Transcript ACCOUNTABLE CARE ORGANIZATIONS

ALEGENT HEALTH PARTNERS
UniNet’s Systemic
Development Of an Accountable Care
Organization
What’s New and How to Adapt?
April 15, 2015
KEVIN NOHNER, MD, MBA
Medical Director Alegent Health Partners
“Change is the law of life, and
those who look only to the past or
present are certain to miss the
future”
John F. Kennedy
WHAT ON EARTH IS AN ACO?
 In simplest terms, it is a group of health care providers
organizing themselves into a team within an integrated
network to achieve three goals: improve quality,
enhance patient satisfaction, and maximize cost
efficiency of services to their patients. The “Triple
Aim”.
 This team does not just take care of illnesses; it is
accountable for the wellness of those they serve and
to act as stewards of how their healthcare dollar will
be spent most wisely
Other CMS ACO PROVISIONS:
 All Medicare patients are considered ACO members
except for those currently enrolled under a Medicare
Managed Care plan. The only “opting out” option is
whether the patient allows CMS to share their claims
data with the ACO, and few patients decline.
 Patients have unrestricted access to any practice or
hospital, and no referral process is necessary
 Physicians continue to submit claims and are still
reimbursed under current fee for service levels
 Participants must accept all patients, no “cherry
picking”
Who and What is Alegent Health
Partners (AHP)?
 In response to the anticipated changes in reimbursement
from the current fee for service (FFS) to a value based
model, UniNet applied and was approved as an ACO
provider with CMS under it’s shared savings plan and are
entering our third year. Current number of patients
assigned to our PCP members is ~ 23,350 covered lives.
 We have certified 7 Nursing Facilities and our Nursing
Home Network team provides management of care at sites
in Omaha, Lincoln utilizes a similar concept with their
Continuity of Care Team (ACP’s and Physician
“Transitionists”)
What are the advantages of contracting
with a Medicare Shared Savings Program
(MSSP) ACO?
 Since ACO providers still are paid at the same FFS rate
as a non-participant, there is little financial downside.
 In a “Shared Savings” model, if savings are achieved and
quality metrics goals are surpassed, some of those
savings are shared with the members
 An “At Risk” ACO model does exist, but few local
organizations have the infrastructure in place to
measure even the quality metrics—even fewer have the
capability of analyzing cost data and performance. For
now it is too risky of a proposition for Nebraskans—but
expect these contracts to appear soon.
Why the change from the volume based FFS
to a Value Based model? Increased healthcare
costs are outstripping our ability to afford
and access care!
These rising costs can have devastating
effects, and there is no reason to
believe financial stressors and access to
the healthcare system will improve:
 A 2007 study in the American Journal of Medicine linked
62% of personal bankruptcies to illness related expenses
 US Census Bureau data reported that the number of
uninsured Nebraskan’s younger than 65 had increased
from 8.9 to 34.9% in the 2000-2010 decade
 The estimated number of Medicare recipients is
projected to double to 80 million Seniors with the
retirement of the Baby Boomers by 2030
So how does UniNet plan to make the
necessary changes?
By adapting and transforming how we
provide patient care.
 Incorporation, Integration of Electronic Health
Records (EHR) by ACO participants and partners.
 Development of Healthcare Teams within each
practice working to the top of their licensure.
 Use of the EHR’s patient registries and claims
based data to monitor and improve quality, identify
and outreach to patients, and reduce expenses.
How to achieve expense reductions and
still have care improvement?
Work to reduce readmissions, ER visits,
excessive length of stay in hospitals or
SNF:
 Development of care transition models
 Close monitoring at times of transitions of
care, calling all patients within 2 days of
dismissal and making sure providers at the next
level are evaluating the change
 RECONCILE MEDS, RECONCILE MEDS!!!
UniNet’s Response: Create a Medical Home
 Transformation of 34 Alegent Creighton Health and 4
Independent PCP Clinics using Patient Centered Home
concepts
 Embedding of Ambulatory Care Coordinators in each Clinic to
do Health Coaching, facilitate access to community services,
monitor population health metrics and identify care
opportunities, and work with patients with chronic diseases
using evidence based guidelines.
