Caring for Children with Disabilities: The View from Inside an Accountable Care Organization

Transcription

1 Caring for Children with Disabilities: The View from Inside an Accountable Care Organization American Academy for Cerebral Palsy and Developmental Medicine, 2014, IC21 Garey Noritz, MD, FAAP, FACP Nationwide Children s Hospital The Ohio State University Columbus, Ohio....

2 Disclosures I have no financial disclosures. This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA.....

3 What's an ACO? Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare/Medicaid patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare/Medicaid program. -CMS.gov....

4 ACOs vs. HMOs 1. ACOs are about creating value, not withholding service. 2. ACOs are local. Where HMOs created large bureaucracies that layered in cost and complexity, ACOs are designed to directly manage healthcare in small, manageable settings. 3. Incentives are aligned. HMOs invested in improving the health of members without reaping the long-term benefit. For ACOs, financial upside is more immediate. 4. Physicians are now more accepting of integration. 5. ACOs offer an array of payment models. 6. Information technology has transformed the capability for population health management. 6. ACOs may not avoid high risk patients. Bob Edmondson, VP Innovation, West Penn Allegheny Health System May 10,

5 Partners For Kids ACO Affiliated with Nationwide Children s Hospital Full risk contracting for Central/Southeast Includes all children on Medicaid Managed Care aged 0-18

6 ODM pays the Medicaid Managed Care Plans an age-sex adjusted per member amount each month for all CFC members in their regions Flow of Funds Ohio Department of Medicaid For children covered under Aged, Blind, Disabled (ABD), this capitated amount is significantly higher. Plan A Plan B Plan C Plan D Plan E PFK provides care coordination, population health initiatives, credentialing, network management Plan passes the capitation for members 18 and under less a small amount for administration (reporting, member service, claims processing) $ $ $ $ Per Member Per Month capitation payments with risk NCH employed physician group paid per member per month capitation payments Community member physicians paid % over Medicaid Other providers (nonmembers) paid % of Medicaid PAA 6

7 Financial Incentives Primary Care Pay for Performance Access Practice Improvement Medical Home recognition, quality collaborative Paying for Quality Outcomes Selected HEDIS measures Well Child Visits Appropriate treatment of URI Asthma medication 7

8 Partners for Kids Structure Physician-Hospital Organization formed in Ohio taxable, not for profit private entity Joint venture between Nationwide Children s Hospital, its employed physicians and contracted community physicians Approximately 95 employed and 180 community PCPs, 480 employed and 50 contracted community specialists (approximately 900 physicians in total) Ohio Department of Insurance considers PFK to be an intermediary organization ---accepts financial risk but not a health plan. Must maintain reserves and stop loss coverage. 8

9 Evolutionary Growth Contracting Strategy Patient Membership Managed Care Strategy Accountable Care Org. (Population Health) 0 9

10 Data Acquisition, Maintenance and Use Plan A Plan B Plan C Plan D Plan E Eligibility Capitation Claims Eligibility Capitation Claims Eligibility Capitation Claims Eligibility Capitation Claims Eligibility Capitation Claims Partners for Kids Data Warehouse Financial reporting Population Management Program Development Quality monitoring Physician Incentives 10

11 Collaborative Learning PFK Care Coordination Tools Accountable Care Organization NCQA PCMH Certification Outreach Increased Access Distance Medicine Web Tools Data Sharing Home Care Technology Partnerships with Other Organizations Standardizing Care Financial Incentives MOC Credit 11

12 Physician - Hospital Alignment 16 Board Members 50% of the board are hospital appointees (2 of which are community physicians) 50% are member physicians elected by their peers Extensive involvement of both community and employed physicians in setting up programs and engaging in quality initiatives---alignment with Hospital s strategic plan Committees include: Internal: Executive, Credentialing, Physician Incentive, Clinical Oversight Wellness: Asthma, Better Birth Outcomes, Diabetes, HNHF Ad hoc and other hospital-based committees 12

13 Population Management Tools Asthma Health Supervision Obesity Preterm Birth Pharm. Provider Focus Collaborative Learning Standard care Technology MOC Credit Certification Partnerships Incentives Patient Activation Care Coordination 13

14 HCIA Grant PFK Expansion Expand the PFK Model New Geography: Akron region (8 more counties) New Population: Aged/Blind/Disabled (SSI + <60% FPL) Shared Savings agreement with state Focus on certain clinical groups Behavioral Health Complex Care BUT Many of the most complicated patients are excluded from or may opt out of PFK

15 Exclusions from PFK Children who are: On Medicaid Waivers In Foster Care (some) In Long-Term Care Facilities In the Juvenile Justice System Patients who receive Title V Funds (in Ohio, Bureau for Children with Medical Handicaps) may opt out....

