ACOs: Transforming Systems with New Payment Models & Community Integration

ACOs: Transforming Systems with New Payment Models & Community Integration Sunnah Kim PNP (Moderator), American Academy of Pediatrics Herbert Druilhet, RN, DNP, FNP-BC Lafayette General Medical Doctors Michael P. Jeremiah, MD, FAAFP, Carilion Clinic Todd Walker, MBA, Rainbow Babies & Children s Hospital, University Hospitals James Colbert, MD, Verisk Health

Lafayette General Health Journey in Population Health Herbert Druilhet RN, DNP, FNP-BC LafayetteGeneral.com

LafayetteGeneral.com

Where are we? Clinically Integrated Network Acadian Healthcare Alliance Patient Centered Medical Home Healthe Intent Population Health Platform Employee Health Management LafayetteGeneral.com

Ochsner Health Network LafayetteGeneral.com

Challenges Health Information Technology Practice Culture Physician Incentives LafayetteGeneral.com

Steps to Success... Continue to refine medical community culture Connecting the dots Payor Contracts Expansion of PCMH best practices into integrated clinics LafayetteGeneral.com

Keys to Success... Physician Collaboration Payor Partnerships Population Health Infrastructure Clinical Care Delivery Operational Improvements Employee and Employer Solutions LafayetteGeneral.com

Carilion Clinic - efforts in population health & accountable care Michael P. Jeremiah, MD, FAAFP

Carilion Clinic 1,026 Licensed Beds 49,000 Admissions 877,000 Primary Care office visits 40 Medical Homes 54,000 Urgent Care visits 11,700 Employees 800 Employed Physicians $1.7B Net Revenue 180+ Primary Care Physicians

Background Strong primary care focus since 1996 large primary care practice joined Implemented group-wide EMR in 2000 Logician/Centricity Created internal scorecards in 2005 reviewing quality of care by provider Diabetes perfect care Hypertension control

Background 2007 - Carilion Health System became Increased physician leadership and a focus on being an Accountable Care Organization 2008 - implemented EPIC system-wide 2010 - opened a medical school with Virginia Tech 2013 - entered MSSP program

Clinic Transition Goals Broaden the number of specialties working at Carilion Standardize our primary care model (PCMH) Optimize referrals within the physician group Fully utilize EMR to enhance communication Strengthen our patient-centered approach

Silos & Synergies Discovered other groups working in the system on similar work Focused on specific P4P metrics Developing protocols and processes Somewhat in silos Opportunities existed for working together Proposal approved to link these efforts under one Accountable Care umbrella

DOCTORS CONNECTED AQC Care Transitions Group SNF Collaboration Taskforce Extensivist Clinic CCMH Central Care Coordination Employee Health Plan Accountable Care Transition Team Tele-Health ED Case Management CHF Transitional Visits Advance Care Planning Pay 4 Performance Team

Aligning Incentives List of Carilion 2016 approved metrics available to choose for scorecards Appropriate Testing for Children with Pharyngitis Rheumatoid Arthritis Management Breast Cancer Screening Colorectal Cancer Screening Diabetes A1c Screening Diabetes A1c < 8.0 Diabetes Nephropathy Screening Adult BMI Assessment High Risk Medications in Elderly Osteoporosis Management in Women with a Fracture

