Reducing Hospital Admissions Through the Use of IT. Steven Milligan MD Medical Director of ACO Management Colorado Health Neighborhoods

Reducing Hospital Admissions Through the Use of IT Steven Milligan MD Medical Director of ACO Management Colorado Health Neighborhoods

Conflict of Interest Steven Milligan, MD Has no real or apparent conflicts of interest to report.

Agenda 1.Background 2.Local problem being addressed 3.Design and Implementation of program 1.ACO patient identification 2.Identification of patients with specific chronic diseases 3.Risk Stratification of patients with chronic diseases 4.Care Coordination implementation 5.Toolkit Implementation 4.Outcomes 1.Readmission outcomes by chronic disease 2.Total Cost of Care Outcomes by chronic disease 3.Quality outcomes across entire population 5.Financial Considerations 6.Lessons Learned 7.Next Steps

Learning Objectives 1. Identify organizational priorities for quality improvement that align with federal pay for value reporting requirements. 2. Outline how to develop IT enabled workflows that allow for improved care management and outcomes for diabetic and cardiac care patients. 3. Describe how to leverage improvements in care delivery and outcome to increase pay for performance revenue and return on investment

An Introduction of How Benefits Were Realized for the Value of Health IT Satisfaction: We have improved communication with our patients and among our caregivers. Treatment/Clinical: We have demonstrated improved clinical metrics such as: improved compliance with disease specific interventions and monitoring. Electronic information/data: We have accomplished population health reporting and improved quality measures reporting and are learning how to aggregate and format the data to effectively communicate with our caregivers. Prevention and Patient Education: We have demonstrated improved condition specific surveillance. Savings: We have reduced unplanned ED visits and 30 day readmissions. http://www.himss.org/valuesuite

BackGround Reimbursement changes have created an environment in which Centura Health felt it was important to participate in the Accountable Care Organization (ACO) structure from the early stages. Centura joined the Medicare Shared Savings Program in 2013. Colorado Health Neighborhoods (CHN) was created by Centura Health in 2012 as an integrated delivery network and currently it has 170,000 attributed lives. CHN participates in a total of seven ACOs and more are in the planning stages.

Local Problem Being Addressed and Intended Improvement COPD, CHF, and Diabetes were targeted for active care planning and management secondary to the high prevalence of disease and high cost of care. Interventions included population identification, risk stratification, identifying care gaps, addressing gaps in care, and ensuring careful transitions of care. In 2013 our system-wide all payers, baseline rate of 30-day readmission for Heart Failure discharges was 9.89%. In an accountable care model this rate would lead to unfavorable results.

Design and Implementation 1. Identification of the people who are covered in ACO in near real time. 2. Identification of patients within the ACO with the specified chronic conditions. 3. Risk stratification to determine those individuals who had higher risk scores and qualified for Care Coordination. 1. Entry into a condition-based registry was accomplished using claims data. 4. Care Coordination is key to improving quality and decreasing cost. 1. This required a tracking tool; a customer relations management software tool was identified for this purpose. 2. 24/7 availability of care coordination services is provided using a call center model. 5. Toolkit creation for the practices and Care Coordination that taught the practices to ask, What is the guideline, what is the measure, how do you document it in your EHR, and how do you use the clinical pathways and action plans? 1. Level 3 NCQA certified Primary Care Medical Homes needed less coaching and support than practices who have not achieved this recognition.

How was Health IT Utilized to Identify ACO Patients? Committing to a population of patients defined by an insurance plan means monitoring care and affecting outcomes that may be happening in an external hospital and in multiple EHRs. Since we are on a standardized single platform EHR for Centura hospitals and practices, and had traditionally only managed those patients who had encounters with our services, this meant new and creative thinking about IT support for such a venture. We receive monthly attribution files from each insurance carrier and use that information to populate alerts.

Identification: ACO Flag in EMR

Identification: ED Flag MSSP flag in ED alerts providers. Care Coordination flag in ED allows providers to be aware that these patients have an Ambulatory Care Coordinator. This Ambulatory Care Coordinator will be alerted by a daily hot spotter report that this patient was in the ED and will be contacted within 24 hours.

