Person-Centered Care and Population Health

Physician Leader Forum Person-Centered Care and Population Health ZIAD HAYDAR, MD, MBA Chief Medical Officer Ascension Health 2013 by the Catholic Health Association of the United States Outline Describe organizational context of population health Discuss person-centered care and population health Lessons from ACOs Implications for future 2 1

3 4 Measures! Current Value-Based Purchasing (VBP) Acute Myocardial Infarction AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival AMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival. Heart Failure Hospital Consumer Assessment of Healthcare Providers HF-1 Discharge Instructions and Systems Survey (HCAHPS) Pneumonia (PN) HCAHPS dimensions: PN-3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received Communication with Nurses in Hospital Communication with Doctors PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient Healthcare-Associated Infections Responsiveness of Hospital Staff SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Pain Management Patients. SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within Communication 24 Hours About After Surgery Medicines End Time. Cleanliness and Quietness of Hospital Environment SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose. Discharge Information Surgeries Overall Rating of Hospital SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During Perioperative Period. SCIP-VTE-1Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery Coming soon for VBP Outcomes Acute Myocardial Infarction (AMI) 30-day mortality rate Heart Failure (HF) 30-day mortality rate Pneumonia (PN) 30- day mortality rate PSI 90 AHRQ patient safety composite CLABSI CAUTI Immunizations SSI -- Colon and Abdominal Hysterectomy Influenza immunization Efficiency Healthcare-Associated Infections Medicare Spending per Beneficiary SCIP INF-9 Postoperative Urinary Catheter Removal on Postoperative Day 1 or 2 Current Inpatient Quality Report (IQR) Acute Myocardial Infarction (AMI) MeasuresX AMI-1 Aspirin at arrival AMI-2 Aspirin prescribed at discharge Readmission Measures (Medicare Patients) AMI-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II AMI 30-Day Risk Standardized Readmission Receptor Blocker (ARB) for left ventricular systolic dysfunction Heart Failure 30-Day Risk Standardized Readmission Surgical Care Improvement Project (SCIP) Measures AMI-4 Adult smoking cessation advice/counseling Pneumonia 30-Day Risk Standardized Readmission SCIP INF-1 Prophylactic antibiotic received within 1 hour prior to surgical AMI-5 Beta blocker prescribed at discharge incision AMI-7a Fibrinolytic (thrombolytic) agent received AHRQ within Patient 30 minutes Safety of hospital Indicators (PSIs), Inpatient SCIP-INF-2: Prophylactic antibiotic selection for surgical patients arrival Quality Indicators (IQIs) and Composite Measures AMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention SCIP-INF 3 Prophylactic antibiotics discontinued within 24 hours after (PCI) PSI 06: Iatrogenic pneumothorax, adult surgery end time (48 hours for cardiac surgery) AMI-10 Statin Prescribed at Discharge PSI 14: Postoperative wound dehiscence Healthcare-Associated Infections Measures SCIP-INF-4: Cardiac surgery patients with controlled 6AM postoperative serum glucose Central Line Associated Bloodstream Infection (CLABSI) Heart Failure (HF) Measures PSI 15: Accidental puncture or laceration HF-1 Discharge instructions SCIP-INF-6: Surgery Patients Hospital with Appropriate Acquired Hair Condition Removal (HAC) Measures IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or without HF-2 Evaluation of left ventricular systolic function volume) SCIP INF-9: Postoperative Foreign urinary Object catheter Retained removal After on Surgery postoperative day 1 or 2 with day of surgery being day zero HF-3 Angiotensin Converting Enzyme Inhibitor IQI (ACE-I) 19: Hip or fracture Angiotensin mortality II rate Air Embolism Receptor Blocker (ARB) for left ventricular systolic dysfunction Complication/patient safety for selected indicators SCIP-INF-10: (composite) Surgery patients with perioperative temperature management Blood Incompatibility HF-4 Adult smoking cessation advice/counseling Mortality for selected medical conditions (composite) SCIP-Cardiovascular-2: Pressure Surgery Patients Ulcer Stages on a Beta III & Blocker IV prior to arrival Pneumonia (PN) Measures who received a Beta Blocker during the perioperative period AHRQ PSI and Nursing Sensitive Care Falls and Trauma (Includes: Fracture, Dislocation, Intracranial Injury, PN-2 Pneumococcal vaccination status SCIP-VTE-1: Surgery patients Crushing with Injury, Venous Burn, thromboembolism Electric Shock) (VTE) PSI 04 Death among surgical inpatients with prophylaxis serious, treatable ordered complications PN-3b Blood culture performed before first antibiotic received in hospital Vascular Catheter-Associated Infection PN-4 Adult smoking cessation advice/counseling Structural Measures SCIP-VTE-2: Surgery patients who received appropriate VTE prophylaxis Catheter-Associated Urinary Tract Infection (UTI) within 24 hours PN-5c Timing of receipt of initial antibiotic following Participation hospital in arrival a Systematic Database for Cardiac pre/post Surgery surgery PN-6 Appropriate initial antibiotic selection Participation in a Systematic Clinical Database Mortality Registry for Measures Stroke Care (Medicare Patients) PN-7 Influenza vaccination status Participation in a Systematic Clinical Database AMI Registry 30-day mortality for Nursing rate Sensitive Care Heart Failure 30-day mortality rate Coming soon for IQR Stroke (STK) Measure Set STK-1 VTE prophylaxis STK-2 Antithrombotic therapy for ischemic stroke STK-3 Anticoagulation therapy for Afib/flutter STK-4 Thrombolytic therapy for acute ischemic stroke STK-5 Antithrombotic therapy by the end of hospital day 2 STK-6 Discharged on Statin STK-8 Stroke education STK-10 Assessed for rehabilitation services Venous Thromboembolism (VTE) Measure Set VTE-1 VTE prophylaxis VTE-2 ICU VTE prophylaxis VTE-3 VTE patients with anticoagulation overlap therapy VTE-4 VTE patients receiving un-fractionated Heparin with doses/labs monitored by protocol VTE-5 VTE discharge instructions VTE-6 Incidence of potentially preventable VTE Mortality Measures (Medicare Patients) Stroke 30-day mortality rate COPD 30-day mortality rate Pneumonia 30-day mortality rate Patients Experience of Care Measures HCAHPS survey Readmission Measures (Medicare Patients) Stroke 30-Day Risk Standardized Readmission COPD 30-Day Risk Standardized Readmission Emergency Department (ED) Throughput Measures AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and Composite Measures ED-1 Median time from ED arrival to departure from the emergency room for patients admitted to the PSI 11: Post Operative Respiratory Failure hospital Structural Measures ED-2 Median time from admit decision to time of departure from the ED for ED patients admitted to Participation in a Systematic Clinical Database the inpatient status Registry for General Surgery Prevention Safe Surgery Checklist Use Immunization for Influenza Healthcare-Associated Infections Measures Immunization for Pneumonia Surgical Site Infection Cost Efficiency Medicare Spending per Beneficiary Catheter-Associated Urinary Tract Infection (CAUTI) AMI Payment per episode of care MRSA Bacteremia Perinatal Care Clostridium Difficile (C.Diff) Elective delivery < 39 completed weeks gestation Healthcare Personnel Influenza Vaccination Surgical Complications Hip/Knee Complication: Hospital-Level Risk Standardized Complication Rate (RSCR) following Elective Primary Total Hip Arthroplasty 2

