AHA-AMGA Learning Fellowship Monthly Webinar October 27, 2016 2:00 3:30pm ET
Reminders Action Plan Due Date: Today, October 27 (send to bsutter@amga.org) In-Person Meeting: November 14-15 at the San Francisco Marriott Marquis Meeting and Webinar Calendar and Archives www.amga.org/fellowship Listserv Questions? Contact Beth! bsutter@amga.org 2
Today s Agenda Davis Health System Project Update Catherine Chua, DO, Director of Public Health Carl Nichols, MBA, CMPE, Chief Operating Officer Advocate Medical Group Project Update Sharon Adams, Vice President of Operations, Central Region Aaron Traeger, MD, Physician Leader Olmsted Medical Center Project Update Tim Weir, MHA, MBA, FACHE, Chief Executive Officer Kathryn Lombardo, MD, President 3
Davis Medical Center Carl Nichols, Vice President of Professional Services Catherine Chua, DO, CMO Davis Health System 4
DAVIS HEALTH SYSTEM 5
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Community Profile Davis Medical Center and its subsidiaries are located in Elkins, WV. Elkins is located approximately four hours west of Washington D.C., three hours south of Pittsburgh, PA, and two hours north of Charleston, WV. These communities are accessible by major interstates and secondary roadways. Davis Medical Center s service area is defined based upon the geographical area in which a majority of their patients occupy. The hospital s primary service area consists of Randolph, Barbour, Pocahontas, Tucker, and Upshur Counties. 8
Chart 1 Population of Service Area: 2000 2030 (Estimated) 89000 88000 87000 86000 85000 84000 83000 82000 81000 2000 *2005 2010 2015 2020 2025 2030 9
SOCIOECONOMICS OF OUR DEMOGRAPHIC AREA Location Median Household Income Median Family Income Barbour County $36,357 $43,805 Pocahontas County $34,761 $46,831 Randolph County $40,146 $49,765 Tucker County $38,663 $51,273 Upshur County $39,188 $48,400 State of West Virginia $41,576 $52,875 United States $53,657 $68,426 10
PERCENTAGE OF MEDICARE AND MEDICAID BENEFICIARIES BY SERVICE AREA 30.00% 25.00% 20.00% 15.00% 10.00% Medicare Beneficiaries Medicaid Beneficiaries 5.00% 0.00% Barbour County Pocahontas County Randolph County Tucker County Upshur County 11
GROSS BILLABLES AND PROJECTED BILLABLES THROUGHOUT THE SYSTEM 2015 2016 Davis Medical Center $208,885,242 $219,619,914 Broaddus Hospital 22,675,427 21,964,214 HFI (Pharmacy and DME company) 13,281,121 13,876,385 Medcorp 651,821 2,757,890 Foundation/DHS 561,220 373,101 Consolidated $246,054,831 $258,591,504 12
Since we last spoke... Since we last met, we have several accomplishments. 1. We have begun restructuring and redefining our administrative roles into a triad with an executive, a Physician, and a nursing supervisor, all responsible for moving this project forward. 2. We have started having monthly meetings with our primary care physicians to discuss standardization of practices. 3. We have already saved money per patient per month over last year s medicare payments per our ACO figures. 4. We have started to discuss risk based contracts with two private payors. 5. We have begun discussions concerning a wellness institute. 6. We have done very well with physician engagement in our PH meetings and also with completing the PH tasks put before them. 7. We have named a CMIO who is working closely with our IT department to standardize the input of data into our system so that we may obtain better results with metrics. 13
Davis Medical Center Summary of Findings Average adjusted expenditures per assigned beneficiary for the time period April 1, 2015 March 31, 2016 are $7,267 9% below 2015 expenditures for Davis and Valley 15% below Ohio River BasinACO average for same time period 20% below Caravan Health average for same time period Strengths Inpatient expenditures per assigned beneficiary are 20% below the Caravan Health average 18% of annual wellness visits have been completed 50% is the goal so we have some work to do! Opportunities Emergency department utilization is 31% above the Caravan Health average 14
New Ideas Did you have ideas that were generated since the kick-off meeting which helped you return to your practice and slightly alter your original plan? If so, what were they and how have you modified your project? We have been put in a position where our project had to be modified, as two private payors have approached us to sign risk based contracts. We have had to move forward quickly with that, and have since changed our focus from actually developing a risk based contract to determining how to educate staff and providers and institute the changes needed to proceed in a risk based environment. We are focusing on engaging physicians in newer, risk based contracts. We have begun to have discussions with outlying private physicians about narrow networks and have joined forces with a tertiary care center to improve our patient access. 15
