1 Provider Network Management & Clinical Performance Optimization In Population Health Management: Preparing For Value-Based Reimbursement #OMPerformance The 2017 OPEN MINDS Performance Management Institute Thursday, February 16, :30am 12:45pm Ken Carr, Senior Associate, OPEN MINDS York Street, Gettysburg, Pennsylvania Phone: All Rights Reserved.
2 Agenda I. The Relationship Between Population Health Management & Value-Based Reimbursement II. III. IV. Seven Key Competencies For Provider Network Management & Clinical Performance Optimization Provider Network Management & Clinical Performance Optimization In Population Health: The Chestnut Health Systems Case Study Provider Network Management & Clinical Performance Optimization In Population Health: The Gracepoint Case Study V. Questions & Discussion All Rights Reserved.
3 The Relationship Between Population Health Management & Value-Based Reimbursement
4 P4P FFS PFS Value-Based Reimbursement Outcomes-based funding Bundled/episodic/case rates Capitation for care coordination Capitation for service delivery All Rights Reserved.
5 Population Health Management Approach Population health management is approach to managing health outcomes and resource utilization of a group needed for success in value-based reimbursement arrangements A best-in-class PHM program brings clinical, financial and operational data together from across the enterprise and provides actionable analytics for providers to improve efficiency and patient care 2 the health outcomes of a group of individuals, including the distribution of such outcomes within the group All Rights Reserved.
6 Four Domains in OPEN MINDS Model For Assessing Population Health Management Readiness Financial Management & Leadership/Governance Structure Alignment of strategy with infrastructure & resources Technology & Reporting Infrastructure Functionality Data leveraged to gain insight Provider Network Management & Clinical Performance Optimization Data analyzed to drive clinical decision-making Consumer Access, Customer Service, & Consumer Engagement Processes to empower consumers and create engagement All Rights Reserved.
8 Seven Key Competencies Of Provider Network Management & Clinical Performance Optimization Provider Organization & Professional Recruiting & Credentialing Care Coordination & Care Management Consumer Screening, Care, Provider Referrals, & Case Authorizations Decision Support & Care Standardization Integration of Physical Health, Behavioral Health, & Social Services Clinical Performance Tracking, Assessment & Optimization All Rights Reserved.
9 1. Provider Organization & Clinical Professional Recruiting & Credentialing Focus: Ability to recruit and management credentials of clinicians that meet the requirements of payer organizations Key Competencies for Success Accreditation in serving consumers with complex needs Ability to recruit and retain qualified clinicians Effective workflows for managing clinician credentials All Rights Reserved.
10 2. Consumer Screening, Provider Referrals, & Care Authorization Focus: Ability to identify high-risk and highneeds individuals and ensure the most effective care management plan and services Key Competencies for Success Ability to identify highutilization consumers Process to screen, assess and refer consumers to the appropriate level of service All Rights Reserved.
11 3. Care Coordination & Care Management Focus: Ability to identify care management needs, obtain payer authorizations and refer to appropriate services Key Competencies for Success Processes in place to receive care management referrals, assess needs and refer consumers for services Authorizations expertise Focus on integration, followup and communications Systems to track usage of other community providers All Rights Reserved.
12 4. Decision Support & Care Standardization Focus: Ability to use data to determine and promote the most effective evidenced-based practices Key Competencies for Success Standardized guide to care management and treatment Implementation of datainformed planning, treatment and referral Continuity of care planning and transition between care settings All Rights Reserved.
13 5. Integration Of Physical Health, Behavioral Health, & Social Services Focus: Ability to ensure that chronic physical health issues are integrated into the care plan Key Competencies for Success Established referral and data sharing relationships with primary care Established protocols for referrals and care transitions Focus on identifying consumer preferences when making primary care referrals All Rights Reserved.
14 6. Clinical Performance Tracking, Assessment & Optimization Focus: Ability to track outcomes, assess how to optimize services, and implement performance improvements Key Competencies for Success Track clinical outcomes and consumer experience by provider organization Assess tracking data to identify best performers and best practices All Rights Reserved.
15 Case Study Examples of Provider Network Management & Clinical Performance Optimization Process for receiving care management referrals Process for profiling and risk-adjusted care planning Process to refer consumers to the most appropriate level of service Marketing that addresses return on investment Processes and tools to facilitate the communication between care teams Protocols for referrals and care transitions with physical health providers System to track hospitalizations and provide timely follow-up post discharge All Rights Reserved.
