Memorial Hermann: A Care Management ACO

HealthLeaders Media LIVE From Memorial Hermann Memorial Hermann: A Care Management ACO Care Coordination and Physician Alignment Drive Nation s Greatest ACO Savings 2 Case Study 2 Lesson 1: Engage, Align, and Empower Independent Physicians to Drive Accountable Care 5 Lesson 2: Accountable Care Coordination: A Care Management, Case Management, and Community- Based Plan 11 Resource Guide Additional Resources From HealthLeaders Media Featuring a live event on November 11, 2015 11 a.m. 1 p.m. ET Memorial Hermann Houston

Case Study // LESSON 1 Engage, Align, and Empower Independent Physicians to Drive Accountable Care BY JIM MOLPUS Memorial Hermann Health System» 12 hospitals» More than 20,000 employees» A top-performing ACO Back around 2007, Houstonbased Memorial Hermann Health System had only a distant promise when it began to talk with area physicians about the concept of clinical integration. Terms like accountable care organization were still mostly left to theory. As Keith Fernandez, MD, recalls, the selling point that he and other leaders of the MHMD Memorial Hermann Physician Network had to offer was a more manageable life for physicians. We had a great advantage over many other groups, recalls Fernandez, now also chief medical officer of the Memorial Hermann Accountable Care Organization. We had a group of doctors in very small practices (averaging 1.8 per practice) that had no collective vision of how they might move successfully into an uncertain future. The doctors were ready to do things differently and were intrigued by models of clinical integration. The concept that attracted the doctors was simple do the right things to care for patients, be measured in quality and cost, and prove to the community and themselves that they were the highest quality and most cost-efficient. Recalls Michael Shabot, MD, executive vice president and chief clinical officer of Memorial Hermann Health System, and founding chairman (now past chairman) of the Memorial Hermann ACO: In a way, our secret was starting early before we knew what the actual goal or plan was going to be. We had a more generic goal of taking better care and more efficient care of our patients. That promise of the future rang true, and success has followed. In the first full year of the Medicare Shared Savings Program in 2013, the Memorial Hermann ACO led all MSSP ACOs with savings of nearly $58 million, almost $20 million more than the next highest ACO. From a ground of zero at-risk lives in July 2012, Memorial Hermann now has almost 240,000 in risk arrangements. 2

Panelists» Keith Fernandez, MD, president, MHMD Memorial Hermann Physician Network, and chief medical officer, Memorial Hermann Accountable Care Organization» Mary Folladori, RN, system director of care management, Memorial Hermann Health System» Paula Lenhart, associate vice president of care management, Memorial Hermann Health System» Christopher Lloyd, CEO, Memorial Hermann Accountable Care Organization» Pat Metzger, senior vice president and chief of care management, Memorial Hermann Health System» Carol Paret, senior vice president and chief community benefits officer, Memorial Hermann Health System» Michael Shabot, MD, executive vice president and chief clinical officer, Memorial Hermann Health System, and founding chairman, Memorial Hermann Accountable Care Organization But building the physician alignment strategy for successful clinical integration took some learning. We sold doctors on the concept of being able to manage their future practice by defining what quality is, improving it, and measuring performance, Fernandez says. In other words, not relying on other people to decide what good quality is, relying on them to report it accurately, and then using that to determine what defines a good doctor. I was really hoping for 500 physicians on the first pass, but we had 1,200 physicians sign up, which was a surprise to me. The number of physicians in the network swelled to almost 3,000 after the success of the shared savings program, and this created a problem. When we looked at our quality metrics at that time, we saw a deterioration in performance. And so we implemented more stringent criteria to both enter and stay in the clinical integration program that would protect the quality and costefficiency of the network. The result was a more specific business agreement that the physicians now sign to join the ACO. It requires physicians to supply EMR data for 90 days, be on a preferred EMR, and agree with and abide by the MHMD compact, Fernandez says. Other requirements include appropriate policies and procedures that govern patient safety. Aligning hundreds of independent physicians meant addressing some initial cultural and governance barriers. Many held true to a spirit of physician autonomy in the state, where historically physician groups had been relatively small and deeply competitive. To create a physician-driven structure that could propel clinical improvement, the physician organization created clinical program committees in each specialty, Shabot says, which focus on evidence-based best practices. While there were just a handful of core committees in the program s first year, that number has since increased to 50. Years and years and years of effort went into this to create quality protocols, safety protocols, and efficiency protocols developed by the physician committees, Shabot says. And then to make them active in the hospitals, we had developed a mechanism for getting them through each of our currently 3