METRICS We are measuring, but, like most everyone else, we are having significant difficulty moving the information from our system to be analyzed. Our numbers were abysmal even in areas that were automatically populated by the EHR. We are actively working now with our CMIO and our IT department as well as with the lightbeam support team to standardize processes among our providers and nurses so that the information is in the right place in the chart to be analyzed. The following is a slide from our ACO delineating the Metrics that we are to be tracking. 16
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Celebrating Accomplishments It s very important to celebrate the accomplishments you make along the way. Have you completed some first steps and celebrated with your staff? We have the highest number of wellness visits registered in our ACO. We have the lowest PMPM adjusted cost in our ACO. We have had excellent physician engagement. Our administration is sincerely dedicated to moving this process forward and improving access and quality in our community. 18
Challenges Have you experienced any challenges or barriers thus far? What are your biggest challenges? Our biggest challenge is the EHR and making it work for us. It is frustrating and difficult to get physician engagement when the work that they are doing is not credited, or when it takes 10 extra clicks to document something. We also faced a challenge of too many cooks, but the re-organization of the administration and hierarchy will help with this as each cook will have a defined role and responsibility. 19
Next Steps What are your next steps? Our immediate next step is to do the readiness survey and take the information that we get from it to start moving forward. By the October meeting, we will have just completed it, but likely will not have gotten information back yet. We expect that we will have to have multiple education sessions to prepare the providers and staff for risk adjustment We are currently continuing the work with the ACO, and are also working with two private insurers to establish risk based contracts. Our CEO wants us to then develop a physician guidance committee to determine how we will proceed with structuring payments under these new systems. We hope to gain more insight into effective contracts and/or compacts through this fellowship. We are developing a Wellness Institute with the hopes that we can expand our preventative services We are working closely with IT to troubleshoot and streamline our processes. 20
Lessons Learned Describe your lessons learned. We have a lot to learn and a long way to go. I don t really have a lot to add here this whole process seems like a learning curve for us since we re just starting down this path. 21
Questions Do you have any questions you d like to pose to the group? As we ARE just starting out. Do you have any suggestions in structuring the contracts for providers? How do you handle mid-levels vs. physicians in these types of contracts? What do the more experienced groups think is a good place to start as far as measuring quality? 22
Advocate Medical Group Comprehensive Care Program 23
Project Overview ED visits and readmit rates are above our targets. As we move to full risk, this will negatively affect reimbursement. Reduce total cost of care relative to full risk patient populations We feel we can provide a higher level of care, safety, and patient satisfaction and reduce acute utilization rates by preventing avoidable hospitalizations and ED visits. Develop an aligned team from both hospital and medical group that will begin looking at high risk patients and provide necessary support and assistance so that these patients receive appropriate medical, social, economic, and spiritual care that will assist them in meeting their healthcare goals. Goal of Coordinated Patient Centered Care 24
Team Members Fellowship team Patients Project manager Nurse lead Advocate Physician Partners Care Navigator Case managers Information Systems Quality team Providers Office staff Mission and Spiritual Care Behavioral Health Community resources Pharmacy Palliative Care Post Acute Network 25
Areas of Focus Identifying appropriate patients Patient medication self-management Dynamic patient centered health record facilitates communication and continuity Psychological/Emotional/Spiritual/Socioeconomic use of appropriate community resources, Advanced Plan of Care, lifestyle changes Identifying patient red flags and educating the patient about being knowledgeable about indications that condition is worsening and how to respond 26
