Delivering High Value Care Through Clinical Integration AMGA 2013 ACO Collaborative Meeting Bill Hensel, MD, Operating/Executive Committee Steve Neorr, Executive Director
Greetings from Cone Health Greetings from Cone Health 2
The Moses H. Cone Memorial Hospital A Brief History Moses H. Cone (1857 1908) Bertha L. Cone (1858 1947) Trust established by Bertha Cone in 1911 to build a hospital as a memorial to her late husband, Moses Cone Construction begins in 1949 on The Moses H. Cone Memorial Hospital Hospital's first patient admitted in 1953 Articles of Incorporation state: No patient shall be refused admittance because of an inability to pay. 3
Cone Health System Overview Facilities 5 Hospitals - 1,035 Acute Care Beds Awaiting final FTC approval to merge with Alamance Regional Medical Center (238 beds; 2,100 employees) 2 Ambulatory Surgery Centers 1 Nursing Home 92 Beds 2 Freestanding Ambulatory Care Campuses, Including a Freestanding ED 100+ Outpatient and MD Facilities, Including JVs in Imaging, Cardiovascular Services, and Oncology Services 4
Cone Health System Overview People Over 8,600 Employees 1,000+ Medical Staff Members; 320+ Employed Physicians in Cone Health Medical Group Patient Care (FY 2012) 49,345 Discharges; 229,834 Inpatient Days; 4.68 509,619 Outpatient Visits; 197,050 ED Visits Finances Over $1 Billion Revenues; $1.9 Billion in Assets Financial Ratios At or Above AA Benchmarks $185 Million Charity/Uncompensated Care (at cost) 5
Cone Health System Market Area Service Area Population 2011 2016 965,124 1,014,621 Inpatients Served = 50.4% Source: ThomsonReuters Market Expert 6
Our Mission We serve our communities by preventing illness, restoring health and providing comfort, through exceptional people delivering exceptional care. Our Vision Cone Health will be a national leader in delivering measurably superior healthcare. Cone Health System Strategic Overview 7 Strategic Target 7
Triad HealthCare Network History and Overview Began as a 20-member physician-led steering committee in fall 2010 Developed over eight months as collaboration between independent and employed community physicians and Cone Health Formed officially in 2011 as a Clinically Integrated Network serving the Piedmont Triad area Is an affiliate of the Cone Health System, but governance and operations is led by physicians Represents a new model of care clinical integration - designed to align physicians and hospitals to improve access, improve quality and lower costs. 8
Triad HealthCare Network Goals Allow physicians to have the opportunity to lead and have a voice in the necessary changes in healthcare versus simply being passive and have change dictated Engage physicians to develop new models of care and true transformation of the local healthcare delivery system Provide resources to physicians to meet the growing demands of accountability and transparency Create greater collaboration and trust among physicians, hospitals, patients and payers Be renowned as a national leader in delivering exceptional health care value in terms of cost, quality and service 9
Triad HealthCare Network Structure and Governance MANAGEMENT Executive Medical Director Thomas Wall, M.D. Executive Director Steve Neorr 21 members: 17 Physicians (9 Ind./8 Emp.) 3 Cone Representatives 1 Community Representative Board of Managers Operating Committee 8 members: 3 Physicians (2 Ind./1 Emp.) 2 Cone Representatives 3 Community Representatives Nominating Committee Oversees day-to-day operations Assist development of physician board memberships Credentialing Committee Quality Committee Contracting and Finance Committee Health Information Exchange ( HIE ) Council Initial and ongoing membership criteria Set clinical performance criteria and review member performance Look at 3 rd -party agreements and determine potential bonus distributions Management and oversight of the THN HIE 1 0
Triad HealthCare Network Quality Committee Structure Quality Committee Patrick Wright, M.D. Chairman Mary Jo Cagle, M.D. Vice Chairman 1 1 Medicine CPC Danielle Ray, MD John Bednar, MD Administrative Chair Gastroenterology Hem/Oncology Infectious Disease Nephrology Rheumatology Dermatology Emergency Medicine Endocrinology Hospital Medicine Pulmonology Hospice /Palliative Care Neurology Primary Care CPC Doug Shaw, MD Yvonne Lowne, DO Administrative Chair Family Medicine Internal Medicine Hospital Medicine Psychiatry Heart and Vascular CPC Ed Gerhardt, MD Tom Stuckey, MD Cardiology Cardiovascular Surg. Vascular Surgery Surgery CPC David Newman, MD John Hewitt, MD Anesthesia General Surgery Orthopedics Ophthalmology ENT Urology Neurosurgery Women s and Children s CPC Kelly Leggett, MD Ron Young, MD Ob/Gyn Neonatology Pediatrics Hospital Clinical Services CPC Josh Kish, MD Mark Shogry, MD Pathology Radiology Radiation Oncology Practice Management Todd Pittman Misti Sellers Administrative Chair Administrative Chair Administrative Chair Administrative Chair Administrative Chair Community Practice Administrators
Triad HealthCare Network Structure and Membership (as of March 2013) Physician-led governance and committees composed of 50/50 split between PCPs and Specialists and employed and independent physicians 776 Affiliated physicians; 324 employed by Cone 55 groups; separate tax IDs 231 Primary Care Physicians across the community 180 Adult Medicine 58 Unique clinic locations; 26 different EMR systems; 7 practices no EMR 51 Pediatricians 11 Unique clinic locations; 4 additional EMR systems 12
