Accountable Care: Health System View CHC Best Practices Forum Katherine Schneider, MD, MPhil Senior Vice President, Health Engagement July 29, 2011
Who we are Southeastern New Jersey s largest health system and largest non-casino employer Dedicated to building healthy communities Nearly 5,000 team members in over 70 locations Core competencies: Health Delivery (acute/episodic care) Health Engagement (health promotion, prevention, chronic disease management) Health Information
National Strategy for Quality Improvement in Health Care Overview April 8, 2011 This document is confidential and is intended solely for the use and information of the client to whom it is addressed.
The framework consists of three aims, in addition to being guided by a set of core principles, that frame the underlying priorities and goals 5
Advice to the Republicans re Medicare reform
The ACO Model A group of providers willing and capable of accepting accountability for the total cost and quality of care for a defined population.
Accountable Care Organizations No Outcome = No Income
Defining the population need for solutions that bridge multiple payers Our own 8500 covered employees/families Several large self-insured employers in area Commercially insured Medicare (fee for service) Medicaid (NJ legislation on Medicaid ACO) Uninsured (largest provider in area) Many in our community move between these frequently need people centered solutions
AtlantiCare s Engaged Plan AtlantiCare Utilization by Membership
Our approach 1. Agree upon outcomes that matter to people and those funding their care 2. Define the care models and systems which result in #1 3. Implement a business model that sustains #2 (assuming fragmented FFS does not)
Transformation from volume to value building capabilities Much broader than ACO as an administrative entity or project to meet Affordable Care Act specs. Turns business model of past 100+ years on its head but supports our vision! Payers, providers, and patients must all have skin in the game towards common goals
Terminology is a challenge Patient-Centered Medical Home Health Home Advanced Primary Care Enhanced Primary Care Transformed Primary Care?Specialty Medical Homes (e.g. cardio, med onc)
Patient Centered Medical Home - Why Leadership Commitment to Mission/Vision/Values Strategic Planning Patient-Centered Medical Home as underpinning of accountable care Voice of the Customer Help! We re drowning in healthcare spend! Help! The system does not meet my needs!
Accountable Population Accountable Provider Org
Accountable Provider Org Dedicated Provider Accountable Population
Special Care Center Redesigning primary care for the chronically ill segment of patients. The daily huddle
Special Care Center (SCC) THE NEW YORKER, January 24, 2011
Special Care Center Triple Aim TM Outcomes Chronic disease outcomes > top decile Marked reduction or elimination of racial/ethnic health disparities 98% medication compliance Patient experience scores improve by 2x 40+% reductions in hospital + ED visits 10-25% reduction in overall cost The term Triple Aim is a trademark of The Institute for Healthcare Improvement. Triple Aim (Value Proposition)
The Health Neighborhood Patient engagement benefit design High value specialists advancing the Triple Aim, supporting the PCMH and care models High value inpatient care Bundled / episode payments Connecting everything across continuum Culture of quality and accountability
Expectations of Physicians Utilize a compatible EMR and be part of HIE with e-clinical and e-prescribe Use AtlantiCare Access Center (nurse triage, after hours, scheduling) Care Managers in practice ( team-based care) Share data (quality, satisfaction, population, health, finance, etc.) Adhere to ACO customer service standards Utilize evidence based protocols Have office records audited for reporting Become a certified medical home if applicable Submit quality measures (PQRI or other) Use new tools such as group visits, chronic disease registries Participate in CG-CAHPS (pt. satisfaction) Participate in peer review
AtlantiCare s Toolbox: Employer/Payer On-site presence Care management services Navigators/Access Center Chronic Care Strategy-Special Care Center Transition Care programs getting people out of hospital and ED safely and quickly Wellness and Prevention programs Benefit design to engage and incent employees
Highlights of Engaged Plan Design Markedly lower share of premium for employee Must complete requirements or lose bonus Preventive visit with PCP Online Health Assessment and Coaching 15 minute telephone intake with health coach Two months of physical activity challenge Smoking cessation program if applicable 73% uptake of plan, 97% compliance to date
Care coordination Build towards 24/7 access to non-er navigation Care Coordination aligned across system, not within silos of system Transitions of care more intensively managed Prevent falling through the cracks Prevent escalating intensity wherever possible Move back to lowest safe/effective level quickly Measure total customer experience, not just satisfaction with visit (transaction)
Key role of IT as connector and analytics beyond the PCMH Inpatient Most Wired Outpatient 179 physicians with electronic records, 43 in the queue Health Information Exchange Infrastructure Next: Enhance IT integration and analytics to support population health data management
Simplified AtlantiCare HIE PHR Wellogic HIE (new AtlantiCare clinical data repository) Physicia n Portal ecw (OP EMR) MedHOS T (ED EMR) Cerner (IP EMR)
The overall analytics architecture leverages the HIE to capture data across care settings. ACO analytics include five broad categories Community-wide Source Transactional Systems McKesson MedHost Cerner ecw Patient Access Claims Data 4 HIE Interoperability Services HIE HIE Operational Clinical Data Repository CCD data 5 1 ETL Harmonize and Conform Business Intelligence Platform - Attribution, Visualization and Reporting Analytical Community Data Warehouse 2 Registry 3 Spoke A Data Marts Data Marts Spoke B Data Marts Data Marts Spoke C Data Marts Data Marts Population Mgmt Physician Performance POC Health Gaps Disease Mgmt Comparative Effectiveness Payers 1 2 3 An overlaying BI Platform manages security, custom views and supports reporting and visualization. The data warehouse (DW) includes both identified and non-identified patient data. Over time, DW should include both clinical and financial data The data marts provide a specialized view of clinical data, relating to a specific subject area. 4 5 Cost data could be captured from existing financial/cost accounting databases (difficult access across care settings). Claims data provides interim source of financial information Claims data also mined for clinical data 30
Inpatient Care Robust inpatient quality measurement and performance management Accredited condition-specific care models (hospital centric) Hospitalists 24/7 Intensivists, Other-ists Other alignment models (e.g. gainshare, comanagement)
Specialty Care Adoption of evidence-based care models Performance transparency Bundled/Episode payments as key alignment strategy Proven Care guarantees Example of oncology medical home Behavioral Health and the medical home
Other critical components SNF / long term care Integration of nurse practitioners Rehabilitative care models Home Care Telemonitoring Hospice and Palliative Care Pharmacy on care team
Key opportunities Define and model transition period from FFS to value based payment Enhance measurement of patient experience across continuum Align care management across continuum Expand care models across continuum including triple aim measurement Expand primary care capacity and medical home options
more key opportunities Enhance IT integration and analytics to support population health data management Address gaps in High Value Network Establish formal entity to meet legal and governance requirements to manage all this
The Leadership Challenge Change leadership today s fundamental skill Burning platform Vision Safe, steady, well informed navigation of transition Provider culture ownership of the solution Robust physician leadership Trust and accountability Recognition of social determinants of health community stewardship
Summary the challenge of the transition period from volume to value