WE SOLD DOCTORS ON THE CONCEPT OF BEING ABLE TO MANAGE THEIR FUTURE PRACTICE BY DEFINING WHAT QUALITY IS, IMPROVING IT, AND MEASURING PERFORMANCE. Keith Fernandez, MD, president of MHMD Memorial Hermann Physician Network and chief medical officer of Memorial Hermann Accountable Care Organization 11 medical executive committees. Getting 11 MECs to agree on the same thing that wasn t easy either. And we put literally scores of quality and safety measures through the MECs in that way over the past seven or eight years. Each of those more than 500 measures sent through the clinical program committees and then to the hospitals started with some basic agreements, says Christopher Lloyd, CEO of the Memorial Hermann Accountable Care Organization. There has to be some focus, Lloyd says. There has to be some reason why certain things are done, and usually that s guided by clinical data and input from a whole bunch of other different team members. Even beyond what clinical condition you identify, you have to ask, what s the point in doing it? What driver are we looking to drive? Do we all have agreement on that before we even step into it? Do we all agree that we re managing a cost metric or we re managing a clinical metric? It just depends from measure to measure, but I think that there s a lot of discussion around making sure that our goals and our roles are in the same direction. Early success and shared incentives have also helped usher in a gigantic cultural change, Fernandez says. I rarely have any trouble with engaging physicians now. In fact, I have to sometimes restrain them. We have 50 clinical practice committees not because I m looking for more committees, but because the doctors are demanding them. I have doctors coming to me now saying, I ve got to get this problem fixed. 4

Case Study // LESSON 2 Accountable Care Coordination: A Care Management, Case Management, and Community-Based Plan Any health system that is taking on risk for the care of a population faces the same hole in its skill set: care coordination. No inpatient enterprise built for feefor-service healthcare has enough hospital-based case managers, ambulatory-based care managers, social workers, pharmacists, health coaches, and community health liaisons to form an ACO efficient enough to create value. Even if they did have the FTE numbers, provider health systems have little experience or existing models for how the pieces of the care coordination team should work together. Memorial Hermann s approach has been a multipronged growth strategy for key areas of care coordination, with the goal that all will eventually meet in the middle to close gaps around patient care. The most growth in terms of overall FTEs has been in the ambulatory care managers who have been attached to Memorial Hermann s MHMD physician network practices; there were a relative handful when the journey to accountable care began, but now there are more than 40. The care managers work to identify and guide chronically ill, high-cost patients through a more efficient system. Mary Folladori, RN, system director of care management for Memorial Hermann Health System, says the care managers work extensively with people who have chronic health conditions, most of whom have one or more of the conditions usually associated with high cost and high utilization: chronic obstructive pulmonary disorder, congestive heart failure, and diabetes. The care management team uses risk stratification tools to identify which of the 240,000 patients in Memorial Hermann risk contracts would benefit from enhanced care coordination. The 5

WHAT WE DO IS BASED ON RELATIONSHIPS AND NETWORKING, KNOWING HOW TO BE THE CATALYST TO MAKE THINGS HAPPEN ON BEHALF OF OUR PHYSICIANS AND THEIR PATIENTS. Mary Folladori, RN, system director of care management for Memorial Hermann Health System care managers are based and work within the regions where the physicians and their patients live. This affords team members an awareness of and access to resources and healthcare services available in different parts of the city. MHMD care managers are equipped to ease care transitions so that a change in venue is no longer perceived as a disruption in care, but instead recognized as a way to improve patient safety and satisfaction. We have built the care management team to follow the member throughout their continuum of care, Folladori says. In order to do that, a multidisciplinary professional team was deliberately assembled and trained as a team that supports members and families based on their unique and changing healthcare needs. The team uses RN care managers and care management assistants who are LVNs, clinical pharmacists, masters of social work, registered health coaches, and communication coordinators. The goal is to engage the member in his or her own care, utilizing motivational interviewing and shared decision-making, Folladori says, adding that because the team represents the member s physician, the engagement rates are higher than those previously achieved by payers. Each member has a primary care manager; however, to gain efficiency, other team members can move in and out, so a patient who needs a pharmacist at one visit and a social worker the next can be accommodated, she says. Workflows and procedures have ensured handoffs between team members are seamless and transparent to the patients. Engagement methodologies can be really simple. Many times we try to get too complex, Folladori says, It can be as simple as an introductory phone call to the member before they leave the hospital. Or for very complex patients, our staff will go in and do a brief introduction at the bedside with the member and 6