 Work to develop an integrated network across the continuum
for transitions —from hospital to SNF to home, and ensure the
patients personal care plan follows and is communicated at
each level, to all providers
 Analyze claims based data from CMS using MedVentive
analytic software, creating utilization and efficiency profiles
for providers to improve quality and cost-efficiency
UniNet’s Response: Create a Medical Home
Neighborhood to access affordable services
 Ancillary service support provided to access services
 Pharmacy: Partnership with Creighton School of Pharmacy
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Medication reconciliation
Patient education
Medication Therapy Management
Medication Assistance Program
 Nutritional Consultants
 Obesity, diabetes, heart disease, etc.
 Social work support
 Community networks and governmental agencies
 Disease management services
 COPD
 Diabetes
 CHF
UniNet’s Care Transition Program
 All discharge calls are now performed by one group for
all 6 Metro hospitals, providing consistency and avoiding
duplicated calls
 Utilization of LACE scores to predict readmission risks

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Length of stay
Acuity of admission
Comorbidities
ER
 1-4 calls made to each patient, dependent on acuity
 Referral to Ambulatory Care Coordinator, PCP
So where do your Post-Acute
Healthcare Agencies fit in?
By collaborating and integrating with the ACO
Network, Post-Acute Care Providers are in
position to both improve patient care and help
ACO’s achieve their goals, a win-win-win
situation:
 By providing seamless care for patients based on what is
the best location /time for the patient (patient
centered)
 Decreasing the number of ER visits and hospital
readmissions through early intervention/notification of
PCP when problems arise
 Providing ongoing medication reconciliation and
education to improve patient compliance
…but to play an integral role within the ACO
Network, Post-Acute providers must be able
to:
 Communicate in an integrated manner electronically with
an ACO’s Ambulatory Care Coordinators, PCP’s, Inpatient Care
Managers, and SNF Transition Teams—with less reliance on
faxed messaging!
 Have secure on-site access to the internet, enabling
connection to the patients’ care plans to ensure continuity
 Provide 24/7 availability for home assessments and to accept
dismissals/transfers from inpatient and non-acute facilities
 Willingly monitor and report outcome and quality data,
manage ancillary services provided along with the costs of
those services
Suggested Core Criteria for SNF Participation in a
Clinically Integrated Network
Measure
Benchmark
 % of patients who would recommend SNF
> 85%
 All Cause 30 day readmission rate
< 10%
 All Cause 90 day readmission-Ortho
< 10 %
 ED visits within 72 hours of SNF transfer
< 10 %
 RN to patient ratio, 24/7
> 1 to 15
 Availability of SNF Admissions 7 days/week
> 12%
Suggested Core Criteria for SNF Participation in a
Clinically Integrated Network
Measure
Benchmark
 ALOS < 21 days
90%
 ALOS-Ortho < 21 days
90%
 MD visit scheduled within 7 days DC SNF
>75%
 BID therapy 7 days per week-Ortho
> 80%
 Therapy within 24 hrs after admission to SNF
> 80%
 Availability of IT infrastructure
100%
to enable integration
Why is that important to you?
 Hospitals are reimbursed under a DRG system by CMS. DRG
payments account for nearly 85% of their total inpatient
revenue. Trends point toward a similar DRG methodology for
post-acute care along with bundling of payments. Integration
and teamwork will not only improve patient care, it will help to
contain costs.
 Medication errors are a major cause of complications sending
patients to the ER and subsequent re-admissions. Attention paid
to medication reconciliation is a powerful tool.
 Future providers (hospitals, physicians, ACO’s, post-acute
caregivers) will be penalized if they exceed readmission
standards –e.g.—see ACO guidelines that follow.
 ACO’s will be monitoring SNF, Home health, PT, OT, and DME
services through claims data provided by CMS and through
patient satisfaction scores to direct their referrals—ultimately
avoiding providers who have inappropriate utilization (for both
over- and under-utilization) which might signify churning or
cutting corners
So, where do the patients go?
 Dismissals to the three main PAC settings (SNF,
HHC, and Hospice) represented 36.6% of total
dismissals and 84.5% of the PAC grouping last year
for Alegent
 Post-Acute (PAC) directed dismissals were
distributed to Skilled Nursing Facilities (SNF,
22.3%), Home Health Care (HHC, 10.9%), and
Hospice (3.4%)
 50.3% went Home without HHC involvement
Why is 7 day a week access for transitioning
patients so important?