16 The Chestnut Health Systems Case Study Orville Mercer, MSW, Vice President, Behavioral Health, Chestnut Health Systems, and President, IBHHC LLC
17 PROVIDER NETWORK SOLUTIONS FOR TARGETED HIGH USER MEDICAID POPULATION ORVILLE MERCER MSW VICE PRESIDENT OF BEHAVIORAL HEALTH CHESTNUT HEALTH SYSTEMS PRESIDENT ILLINOIS BEHAVIORAL HEALTH COALITION LLC. Chestnut Health Systems / Illinois Behavioral Health Home Coalition LLC.
18 Illinois Medicaid Managed Care > 2 million citizens
19 IBHHC Project Summary 1. Managed Care company engaged Provider Owned Network in a project to address HIGH USERS throughout Central Illinois. 2. Evaluation of project based on evaluation of total health claims Pre referral and Post referral at 3,6,9 month intervals. 3. Annualized savings of approximately 1 million dollars realized on co-hort of 79 high users. If scaled 25 times (2000), savings of 26 million might be realized. 4. Currently negotiating this scale up 5. What is a good enough ROI? 2/1 ; 3/1; 4/1;???
20 2-3 inpatient episodes < 6 months 2 or more ED visit < 6 months MLR 300% % based on claims What is a high user? Chronic co-morbid conditions (3-5) Drug abuse/ addiction
23 Provider Owned Network IBHHC LLC 1. Six Not-For-Profit Owners 2. All providers licensed / credentialed and contracted with all M/C companies in their region 3. Providing comprehensive services directly or through agreements million in annual revenues into network annually 40,000 clients served annually 22 counties served 33 hospitals in network
24 Network Characteristics 1. Integrated Care Activities 5 major geographies with FQHC status or co-located FQHC partners partners with / had SAMHSA funded Primary care behavioral health integration projects 3. Best Practice Pharmacies 4 Genoa pharmacies located in 4 most populated partner sites 4. FY Certified Group Leaders through the Stanford Chronic Disease Management Program 5. Care Management Technologies / Predictive Analytics 6. FY 18 System wide utilization of the Patient Activation Measure
25 Network Activities 1. TCM teams / leadership participate in ongoing Learning Community Activities 2. Fidelity to all training requirements / Baseline testing pre-post 3. Special emphasis on: Motivational Interviewing --BH and Primary Care Recovery Oriented Philosophy Social Determinant's of Health 4. Network Wide PAM utilization 5. Care Management Technologies Reviewed by project Reviewed by network partner and region
26 Network Staff Course Training Behavioral Healthcare Breast Health and Breast Cancer Blood Pressure/Hypertension Cardiovascular Health and Heart Disease Cervical Health and Cervical Cancer Colorectal Health and Colorectal Cancer Health Coaching and Motivational Interviewing Health Literacy Healthy Eating Active Living Navigating Health Insurance Pre-Diabetes and Diabetes Prostate Health and Prostate Cancer Social Determinants of Health Disparities
27 "Local Solutions Community Provider Synergies
28 Information Flow M.C. CMT Impact on claims IBHHC Clinical Intervention
29 Using Data to Solve Real Problems CMT Analytics Let s solve this problem by using the big data none of us have the slightest idea what to do with.