family. Or it could be one of our unlicensed support team members who goes to the patient s home to let them know that Dr. Smith s care manager, Debbie, is going to call them tomorrow just to see how they re doing. They may leave them a magnet or a bright-colored piece of paper to remind them, because these patients get so overwhelmed when they go home. We try to keep some of those things really simple. Oftentimes, the role of the care managers is to be an expediter or facilitator for a member who is stuck in a tight spot in the system. One example is that we had a member who was understandably anxious and wanted to have a biopsy for a potential cancer diagnosis as soon as possible, rather than in the three-week time period it was originally scheduled for, Folladori says. Obviously she was very frightened. Her surgeon s office was having scheduling challenges and initially couldn t schedule her biopsy sooner, and that was very distressing for her. We dug into it. Turned out it was an OR scheduling matter. Someone on our team had the right contact in OR scheduling. She was able to get the case scheduled for the next day. What we do is based on relationships and networking, knowing how to be the catalyst to make things happen on behalf of our physicians and their patients, Folladori says. Some members require a higher level of care, and for those people Memorial Hermann has designed and expanded its supportive medicine program (also known as palliative care). The supportive medicine team is a physician-led interdisciplinary care team that is focused on improving quality of care delivery for patients with serious and life-threatening illnesses by providing an extra layer of support. The supportive medicine team is led by Sandra Gomez, MD, a palliative care specialist, and includes nurse practitioners, registered nurses, social workers, chaplains, and counselors. Care is focused on providing patients with relief from the symptoms, pain, and stress associated with their illness, whatever the diagnosis. The goal of care is to improve quality of life for both patients and families. Supportive medicine programs are located at eight Memorial Hermann hospitals and four outpatient clinics. The expansion of this service has allowed for more than a 27% increase in the number of patients served from 2013 to 2014. 7

Patient satisfaction surveys were distributed to gauge the effectiveness of supportive medicine consultations. The results showed significant improvement in pain control after supportive medicine became engaged in the patients care: 92% of patients/families rated their pain control as Excellent after a supportive medicine consult vs. only 41% who rated their pain control as Excellent before the consult. Eighty percent of patients who received a supportive medicine consult identified that they would have preferred to have been consulted earlier in their diagnosis so they could have benefitted earlier from these services. Ninety-six percent of patients indicated that they would recommend these services to another patient with a serious or life-threatening illness. Memorial Hermann s hospital-based care management team is likewise looking for ways to reach out from the inpatient stay, particularly in populations at high risk for readmissions or unnecessary admissions, says Pat Metzger, senior vice president and chief of care management at Memorial Hermann Health System. The care management team has started to look for tools, partnerships, and communication to close gaps, recognizing that no health system can hire enough care managers to cover everything, Metzger says. One recent example is Virtual Care Check, a remote patient monitoring system for patients with chronic heart failure, diabetes, chronic respiratory issues, or pneumonia. Patients are given a dedicated 4G tablet device, along with weight scales, pulse oximeters, glucometers, and blood pressure monitors. Physicians customize a plan that blends the wireless data with a patient daily survey. If certain downward indicators are met, a member of the care management team will call to assess the need to either get the patient back in or assign other resources. We have about 300 patients through the system currently, Metzger says. We ve begun to see decreases in the cost of care associated with their care. We see fewer hospitalizations for them, and when they do come in they re less complicated or less complex than they might have been left to their own devices. Telehealth tools can only go so far, so Memorial Hermann is partnering with its preferred ambulance provider to send paramedics with special training to check on patients at their homes who fit into a troublesome gap: sick enough to need some monitoring but not sick enough to need home health or skilled nursing. There are those patients that we look at and we have this kind of 8

