for Optimized Care Coordination High Risk Clinics for Commercial Patients- Behavioral Orientation ESRD Medical Home Complex / Disease Management Palliative Care
Home Care Program Top 2-3% most at-risk patients Comprehensive assessment: Living conditions Social and financial needs Medication regimen Medical and behavioral health Advanced Care Planning Palliative care 967 Distinct Patients: 4512 member months
Comprehensive Care Clinic Advance care planning Medication reconciliation Disease and Care Plan education Behavioral health assessment Access to additional community resources Post Hospitalization Clinics Comprehensive Care Centers Geriatrics Centers of Excellence Commercial Patients- Biopsychosocial Medicine 426 Distinct Patients: 1141 member months
ESRD Program Target CKD Stage IV and V Provide complex care management Improve primary care provided to dialysis patients Emotional and physical preparation for Patients and caregivers prior to dialysis Establish early access placement Reduce emergency vascular interventions Increase treatment adherence and promote self-management Advanced care planning 149 Distinct Patients: 905 MM
Behavioral Health PCP based behavioral health consultant/care manager Focus on Patients with diagnosis: Depression, Anxiety, Dementia, Chemical Dependency Emphasis on Collaborative Care - IMPACT on steroids Specialty behavioral health (chronic care) Behavioral health medical/surgical hospital inpatient Residential behavioral health
Improve Competency in End of Life Management Focus on Goals of Care, Quality, & Dignity Complete an Advance Care Plan (Advance Directive & Medical Note) Patient s Values Treatment Options Expectations & Limits Communication End of Life Care Plan Patient s Clinical Condition Prognosis & Quality of Life 13
Evidence-Based Medical Treatment Optimal Treatment of Pain and other Symptoms Care Throughout the Course Of Patient s Illness Care Provided Wherever Patient is located Home, Hospital Quality of Life - Medical Care for a Patient with a Non Curable Illness
Define Stakeholders, Role and Process for Communication in Care Patient /Family Hospitalist /Care Manager Primary Care Physician Pulmonologist High Risk Physician Home Health RN DME - Respiratory Therapist Home Care Team MD, NP and SW
Erase Myths and Demystify Misconceptions Discuss What Palliation Is and What it Isn t Insure the Health Care Team understands the Value Palliative Care Services Knowledge about Components of Advanced Care Planning Philosophy of Palliative Care Team Members must Understand Their own Belief System about Death and Dying Describe the Evolution from Palliative Care to Hospice
All Stakeholders Must be Educated and Conversant on Principles/Goals of Advanced Care Planning (ACP) and Palliative Care (PC) HCP Team Members have Expertise in ACP This Team will continue Training and Learning about Concepts and Tools Ongoing Training ensures Team Members Communicate the same message to the Patient, Family and Caregiver(s) Community IPA Physicians are Critical to Guarantee ACP for their Patients by Identifying Patients at Risk and Initiating the ACP Process
CCM and Social Workers will Support IPA Physicians in the Process of ACP and Facilitate the Work with the IPA Physician /IPA Office Team Staff Every Clinician, Primary and Specialty Care have a Role in the Process No missed Opportunities Nurses, Care Managers, Social Workers, Medical Assistants are Key to Keeping the Patient Engaged in the Evolving Process of ACP Focus on the Needs of the Patient and Family Regularly Communicate Changes Condition to the Team
Proactive Advanced Care Planning Best time to Discuss End of Life (EOL) is when the patient is in Good Health and EOL is a theoretical concept Prioritize Patients Focus on Seniors First Thereafter - 21 years old and Above
When to Refer to Palliative Care Frequent visits to Emergency Department (>1X per month for same Life Threatening Illness) More than one Hospital Admission for same Life Threatening Illness in last 30 days Prolonged length of stay (>5days) without evidence of improvement Any Unexpected ICU Admission with an Extended Stay An ICU Admission with Documented Poor Prognosis Question to treating Physician: Would you be surprised if the patient were to die in the next 12 months? VES 13 Score of over 5
When to Refer to Palliative Care Poor Prognosis - Life Limiting Disease Life Threatening Cancer Diagnosis Advanced COPD Stroke with significant function loss End Stage Renal Disease Advanced Cardiac Disease (CHF with LVEF<25%, Severe CAD) Palliative Care Screening Score of >4 (See Palliative Care Screening Tool)
When to Refer to Palliative Care Unacceptable level of Pain or other Symptoms such as Dyspnea, Anxiety, Agitation, Anorexia, Depression, Drowsiness, Inactivity, etc Team/Patient/Family needs help with Complex Decision-making and Determining Goals of Care Patient has uncontrolled psychosocial and Spiritual issues in context of Life Threatening Illness Disconnect Between Physician and Specialist About Prognosis and Goals of Care Disagreement among Patient and Family Members