Triad HealthCare Network Driving Care Transformation Deployment of advanced IT resources to support population management Care Management team to support practices Assistance to achieve Patient-Centered Medical Home recognition and practice transformation Facilitate care process redesign 13
Triad HealthCare Network Key IT functions considered to transform delivery Aggregate clinical data from disparate sources EPIC, community EHRs, payer claims data, other hospitals, reference labs, radiology results, etc. Deliver actionable clinical data to physicians - at the point of care, disease registries, portals, faxes, etc. Proactively identify those at the highest risk ability to make proactive interventions in disease progression Routinely report physician performance and compliance to national metrics, benchmarks and standards Report and manage cost efficiency among providers 14
Information Technology/Analytics Systems Health Information Exchange ( HIE ) Interfaces with community providers and aggregates clinical data Hospitals Physicians Labs/Pharmacy/Radiology Master Patient Index ( MPI ) Provides portal view to all providers Clinical Performance Reporting System Reports performance to quality metrics Provides clinical protocol engine; Clinical recommendations Point-of-care reports Patient disease registries Claims data integration Case Management module care documentation, communication Population analytics, utilization, case management module Patient stratification; Predictive risk Utilization and cost efficiency analytics 15
Triad HealthCare Network The challenge of aggregating data in a community POC Report Pop mgmt Performance Primary care providers EMR CINA Edge Server at Practice DB Replication Aggregate Clinical CDR THN Server (CINA Datamart) Practice CDR THN Quality Clinicals / Procedures ODBC/SQL Direct Claims DB User Access Population Reports Payers (CMS to begin with) Claims System Claims Data CSV / SFTP Clinicals CSV/SFTP EMPI CSV/SFTP Payer Data (Future) CSV/SFTP (POC records PDF) Incremental Clinical Data Practice Care Mgr User Specialist Providers & Providers not in CINA HIE CDR EMR ADT & Clinicals HL7, CSV / MLLP, SFTP, WS Wellogic HIE (Amazon Cloud) (Care Plan PDF) EMPI Portal EMPI ADT, SIU, ORU, ORM HL7/MLLP Optum Care Suite (Hosted at Optum) IP CT II THN Care Mgr User Risk Stratification HL7/MLLP HL7/WS HL7 / MLLP Provider Portal EMR EMR Lite ADT (A01 - A08) HL7/MLLP HL7 / MLLP LabCorp Quest Solastas GSO radiology / Canopy Providers with no EMR Hospitals EPIC Clinicals: Encounter, Vitals problems, Meds, Allergies, immunization, Procedures, Social hist., Fam hist. 16
CINA Point of Care Report Improving Care Delivery to Patients Guides decision making at the Point of Care Drives consistent care delivery across providers / practices / THN Promotes team based care delivery Integrates data beyond the EMR claims, hospital, community Encouraging Patient Responsibility Provides easily accessible tool for Patient Engagement Encourages talking points between the patient and care team Benefiting Practice Management Enhances current / new revenue generation Highlights ACO required metrics for reporting 17
Sample Clinical Decision Support at the Point-of-Care Diagnoses and Meds are prioritized to highlight chronic conditions Practice Performance Feedback Action Items and Goals are highlighted for quick reference and visibility Labs, Calculations and Diagnostic Procedures pertinent to the Action Items are displayed for easy reference 18 Targeted reminders for nursing staff allow better leverage of provider time and more efficient workflow
Wellogic Health Information Exchange 19 Connects healthcare information systems and devices across the continuum of care: Primary care physician & specialist offices Hospitals Long term care facilities Laboratories Imaging Centers Pharmacies Payers Creates one patient one record across all venues of care Delivers tests, reports, alerts, and decision support recommendations wherever necessary
Wellogic Health Information Exchange Screen Shots Presents longitudinal view of patient in the community 20
Wellogic Health Information Exchange Screen Shots Click on Lab Value for Full Panel 21
Optum Population Management/Analytics Overall impact of Optum Risk stratification and interventions Who should THN Care Management help manage? Severity of illness determination Utilization, cost efficiency PCPs, SCPs, Episode Treatment Groups (ETGs) Effect on day to day PCP activities Communication with THN Care Management 22