16 Opportunities: New Geographies Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot

17 Opportunities: New Kinds of Patients Complex Care Clinic Telehealth Unlicensed Staff RN/SW Case Managers

18 Centers for Medicaid & Medicare Innovation (CMMI) Award Nationwide Childrens Akron Focus Area Existing CMMI Existing CMMI Prematurity X X DM X Asthma X X Health Supervision X Obesity X Complex Care NEW X X Behavioral Health NEW X X Infrastructure X X X

19 Health Care Innovations Award Grant Awarded 7/2012 to improve quality/reduce cost $13.1M awarded over 3 years Funding key initiatives: Expanding the PFK model to Akron Children s Focusing on children with complex needs care coordination weight management standardization Focusing on children with behavioral health needs reducing readmissions transition care/care coordination appropriate drug management support through Parent Partners 19

20 Major Challenges Feeling comfortable with the risk when you don t have a lot of control! Regulatory issues---changing Medicaid landscape with little ability to influence, no seat at the table Maintaining managed care plan relationships and ongoing collaboration Competing priorities Data management Many children excluded whom we want to impact

21 Delegated Care Coordination Although informal in the past, now officially delegated to do care coordination for: Molina Buckeye Paramount Working on United---may be delegated by mid year. Will likely not be delegated by CareSource 21

22 SPECIFIC AIMS: HCIA Grant PFK Expansion A. Cost = By 6/2015: Reduce per member per month by 1.1% for TANF and 2.0% for Disabled Reduce 60 day PFK behavioral health readmissions by 30% from 9.8 to 6.9% Decrease hospital days of tube fed children by 10% Reduce Summit County neonatal days by 10% B. Quality = By 6/2015: Increase completed 30 day outpatient PFK medical follow up after behavioral health hospitalization from 29% to 65% by 6/2015 Proactive care plan implemented for children with feeding impairment and neurodevelopment disorders from 0% to 85% C. Increase Health = delivery By 6/2015: of progesterone to pregnant Decrease women Columbia with Impairment prior preterm Scores birth from in discharge Summit to 60 days post County discharge by by 20% 15% for >75% of PFK patients admitted for treatment of psychiatric diagnoses Increase by 10% proportion of tube fed kids between 5%ile & 95%ile for weight on growth chart each year Decrease preterm birth rate to 11.6% from 13.3% in Summit County. KEY DRIVERS Payment Reform Care Coordination/Case Management Improvement Science and Implementation Health Information Technology Patient, Family, Community Engagement SECONDARY DRIVERS Risk Model & Contracting Patient Centered Medical Home Specialty Network Performance & Extenders Data Capture, Analysis & Reporting Home Care Technologies INTERVENTIONS Managed Care Orgs/PFK Contracts Pay 4 Performance Contracts Quality Collaboratives Resource Consultation Line Care Coordination and Plans Telemedicine Clinic Home Progesterone Promotion Cervical Screening Parent Training, Advocates GLOBAL AIMS: Expand PFK model to reduce costs, improve care and enhance outcomes for Medicaid children in Ohio 22

23 SPECIFIC AIMS Cost: By 6/2015 Reduce 60 day PFK behavioral health readmissions by 30% from 9.8 to 6.9% Quality: By 6/2015 Increase 30 outpatient follow up after behavioral health hospitalization from 29 to 65% Health: By 6/2015 Decrease Columbia Impairment Scores from discharge to 60 days post discharge by 15% for >75% of PFK patients admitted for treatment of psychiatric diagnoses GLOBAL AIM: Prevent Psychiatric Youth Crises Behavioral Health KEY KEY DRIVERS Mental Health and Primary Care Access Payment Reform Care Coordination/Case Management Improvement Science and Implementation Health Information Technology Patient, Family, Community Engagement HCIA NCH PFK INTERVENTIONS Consultation Line Pediatric Psychiatry Network PCP Collaboratives ADHD Collaborative Building Mental Wellness Telehealth Telepsychiatry Teletherapy, e-therapy Healthspot Pay 4 Performance Contracts Managed Care Orgs/PFK Contracts Second opinion program for medication use Care Coordination Public awareness and education Triple P Program Parent Partner Initiative 23