Pilot Screening Tool AMG or APP Primary Care MD NO Yes PT DOES NOT MEET Criteria for pilot Continue with screen Criteria 1 point 2 Points 3 points N/A Behavior Health Screen Score 7 to 10 >10 Readmission Score Medium High Payor Other BCBS, MCA, Meridian, MSSP PCP Practice Encounters in last 6 months (inpt, obs and ED) Other AMG or APP practice AMG Sugar Creek (Medical Center) & AMB Family Practice (ABOC) <2 3 to 5 >6 Anticipated DC Disposition Home Within 30 mile radius of Hospital? YES NO 27
Steps Identify the patients by use of a risk score Initial visit identify patients readiness to change, assessment, mandatory referrals to chronic care clinics In home visit assess environment and barriers, set goals Office visit discuss plan and coordinate care Ongoing management multi-disciplinary team, organize resources and execute plan Graduation patient goals met 28
ACCOMPLISHMENTS: Several teleconferences with team Meetings with project management to discuss the program Meetings with lead nursing to discuss program start up Collection of data to include prior programs, concepts, and system need Investigating use of Perfect Serve to notify physicians of ED visits and admissions 29
New Ideas We were originally only going to implement this at one Advocate location but after discussions decided to roll this out at both AMG locations that have leadership involvement in the Fellowship program. 30
Outcomes Measurement metrics: Reduction in Emergency Medicine visits Reduction in admissions and re-admissions Reduction in medication reconciliation errors Increase in advanced directives Improvement in patient quality of life Reduction in total cost of care Improved patient satisfaction Length of Stay In-Network Post Acute Rate 31
Celebrating Accomplishments Identifying team participants Commitment and interest of the team and leadership Project that can be used throughout the system 32
Challenges Time Commitment Distance Patient interest Buy in of all team members Physician engagement Resources Data collection outside of system Obtaining claim history 33
Next Steps Identify team members Identify metric measures Develop communication process Identify patients Develop process BEGIN. 34
Lessons Learned Too early in process 35
Questions Has anyone done anything similar and what advice would you give us moving forward? 36
Olmsted Medical Center Rochester, MN 37
Since we last spoke... 1. We were interested in establishing the infrastructure and relationships for Medicare ACO and Self-Insured Direct Contracting 2. A substantial amount of progress has been accomplished through the establishment of key committees: Governance Operations Care Management Network/Service Area Data Reporting Product and Marketing Service and Experience 38
New Ideas 1. In our evaluation of the product and marketing, our service area analysis prompted us to evaluate our current depth of services. As a result, we intend on developing several clinical services and recruit additional specialists. 2. Operationally, through the process, there were several operational areas that were reviewed. These include 24/7 nursing support, NCQA certification and our service experience expectations. 39
Outcomes: Measurement and Data 1. We are just at the beginning of the process, and so have very little new data. Measurement will include many clinical areas that are similar to Minnesota Community Measurement data and patient satisfaction. 2. We are still waiting for CMS attributed lives file which is necessary for joining the Medicare ACO consortium. We are currently reviewing how utilizing an external data warehouse impacts/complements our current population health and EMR databases. 40
Celebrating Accomplishments 1. We haven t really celebrated yet. 41
Challenges 1. Some of our biggest challenges are forging new external relationships that are new to our organization. These include: Creating referrals patterns to University Medical Center Partnering with an insurance company on defining a value proposition for selfinsured employers Internally concluding that we need to continue to expand our clinical services 2. Communication strategies and local community leader conversations and educational requirements. 42
Next Steps 1. Continue with the governance meetings and discussion. 2. Recruit and develop several new specialty clinical areas. 3. Review and commit to Medicare ACO by month-end in partnership with several other regional healthcare organizations. 4. Acquire and implement population health software. 5. Complete external parties review of our quality and informatics department for feedback on contemporary structure. 43
Lessons Learned 1. Relationships are challenging and are formed one step at a time. 2. Politics are always on the table. 3. Communicate, communicate, communicate. 44
Questions 45