The Road to Reform: Out of Chaos Comes Care Coordination Mark Green, MBA,PMP,LSSBB AVP Transition Management Ochsner Health System
Ochsner Health System
Ochsner Risk Populations Full risk 34,000 Medicare Advantage seniors (Humana) 19,000 employees + dependents (self-insured) Shared Savings 22,000 Medicare (ACO-MSSP) 9,000 Medicare Advantage (PHN) 47,000 BCBSLA commercial 7,000 CIGNA commercial 21,000 United commercial Total risk: 158,000 out of 400,000 (>1/3)
Why Care Coordination You Ask! The Plinko effect Problem: Without aligned Care Coordination across the Continuum of Care patients have little guidance on how to / what to do until they land at the next care setting often weeks or months between appointments. They bounce around the space and often face issues and complications that result in exacerbation of conditions, or even readmissions to the acute care setting as a result of the silos and unaligned care
But How the Heck Can you Prove Value in Both Worlds Managing Across the Crevasse Fee for service All about volume More visits More procedures Minimal Incentive for Coordination of Care Silos aren t necessarily detrimental to financial sustainability Focus on specialists Value-based payment All about quality & cost Transparent data Managing populations Accountable care Clinical variation Reward quality Focus on primary care Aligned incentives
Reality On Any Given Day in Healthcare
Building Care Coordination Programs From Both Banks Volume Value
Case Study #1 A 24 Hours Nurse Triage / advice line is operationalized under our ACO. It historically was seen as a way to drive ACO patients to the most appropriate care setting. However given the current interest in patient wanting Care Everywhere the use of the 24/7 service is open to the systems general patient population. During 2014 the call center had 30k inbound calls Patient Value Based Volume Based Patients are able to call the center 24/7 and get a validated disposition to their symptoms they presented with. If Non Emergent the call center can book an appointment in a clinic setting Patients are able to be managed into clinic setting from the call center thus driving revenue for the volume based payment models. Each clinic visit drives $150 in incremental revenue on average Patients are able to be directed away from the emergency room setting when not appropriate conditions exist. The difference between a clinic visit and a ED visit is > $1,000
RESULTS Case Study #1 2014 Results for the Nurse Advice Line 30,928 Total Triage Calls 27,041 Non Emergent 87.43% 6K+ Home Care Outcomes 15k+ Primary Care Visits 3,887 Emergent 12.57% 3k ED Now 357 Call 911 Now 121 Call Poison Control Now
Case Study #2 GI metrics were targeted for improvement, this included providing both Colonoscopies as well as Fecal Occult Blood Tests to patients identified as having a gap in this care. And ultimately was negatively affecting our HEDIS score in this area Patient Value Based Volume Based Patients are now able to have an alternative to just a colonoscopy for screening purposes. Patients are much more likely to schedule a colonoscopy after a positive FOB test if apprehensive in the beginning about the scope Additional volume is now being driven into the GI service-line through the inclusion of the FOB promotion. While apprehensive at first due to questions of loosing revenue the program has proven successful at increasing volumes Managed care quality metrics on CA screenings are now increasing due to the inclusion of the FOB testing through the GI service line. Early detection also decreases the likelihood of catastrophic patient costs due to late stage diagnosis
RESULTS Case Study #2 GI Screening Program Increased Colon Ca HEDIS outcomes by 20% 12k Automated Calls Made to Care Gap Identified Patients 2,500 FOB tests mailed out to Patients 167 Additional Polyps found via Colonoscopy from positive FOB that otherwise would not have been found!!
Acute Care - Discharge Program Case Study #3 Patients often find themselves caught in the no care zone after being discharged from acute care settings. A robust transitional management program was developed that guided the patients through the danger zones with both direct and collaborative staffing out of Ochsner's Care Coordination Center Patient Value Based Volume Based Patients now have a collaborative partner to help them navigate the care gap between Acute Care settings and the next care setting often weeks after discharge. This partnership allows them to remain out of the acute care setting in a readmission incident Patients are now transitioned back into the primary care setting in 7-14 days for follow up care management. This drives additional revenue to the clinic setting that had not been realized before. Average low acuity visit is $150 and high acuity is $250 Patients managed through the program are 20% less likely to readmit to the acute care setting than those not following this care pathway. The difference between a readmit at $10k and a clinic visit is often > $10k per encounter
RESULTS Case Study #2 Post Discharge Transition Management Program. Increase Scope of Work through collaborations going from 200 patients managed a month to 700 patients 7,200 Patients Managed across the system Average Reduction of 20% in each region against the population not reached / managed Acute Care - Discharge Program $1 million cost avoidance savings in our MA population alone Increased Revenue on 1,200 TCC visits complete falling to the clinic operations
The Future Is Near Automated ED Discharge Call Program 800 discharges a day out of the system with very little coordinated follow up care. The new program will be aimed at automating a standardized approach to follow up with patients the next day based on need. Calls will be placed based on Patient demographics and needs, for example patients without an identified PCP in our EMR would get a warm hand off to an agent once they opt in to establish care in the PCP / IM division of care. Without the automation front ending the calls we would need 15-20 FTE s to accomplish the same outcomes of calls made
Modeled Opportunity Automated ED Discharge Call Program Modeled outcomes from like interventions show a 10 15% opt in on the automated calls. This would drive 80-120 patients a day of incremental business The calls cost me.08 cents each and the potential revenue for clinic visit at $100 value would be 8-12K a day assuming that none are new patients that would drive additional downstream value to the system.
Levels of Care Coordination Programs and Capabilities Single Provider No EMR Small Group Practice Small Hospital Facility Large Health System, ACO, Insurance Payer Diabetic Diagnosis + HbA1c <7.5 Diabetic Diagnosis $10,000 Available for the Care of the Population is split evenly $1,000 each among all Patients falling into this category Diabetic Diagnosis + HbA1c <7.5 Now we can Spend $1,500 each on the High Risk patients and $785 on each of the Low Risk Patients Diabetic Diagnosis + HbA1c >7.5 Now we can Spend $3,000 on the Highest Risk patient, $1,500 on each on the next highest, Diabetic Diagnosis + HbA1c >7.5 + Adherent with Medication $1,000 on the Diabetic next Diagnosis level + HbA1c >7.5 and + Non Adherent with Medication + Social Support $250 each the Lowest Risk Patients Diabetic Diagnosis + HbA1c >7.5 + Non Adherent with Medication + no Social Support
Questions Mark Green, MBA,PMP,LSSBB markgreen@ochsner.org AVP Transition Management Ochsner Health System