Medicare Shared Savings Program ACO Learning System

Transcription

1 Medicare Shared Savings Program ACO Learning System Coordinating Care for Beneficiaries with Complex Care Needs Wednesday, June 24, :30 4:00 PM ET Audio for this session can be streamed through your computer, or accessed by phone by dialing ; access code: 25869

2 Disclaimer The comments made on this call are offered only for general informational and educational purposes. As always, the agency s positions on matters may be subject to change. CMS s comments are not offered as and do not constitute legal advice or legal opinions, and no statement made on this call will preclude the agency and/or its law enforcement partners from enforcing any and all applicable laws, rules and regulations. ACOs are responsible for ensuring that their actions fully comply with applicable laws, rules and regulations, and we encourage you to consult with your own legal counsel to ensure such compliance. Furthermore, to the extent that we may seek to gather facts and information from you during this call, we intend to gather your individual input. CMS is not seeking group advice.

3 Past Webinar Materials Interested in past Learning System events? Go to to access recordings and summaries of past webinars, including: Strategies of SSP ACOs Achieving Shared Savings -- 4/15/15, 4/29/15, 5/12/15, 5/19/15 Evidence Based Medicine 1/7/14 and 1/24/14 Internal Cost and Quality Reporting 4/17/14 and 5/22/14 Provider Engagement 9/9/14 and 10/1/14 Beneficiary Engagement 10/22/14 Advancing Primary Care 11/14/14 Coordinating with Post Acute Care Providers Coordinating with Hospitals and Specialists 12/15/14 Strategies of ACOs Sharing in Savings in /4/14, 4/11/14, 5/2/14, 5/16/14 Materials for these webinars are located in the Program Announcements section of the Portal, under Learning System Webinar Materials 3

4 Webinar Agenda Housekeeping items Introduction MaineHealth ACO Broward Guardian Q&A Wrap-up

5 The widget menu located at the bottom of your event console provides access to various resources for a webcast. Should you accidentally minimize any of your widgets, you can open them again using the widget menu. The Help widget provides immediate access to technical resources and information, like the system requirements and technical FAQs. In addition, you can test your system to see if you are meeting the minimal technical requirements The Q&A widget allows attendees to submit questions to the presenters technical or content related at any time. The Slides widget is the presentation display area for the PowerPoint slides that are presented to the audience. It also displays any polling questions. The Resource List widget contains documents related to this webcast. The Closed Captioning widget opens a separate URL featuring the live closed captioning feed for the webcast. The Survey widget contains a link to a survey, which you can use to submit feedback about the webcast.

6 MaineHealth ACO Cindy Tack, LSCW, MS.MEdL Senior Director, Clinical Initiatives

7 Complex Care Management in the ACO Environment Science, Art and Blood, Sweat & Tears June 24, 2015 Cindy Tack, LCSW, MS.MEdL Senior Director, Clinical Initiatives MaineHealth ACO MMC PHO - Portland, Maine

8 Presentation Objectives Describe MaineHealth ACO s strategy for improving care of patients who are identified as complex and at risk Apply lessons learned from training of interdisciplinary and interagency tailored care teams Anticipate positive shifts in culture and strategies to facilitate innovation and engagement

9 Landscape

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11 4-Point Strategy for ACO Success Primary Care Our primary care practices will operate as Patient Centered Medical Homes, and be financed to do so Care Coordination MaineHealth will assess, consolidate and/or reorganize systemwide care coordination resources to ensure the right focus on the right patients Information Technology Improve information available to clinicians at the point of care by aggregating real-time claims and select EMR information Transparency A physician-led peer review program will focus on reducing unwarranted variation in care

12 Definition, Vision, Goals Care Coordination is the deliberate organization of care activities and information exchange that ensures every patient receives the care he or she needs at every point along the continuum. Culture of Patient Centered, Integrated Care Communication & Information Technology Population Health to Complex Care Management Continuum Patient care is coordinated, continuous, tailored and based on shared responsibility Successfully activate the full use of cross system tools and processes to be used by all providers for all patients Patient data is accessible, actionable and transferrable Care / Case Management is aligned with patient and population needs Become a leader in integrated, coordinated care through the optimization of our care management model for at-risk patients

13 Regionally Focused Care Coordination Program

14 I have not failed. I ve just found 10,000 ways that won t work. Thomas Edison

15 Patient Identification Clin Fin /01/ /01/

16 Patient Detail Dashboard

17 People are not resistant to change. People are resistant to being changed. Peter Senge

18 Care Management Evolution

19 Care Coordination Responsibilities

20 If you build it, they will come. Kevin Costner in Field of Dreams

21 Regional Partnership Complex Care Management Program Integration Focused Strategy #1 Care management organized into teams embedded in their unique regions Each regional team will have a Team Lead (TL) TL review team s data and outcomes TL collaboratively study patient gaps and unmet needs TL identify training needs TL ensure effectiveness of protocols and procedures Focused Strategy #2 Regions hold regular meetings to review regional data and outcomes Regions hold regular meetings to identify barriers to success and problem-solve solutions Outcomes 35% increase in risk patients matched with a complex care management resource 25% improvement in bidirectional, closed-loop communication between CM and regions Improved employee engagement evidenced by 95% participation in regional meetings

