Advancing Popula/on Health and Consumerism 44,954 Senior Enrollees 274,345 Commercial Enrollees 66,070 Commercial ACO Members
Popula/on Health Risk Stra/fica/on: Keep Pa/ents Healthy, Happy & at Home Tier 4: Complex 5% Chronic Diseases with two hospitalizakons; Needs co-ordinakon of care 15% Reduce avoidable hospitalizakon Tier 3: High Severity Programs for Chronic Diseases Implementa/on of evidence based guidelines Tier 2: Moderate Severity 20% Walking well; need periodic screening tests Preven/ve Care Reminder Program Annual wellness exam and targeted outreach Tier 1: Low Severity 60%
260,000 pakents FTE working at top of their license COMPLEX Care at Home NURSE Navigator Nurse PracKKoners/MD Social Worker, Case Manager MulKple Chronic CondiKons Need co-ordinakon of care Reducing avoidable HospitalizaKon Programs for Chronic Diseases Reaching goals as per evidence-based guidelines for chronic disease Diabetes, Asthma, CHF, COPD, Obesity, HTN Walking well; need periodic screening tests Preven/ve Care Reminder Program Case Manager RN, Chronic Care RN Disease Manager level 2 & 3, Pharmacist Care Coordinator Diabe/c Educator Health Coach Pharmacy Tech
# of Referrals 1000 900 800 700 600 500 400 300 200 100 0 Nurse Navigator: One #/e-referral does it all Volume By Month 884 891 735 772 645 754 705 550 505 534 543 467 413 395 337 346 319 376 301 359 311 232 247 294 298 323 292 306 187 204 147 131 118 93 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15
Fee for Service Challenge: Moving from Individual to Team Based Value Based Accountable Care 20 minute visit 22 pa/ents a day Unknown Health Risks Episodic Care Panel Management Health Risk Assessment Quality Care Preven/ve Care Total Cost of Care Pa/ent Experience
Care at Home Program Average age is 83 Current enrollment: 135 Mix of MA, Next Gen ACO and Duals Doctors refer pa/ents deemed at risk Diagnoses mul/ple chronic and severe condi/ons U/liza/on data Func/onal limits that inhibit appointments at clinics Frequency of visits varies
These are complex pa/ents. High cost: based on u/liza/on data supplied by plan based claims High risk: based on predicted future u/liza/on High social needs
CAH Staffing Team based care 1 RN Case manager - coordinates care and handles calls and guides pa/ents. 4 NPs making visits: usually one /me per 6 weeks. NP does 5 visits a day. First visit is 60-90 minutes, and the subsequent ones about 40 mins. 1 Social Worker when needed; assists with behavioral issues; support groups MAs Each pa/ent retains their Primary Care Physician
How do you scale and sustain CAH? 1. Create business case 2. Calculate ROI 3. Share with leadership
Business case: Defini/on Jus/fying an organiza/on s expenditure based on the posi/ve economic consequences to that organiza/on.
A BUSINESS CASE TYPICALLY BEGINS WITH THE EXISTENCE OF A FINANCIAL BURDEN IF NO INVESTMENT IS MADE $
Examples of ECONOMIC BURDENS RELATED TO HEALTH CONDITIONS The cost to Medicare of a hospital readmission within 30 s days of discharge is about $18,000. More than 25% of Medicare expenditures are provided in the last year of life. Cost per hospital stay for those adults that die in the hospital is over $112,000. The annual Medicare spending for an individual with three or more co-morbidi/es and with demen/a is about $50,000.
The bigger the burden, the bigger the opportunity
The Steps to crea/ng the business case 1. Measure and add up the expected benefits in terms of cost savings plus any revenue enhancements to get gross benefits 2. Es/mate the total costs of the program 3. Subtract these costs from the gross benefits to get net benefits 4. Omen the net benefits are expressed as a percentage of the program costs - and called return on investment or ROI, for short 5. The ROI is compared to a hurdle rate - a minimum percentage that any investment must generate to be considered aprac/ve
CAH: Step 1 1. Measure and add up the expected benefits in terms of cost savings plus any revenue enhancements to get gross benefits Cost savings: Reduc/on in admissions, readmissions, ED Team-based care, using non-licensed staff Revenue enhancements: ACO reimbursement
CAH: Step 2 2. Es/mate the total costs of the program To consider Staffing IT Transporta/on Other social service..
CAH: Step 3 3. Subtract these costs from the gross benefits to get net benefits Summarize using ROI Calculator Tool Example
CAH: Step 4 4. Omen the net benefits are expressed as a percentage of the program costs - and called return on investment or ROI, for short
CAH: Step 5 5. The ROI is compared to a hurdle rate - a minimum percentage that any investment must generate to be considered aprac/ve
Decreasing 30 days Readmissions Decreasing CHF Admissions HF Admissions per 1,000 Members per Year Senior HMO PopulaKon 40.00 38.00 36.00 34.00 32.00 30.00 28.00 26.00 24.00 22.00 20.00 32.75 32.33 29.63 28.72 24.16 CY2011 CY2012 CY2013 CY2014 CY2015 CHF Admission Cost Savings over a 2 yrs. period CY 2013 per 1,000 members per year: 32.33 CY 2015 per 1,000 members per year: 24.16 Reduc/on in admissions per 1,000: 8.17 Mean Cost of Senior Hospitaliza/on (MEPS): $18,554 Es/mated Cost Savings $2,615,923
ARU: Decreasing Acute Admissions per 1,000 Members Hospital Admissions per 1,000 Rate for SRS Senior HMO 255 240 225 243 236 229 225 Fiscal Years Year to Date 210 207 Goal 195 197 196 202 202 199 194 180 165 Goal: 203 Acute Admission Cost Savings in 2014 CY 2013 per 1,000 members per year: 222.00 CY 2014 per 1,000 members per year: 204.00 Reduction in admissions per 1,000: 18.00 Mean Cost of Senior Hospitalization (MEPS): $18,554 Estimated Cost Savings for 2014: $5,116,117 22
Transi/ons of Care 85% consolida/on Senior HMO pa/ents at nine SNF facili/es 20.00 15.00 10.00 5.00 0.00 # Days Stay Reduced 17.20 13.10 Average Length of Stay Days Before 2015 Medicare ACO program (assuming 30,000 a?ributed members) 2 days LOS = $2 M 2% Readmit rate = $0.5M 30% 20% 10% 0% 30% 20% 10% 0% Direct Readmissions from SNF to Acute Care (30 days) 24% 10% 30 day readmission Before 2015 Post SNF Discharge Readmission Rate 10% Readmission to Hospital 30 days Post SNF discharge Baseline data source from Lean six sigma study period Oct 2011 to Dec 2012 Before 2015
Care at Home Program Outcome Analysis InpaCent Admissions and ER visits per 1,000 per Year (33 months analysis 12/2013 to 09/2016, unique pacents see 1371) Pre-Engagement Post-Engagement 1244 56% Improvement 28% Improvement 980 702 542 Inpa/ent Hospital Admissions per 1,000 per Year ER Visits per 1,000 per Year
ROI Calculator Tool Link to tool hpp://www.thescanfounda/on.org/businesscase-person-centered-care Discussion How have groups looked at suppor/ng budget for care teams? How have shown effec/veness of program? What outcomes calculated?