Annual Trends

Table 3.2 Impact on Preventive Care Carilion Clinic Medical Home Performance by Measure and Period 2009-2014 PREVENTIVE MEASURE BASELINE Year Prior to Transition YR 1 YR 4 HEDIS National Mean (2013) % CHANGE Baseline to YR 4 Breast Cancer Screening Percentage of women 40-69 years of age with a mammogram in the past two years 41.6% 65.6% 60.5% 64.2% 45.4% Pneumococcal Vaccination Percentage of patients >65 years of age with a pneumococcal vaccination 67.6% 78.0% 80.0% 71.7% 18.3% Tdap Immunization Percentage of patients 19-64 years of age with a Tdap vaccination 55.9% 55.7% 57.2% U/A 2.3% Data Source: Clinical Informatics and Analytics. Monthly Ambulatory Performance Reports. 2009-2014. Clinical Measures: NCQA. State of Health Care Quality, 2012; approved for use by Ambulatory Quality Committee. Baseline: Entries are means for all nine sites; snapshot taken 12 months prior to model transition. Reporting Periods: Do not equate to calendar years because of staggered site transition starting dates. HEDIS National Mean: NCQA. State of Health Care Quality, 2013; weighted per payment contribution within the nine sites; method approved by NCQA in 2010. % Change: the per cent change from baseline to YR 4 result.

Number of ED Visits Medical Home Impact on ED Utilization (All Patients with 1 or more ED Visits before Medical Home Engagement) 250 200 229 33% n = 139 150 153 55% 100 103 50 0 One Year Before Medical Home Engagement One Year After Medical Home Engagement Two Years After Medical Home Engagement Changes in ED Utilization After Medical Home Engagement (Year 1 vs. Baseline) # Pt's Decreased Utilization 93 66.9% # Pt's Increased Utilization 28 20.1% # Pt's No Change 18 12.9% Number of Patients 139 Changes in ED Utilization After Medical Home Engagement (Year 2 vs. Baseline) # Pt's Decreased Utilization 97 69.8% # Pt's Increased Utilization 13 9.4% # Pt's No Change 29 20.9% Number of Patients 139

UH Rainbow Care Connection Integration of Primary Care into a Pediatric ACO Todd J. Walker MBA Business Manager, Pediatric Clinical Integration and Accountable Care Rainbow Babies & Children s Hospital 2015 University Hospitals Health System, Inc.

Practice Integration Methods Medical Advisory Council Practice-tailored facilitation Clinical best practice toolkits CME and MOC events Integrated Behavioral Health Services Physician scorecards and practice rankings 2015 University Hospitals Health System, Inc.

UH RCC Provider Network 161 Pediatric Providers 60% UH, 40% Independent 32 Practices 51 Sites 2015 University Hospitals Health System, Inc.

Medical Advisory Council Early in the development of our ACO we created a Medical Advisory Council which supports physician involvement The council is comprised of one representative from each practice The council meets twice a year to offer feedback on our quality metrics We ask that the practices include their Office Managers in our meetings 2015 University Hospitals Health System, Inc.

Goal Triple Aim Outcomes Improve health of the population Enhance patient experience of care Reduce / Control per capita cost of care Payer Partners Insurers Employers States CMS 2015 University Hospitals Health System, Inc.

Practice Tailored Facilitation Practice facilitators Full office staff education Process re-design Performance feedback IT and data assistance Outreach and education 2015 University Hospitals Health System, Inc.

Practice Tailored Facilitation % of eligible children receiving targeted services 100 50 0 80 0 78 3 99 52 PBF Baseline PBF 4 month Fluoride Varnish BMI All HEDIS measures Lead screening 2015 University Hospitals Health System, Inc.

Practice Tailored Facilitation: Quality Year 1 Year 2 Year 3 Year 4 Fluoride Varnish Application Lead Screening Obesity Asthma Management Upper Respiratory Infection Well Child Care (3-6) Preferred Drug List Compliance Well Child Care (13-18) Pharyngitis Adolescent Vaccine ADHD Literacy Safe Sleep Habits Maternal Depression Early Childhood Education 2015 University Hospitals Health System, Inc.

Clinical Best Practices 2015 University Hospitals Health System, Inc.

Self-Monitoring Dashboards 2015 University Hospitals Health System, Inc.

CME & MOC Events Three times a year we release toolkits for the practices within our ACO on conditions such as : ADHD Asthma Headache Concussion We provide MOC credit for QA participation Evening CME events on best practices 2015 University Hospitals Health System, Inc.

