Comprehensive Primary Care: Our Success Story March 2, 2016 Tamra Lavengood, RN, BSN, MSN CPC Coordinator and Clinical Performance Coordinator Centura Health Physician Group, Centura Health Will McConnell, PhD, MBA, MS VP Operations and Outreach Strategy Mercy Regional Medical Center, Centura Health
Introductions Tamra Lavengood, RN, BSN, MSN, CPNP, CCNS Clinical Performance Coordinator for Centura Health Physician Group in Colorado Coordinator for the Comprehensive Primary Care Initiative for Mercy Family Medicine in Durango, Colorado Will McConnell, PhD, MBA, MS VP Operations and Outreach Strategy for Mercy Regional Medical Center in Durango, ColoradoWill McConnell, PhD, MBA, MS VP Operations and Outreach Strategy Mercy Regional Medical Center
Conflict of Interest Tamra Lavengood, RN, BSN, MSN Will McConnell, PhD, MBA, MS Have no real or apparent conflicts of interest to report
Learning Objectives Objectives: Identify four qualitative and four quantitative elements used to determine an individual's health risk Construct an adaptation of a paper or electronic risk stratification tool using the Mercy Adult Risk Stratification Tool (MARST) Adapt a methodology for emergency department (ED) and hospital follow up Influence electronic health record (EHR) vendors to adapt a risk stratification methodology that assesses the whole person Influence the current healthcare environment to prepare for population health management
Agenda The Beginnings What is the CPC Initiative? Why did Mercy Family Medicine choose to participate? Barriers Our Comprehensive Primary Care Initiative Story Task Force 9 milestones, key elements Empanelment Risk stratification Mercy Adult Risk Stratification Tool (MARST) development Care Management vs. Care Coordination ED and hospital follow-up Outcomes and lessons learned
Benefits Realized for the Value of Health IT STEPSTM VALUE CATEGORIES Treatment/Clinical: Care Management for high-risk patients identified by risk stratification looking at the whole person; ED and hospital follow-up care management; and care management to include behavioral health integration Savings: Realized by decreased Per Member Per Month (PMPM) expenses for Medicare population due to decreased ED utilization, hospital admissions for any cause and hospital admissions for Ambulatory Care Sensitive Conditions (ACSC) http://www.himss.org/valuesuite
What is the Comprehensive Primary Care Initiative? Four-year multi-payer initiative designed to strengthen primary care Population-based care management fees and shared savings opportunities to participating primary care practices to support the provision of a core set of five Comprehensive primary care functions. Risk stratified care management Access and continuity Planned care for chronic conditions and preventive care Patient and caregiver engagement Coordination of care across the medical neighborhood https://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative/
What is the Comprehensive Primary Care Initiative? Demographics 474 practice sites 2,200 practitioners 2.7 million active patients 38 public and private payers 335,000 Medicare beneficiaries Purpose Improved care Better health for populations Lower costs Inform future Medicare and Medicaid policy https://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative
What is the Comprehensive Primary Care Initiative? Payment Model Participating primary care practices receive two forms of financial support on behalf of their fee-for-service (FFS) Medicare beneficiaries: A monthly non-visit based care management fee The opportunity to share in any net savings to the Medicare program https://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative
Why did Mercy Family Medicine Choose to Participate? Value-based purchasing was getting a lot of attention We needed to identify viable payment models and prepare for the future Cost neutral solution Alignment with PCMH status Great group of clinicians and staff Huge potential within CPC Timing was right
Barriers to get the Comprehensive Primary Care Initiative started One more thing to do Do we have the bandwidth? Moving into uncertain territory with CPC A lot of additional reporting and process work would be needed No real quantifiable risk stratification tools in the beginning Practice was recently acquired
Comprehensive Primary Care Initiative: Our Story Center for Medicare and Medicaid had a great idea! Privileged to be a part of initiative Started with a Task Force
Comprehensive Primary Care: 9 Milestones 1. Budget 2. Care management for high-risk patients 3. Access and continuity 4. Patient experience 5. Quality improvement 6. Care coordination across the medical neighborhood 7. Shared decision making 8. Participation in learning collaboratives 9. Health Information Technology