Patient and Family need to understand that they have Choices The Patient Must have a Voice in the Process The Goal is to Understand what the Patient Wants Never get into a Power Struggle with Patient, Family or Caregiver Appreciate Cultural, Religious and Social Factors in ACP and EOL Caregiver and Family Support and Training
POP- Educational Portal for Patients and Families Advanced Care Plan in place and in the Electronic Medical Record for Team Access Process in place encouraging Patients to document ACP Employees incentivized to have Advanced Care Planning documents completed and in Electronic Medical Record Prioritize Patients VES 13 - Identify Patients who are Vulnerable for decline and death Senior Wellness Assessments Yearly History and Physical
Strategies and Tools IPA Implement IPA Primary Care Physician Plan for Advanced Care Planning and Palliative Care Use HCP Approach to Beginning Palliative Care Program for IPA Offices Provide Tools and Incentives for IPA Office Communicate Advanced Care Planning Implementation Plan including: 5 Wishes and POLST available from PiP Physician Portal Scan IPA Patient Forms into EMR and Track Incentivize IPA Physicians for Advanced Care Planning Define Quality Assurance of Advanced Care Planning Process Hospice Process Promote use of HCP Partner Hospice Vendors
Purpose : Palliative Care Specialist works with Team to provide Patientfocused and Family centered care Optimizes the Management of: Pain and other symptoms such as nausea, Dyspnea, Anxiety, Agitation, Anorexia, Depression, Drowsiness, Inactivity etc. Define Functional status and Plan for Deficits Promote the highest quality of life for Patient/Family Educate the Patient/Family to promote understanding of the underlying disease process Establish an environment of comfort and healing Plan for Appropriate level of care in a rapid manner for all Transitions Assist with Actively Dying Patients and their Families Prepare for End of Life Decisions Educate community healthcare providers Provide Palliative Care in Specialty Clinic, SNF, Home and Hospital
Ensures: Communication between Patient, Family and all Healthcare providers Collaboration with Primary Care Physicians and Specialists in Developing the Plan for Care Collaboration with Partner Hospice programs and Case Management Programs Social Work consult for Provision of referrals to appropriate Community Support Organizations Definition of immediate and long-term goals of care Advanced Care Planning
Consultation Service Support PCP /Specialist with newly diagnosed, challenging Patient/Family/ Caregiver Hospitalist/SNF ist Facilitate The Conversation Family Meeting Everyone Hear the Same Message Aggressively discuss, Conservative Medical Management
Investigate Status of ACP in EMR Ideally PCP + Team has ACP work done Diagnosis may Require Emergency Intervention Coordinate Specialists Facilitate Changes to the Plan ACP/ EOL is Patient and Family Centric Providing Advocacy for the Patient if Key For Challenges Cases, Garner Support
Partner with In Patient Team Focus on Patient/Family Advocacy Facilitate Family Meetings and Conversations Provide - Support for the Patient/Family to Truly hear Their Wishes Empowerment through Planning and Decision Making Education Discussion Regarding Clinical Changes Facilitate Transition to Out Patient Programs
Provide Post Discharge Care for Patients Recently Hospitalized Work with Patient/Family over the Process of the Illness, Over Levels of Care and Over Time Guaranteed Team Communication Documentation and Revision of Patient EOL Goals Assist with Patient/Family Education for Progression of Illness Identify and Manage Issues including Symptoms Alert Social Worker for Consult for Social Issues and Solutions
Medical Management Maximize the Plan Supportive Care Symptom Management Introduction of Hospice Glide Path from Chronic Disease Management to Palliation to Hospice
Institute Advanced Care Plan Program for HCP Clinicians & Employees Include Palliative Care Goals as part of Organizational Mission and Vision Define Target Populations and frequency for Advanced Care Planning interventions Develop, Adopt & Implement Evidence-Based Guidelines for Last Year of Life Develop Alternative Care Options for Patients Define Consistent Policies &Procedures in End of Life Care Decrease Process Variability for Better Adherence and Outcomes Ensure appropriate Administrative support (i.e., documentation)
Staff Educated on Tools Tools/Forms available POLST, 5-Wishes, California Advanced Care Plans Define Team Care as it relates to roles and End of Life Define Optimum Care Processes for IPA patients Insure that Palliative Care/Advanced Care Planning are Used for Appropriate Patients
Improve Quality of Life for Patients with chronic debilitating disease or terminal illness Improve patient s pain and symptom management and decrease suffering Decrease episodes of Emergent Care through Better Management of overall the Patient s Care and Plan Over time, Transition Patient from Palliative Care to Hospice Care when appropriate, Improving overall quality of life throughout the course of illness. Decrease hospital readmissions Support Patients so they May Die where they Wish
