Adirondack Medical Home Pilot Overview Dennis Weaver MD MBA November 2, 2010
Critical Success Factors Lessons Learned Partnership among all stakeholders is essential Must define common goals and timelines Triple aim: access, quality, cost Economic incentives and risk proposition are the ultimate drivers of transformation Primary care re-vitalization / transformation critical Transformation costs Operational costs 1
The US Healthcare Delivery System is Broken High Cost / Poor systemic quality Limited access to care Rescue care vs. prevention Chronic disease Obesity is the new smoking Limited to no care coordination Physicians leaving practice 2
Components of Delivery System Reform Access to Care Primary Care Care coordination Prevention Health information technology New payment models 3
Patient Centered Medical Home Personal physician Physician directed medical practice Whole person orientation Enhanced Access Care is coordinated and/or integrated Quality and safety Payment reform recognizes additional value 4
PPC-PCMH Content and Scoring Standard 1: Access and Communication A. Has written standards for patient access and patient communication B. Uses data to show it meets its standards for patient access and communication Pts 4 5 9 Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety checks C. Has electronic prescription writer with cost checks Pts 3 3 2 8 Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information (mostly nonclinical data) B. Has clinical data system with clinical data in searchable data fields C. Uses the clinical data system D. Uses paper or electronic-based charting tools to organize clinical information E. Uses data to identify important diagnoses and conditions in practice F. Generates lists of patients and reminds patients and clinicians of services needed (population management) Standard 3: Care Management A. Adopts and implements evidence-based guidelines for three conditions B. Generates reminders about preventive services for clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans, assessing progress, addressing barriers E. Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities Standard 4: Patient Self-Management Support A. Assesses language preference and other communication barriers B. Actively supports patient self-management Pts 2 3 3 6 4 3 21 Pts 3 4 3 5 5 20 Pts 2 4 6 Standard 6: Test Tracking A. Tracks tests and identifies abnormal results systematically B. Uses electronic systems to order and retrieve tests and flag duplicate tests Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic system Standard 8: Performance Reporting and Improvement A. Measures clinical and/or service performance by physician or across the practice B. Survey of patients care experience C. Reports performance across the practice or by physician D. Sets goals and takes action to improve performance E. Produces reports using standardized measures F. Transmits reports with standardized measures electronically to external entities Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support Pts 7 6 13 Pts 4 4 Pts 3 3 3 3 2 1 15 Pts 1 2 1 4 5
NCQA Must Pass Criteria 1. Access to care policies and procedure 2. Data to demonstrate access standards 3. Organize data in physician office records 4. Identification of three (3) important conditions 5. Adopt evidence based guidelines (Diabetes / Childhood Obesity) 6. Actively support patient self management 7. Track tests and identify abnormal results systematically 8. Track referrals systematically 9. Measure clinical and/or service performance across the practice and / or by physician 10. Report performance across the practice and/or by physician 6
NCQA: PPC-PCMH Recognition Levels Level 1 5 /10 Must Pass 25 pts Level 2 10/10 Must Pass 50 pts Level 3 10/10 Must Pass 75 pts 7
NCQA: PPC-PCMH Recognition Levels Level 1 Paper Based 5 /10 Must Pass 25 pts Level 2 Electronic Disease Registry 10/10 Must Pass 50 pts Level 3 Electronic Medical Record 10/10 Must Pass 75 pts 8
NCQA Recognition Criteria - Capabilities Information Technology 77 elements (46%) Care for 3 specific conditions 24 elements (14%). Examples include: Diabetes / HTN / CAD - Hyperlipidemia Childhood Obesity / Asthma / Prevention - ADHD Coordination of care 21 elements (13%) Access to care 15 elements (9%) Performance Reporting 8 elements (5%)
Geisinger Experience 20% Decrease in hospital admissions 7% Decrease in Total Cost of Care 10
Adirondack Region Medical Home Pilot Codified in 2009 Legislation provides antitrust protection NYS Department of Health and Department of Insurance will provide supervision; Selected as NY applicant to CMS Five-year duration starting Jan 2010 Pilot is expected to: improve access to primary care providers improve the quality and safety of care lower costs over the long-term retain physicians in the North Country Focus on delivery healthcare value breakeven in Year 3