Identification: Provider Rounding List Flag The ACO flag is meant to trigger all caregivers to inform the patient that they are eligible for extra services, and that a care coordinator may call them after departure or discharge to explore ways that we can help them navigate their condition and the care needed for it.

How Was Health IT Utilized to Identify the Chronic Disease Cohorts? The monthly attribution files from each insurance carrier are uploaded to a third party service to identify the chronic disease cohorts using claims data.

How Was Health IT Utilized to Identify High Risk Patients? We then identify the primary care home for those high-risk individuals who will receive interventions.

How Was Health IT Utilized in Care Coordination? Care coordination is documented and tracked in a CRM tool. Currently 21 different EHRs are used within our CHN network, and for that reason have opted to centralize the care coordination in a CRM rather than in any one EHR. Working with our local HIE to deliver ADT data from external hospitals to our database. Centura hospital ACO admissions are identified by a flag in the system EHR via an electronic data feed that we receive from the payers which designates patients who are participating in these ACO programs so that caregivers and case managers are aware of these patients at each point of contact. Within 15 minutes of the admission order, an automated page is sent to the inpatient case manager on ACO patients. A report is run every day for the hospital-based case managers to identify the ACO patients in order to proactively work on smooth and seamless transitions of care to the patient s home. Data is fed from our EHR to our post-acute care database so that our ambulatory based care coordinators are aware of risk level and issues and participate in care documentation.

Chronic Care Toolkit Collaborating with the physicians of CHN, toolkits were developed that include patient action plans for CHF, COPD, Asthma, CAD, and Diabetes.

Care Plans Care needs to be coordinated so that the right care is delivered in the right place at the right time. Prompt notification of ED visits and of inpatient admissions, both to Centura hospitals and to external hospitals were important to Care Coordination. A communication link with the patient s primary caregivers were needed along with education and a toolkit for those PCP s.

Evidence Based Guidelines CHN created Evidence Based Guidelines to provide our ACO providers with easy to access clear guidelines for the care of their patients.

Action Plans Our action plans use the familiar red light/yellow light/green light model to guide patients. Patients in the Green Zone are doing well and need routine follow up. Patients in the Red Zone have decompensated and need Emergent care immediately Providers have been given a choice for dealing with patients in the Yellow zone. They can either receive a call from the Care Coordinator who will request that the provider see them that day or they can use Evidence Based Standing order sets. Action Plans Available in CRM for Care Coordination use and for use after hours by call center.

Standing Order Sets Providers then have Evidence Based standing orders associated with each stage of each action plan to guide their care decisions. These standing order sets are integrated into the CRM for Care Coordination use and for use after hours by call center.

ACO Measure Description Designed to help standardize metrics by: Describing metric Defining metric Provide tools to help providers meet metric. Provide feedback to providers about how they are progressing to meet the metrics.

Standardized Patient Education Patient information is provided from the inpatient care, outpatient care and in home sides which can provide patients with conflicting information. Goal is to standardize what information is provided to the patient and make this information accessible in one place where all care providers can access.

Value Derived Outcomes: CHF Chronic Disease Management: CHF* Months Benchmark (Norm) CAC 2013 Avg CAC 2014 Avg CAC 2015 YTD % Change From 2013 Utilization Data PMPY $33,830 $31,073 $30,274 $28,487-8.32% Readmission Rate 22.65% 20.37% 18.50% 16.60% -17.48% Quality Data Care Gap Index 11.28 11.06 10.62 9.37-15.26% Efficiency Indices Cost Index (Actual Costs/Predicted Costs based on 1.00 1.15 1.10 0.99-13.62% Relative Risk Score) Admission Utilization Index (Actual Admits/Predicted Admits) 1.00 1.18 1.12 1.02-13.28% ED Utilization Index (Actual/Predicted ED Visits) 1.00 1.19 1.31 1.34 12.18% This program has achieved a 17.48% reduction in readmission for CHF, and has reduced the overall annual cost of care by 8.32%.

