1 MGH is an integrated service organization in central Maine serving approx. 190,000 individuals KRHA (PHO) 28 PC sites serve 115,000 KENNEBEC VALLEY COMMUNITY CARE TEAM JOAN ORR MCHES, MBA DIRECTOR ACCOUNTABLE CARE & KVCCT OPERATIONS BECKY COLWELL RN, BSN, MBA DIRECTOR OF INTEGRATED CARE MANAGEMENT Jefferson Population Health Colloquium March 19, 2014 Post Conference Advanced Track--Clinical Team Structure & Workflow
We re Sense-makers 2 We work with people with multiple health needs and high utilization of services to improve their understanding and better coordinate their care according to their preferences, values and priorities. We take time to understand our patients stories and vary our scope and delivery of care based on that fuller understanding
Implementing an ACO Framework Using Population Health Management 3 Fully Insured Commercial Self-Insured Commercial Medicare Medicaid Self-Pay Reimbursement Methodology: Partial PMPM to Global PMPM Incentivize Efficiency and Reward Quality Medical Specialties Surgical Specialties Hospital Based Services Geriatrics & Palliative Care Primary Care Moving to Patient Centered Medical Homes (PCMH) and Hot Spotter strategies Healthy Chronic Acute Post- Acute and LTC End of Life
KVCCT Organizational Chart Current Funding is from Advanced Payment for PCPs & Care Coordination MAPCP Pilot Project (ending December 2014?) $325,000 ACO Contracts with Commercial Payers $625,000 Long-term Sustainability thru VBP contracts + MaineCare (Medicaid) 5-1-14 & MSSP 1-1-15
5 Our Service Area KRHA 28 Practices 115,000 Patients Framework for Population Health Management Discrete Population Internal & External Data Sources HIGH Cost LOW Cost HIGH Diseas e Burden A LOW Disease Diseas e Burden Burden B POPULATION & GOAL Unusual Diagnosis, Trauma or One Time Catastrophic Event High Cost High Need Manage high costs & provide care coordination Chronic Disease Monitor compliance rates & close gaps in care Healthy Manage risk factors & gaps in care INTERVENTION System Navigation & Support Complex Care Management KVCCT KVCCT Disease Management and Monitoring Practice Primary Care Mgmt. Wellness Programs Priority A, B Adapted from Verisk Health
Our Patients (Medically Complex but NOT Too.) 6 131 Patients Since its inception (May of 2012) Currently Active in CCT 63 Pending - 11 Graduated 57 The jury is still out but Above does not include: Category 12 Months B4 To Date After CCT # ED Visits 439 108 Admissions 185 36 Discharged 52 patients enrolled but did not reach goal. Declined 48 This is a tough population to engage! Care Coordination 395 These are mostly commercial patients managed in with a payer or practice care manager collaboration
Our Work/Patient Needs 7 Average length of time in the CCT 170 days (includes 7 days a week) 33% have poly-pharmacy 55% need social services 46% needed health education 71% needed community support/resources Average # of visits per patient 11 3.6 home visits 8.3 phone visits.6 visits co-accompanying patients to their provider
Care Team Roles 8 Current Care Management Team Future/Scaling-Up Panel Analysts RN Care Managers SW Care Managers Community Health Workers &/or Lay Navigators Stratify claims & utilization data Identify high-cost high need individuals Create actionable reports Track service data Track referrals Office/clerical support Comprehensive assessment Medication Reconciliation Communicate with PCP and other providers Develop care plan with patient Community resources Housing Transportation Financial Food, Heating Oil MaineCare Coach and support patient & family to reach their identified goals Accompany to medical visits Connect to community supports Medical Director Psychiatric N.P./Psychiatrist Pharmacist Medical resource BH treatment resource Resource for all things Approach to Knowledge of BH resources and medication providers processes Considerations for discussion Clarity around goals Guidance and wisdom for tough cases with PCP
Considerations in determining team structure 9 Program Model Service location Population served Community Resources Available Team mix Clarify roles Opportunities for community collaboration
10 Some of our lessons & aphorisms From our Medical Director: If there is no clear reason to admit a patient, there will never be a clear reason for discharge. Have an exit plan. Frequent question in case conferences: Are you working harder than the patient? From our Psych NP: Remember that we are responsible for the treatment we provide. We are not responsible for the outcomes. From Jeff Bezos: Be stubborn about the vision but flexible about the details.
11 Develop your own lessons learned, slogans, & favorite aphorisms! This work is not for the faint of heart Beware of the my patient syndrome we cannot be successful without teamwork Listen to, support, and develop the core team
Draft Maine Community Care Team Referral Process Alignment of CM Resources (Pre referral) Identify Patients & Respond Engage Patients CCT Interventions Graduation CCT develops report capacity: portals, hospital data, HIN CCT identifies patient from data Pt referred to CCT CCT develops workflows & comm systems w/cm resources & practices Practice aware of CCT & other CM options Practice enables EHR access for CCT. Practice identifies point person to make CM referrals Payer/ external CM identifies pt Practice identifies pt Yes CM accepts pt Meets criteria? Other appropriat e CM? Notify practice Notify pt No No Yes Engage pt: face to face, call or letter Notify practice Outreach successful? 1st pass, 2 nd pass & disch letter No Yes No, plateau or lost to follow up Meet pt Set goals, expectations, disch plan Home visit Further visits/referrals: health educator, telehealth, transportation, hospice etc) Goals met? Yes Discharge Graduate DRAFT H. Peterson 01/22/2014 Notify practice Monitor utilization
THANK YOU 13 This is difficult work with a very challenging population we can & do make a difference but not with all patients & that is OK. Patients might not be ready. You can t rescue everyone. We need to recognize & celebrate our successes & share the stories with ourselves, & other providers. We appreciate your time to allow us to share ours with you!