Shared Savings Models Sub-Category Summary Model Concept Base Payment Structure Shared Savings Risk Organizational Targets Medicare Shared Savings Program (MSSP) Promotes accountability for Medicare beneficiaries; improves the coordination of FFS services; encourages investment in infrastructure; and rewards higher value care. Focused primarily on shared savings; targeted at easing organizations in to the ACO concept/model. Maximum sharing up to 50% based on the maximum quality score with a performance payment limit of 10%. Two tracks hospitals may join: Track 1 - Shared savings only track for the duration of the first agreement period. Track 2 - Allows more advanced organizations to take on performance-based risk for a higher reward. Track 1 does not require providers to bear risk for excess costs. Unlimited. Pioneer ACO Model Promotes accountability for beneficiaries; improves the coordination of care; encourages investment in infrastructure; and rewards higher value care. Higher levels of shared savings opportunities, but accompanying risk levels. Year 1-60% shared savings and shared losses subject to a maximum of 10% of total projected Medicare Part A and B expenditures for the ACO patients. Year 2-70% shared savings and shared losses subject to a maximum of 15% of total projected Medicare Part A and B expenditures for ACO patients. The first two years of the Pioneer Model are a shared savings payment arrangement and the third year is focused on transitioning to a more intense population health methodology, depending on the success of years 1 & 2. Higher levels of risk and shared savings in first two years than MSSP. Up to 30 with focus on advanced, integrated organizations. CMMI Bundled Payment Contract Encourages providers to work together for better management of patient population. Targeted at a single payment for services related to a clinical condition or specified episode only, rather than for all care for a patient during a specified time period. Four potential models driven primarily on care setting and service type. Not a shared savings program. Providers keeps savings, but must bear risk for excess costs. Providers must bear risk for excess cost per episode of care. Open applicants are encouraged to implement cross-provider care improvements. 5 5 About Ascension Health Facilities and Staff Sites of Care 1,935 General Acute Care Hospitals 103 Long-term Acute Care Hospitals 3 Rehabilitation Hospitals 3 Psychiatric Hospitals 4 Joint Ventured Hospitals 18 Available Hospital Beds 20,841 Associates 150,000 Care of Persons Living in Poverty and Community Benefit Programs: $1.5 Billion FY13 Financial Information (in millions) Total Assets $26,003 Operating Revenue $16,987 Operating Income $451 6 3