sixth sense that they re not going to do well, Metzger says. The paramedics take vital signs, listen to lungs, listen to hearts, check medications, and do a safety evaluation. If needed, the paramedics work with the case management team to schedule a primary care visit, or intervene if a trip back to the hospital or emergency room is necessary, Metzger says. Memorial Hermann has also: Created a preferred provider network with 60 Houston-area postacute providers, who agree to share data and outcomes on Memorial Hermann s information exchange. The quality data is then shared when patients are selecting a skilled nursing facility, Metzger says, though patients are free to choose their own provider. Put more emphasis on palliative and supportive care earlier in the care management process. We ve worked with the physician group to suggest that perhaps those patients need to be caught more in an ambulatory setting in the physician s offices where the whole topic of palliation and the whole topic of managing advanced illness can be had when the patient s not lying in a critical care bed in the ICU, Metzger says. One of the underlying challenges is in accurately and quickly identifying at-risk patients. Memorial Hermann currently uses a patchwork of disease management and population health tools, and has put out a request for information for a tool that will identify and close the information gaps through the entirety of the patient s needs. We re probably no further ahead than anybody else in terms of our ability to have one common tool, says Paula Lenhart, associate vice president of care management for Memorial Hermann Health System. But we have recognized and are moving forward with trying to secure a common platform that will help us risk-stratify patients in a way that we all understand. Ultimately, volume is growing faster than capacity for Memorial Hermann in Houston. Even with an ambitious accountable care and case management program, the system is also investing heavily in community health and prevention to bring down overall community health disparities, says Carol Paret, senior vice president and chief community benefits officer for Memorial Hermann Health System. 9

Paret sums up the goal of the community health approach: We are all for how you treat a diabetic patient better, but our goal has got to be how you don t have the diabetic patient to begin with. There s just not enough money to take out of the system by tweaking the medical care. One of the system s community programs has been school-based health programs in 10 clinics serving 70 schools. The program provides 12-month, free medical, dental, mental health, nutrition, and navigation to kids. We can show from a medical perspective that our kids don t have asthma exacerbations, for example, they don t use ERs, Paret says. We can show from a dental space that we re meeting the [federal government s] Healthy People 2020 goals already. We can show from a mental health space that the kids that we re serving have decreased suspensions and detentions, increased GPAs, decreased absences. But to truly make a significant impact on community health requires a new, and in many ways counterintuitive, way of thinking for providers used to looking through the health system prism, Paret says. If I am an hourly worker, do I really want to go to a health clinic where I may need an x-ray, and I have to make a second appointment and take a second day off work. Then I may need a specialist, so there is a third appointment. If I go to the ER and starting at, let s say, 11 at night and I m seen at 3 in the morning, I might give up a night s sleep, but I get everything I need in one stop. What s better for my life? That s where health systems and their smart minds and their analytics get all out of whack, Paret says. You ve got to understand the lives of the people whose actions you are trying to change. Jim Molpus is leadership programs director for HealthLeaders Media. He may be contacted at jmolpus@healthleadersmedia.com. 10

RESOURCE GUIDE For Further Study Leadership at Memorial Hermann has developed a care management ACO that focuses on care coordination and physician alignment to drive outcomes and savings. For further study, consider the following resources: Resource 1: The Need to Revisit Care Coordination, Clinically and Financially This piece is adapted from an analysis by Michael Zeis, senior research analyst, in the July 2015 HealthLeaders Media Intelligence Report, Care Coordination: Closing the Gaps Along the Continuum. Care coordination in the form of patient transfer is a relatively mature activity, at least in the acute care environment, but new attention to value-based care and at-risk reimbursements means that care coordination is poised for development and growth. What are the top three challenges your organization faces in developing and extending care continuum collaboration? Dealing with payers protocols or regulations Lack of standardized EHR Lack of commitment from care partners Lack of financial incentive Lack of technology solutions Lack of details on others services, capabilities Lack of details on family support options Skilled nursing facilities 28% 25% 19% 18% 42% 41% 57% 50% Multi-response; among hospital and health system respondents. SOURCE: HealthLeaders Media Intelligence Report, Care Coordination: Closing the Gaps Along the Continuum, July 2015; hlm.tc/1kwlhwk. Just over two-thirds (68%) of healthcare leaders say their organization has a care transition function that supports patient transfers to or from hospitals, which is the setting with the highest percentage of supported transfers. Other settings cited ranges between 40% (for clinics 11