Integrated Behavioral Health Office-based psychiatric SW PCP psychiatric telephone consults Access and referral programs ED crisis intervention SW 2015 University Hospitals Health System, Inc.

Physician Scorecards & Practice Rankings 2015 University Hospitals Health System, Inc.

Insights from Case Studies of Primary Care Transformation within ACOs James Colbert, MD Senior Medical Director, Verisk Health Consultant, ACO Learning Network, Brookings Instition Instructor in Medicine, Harvard Medical School

Physician-Led ACOs Current Issues Very little literature exists on implementation efforts leading to the success of physician-led ACOs A study released recently revealed common gaps in readiness of organizations to become successful ACOs: Lack of human and fiscal resources Few care management tools Underutilization of health information technology Communication challenges Lack of knowledge regarding quality performance measures Source: Steckler, Feldman and Watts. A Physician-led Accountable Care Organization: From Award to Implementation. American Journal of Managed Care September 24, 2015 37

Focus on Primary Care Transformation Primary care is central to the identity of a physician-led ACO Primary care + ACO = Success Mixed results from studies of financial return on investment for PCMH Yet, data suggest tying medical home to shared savings model may be a winning combination Brookings Institution Partnership with Patient-Centered Primary Care Collaborative PCPCC participated as reviewer for 2014 Brookings Institution ACO Implementation Guide Resulting discussions led to the idea of a collaboration between the ACO Learning Network and PCPCC 38

Primary Care Transformation within ACOs Building on work done for the physician-led ACO toolkit, the Brookings Institution s ACO Learning Network delved deeper into how ACOs are engaged in advancing primary care to identify best practices and lessons learned. Purpose To showcase examples of primary care transformation efforts that are taking place within accountable care arrangements Methods Stakeholder interviews Literature reviews Outcome A series of five case studies highlighting how ACOs are using advanced primary care approaches to achieve the goals of improved quality and reduced costs 39

Five Highlighted Organizations Adirondacks ACO - Northern New York Anne Arundel Medical Center - Eastern Maryland Bon Secours Medical Group - Virginia Hennepin County Medical Center Minnesota WellSpan - Pennsylvania 40

Common Themes Organizational Commitment to Primary Care Transformation: All five organizations had core commitment from leadership to support primary care innovation Many partnered with commercial payer to fund incentives for PCPs to improve quality Staffing Changes to Support Team-Based Primary Care: Medical assistants Data Analysts Dedicated RN Care Managers Health Coaches Pharmacists Behavioral Health Professionals Development of Care Management Programs: Models included embedded CM, home visits, call centers Assist with disease management, coordination of care, connections with community resources 41

Common Themes Implementing Transitions-of-Care Programs Successful discharge plan involves coordination of care between inpatient medical team and patient-centered medical home Elements include patient education, post-discharge phone call, visit with PCP Strategic use of Medicare TCM codes Provider Engagement Initiatives Importance of physician champions Helping clinicians to realize the value of care managers and physician extenders Collaborating around quality initiatives Gaining support of hospital partners and treating them as colleagues 42

Common Themes Engaging the Entire Team While strong physician leadership is necessary, it is not sufficient to truly transform care. Practice office staff support is integral. Building Health IT Infrastructure All organizations cited the need for improved health IT to enable population health management While many organizations initially used internal funds to improve health IT and data analytic capabilities, some also took advantage of external grants. Governance that Involves Clinicians, Patients, and Families Primary care clinicians as essential members of central leadership Patients and families should be active participants in governance 43

Policy Implications How should primary care delivery reform be funded? Commercial payers Large healthcare systems CMS Rethinking incentives for primary care practitioners Motivating providers to change practice patterns, implement team-based care How do we attract primary care team leaders? Support for primary care health IT and analytics Managing data is key to successful primary care and population health How best to integrate specialty care into the ACO Medical home neighborhood model Distributing shared savings to specialists 44