7 Major Sites of Care Hospitals by Type Senior Care and Living Facilities Long Term Care/Skilled Nursing Independent and Assisted Living Community Services Beds General Acute Care 103 18,712 Rehabilitation Hospitals 3 173 Psychiatric Hospitals 4 324 Long Term Acute Care Hospitals Joint Ventured Hospitals (<50% ownership) 3 144 18 1,488 Beds 34 3,745 9 1,823 Other Living (HUD, other) 4 377 PACE Programs/Enrollees 3 726 Mobile Clinical Services 35 Wellness Centers 20 Community and Social Programs 162 Dispensary of Hope Sites 82 Other Miscellaneous Services 123 Ambulatory Care and Diagnostics Ambulatory Surgery Centers 69 Occupational Health Programs 49 On-Site Employer Clinics 16 Free-standing Imaging Sites 148 Retail Lab Collection Sites 265 Primary Care Clinics 371 Retail Pharmacy Sites 42 Sleep Centers 16 Virtual Care Programs 64 Community Health Centers 5 Emergency Services Urgent Care Sites 46 Emergency Medical Services (EMS) Post Acute Services 28 Durable Medical Equipment 16 Home Health Services 25 Hospice Services 27 Outpatient Rehabilitation Centers 188 Ascension Health Footprint Lourdes Health Network Pasco, WA Carondolet Tucson, AZ Daughters of Charity Health System, California, is an affiliate of Ascension Health 8 Ascension Health is the largest Catholic and private nonprofit health system in the United States, operating in 23 states and the District of Columbia. 4

Ascension Integrated Strategic Priorities Aspiration: Vital Catholic health ministry called to improve health and healthcare through sustainable, values-inspired innovation. Strategic priorities: 1 Create sustainable person-centric delivery system to serve individuals throughout their lifetime 1A 1B 1C Transform our local health ministry operations Assemble standardized physician practice management services offering as foundation for enhanced physician relationships Build the physician/ caregiverdriven, person-centric & communitybased care delivery model of the future 2 3 Build best in class services businesses that enable our delivery system and strengthen Catholic healthcare by serving other organizations Continue to innovate, incubate and acquire new solutions, services and capabilities to strengthen our health ministry in a rapidly changing environment 4 Ensure the healthiest, most inspired Associates as we realize our Model Community ambition 5 Develop strong, diversified financial platform to support and sustain our combined ministry 9 In Other Words Opportunities for income improvement from inpatient volume growth or commercial rate increases are limited Population health capabilities need to be developed Cost structures must fundamentally change Access to care for the poor will continue to challenge the delivery system The basic relationships and care model between hospitals, doctors, and patients will change dramatically Leadership in palliative care and end of life care is part of Catholic identity 10 5

