2016 Experian Information Solutions, Inc. All rights reserved. Experian and the marks used herein are service marks or registered trademarks of

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1 2016 Experian Information Solutions, Inc. All rights reserved. Experian and the marks used herein are service marks or registered trademarks of Experian Information Solutions, Inc. Other product and company names mentioned herein are the trademarks of their respective owners. No part of this copyrighted work may be reproduced, modified, or distributed in any form or manner without the prior written permission of Experian. Experian Public.

2 ACO Success through a 30-Day Transition of Care Process Jennifer Toms, Innovista Health Solutions

3 Agenda Introduction About Innovista Transition of Care (TOC) Overview TOC Program Goals & Benefits TOC Workflows Initial TOC Program Updated Program with CareCertainty Conclusion and Questions Patient/Physician/Hospital responses to new program Successes and Goals moving forward (5 mins) Conclusion/Q&A? (5 mins) 3

4 Innovista: Information & Company Goals Leading Population Health Management organization founded in October 2013 Locations in Illinois and Texas Enable physicians to manage all types of value based agreements that can enable independent physicians to stay independent Improve clinical quality, utilization/cost, value, physician satisfaction Lower the cost of care across the healthcare continuum by: Building and managing high-performing, quality, physician networks Combining information, technology and people to identify, communicate and manage physician behavior change and drive performance.ng support and tools necessary to manage population health a Delivering certified programs to exceed health plan requirements 4

5 Innovista: Background / Growth Employees 20 Networks 2 Members* 46,000/*All PCPs 200 Employees 60 Networks 6 Members* 187,000/*51,000 PCPs 700 Employees 115 Networks 18 Members* 300,000/*58,000 PCPs 1000 Employees TBD Networks 31+ Members* 400,000+/*??? PCPs ** *** Contracts/Plans 8 Contracts/Plans 15 Contracts/Plans: Fee for Service Pay for Performance Shared Savings Limited Risk Delegated * Medicare lives ** Innovista launched October Contracts/Plans 5

6 Innovista: Service Platforms 6

7 Care Coordination: The Transition of Care Program CMS started reimbursing providers on January 1, 2013 Provided to: Patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision Patient making during transition from an inpatient hospital setting, partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient s community setting Estimated 80% of serious medical errors involve miscommunication during the hand-off between medical providers ~ 2.6 million seniors are readmitted within 30 days, at a cost of over $26 billion every year About 70% of all discharges qualify for Transition of Care Services 7

8 Transition of Care: Goals 8

9 Transition of Care: Cost Containment $2,640,000* $12,000,000* *Cost example specific to Innovista s IL Market 9

10 Transition of Care: Requirements 30-day period begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days. During the 30 days beginning on the date the beneficiary is discharged from a hospital inpatient setting, you must furnish the following three components: Face-to-face visit Medical Complexity Determination Medication Reconciliation Completed within 7 or 14 days of discharge An interactive contact Two attempts made with 2 business days of discharge Telephone, , or face-to-face Additional non-face-to-face services 10

11 Transition of Care: Program Completion Must document the following information in the beneficiary s medical record: Date the beneficiary was discharged. Date you made an interactive contact with the beneficiary and/or caregiver. Date you furnished the face-to-face visit. The complexity of medical decision making (moderate or high) 11

12 Innovista s Transition of Care Workflow 12

13 Questionnaire: TOC Follow-Up: Completion: ED Notice: Adm. Notice: DC Notice: Transition of Care Program Notification sent to PCP alerting office of member ED encounter Notify PCP of Obsv/Inpatient Admissions based on ADT feed from facilities Notify PCP of discharge & engage with PCP office to ensure post-dc appointment has been scheduled. Message includes encouragement to schedule post-ed appointment with member Includes facility name & department, admission date, admitting diagnosis, admitting &m attending providers Includes facility name admit day & discharge day, LACE score, diagnosis, member contact info, and alert that 30- Day TOC Program has been initiated. TOC Questionnaire completed telephonically with member within TWO business days of discharge. Min. 2 attempts made. Completed Questionnaire immediately sent to PCP so it can be reviewed during the follow-up appointment Contact PCP Office to Verify that member kept appointment & that medical complexity was determined All additional requested calls & 30-Day TOC completion call made to member, as needed TOC Summary sent to PCP office detailing completed program components TOC Billing instructions included, if requested 13

14 Transition of Care Program: Initial Program Response Innovista Care Team: Tedious to record all program components in Excel Spreadsheet Time wasted entering information into notifications and records Nothing driving workflow or reminding team of deadlines Physicians: Patient cases missing or incomplete Low volume of cases managed Lack of customization for individual practices Hospital Staff Eager to participate Need to custom workflows based on facility 14

15 Transition of Care: CareCertainty Workflow Driven by System Auto-Generated Notifications Customizable by Facility, PCP, Internal Departments, Encounter/Task Type ED Encounter Notifications Observation/Inpatient Admission Notifications Observation/Inpatient Discharge Notifications Post-Discharge Member Services 15

16 Transition of Care: CareCertainty Notification Demo Demo of Test Patient %2fSuiteHome 16

17 Transition of Care: Responses to the Updated Program Innovista Care Team: Incomplete TOC Programs reduced from 45% to 0% Focus shifted from data entry to patient management Simplified team collaboration Early reports generated by CareCertainty system Physicians: Receive increased number of notification Information from wider variety of hospitals More patient detail provided to physicians prior to patient appointments Easy to customize notification type per practice Hospital Staff Positive response to notification system and demo Customized notifications based on facility has lead to increased hospital cooperation and eagerness to provide more/better patient information 17

18 Transition of Care: ACO Success First commercial ACO contract for an IPA saved over $250K with ~4K lives in 2015 Reduced loss for one client by 50% Went from $5M loss to $2.5M loss 18

19 Goals Moving Forward Train physicians and their staffs on the electronic messaging capabilities of CareCertainty Expand current program model to additional groups/contracts Work with Post Acute Care Facilities to implement admission, concurrent review, and discharge planning workflows Develop Chronic Disease Management and Clinical Escalation Programs Implement procedures for high risk readmission patients based on calculated LACE score 19

20 Conclusion Thank you! For more information on billing the PFS for TCM services, refer to Frequently Asked Questions about Billing the Medicare Physician Fee Schedule for Transitional Care Management Services. MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet- ICN pdf 20

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