Home Health Care
Day
Dismissed
# of Cases
% of Cases
Hospice
# of Cases
% of Cases
Sunday
56
6.7 %
9
3.0 %
Monday
156
18.6 %
44
14.8 %
Tuesday
125
14.9 %
45
15.2 %
Wednesday
137
16.4 %
58
19.5 %
Thursday
133
15.9 %
52
17.5 %
Friday
136
16.3 %
53
17.9 %
Saturday
94
11.2 %
56
12.2 %
837
100 %
297
100 %
Totals for 6
months
Hospital Dismissals by Day of the Week
Why is 7 day a week access for transitioning
patients so important?
Although seemingly a small thing, being able to go home or to
transfer on a weekend not only is in the best interest of the
patient, it prevents wasted resources. Providing 7 day a week
therapies can benefit patients and improve outcomes at an
overall reduction in costs.
By removing the incentive for providing volume of services, and
incentivizing those that are truly needed we can increase the
value of services we provide.
Collaboration/Integration will be necessary for survival in the
future and to become the “Post-acute Provider of Choice” in
an increasingly competitive market.
Sharing of both claims-based and quality data will be matched
with evidence based guidelines to identify outliers.
2015 CMS ACO MSSP Quality
Performance Standards
33 ACO metrics broken into 4 Domains
 Patient/Caregiver Experience-- 8 individual survey module
measures (1 New)
 Care Coordination/ Patient Safety--10 measures
(1 Removed, 5 New)
 Preventive Health-- 8 measures
(No Change)
 At-Risk Population-- 7 measures, including a new 2 component
diabetes composite measure
(5 Diabetes Metric Composite Removed, 1 New)
Patient/Caregiver Experience Domain
CMS CHAPS Survey
 ACO #1
Getting Timely Care, Appointments, and
Information
 ACO #2
How Well Your Doctors Communicate
 ACO #3
Patients’ Rating of Doctor
 ACO #4
Access to Specialists
 ACO #5
Health Promotion and Education
 ACO #6
Shared Decision Making
 ACO #7
Health Status/Functional Status
 ACO #34
Stewardship of Patient Resources (New)
Care Coordination/ Patient Safety Domain
 ACO #8
Risk Standardized, All Condition
Readmissions
 ACO #9
ASC Admissions: COPD or Asthma
in Older Adults
 ACO #10 ASC Admission: Heart Failure
 ACO #11 Percent of PCPs who met Meaningful Use
Requirements
 ACO #13 Screening for Future Fall Risk
Care Coordination/ Patient Safety Domain
• ACO #35 SNF 30 Day All-cause Readmissions
• ACO #36 All-cause Unplanned Admissions
with Diabetes
• ACO #37 All-cause Unplanned Admissions
with CHF
• ACO #38 All-cause Unplanned Admissions
with Multiple Chronic Conditions (MCC)
• ACO #39 Documentation of Current Medications
in Medical Record
Preventive Health Domain
 ACO #14
Influenza Immunization
 ACO #15
Pneumococcal Vaccination
 ACO #16
Adult BMI Screening and Follow-up
 ACO #17
Tobacco Use Screening and Cessation
Intervention
 ACO #18
Depression Screening and Follow-up
 ACO #19
Colorectal Cancer Screening
 ACO #20
Breast Cancer Screening
 ACO #21
Screening for High BP and Follow-up
At-Risk Population Domain
 ACO #27
 ACO #28
Percent of beneficiaries with diabetes whose
HbA1c in poor control (>9 percent)
Percent of beneficiaries with hypertension
whose BP < 140/90
(#27 and # 28 are scored as a composite with a
value equal to 1/7th of the Domain score)
 ACO #41
Diabetic Eye Exam
At-Risk Population Domain
 ACO #30
Percent of beneficiaries with IVD who use
Aspirin or other antithrombotic
 ACO #31
Beta-Blocker Therapy for Left Ventricular
Systolic Dysfunction (LVSD)
 ACO #33
ACE Inhibitor or ARB Therapy for Patients with CAD
and Diabetes and/or LVSD (LVEF < 40%)
 ACO #40
Depression Remission at 12 Months (New)
In Summary:
 Changes are coming!!
 Healthcare expenditures are not sustainable at
current rates of growth, we must find ways to
reduce costs
 We need to utilize technology as a resource to
improve the quality of our patients lives—both in
the care we provide and promotion of
safety/decrease in errors
 Development of care teams that are patient
focused will achieve greater improvements by
working together than in isolation, and the teams
must include all who provide care for that patient
We are the stewards of the
future healthcare
provided to our patients!