24 Behavioral Health Parent Partners Intervention Primary goal Provide support to parents and families coping with children with behavioral problems Secondary goals Assist parents in identifying their own needs and concerns Education and teach skills focused on coping, self-care, crisis management, problem solving, and personal skill development Provide emotional support and facilitate sharing of experiences and social connections to other parents Facilitate the empowerment of parents in decision-making

25 ADHD Medications....

26 Complex Patients A child with One of about 60 neurologic conditions* AND A feeding tube *These neurologic codes were selected by our team from ICD-9 as those diseases most likely to result in functional dependency (For a list of these codes, please me at Garey.Noritz@NationwideChildrens.org)....

27 SPECIFIC AIM Cost Care Decrease hospital days per 10,000 member months for tube fed patients from 24.8 to 22.3 days for 12-month period ending 6/30/2015* Proactive Care Coordination will be provided for 85% of children with feeding impairment and Neurodevelopment Disorders from a baseline of 0% by 6/30/2015 Health Increase by 10% annually the proportion of NCH/ACH tube fed kids between the 5 th percentile & 95 th percentile for weight on standard CDC growth charts GLOBAL AIM Improve Health of children at risk with tube feedings or other technologies Complex Care KEY DRIVERS Virtual Care Management Support infrastructure Tertiary Care (Hospital-based care) Home Management Support INTERVENTIONS PCP Training on Complex Care Resources provided to PCPs for Complex Care Patients Centralized Medical Care Coordination as needed in cooperation with PCP Family-Centered Care Planning G tube insertion/removal protocol Scheduled formula evaluations Home visits for tube mechanics and training Telemedicine Tube Advice Self Management resources (e.g. Home medication list) for Care Plan 27

28 HCIA Self-Monitoring Dashboard Complex Care: May 2014 AIM #1: Decrease by 10% NCH Inpatient Hospital Days/ 10,000 PFK Member Months over 12-Month Period for Tube-Fed Children Initiatives: Modify Feeding Tube Placement orders in EPIC to establish provider responsible for nutrition management Construct Complex Feeding Smart Form in EPIC to organize feeding tube related information for providers and families Parent Education: journey board, workbook, videos, webpage, app, Family Resource Center kiosk 9/6/

29 HCIA Self-Monitoring Dashboard Complex Care: May 2014 Secondary Program Aim for June 30, 2015 Baseline Results this Month Goal Decrease the average length of stay for tube-fed children at NCH by 10% from a baseline average of 6.7 days for Jul2011- Jun2012 to average of 6.0 days for the 12 months ending June 30 th, days 12 month average through May 2014: 4.8 days (28% from baseline) 6.0 ( 10% from baseline) Med. Dir. of Comprehensive Health Care Service (CCHCS) Starts HCIA Grant Awarded/Feeding Dietician & Tube Task Force RN Join CC Formed Team Care Coordination Expanded Desired Direction of Change Month with patient(s) yet to be discharged Group Avg: Discharge or to-date LOS for all admissions in the month; admission months containing patients still in the hospital as of June 15, /6/2014 are color-coded red and are subject to change in upcoming months until patients are discharged Group Size: Admission month for those with a tube-fed related visit (any patient class) in the prior 12 months. 29

30 HCIA Self-Monitoring Dashboard Complex Care: May 2014 Secondary Program Aim for June 30, 2015 Baseline Results this Month Goal Decrease the # of tube-fed children admitted to NCH by 10% from a baseline average of 15.5 admissions/100 cohort patients for Jul2011-Jun2012 to an average of 13.9 admissions/100 cohort patients for the 12 months ending June 30 th, admissions/ 100 cohort pts 12 month average through May 2014: 13.4 admissions/100 cohort patients (13% from baseline) 13.9 admissions/100 cohort patient ( 10% from baseline) Med. Dir. of Comprehensive Health Care Service (CCHCS) Starts HCIA Grant Awarded/Feeding Tube Task Force Formed Dietician & RN Join CC Team Care Coordination Expanded Desired Direction of Change 9/6/