Comprehensive Primary Care Initiative: Our Story CMS selected key elements that aligned with Patient Centered Medical Home elements Milestone 2: Empanelment; Risk Stratification; Care Management; Behavioral Health Integration
Comprehensive Primary Care Initiative: Our Story Empanelment End of 2012 = 79% End of 2015 = 99.9% Four Cut Method (1) Care Teams (1) Panel Size: How Many Patients Can One doctor Have?, Mark Murray, MD,MPA, Mike Davies, MD, Barbara Boushon, RN,Fam Pract Manag. 2007 Apr; 14(4):44-51
Comprehensive Primary Care Initiative: Our Story Risk Stratification All 500 clinics asked to develop their own risk stratification methodology Mercy Family Medicine reviewed tools from: California Quality Collaborative AAFP Risk Stratification Tool Telluride Medical Center in Colorado (another CPC practice)
Risk Stratification in CPC Practices Comprehensive Primary Care practices risk stratify their patients by: Clinical intuition: 71% Practice developed clinical algorithm: 61% Published clinical algorithm: 40% Claims: 24% EHR methodology: 19% Practices were able to select more than one method
Comprehensive Primary Care Initiative Our Story Developed our own Mercy Adult Risk Stratification Tool (MARST) and the Mercy Pediatric Risk Stratification Tool (MPRST) Critical to have not only Objective elements but Subjective elements as well
HIT Needed for Risk Stratification Using the system we had Our risk stratification elements flow exactly like our EHR
Mercy Adult Risk Stratification Tool Have risk stratified over 14,300 patients 1.1% Highest risk Level 6 20.4% High risk Level 5 (6.5%) and Level 4 (13.9%) 25.3% Medium risk Level 3 26.5% Low risk Level 2 26.7% Low risk Level 1
Risk Stratification and Care Management
Risk Stratification Care Management
Behavioral Health Integration Behavioral Health care is needed for the majority of level 6 patients In house Licensed Clinical Social Worker Warm handoffs Scheduled patients Evaluation tools: PHQ9 Tracking depression screening
Care Coordination Care coordination across the Medical Neighborhood Emergency Department discharges Hospital discharges
Medicare Expenses Per Patient Per Month, All Attributed Patients
Medicare Expenses Per Patient Per Month, for Patients in the Highest Risk Quartile
Hospital admissions, ED Visits, 30 day Re-Admissions for all attributed Medicare Patients
Hospital admissions, ED Visits, 30 day Re-Admissions for all Medicare patients in the highest risk quartile
A Summary of How Benefits Were Realized for the Value of Health IT STEPSTM VALUE CATEGORIES Treatment/Clinical: Care Management for high-risk patients via shared care plans, and improved communication with providers both inpatient and outpatient; Care Management, including behavioral health integration for high-risk patients and for chronic disease management led to reduced ED visits and hospitalizations for any cause and for Ambulatory Care Sensitive Conditions (ACSC); Care Management communication between the inpatient and outpatient settings for ED and hospital discharges enabling follow up at 97.5% within 1.8 day for ED visits and 96.7% within 8hrs for hospital discharges http://www.himss.org/valuesuite
A Summary of How Benefits Were Realized for the Value of Health IT STEPSTM VALUE CATEGORIES Savings: Decreased Per Member Per Month (PMPM) expenses for Medicare population of $608, 10 th lowest in Colorado region of 75 practices of which $677 is the median and high $1,168; decreased for Highest-Risk Quartile PMPM expense of $989, 10 th lowest and median of $1,191 and high $2,247 for Colorado region Decreased ED utilization by 5% from 611 to 580 (not risk adjusted) per 1000 Medicare patients per year from last quarter equaling cost savings of $52K ($650/visit) Decreased hospital admissions for any cause of 1.1% per 1000 Medicare patients per year from last quarter cost savings of $135,200 ($26,000/stay) Decreased hospital admissions for Ambulatory Care Sensitive Conditions (ACSC) by 8% per 1000 Medicare patients per year from last quarter cost savings of $135,200. Total cost savings annually $1,289,600 http://www.himss.org/valuesuite
Questions Please reach out to us: Tamra Lavengood RN, BSN, MSN Will McConnell PhD, MBA, MS Clinical Performance Coordinator VP Operations and Strategic Outreach CPCI Coordinator Mercy Family Medicine Mercy Regional Medical Center Centura Health Physician Group Centura Health 970-764-3798 (direct) 970-764-3907 (direct) 970-759-2370 (cell) willmcconnell@centura.org tamralavengood@centura.org 1 Mercado Street Suite295 Durango CO 81301