Value Derived Outcomes: COPD Chronic Disease Management: COPD* Months Benchmark (Norm) CAC 2013 Avg CAC 2014 Avg CAC 2015 YTD % Change From 2013 Utilization Data PMPY $23,887 $19,579 $19,568 $19,314-1.36% Readmission Rate 20.37% 16.84% 15.91% 14.06% -16.54% Quality Data Care Gap Index 9.29 9.03 8.72 8.08-10.54% Efficiency Indices Cost Index (Actual Costs/Predicted Costs based on 1.00 1.06 0.99 0.91-14.30% Relative Risk Score) Admission Utilization Index (Actual Admits/Predicted Admits) 1.00 1.04 0.97 0.90-12.97% ED Utilization Index (Actual/Predicted ED Visits) 1.00 1.12 1.14 1.16 3.76% This program has achieved a 16.54% reduction in readmission for COPD, and has reduced the overall annual cost of care by 1.36%.

Value Derived Outcomes: Diabetes Chronic Disease Management: Diabetes* Months Benchmark (Norm) CAC 2013 Avg CAC 2014 Avg CAC 2015 YTD % Change From 2013 Utilization Data PMPY $16,360 $13,878 $13,878 $14,204 2.35% Readmission Rate 18.85% 15.56% 13.80% 13.87% -10.83% Quality Data Care Gap Index 8.91 10.38 10.02 8.53-17.87% Efficiency Indices Cost Index (Actual Costs/Predicted Costs based on Relative 1.00 1.03 1.00 0.96-7.32% Risk Score) Admission Utilization Index (Actual Admits/Predicted Admits) 1.00 1.03 1.00 0.95-8.28% ED Utilization Index (Actual/Predicted ED Visits) 1.00 1.08 1.08 1.13 3.78% We have achieved similarly promising results in addressing diabetes with an 10.83%% reduction in readmissions.

Value Derived Outcomes: Quality The national median composite quality score for MSSP is 84% to 86%. Centura s MSSP Composite Quality score is 91.73%. We attribute this to establishing personal relationships with our highest risk clients to gain their trust and cooperation with the process measures and action plans that we recommend.

Financial Considerations Cost Estimated total implementation cost: $761,000. Benefits PQRS payment incentives: Our Centura owned group practice (CHPG) received approximately $71,000 in PQRS incentive payments in 2015 for CY 2014. Centura received approximately $1,112,500 in Shared Savings in 2015 from 2 of our private payer ACO s. In our self-insured program, we have generated a $1M reduction in total cost of care for clients with frequent ED use. In the MSSP Population, we generated a $1.7M reduction in total cost of care for the chronic disease population.

Lessons Learned We have maximized the support we deliver through our system EHR, but have been willing to look to other more specialized software for unique aspects of the project. Knowing that care coordination across many locations of care and many EHRs is the key, we have learned to use a suite of IT tools for care management, client tracking, and conditionbased registry management.

Next Steps 1. In 2015 Centura Health partnered with Davita Healthcare Partners to create Fullwell which is providing a suite of population health tools to CHN. Currently Fullwell is rolling out an online portal where providers will be able to access the clinical guidelines, tools, metrics and quality reports in one place. Metrics currently provided by each payer and a scorecard is manually created by CHN to display progress. These will soon be available on the portal. Currently CHN prepares reports to clearly display individual provider, practice, ACO, and benchmark data so that each provider and practice understands their performance in comparison to expectations and to a benchmark. These reports will soon be available on the portal, with coaching available about how to improve. 2. Applying lessons learned from the proof of concept to other applicable populations.

Questions? Steven Milligan MD Medical Director of ACO Management Colorado Health Neighborhoods stevemilligan@centura.org https://www.linkedin.com/in/steven-milligan-66543367 Twitter: StevenMilligan@cfccdocs MyCHN.org

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