ADK Providers are committing to E-prescribing Become certified medical homes within one year Using NCQA standards (level 2 or level 3) Advanced access Care Coordination / Disease Management Health Information Exchange Quality measurement and improvement Use of patient and provider surveys Increase efficiency - generate ROI
Payment Methodology Care coordination and management fee - $7pmpm Traditional Fee for Service Pay for Performance (P4P) 13
Adirondack Medical Home Pilot Participants Payors State of New York Medicaid Fidelis State of New York the Empire Plan Excellus Empire Blue BSNENY - HealthNow MVP Medicare application pending Providers: Clinton, Franklin, Essex, and Hamilton Counties: CVPH & Plattsburgh Adirondack Med Ctr (TriLakes) Elizabethtown Hospital Inter-Lakes Hospital Alice Hyde Hospital & Malone Hudson Headwater Health Ntwk 14
Provider Participation 33 Practices Plattsburgh/Malone 27 practices Tri-Lakes 3 practices Lake George 3 practices 98 primary care physicians (225 primary care providers) 51 specialists focused on diabetes (endocrine, nephrology, ophthalmology, cardiology, podiatry) Approximately 100k patients
ADK Medical Home Pilot Organizational Structure Standard setting / Coordinating Role Service Contracting Development Activities New Initiatives
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Physician Practice Support Organizations Pods Patient identification and Payment coordination Quality improvement activities Chronic disease management PharmD, Social Worker, Disease Management Nurse Care coordination /Case management /Disease management Care plan construction and education Data warehousing (EMR and Health Plan claims data) Clinical decision support Analytics 19
Clinical Process Flow Patient ID and Stratification Patient Outreach Clinical Encounter Physician Clinical Encounter Non-physician Patient Follow-up Patient Monitoring
Pilot Participation Requires Measurement Access to care Clinical Quality - Evidence based guidelines Adult Diabetes / Hypertension / Coronary Disease Pediatric Childhood Obesity /Asthma / Prevention Efficiency Inpatient / ER / Formulary Utilization and Total Cost Patient and Provider Surveys Pilot measures committee: All stakeholders utilize the same measures!!! 21
Technology Infrastructure Health Plans Payor Data Warehouse EHR Data Warehouse( QDC) Clinical Transaction Content ADT, Meds, Lab/rad/departmental reports (HL7 content) Clinical summary info (C32 content) Claims data flow Web application Access to web viewer Claims portal Clinical quality portal Clinical care portal 45 Specialty Providers Health Plans 3 PPSOs 33 Primary Care Practices 2 GFH Specialty Practices 6 Hospitals
Clinical Transaction Content Detail Hospital-to-HIXNY Practice-to-HIXNY HIXNY-to-practice HIXNY-to-QDC ADT, Meds, Lab/rad/ departmental reports (HL7 content) ADT Lab/path/micro results Imaging reports Current and prescribed medications Departmental reports (availability may vary by hospital) Discharge summaries NA C32 content will be available to Practice EHR s for consumption EHR vendor consumption capabilities are vendorspecific Lab/path/micro results Imaging reports NA Clinical summary info (C32 content) Note: C32 content for Practice-to-HIXNY exchange is per HITSP harmonized standard. HIXNY version may differ slightly. NA Patient demographics Language spoken Health care provider info Health insurance info Allergy/drug sensitivity Problem/condition Medications Pregnancy Information source Advance directive Immunizations Vital signs Results Encounter type Procedures Social history Comment Plan of care Family support C32 content / HIXNY Patient Record Available through HIXNY portal Patient demographics Language spoken Health care provider info Health insurance info Allergy/drug sensitivity Problem/condition Medications Pregnancy Information source Advance directive Immunizations Vital signs Results Encounter type Procedures Social history
All Pod View Health Plans Payor Data Warehouse CIS EHR Data Warehouse( QDC) Clinical Transaction Content Lab/rad/departmental (HL7 content) Clinical summary info (C32 content) Claims data (specification TBD) Dashed indicates scoping underway Faded indicates project scoped but not yet live 3 practices Adirondack Medical Center 27 practices Champlain Valley PH Alice Hyde Medical Center Pod 1 3 practices 2 GFH Specialty Practices Glens Falls Hospital Inter-Lakes Health E-town Hospital Pod 3 Pod 2
Data Warehouses Health Plans EHR Data Warehouse (QDC) Payor Data Warehouse Claims portal Clinical quality portal Clinical care portal
Critical Success Factors Lessons Learned Partnership among all stakeholders is essential Must define common goals and timelines Triple aim: access, quality, cost Economic incentives and risk proposition are the ultimate drivers of transformation Primary care re-vitalization and transformation Transformation costs Operational costs 26
Questions and Concerns Dennis Weaver MD MBA (703) 626-7112 Dennis.WeaverMD@EastPointHealth.com 27
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