30 Tipping Point Problem Co-morbid & Complex Disease States Solution Data Enabled - Targeted Case Management
31 CMT: How Analytics Works A web-based data analytics solution supporting population health Works in the background to aggregate, analyze and interpret data Supports evidence-based management of complex populations Enhances clinical and financial risk analysis
32 CMT s Population Health Cycle Data Targeted evidencebased interventions for patients and care team Improved Outcomes Meeting the Triple Aim of Improved Care, Improved Health and Lowered Costs
33 IBHHC Cohort Population N = 79 Mood Disorders = 68 Alcohol and Drug Abuse Disorders = 56 Psychotic Disorders = 43 Medical comorbidities Ambulatory Care Sensitive Conditions (ACS): 1 member has 13; 2 have 8; 1 has 7; 2 have 6; 4 have 5; 6 have 3; and the rest have 2 or less. 33 individuals have hypertension 20 have asthma 16 have metabolic disorder, lipid. 46 (58%) have an Ambulatory Care Sensitive Condition (ACS)
34 Hospitalization and ED Trends Year / Month ED Visits - Behavioral ED Visits - Non-Behavioral Hospitalizations - Behavioral Hospitalizations - Non-Behavioral 2015/ / / / / / / / / / / / / / / % Change from Jan in April (last month of complete medical data) -58% 23% -55% 167% ED Visits - Behavioral ED Visits - Non-Behavioral Hospitalizations - Behavioral Hospitalizations - Non-Behavioral
35 CHCS Multi-Morbidity
36 ADMITS, BED DAYS, ED VISITS AND PMPM% CHANGE OUTCOME IP ADMITS / 1000 (AUTH) BED DAYS / 1000 (AUTH) ED VISITS / 1000 PRE 4,531 18,301 12,106 POST 1,942 7,288 8,385 DIFFERENCE 2,589 11,013 3,721 % DIFFERENCE 57% 60% 31% OUTCOME MED PMPM RX PMPM TOTAL PMPM PRE $2,375 $324 $2,699 POST $1,217 $411 $1,629 DIFFERENCE 1, ,070 % DIFFERENCE 49% -27% 40% 6 Month Data: 53% increase in rx PMPM 51% decrease in IP admits 58% decrease in bed days 25% decrease in ED visits 30% decrease in total PMPM
37 Best Practice Pharmacy services
39 Top 5 Co-Morbid Diagnosed ACSC Population Volume (per 1000 patients) Hypertension, Essential Asthma Diabetes Mellitus Urethral/Urinary Tract Disorder, Other Top 5 Co-Morbid Diagnosis Heart Failure
40 Top 5 Care Gaps with the Highest ED Utilization Volume of ED Visits (per 1000) DIABETES - NO ACE INHIBITOR OR ARB DIABETES - ABSENCE OF A STATIN CARDIOVASCULAR - HISTORY OF CARDIOVASCULAR DISEASE, NO EVIDENCE OF STATIN Top 5 Care Gaps with Highest ED Visits CARDIOVASCULAR - HISTORY OF CARDIOVASCULAR DISEASE, NO EVIDENCE OF BETA- BLOCKER DIABETES - NO BETA BLOCKERS
41 Hospital and ED Utilization Comparison
42 Client Success Stories Female Treatment includes personality disorder, depression, substance abuse (crack and alcohol), and metabolic syndrome. She has a long history of criminal involvement and homelessness. Hospitalizations have dramatically decreased and he has started engaging with treatment and attends appointments with her prescriber. She is now completing a 28 day inpatient residential substance abuse treatment program and will be linked with a transitional living facility upon completion. Male He received several criminal charges stemming from chronic poly-substance dependence. He is now beginning to engage with staff and has developed a plan for completing goals including obtaining his GED, remaining sober, and following through with mental health treatment. Female Treatment includes schizoaffective disorder and intellectual disabilities. Previously lived in a financially exploitive and abusive environment and was transitioned into a group home. She is now happy and has not required hospitalization.
43 Client Success Stories Female Treatment includes opiate dependence, anxiety, and diabetes. Using data from CMT we were able to understand the severity of this client s substance abuse (opiates) as well as physical health conditions (diabetes). After losing custody of her children she has started engaging with us and is now attending appointments and will begin parenting classes. Male Treatment includes conduct disturbance, depressive disorder, psychosis, and PTSD. He had a history of about 2 hospital stays per month from 6/2015 until we began working with him near the end of January and has struggled with chronic homelessness. Hospital stays have decreased to one per month for inpatient stays. In addition, he is now following through with substance abuse treatment and has continued to participate in an inpatient residential substance abuse treatment program for the past three months.