31 Cumulative % of Patients in the Feeding-Tube Cohort with Info In Smart Form Section/Field Oct-13 HCIA Self-Monitoring Dashboard Complex Care: May 2014 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Process Measures Meets Expectations Mitigation in Progress Requires Attention Not started Program Aim for June 30, 2015 Monthly Process Measure Results Goal Notes Status Decrease by 10% NCH inpatient hospital days per 10,000 PFK member months over a 12-month period for tubefed children. Cumulative percent of feeding-tube patients in the cohort with information in the Complex Feeding Smart Form in EPIC Complex Feeding Smart Form Usage in EPIC 40% 35% 30% 25% 20% 15% 10% 5% 0% Procedure Detail Section Last Nutrition Assessment Field Care Team Section Weight at Goal Field EPIC Complex Feeding Form Rollout milestones: 10/1: Available to providers in CP Clinic, Complex Care and IDF 11/1: Available to all providers # of families assessed for tube feeding competence in the Family Resource Center 5 families 9/6/

32 HCIA Self-Monitoring Dashboard Complex Care: May 2014 AIM #2: Provide Proactive Care Coordination for 85% of Tube-Fed Children with A Neurodevelopment Disorder Initiatives: Global Care Coordination with Complex Care Flag Health Care Assessment Every 6 Months Care Plan Post Inpatient and ED Discharge Follow-Up 9/6/

33 HCIA Self-Monitoring Dashboard Complex Care: May 2014 Program Aim for June 30, 2015 Baseline Results this Month Goal Proactive Care Coordination will be provided for 85% of children with a feeding tube and neurodevelopment disorder(s). 0% May 2014: 55% 85% Patients with A Feeding-Tube Dx/Px in Prior 12 Months and A Neuro Code As early as Jan 2010, Ages 0-18 Feb-14 Apr-14 May-14 Cohort N* # Offered Care Coodination # Discharged from Care Coordination 49 # Actively Enrolled 185 # Outreach but No Care Coordination 72 # No Care Coordination Activity 251 * Excludes deceased patients 9/6/

34 HCIA Self-Monitoring Dashboard Complex Care: May 2014 AIM #3: Increase by 10% Annually, the Proportion of NCH Tube-Fed Children between 5 th and 95 th Percentile for Weight on Standard Growth Charts from Baseline Initiatives: Construction of the Complex Feeding Smart Form in EPIC Standardizing RD involvement for patients with a feeding tube Complex Care App with Feeding Journal targeting patients with low weights 9/6/

35 HCIA Self-Monitoring Dashboard Complex Care: May 2014 Program Aim for June 30, 2015 Baseline Results this Month Goal Increase by 10% annually the proportion of NCH tube-fed children between the 5 th percentile and 95 th percentile for weight on standard growth charts. 59.5% 12 month average through May 2014: 63.4% (0.2% chg from last month; 6.4% from baseline) Month of May14: 63.5%/72.5% with Accept Wt Pts 79.2% ( 33% from baseline) Med. Dir. of Comprehensive Health Care Service (CCHCS) Starts HCIA Grant Awarded/Fe eding Tube Task Force Formed Dietician & RN Join CC Team Care Coordination Expanded Note: Beginning June 2012, the baseline shifted upward from 59.5% to 62% 9/6/2014 *Number of patients who were in weight range PLUS patients out of weight range but with acceptable weights per dietician notes in Apex patient registry or in EPIC Nutrition Smart Form 35

36 Transition- Challenges Ensuring Continuous health coverage after age 19 (or 26). Continue care management Transfer to adult systems as appropriate. Staying on Medicaid (Ohio) On Waiver OR On SSI OR Income based....

37 Conclusions An ACO is a workable model for organizing the care of children with disabilities. An ACO can improve care while reducing costs. The Successful ACO requires: Close collaborations between physicians and organizations A family-centered approach to health care A vision that values outcomes over throughput A willingness to take financial risk A significant investment in data management....

38 Thank You!