or federally qualified health centers) and 55% (for home health agencies), which gives hospitals a clear, but not commanding lead. Despite the growing expectation that primary care physicians should occupy pivotal spots in care coordination activity, primary care practices are in the middle of the group, with 53% of respondents saying their organization has a care transition function that supports patient transfers to and from primary care. That means that half the people out there are being coordinated without [a primary care] physician s direct involvement, says Gaurov Dayal, MD, former president of healthcare delivery for St. Louis based SSM Healthcare, which operates 19 hospitals, an insurance company, nursing homes, homecare, hospice, telehealth, and a technology company. Resource 2: How Patient Flow Nurses Help Cut Readmissions This piece is adapted from an August 4, 2015, online column by Jennifer Thew, RN, senior nursing editor. When she noticed RNs weren t always able to make patient discharge a top priority, Baptist Health Lexington s CNO created a new nursing position to improve the discharge process. The result has been a direct benefit for pay-for-performance indicators. Do the worst first. That s advice my preceptor gave me when I was a new nurse. It was her quick-and-dirty tip on how to prioritize patient care. Her point was that I should focus my attention on the patients with the highest acuity levels or who were the most unstable. Postop patients or those with drains, tubes, deep-brain electrodes, or changes in neuro status should have dibs on my time and care intensity. A few years ago, Karen S. Hill, DNP, FAAN, chief operating officer and chief nursing officer at Baptist Health Lexington in Kentucky, noticed nurses at her facility were also engaging in this type of prioritization. If they had an assignment and a patient was going to go to the OR or the cath lab, that patient rose in the level of priority, Hill told me, and sometimes the patient who was more stable or going to be discharged was not the most important thing they were doing. But, as she points out, healthcare has evolved, and a greater emphasis is now placed on issues such as preventive care, quality outcomes, and continuity of care, which can all be affected by how well patients understand their discharge instructions. I ve seen a huge transition in my nursing career from high-acuity hospital-focused care to, now, a focus on wellness across the care settings, says Hill, who has been a nurse for 37 years. As we ve done that, one of the things that I ve tried to do is to help develop a different way to look at hospital care. 12

About the Host An integrated health system, Memorial Hermann is known for world-class clinical expertise, patient-centered care, leadingedge technology, and innovation. The system, with more than 20,000 employees, serves to advance health in Southeast Texas and the greater Houston community. Memorial Hermann s 12 hospitals include three hospitals in the Texas Medical Center (the Texas Trauma Institute, a level I trauma center that houses the Life Flight air ambulance, a hospital for children, and a rehabilitation hospital), eight suburban hospitals, and a second rehabilitation hospital in Katy. The system also operates three Heart & Vascular Institutes, the Mischer Neuroscience Institute, three Ironman Sports Medicine Institute locations, cancer centers, imaging and surgery centers, sports medicine and rehabilitation centers, outpatient laboratories, a chemical dependency treatment center, a home health agency, a retirement community, and a nursing home. As an accountable care organization, the system also offers employers health solutions and health benefit plans through Memorial Hermann Health Insurance Company. When Memorial Hermann was chosen to join the Medicare Shared Savings Program, Medicare attributed 24,000 of its covered beneficiaries to the system; that has grown to 30,000. Memorial Hermann rapidly processed the underlying metrics to identify opportunities to reduce cost in this population and achieved 100% compliance with year 1 quality requirements. For the first 18 months, MHACO earned the distinction of being one of the top-performing ACOs in the country, saving Medicare more than $58 million as part of its Shared Savings Program. Continued success in the MSSP will require the system to conform to even higher standards of quality and efficiency. About Us HealthLeaders Media is a leading multi-platform media company dedicated to meeting the business information needs of healthcare executives and professionals. To keep up with the latest on trends in physician alignment and other critical issues facing healthcare senior leaders, go to www.healthleadersmedia.com. Sponsorship For information regarding underwriting opportunities for HealthLeaders Media LIVE, contact Sales@healthleadersmedia.com or 800-753-0131. Executive Vice President and Publisher ELIZABETH PETERSEN epetersen@hcpro.com Leadership Programs Director JIM MOLPUS jmolpus@healthleadersmedia.com Editorial Director EDWARD PREWITT eprewitt@healthleadersmedia.com Managing Editor BOB WERTZ bwertz@healthleadersmedia.com Media Sales Operations Manager ALEX MULLEN amullen@healthleadersmedia.com Copyright 2015 HealthLeaders Media, 100 Winners Circle, Suite 300, Brentwood, TN 37027 Opinions expressed are not necessarily those of HealthLeaders Media. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. 13