44 There has to be an easier way for me to get my wings. Clarence Oddboddy Angel 2nd Class It s a Wonderful Life
45 The Gracepoint Case Study Maurice Lelii, LMHC, NCC, Director, Outpatient Services, Gracepoint
46 Provider Role In Value-Based Delivery Maurice Lelii LMHC Director of Outpatient /Managed Care February 16, 2017
47 Gracepoint Overview 1 Gracepoint, formerly Mental Health Care Inc., is a private, non-profit behavioral healthcare organization founded in 1949 by the Tampa Junior League. Gracepoint provided services to more than 21,000 individuals (2016) in Hillsborough County, and employs 600 staff members. Specific Populations Served Adults, Adolescent, and Children with mental health and substance abuse issues Adults with Severe Persistent Mental Illness Adults in the criminal justice system Children with behavioral health/special education needs Children in child welfare Adult Homeless services Elderly and Supportive housing programs 1. Gracepoint Annual Report. Retrieved July 2016 from Gracepointwellness.org:
48 Gracepoint Services 1 Central Intake No Wrong Door Baker & Marchman Act Receiving Facility Adult Crisis Stabilization Unit - 60 bed Children s Crisis Stabilization Unit - 28 bed Community Action Team (CAT) Mobile Crisis Response Team Homeless Services Forensic Treatment Program - 30 bed Outpatient Program Psychotherapy/Medication Management Clinics Intensive Case Management Psychosocial Rehabilitation Program ** Value-Added Services 1. Gracepoint Annual Report. Retrieved July 2016 from Gracepointwellness.org: **High Utilizer Project **Telehealth **Onsite Pharmacy **Integrated Primary Care (Tampa Family Health - FQHC)
49 Gracepoint Value-Added Services Health Home 1 Onsite integrated medical primary care services Joint venture with Tampa Family Health (FQHC) Telehealth 1 Currently used in our Central Intake, CSU, Outpatient medication and case management program Onsite Pharmacy 2 Joint venture with Genoa Healthcare 1. Gracepoint Annual Report. Retrieved July 2016 from Gracepointwellness.org: 2. Gracepoint Resource Guide. Retrieved July 2016 from Gracepointwellness.org:
50 High Utilizer Care Coordination October 2015, initiated High Utilizer Project Goals: Reduce re-admissions to CSU and Hospital ER Determine the root cause for admissions Provide comprehensive coordination of care
51 High Utilizer Care Coordination October 2015, initiated High Utilizer Project Program Components: Established a care coordination specialty team with a representative from every Gracepoint program Established an internal IT 24/7 alert system Streamlined access for referral and admission to all Gracepoint programs via EHR referral system Weekly care coordination case review meetings
52 High Utilizer Care Coordination High Utilizer = (3) CSU admissions within 90 days 92 Adult High Utilizers were identified from January 2015-June 2016 Results: 75% (69) identified have < 1 readmission to Gracepoint. 25% (23) identified continue to be readmitted > 1 to Gracepoint.
53 High Utilizer Care Coordination Funding Data 58% (53/92) of all adult high utilizers are insured. 77% (41/53) of insured have < 1 readmission. 42% (39/92) of all adult high utilizers are DCF funded. 72% (28/39) of DCF funded have < 1 readmission.
54 Value-Based Contracting: Health Plan You are as good as your network! Full continuum of services Comprehensive high quality clinical team Open Access System of Care Inpatient Crisis Stabilization Aftercare Services Intensive Case Management Pharmacy Management HEDIS/Quality Measures Primary Care Integration Affordable pricing of services HEDIS=Health Effectiveness Data Information Set
55 Value-Based Contracting: Provider You are as good as your partnerships! Full continuum of services Comprehensive high quality clinical team Open Access System of Care Inpatient Crisis Stabilization Aftercare Services Intensive Case Management Pharmacy Management HEDIS/Quality Measures Primary Care Integration Affordable pricing of services HEDIS=Health Effectiveness Data Information Set
56 Model Comparison 1 Fee For Service Greater Administrative Costs Lower Cost Controls Greater Risk of Strained Partnership Capitation Lower Administrative Costs Greater Cost Controls Greater Risk of Collaborative Partnership Value Based Incentive /Gain Share Program to Drive Provider Performance 1. Gracepoint internal data.
57 Gracepoint Capitation Model 1 One of the five founding members of Florida Health Partners contract entity with Florida s Agency for Health Care Administration Area 6 Medicaid waiver program Partnership between regional providers and ValueOptions Capitation based on covered lives, provider s revenue based on 90% encounter MLR, shared risk with Area 6 partners Reporting requirement: service encounters, quality audits MLR=Medical loss ratio, UM=Utilization management 1. Gracepoint internal data.
58 Questions & Discussion
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