C24: Addressing Social Determinants in a Medicare Shared Savings Program Accountable Care Organization
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1 C24: Addressing Social Determinants in a Medicare Shared Savings Program Accountable Care Organization Rob Fields, MD Medical Director Robert.Fields@msj.org IHI National Forum I 1 Lori Brown, PharmD, BCACP Director of Clinical Operations Lori.Brown@msj.org Disclosures Dr. Fields and Ms. Brown have no disclosures or conflicts to report IHI National Forum I 2 1
2 Objectives Identify and implement an organizational plan for addressing social determinants in an ACO or clinically integrated network Develop a financial model and justification for addressing social determinants in a value-based model Develop the technical and political infrastructure to engage community partners in value-based payment systems IHI National Forum I 3 IHI National Forum I 4 2
3 IHI National Forum I 5 accessed IHI National Forum I 6 3
4 IHI National Forum I 7 accessed IHI National Forum I 8 accessed
5 15.8% of adults aged 60+ in the U.S. are at risk for hunger 1 28% over 65 live alone 2 31% of the nation s homeless population is over 50 years 3 IHI National Forum I MHP Growth and Formation IHI National Forum I 10 5
6 MHP Footprint 2018 IHI National Forum I 11 Primary Care Providers Pediatricians MHP Providers at a glance 432 Office Practicum NextGen Medinformatix Meditouch Greenway Epic e-md Cerner no PCA PCA allscripts E-clinical care360 Athena amazing charts Independent PCPs Employed PCPs Independent Specialists Employed Specialists IHI National Forum I 12 6
7 MHP Population 58,140 Medicare (MSSP) 18,278 Mission Health 8,437 Humana MA 4,752 United Healthcare MA Plan 1,356 Healthy State Commercial 83 Healthy State MA 91,046 total patients as of October 2017 IHI National Forum I 13 MHP Care Coordination Team Pathways Hub model Social determinants of health Each pod establishes a personal relationship with the practice Access, access, access Great learning environment Pod 5: RN Pod 4: RN Pod 1: RN Shared Resources: PharmD, 2 pharmacy technicians, 2 LCSWs, psychiatrist, CaraMedics, CHWs, medical director, Community Resource Specialist Pod 3: RN Pod 2: RN IHI National Forum I 14 7
8 Care Coordination Team Training WNC Culture MI CRM Weekly check ins Monthly case reviews - with community partners Community partners IHI National Forum I 15 IHI National Forum I 16 8
9 Pathways-Hub model with a Twist AHRQ endorsed Care Coordination model 1. Find 2. Treat 3. Measure Pathways-HUB Focus on Social Determinants of Health Non-clinical focus Barriers to Care Follow through to completion Plus typical Medical approach Identify clinical risk Disease specific education Patient Centered approach IHI National Forum I 17 accessed Community Care Plan Referral to social service agencies are electronic in tool Pathway opened Assigned to specific agency Tracking and Referrals Appointments Productivity Phone calls Pathways Opened Closed complete Closed incomplete The Mechanics IHI National Forum I 18 9
10 Transition of Care Provider Referral High Risk for Admission Comprehensive Initial Assessment Open Pathways Financial Transportation Medical Home Medication Access Housing Food Security Legal Support Education Palliative Care EblenCharities Bus Vouchers Primary Care Provider Home delivery Homeward Bound MANNA food bank Pisgah Legal Services ABIPA CHWs Care Partners WCMS Mountain Mobility Project Access Low Income Subsidy applications Meals on Wheels CaraMedics Four Seasons Ride Health Patient Assistance Programs Healthwiseand Athena Well IHI National Forum I 19 Readmissions: MHP Network vs. Transitions Program IHI National Forum I 20 10
11 Impact on Cost by MARA Risk Score 2016 vs $4,000 $3,500 $3,000 $2,500 36% Reduction In cost in our highest risk group $2,000 $1,500 $1,000 $500 Average of CY-2016 Average of CY-2017 $0 < z10+ IHI National Forum I MSSP By the Numbers IHI National Forum I 22 11
12 2016 MSSP By the Numbers IHI National Forum I % North Carolina ACOs: Benchmark and Quality Scores 97.6% $14, % $12, % $10, % 60.0% $8, $8, $6, % $4, % $2, % QualScore UpdatedBnchmk MHP $- IHI National Forum I 24 12
13 2016 MSSP By the Numbers IHI National Forum I 25 IHI National Forum I 26 13
14 Thank You! IHI National Forum I 27 14
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