Population Health Financial Risk Management Capabilities Network Development and Management Person-Centered Care Analytics Physician/Caregiver Development and Engagement 11 12 Ascension Health Value-based Healthcare Delivery Efforts Lourdes Health Network Pasco, WA Mercy Care Medicaid HMO Seton Health Plan, Seton Health Alliance, and Pioneer ACO Genesys PACE, Genesys HealthWorks, and Genesys PHO Pioneer ACO Accountable Care Consortium Commercial ACO Quality Health Solutions Commercial ACO Alexian Brothers MSSP ACO Alexian Brothers PACE Community Care Health Plan Via Christi PACE Partners in Care MSSP ACO Network Health Plan HealthChoice PPO VIVA Health Plan MissionPoint Health Partners MSSP ACO, 13 CMMI Bundles, Commercial ACO St. Thomas Medical Group MSSP ACO Catholic Medical Partners MSSP ACO Maryland Physicians Care MCO Medicaid HMO Capital Clinical Integrated Care Network (CMMI Innovation Grant) St. Vincent s HealthCare 3 CMMI Bundles Ascension SmartHealth (a) Jacksonville, FL; Tulsa, OK; Pensacola, FL; and Wichita, KS submitted MSSP applications for January 2014 start (b) Seton Pioneer ACO transitioning to MSSP beginning January 2014 (c) Map current through June 2013 6

Pioneer ACO Savings Only 0.3% costs increase for 669,000 beneficiaries in 2012 (compared to 0.8%) 13 out of 32 pioneer ACOs produced shared savings Pioneer ACO Quality All demonstrated care improvement Several ACOs developed innovative care management models Pioneer ACO Impact on Health Care Organization Significantly negative impact 13 Achieving Lower Costs Over 12% decline in total costs for first 15,000 members 14 7

Producing Better Outcomes Over 50% decline in readmission rates 15 Fee For Service versus Fee For Value Urban Myths 1. Market share and hospital volume 2. Counting encounters versus counting lives 3. Physician employment versus physician alignment 4. Challenges and Stark Laws 16 8

Ascension Health Lessons Quality and cost are independent outcomes It takes more than ACO shared savings models to succeed in serving populations 17 Population Health and Person Centered Care in the Catholic Ministry Catholic social teaching, social justice, and population health Catholic social teaching, human dignity, and person centered care Connection between population health and person centered care Each human is a microcosm of the universe. Louise de Marillac, Thoughts on the Feast of St Fiacre 18 9

Picker Institute Definition 1. Respect for the patient s values, preferences, and expressed needs 2. Information and education 3. Access to care 4. Emotional support to relieve fear and anxiety 5. Involvement of family and friends 6. Continuity and secure transition between health care settings 7. Physical comfort 8. Coordination of care Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL. Through the Patient s Eyes: Understanding and Promoting Patient-Centered Care. San Francisco, Calif: Jossey-Bass; 1993. 19 Translated Picker s work into primary care 1. Superb access to care 2. Patient engagement in care 3. Clinical information systems that support high-quality care 4. Care coordination 5. Integrated, comprehensive care and smooth information transfer 6. Ongoing, routine patient feedback to a practice 7. Publicly available information on practices J GEN INTERN MED 2005; 20:953 957. 20 10

For Underserved Populations Kellogg Foundation: 1. Welcoming environment 2. Respect for patients values and expressed needs 3. Patient empowerment or activation 4. Socio-cultural competence 5. Coordination and integration of care 6. Comfort and support 7. Access and navigation skills 8. Community outreach 21 Care that: Explores the patient s main reason for the visit, concerns, and need for information Seeks an integrated understanding of the patient s world that is, the whole person, emotional needs, and life issues Finds common ground on what the problem is and mutually agrees on management Enhances prevention and health promotion Enhances the continuing relationship between the patient and the doctor 22 11

Limitations of definitions The example of centers of excellence and the need for house calls 23 Challenges The example of Access: Call light Clinic appointment Response to patient s telephonic inquiries Expectations of response (timely, yet sub-optimal responses) Relative urgency of access (tissue diagnosis after abnormal mammography) 24 12

Hierarchal Framework Ambulatory Care Hospital Subacute and LTC Home Care End of Life Care Disease Physiology Comfort (pain, sleep, privacy) Function (ADLs and IADLs) Mental (fear, depression ) Pain management protocols (bowel and bladder, food preferences ) Ambulation Access Third appt. Call light response Therapy and activities Autonomy Family Care planning Care Coordination Spirituality Cultural Sensitivity Care planning and design Disclosure 25 Strategic Organization To Serve Populations Focus on quality - Organizing central leadership around safety, equity, experience, process reliability Role of leadership - Creating a passion for service and continuous improvement - Empowering middle management with QI science Focus on market segments - Systematic focus on horizontals: long term care, physician enterprise, home care, hospital, segment, etc. Focus on customer segments, service lines, and demographic segments 26 13

Example of Physician Enterprise High Performing Medical Group Network Development 27 Discussion Thank you for your interest. Ziad Haydar ziad.haydar@ascensionhealth.org 28 14