22 Care Management Training for Practice Staff

23 Care Coordination Characteristics

24 Questions? Cindy Tack, LCSW, MS.MEdL Senior Director, Clinical Initiatives MMC Physician - Hospital Organization 110 Free Street, Portland, Maine tackc@mmc.org

25 Questions & Answers Please submit questions using the Q&A panel in the event console

26 Broward Guardian, LLC John Harkins Executive Director

27 A Holistic Approach to Improving Beneficiary Health Medicare Shared Savings Program ACO Learning System

28 ACO Background Start Date: January 2014 Track 1 Model No Advance Payment Memorial Healthcare System(MHS) is Participating Provider 75 Participating Providers 9,000 Attributed Beneficiaries 95% EHR Penetration with 15 different platforms (most common EHR is eclinicalworks promoted by MHS)

29 Broward Guardian Culture Collaboration between Memorial Healthcare System(MHS) and Community based Primary Care Physicians. MHS is the 4 th largest public health system in the country and the only hospital provider in the market Located in Southern Broward County, boarding Miami-Dade County. Geographically small, but diverse population mix Extremely high benchmark MA(Medicare Advantage) Risk penetration is high (preferred method of contracting for providers and payers)

30 Focusing on the Three- Part Aim (Quality/Access/Costs) Strategy Driven by Limited Access to Capital Reality: Generate Savings or Close up Shop Focus on Short Term Savings Strategies Cost verses Benefit Short Term verses Long Term Physicians understand the relationship between Quality and Savings More Primary Care Utilization Avoid Unnecessary/Avoidable Utilization

31 Broward Guardian Care Coordination Model Engage High-Risk Patients High Cost and High Risk Develop Individual Care Plans Beneficiary/Caregiver/Provider Include Personal Goals Frequent Interaction and Contact Right service, Right Time, Right Place Reduce Avoidable Readmissions Reduce Unnecessary ED Utilization Eyes and Ears of the PCP

32 Borrowing from the Managed Care Community Chronic SNP(Special Needs Plans) Management Comprehensive Assessment Risk Stratification Individualized Care Plans Manage/Evaluate/Reassess Managed Long Term Care (MLTC) Home and Community Based Services Caregiver Engagement Holistic Approach

33 Comprehensive Assessment Looking Beyond the Clinical Florida 701B Assessment Tool Medicaid Qualification Managed Long-Term Care Holistic Approach Mental Health/Behavioral/Cognition Nutrition Health Conditions Specialized Services Medications Caregiver Information

34 The Hidden Risk A Real Life Example Patient Smith age 70 Diabetic/CHF (non-compliant) Patient Constantly Rescheduling Visits Does not get lab work when ordered Inconsistent Medication administration No glucose records Reports poor eating decisions The REAL Risk Factors Patient is primary caregiver for disabled spouse No extended family Struggles to put food on the table No air conditioning Only available transportation is neighbor

35 Empower the Coordinators to Think Outside of the Box!!! Success in any Disease Management or Care Management model is dependent on Patient Engagement and Self- Management. What can we do to help enable the patient to be more engaged?

36 Community Partnership Area Agency on Aging(AAA) and the Aging and Disability Resource Center(ADRC) Provide and Coordinate Services Free to the Beneficiary Free to the ACO Added Resource

37 Integrating and Coordinating Comprehensive Care Plan Clinical Interventions Non-Clinical Interventions Direct Referrals to Community Agencies Assistance with locating, qualifying, applying for services Meals on Wheels Transportation Social Programs Self-Management Training Programs Diabetes Self-Management Chronic Disease Self-Management Falls Prevention Program More Eyes On The Beneficiary

38 Key Areas of Focus - Summary Reducing Unnecessary and Avoidable Hospital Utilization Reduce ER/ED Utilization Reduce Readmission Rate (24%) Promote Primary Care Utilization Identify Gaps in Care Facilitate the Flow of Information Remove Barriers Identify Risk Factors Develop Comprehensive Care Plan Utilize Community Resources Become a Beneficiary Advocate

39 Contact Information John Harkins Executive Director Broward Guardian (954) Thank You!

40 Questions & Answers Please submit questions using the Q&A panel in the event console

41 Please give us your feedback! Open the survey widget located in the widget menu at the bottom of your event console.

42 Thank you! Slides and a link to the webinar recording will be posted to the ACO Portlet. A recording will also be available tomorrow from the audience link you used to attend today s event. Please complete the webinar evaluation Feel free to send questions, comments, and suggestions for future topics to ACOLearningActivities@mathematicampr.com