Metrics Deaths in Hospital Hospice Conversion, Median and Ave LOS Hospital Admits and Days per Thousand Patient /Family/Physician Satisfaction Reduce number of Patients Receiving Futile Care Reduce total cost of care in patients last 6 months of life (i.e., futile care) Increase Percentage of Patients with Advanced Care Planning Age 21-64 annually; 65+ - every 6 months
Patients no longer see Hospitalization as a Benefit to Demand Alignment between Patients, Families and Physicians that Hospitalization is a failure of the Health Care Delivery System Independence is the Primary Goal for Patients Empowerment of Patient- Medical Group Partnership to Avoid Unnecessary Hospitalization
Developed Innovation Process at HCP Developed Innovation Teams to re-engineer processes Representation of Central and Regional Operations, Clinical and Care Management Teams Encourage Experimentation and Failure that Leads to Success
The Whole is Greater than the Sum of the Parts Design Programs for the Most Frail, Chronically Ill patients with highest admission rates and adapt for all other patients Design Programs for IPA patients and adapt for Group/ Staff Model Patients Statistical/Clinical Risk Stratification - Patient Selection Measure Clinical Results and ROI of programs over time Fluid Program Development- test and constant re-engineering Regional Experimentation- Region 2/ LA- R&D Shop for HCP Cross Regional Fertilization and Best Practices to Achieve Clinical Optimization HCC Driven Quality Initiatives for Improved Differential Diagnosis and Treatment Plans = Medical Management Infrastructure Redesign- Connect Revenue Enhancement and Expense Reduction
Results of Re-engineered Medical Management- 600 days/k MA seniors. Getting there by using intelligent, centralized systems, as opposed to one-off Super Dr. Welby is crucial... Bringing services into the home is pure gold. Doing it while bearing full hospital risk is essentialreinvestment of the health care dollar Astonishing- CA composite is 982 for MA 1660 for FFS Medicare National average for FFS Medicare is 1900 Many states hit above 2500!
Use of Home Technology Electronic Medical Records Use of Internet Connectivity
Disruptive Innovation (Breakthrough or Discontinuous)- The invention of new / unique health care services developed to make health care more affordable and accessible = a reinvention of the norm vs complete redesign Process Improvement vs. Incremental Innovation The method by which complicated expensive health care products and services are converted into more elegant, cost-efficient care while exploiting existing technologies Clayton M. Christensen
Respect and Give Credibility to Innovation Leaders- Future is our Present Don t Accept the Status Quo Motivate and Reward Change, Energy and Passion Non-hierarchical- Distribute Decision-Making to all in Organization- responsibility to innovate and right and authority to be wrong Value Collaboration from all levels Reward and Learn from Failure fostering Creativity, Tension and Collective Memory Stage Chaotic Change and Thrive in Uncertainty Celebrate the Human Spirit Minding Organization- Right Hand knows and trusts the Left Hand without Supervision
Jack of All Trades with some expertise Passionate Individualistic Problem Solver Out of the Box View of World Cross Polination Motivated Creative
Must be on a mission Must have a vision even if it is wrong Must be willing to accept failure Make opportunities of obstacles Love a challenge Team Problem Solving
Hierarchy based Bureaucratic Anonymous Top-down Senior Executives decide on the Innovation Team Cleanliness Experts must be the Innovators
Physician ownership of the Patient Team Care and Teamwork Support Physician and Patient to Enhance Outcomes Motivate and Incentivize Physicians and the Health Care Team Right Care / Right time /Right Place Every Time Best quality care = most cost effective care Educated Patients Educate Patients regarding their Disease and Care Plan Educate Patients on How, Where and When to access care Quick Access to Care Use Risk Stratification to Identify Patients at Risk Prior to catastrophic need
Technology + Clinical Intervention = Solution for Care Life Care & Quality Care Plan with Documented Decisions Comprehensive assessment Clinical and Social Medication Reconciliation Technology connecting all care information Infrastructure to Care for the 20-30% Highest Risk Patients Appropriate transitions of care - entire continuum Communication you can t over communicate Commitment to the Patient and their quality of life
HealthCare Partners has integrated best practices in our clinical processes to improve outcomes from the following national Programs: GRACE- Indiana University- Counsel/ Callahan HomeCare ACOVE- UCLA- Reuben/ Wenger Care Transitions- Coleman Guided Care- Bolt Primary Care Redesign- Bodenheimer Care Management Plus- Oregon Health Sciences Dorr AICU- PBGH- HCP Integrated and Coordinated Care- ACO- HCP