23 SERVICES METHODS WHAT THIS MEANS RESULT Provider Collaboration Goal Collaboration Team Collaboration of Barriers High-Risk Community CM Relationship Building Health Belief Model Utilized Evidenced-Based Education Advanced Directive Planning Care Transition Disease Management Community Resource Referral Med Adherence Program THN Care Management Impacting Health and Wellness Outcomes for All Coordination of Serivces Assessment within 24-72 hours Post-acute Health Promotion Model Utilized Evidenced-based Education Eligibility Determination Payer Collaboration Medication Box Fills Pharmaceutical Engagement Consistent Message to Patients Patients Assessed at Home Holistic Plans Implemented Patient and Family Engagement Standardized Assessment Call Early Identification of Barriers Plans to Remove Barriers Engage Members in Goal Setting Educate Toward Self-Management Members Connected With Services Reduces Barriers to Treatment Reduces Barriers to Quality of Life Reduced Confusion of Timing Meds Improved Adherence to Meds One Multifaceted Plan for Quality Outcomes Improved Self-Monitoring Reduced Emergency Room Visits Reduced 30-Day Readmissions Advanced Directive Goals Improved Quality of Life Reduced 30-Day Readmissions Improved Self-Management Treatment Goals Achieved Improved Outcomes Coordinated Services Improved Quality of Life Treatment Goals Achieved Consistent Med Optimization 24-hour Nurse Access Line Timely Access for Questions Reduced Anxiety about Unknown Reduced Emergency Room Visits
Triad HealthCare Network Care Management Team Supports Practices Rhonda Rumple, RN, MSN, CCM - Program Director RN Care Managers (16) Licensed Clinical Social Workers (3) RN Hospital Liaisons (2) Care Management Assistants (2) Geriatric Nurse Practitioner (1) Clinical Pharmacist Manager (1) Access Data Base Specialist (1) 24
Engaged TransforMED to lead PCMH initiative Train the trainer model Triad HealthCare Network PCMH Assistance Teamed with local Area Health Education Center (AHEC) to provide boots on the ground Funding one AHEC FTE dedicated to THN PCMH initiative Identified 24 initial practices expressing interest to go through process Wave 1: 5 practices; Late March 2013 Wave 2: 13 practices; June 2013 Wave 3: 4 practices; September 2013 Wave 4: 2 practices; January 2014 25
Readmissions - System-wide breakthrough project CHF COPD Pneumonia High ED use/past Admissions Care Transitions Hand offs, access Chronic disease management CHF Diabetes Sanofi support Hypertension Triad HealthCare Network Facilitating Care Process Redesign 26
Triad HealthCare Network Contracting Approach Initial focus on quality, not joint FFS, contracting Practice maintains control of billing and collection Practice makes claims and EMR information available Goal to create community Clinical Data Repository (CDR) Focus on incentive-based contracts based on quality and cost control initiatives P4P, shared savings, gain sharing THN negotiates a Savings/Bonus Pool with the payers government, insurance companies and employers THN is responsible for managing / distributing bonus payments 27
Insurers and Employers Triad HealthCare Network Business Model P4P Shared Savings Gain Sharing Negotiated Incentive-Based Contracts Continue Current Fee-For-Service Claims & Payment Structure Quality Bonus Payout Based On THN Goals and Performance Measures POC, Registry, Performance Data 28 Physicians Claims and EMR Data
Triad HealthCare Network First Year Accomplishments Affiliated with over 750 community physicians over 50% independent Developed physician-led infrastructure Identified 129 quality metrics across all major specialties Approved to participate in Medicare Shared Savings Program as ACO Over 40,000 Medicare beneficiaries Identified and begun deployment of Clinical Performance Reporting System, Health Information Exchange ( HIE ), and population analytics, utilization, case management modules Identification and hiring of case management team 29
Triad HealthCare Network Lessons Learned Administrative Perspective PCP alignment/attribution is difficult Not prepared for initial MSSP list Underestimated time and effort to send letters to 40,000 patients Interfacing and connecting practices takes longer than anyone will tell you Vendors are all learning too EMR data is not structured and standardized and time consuming to validate Clinical data is difficult to aggregate and report must standardize 30
Triad HealthCare Network Lessons Learned - Administrative Perspective Need a plan to educate and train multiple clinics (physicians and staff) Should have required EMR use to participate Develop a model to distribute maybe money earlier versus later Plan well ahead for care management and analytics Have a plan to manage your population assuming you do not have much data initially Limit your initiatives and focus on key areas You can have a lot of ammunition and never get a shot off. 31
Triad HealthCare Network Lessons Learned Physician Perspective Take the time to develop understanding, unity and buy-in from your core physician leaders. Physician culture is one of skepticism. Don t expect full buy in from all physicians at first. Physicians witnessing the health system committing resources based on the potential is very influential. ACO leadership needs a balance of internal and external representation old and new. Physician engagement is key. Provide many opportunities for involvement. 32
Triad HealthCare Network Lessons Learned Physician Perspective Be cognizant of and transparent about hot button topics money, employed vs. independent, PCP vs specialists; MEC Focus on Primary Care. Need to expand physician definition of professionalism to include a vision of a team and bigger picture. Be aware and sensitive to change overload. Don t expect too much help from the government 33
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