Transcript Bridges Health Payment Model

Comprehensive Complex Care
Model for Central Oregon
An Innovative Community Collaborative
Patient Story
Rebecca is a 53-year-old patient who moved to Prineville a few years ago. She came
to Mosaic with multiple medical issues including Type 2 diabetes, high blood pressure
and the effects from a debilitating stroke a few years ago. Additionally she had
severe social anxiety, depression and had made multiple suicide attempts.
Rebecca’s Mosaic provider began by sorting out her 28 medications and multiple
medical issues while a Community Health Worker (CHW) helped Rebecca start the
process to sign up for Medicaid. The CHW also started helping her look for housing
and furniture to go with it so she could get out of an unsupportive home situation.
Rebecca also started seeing the Mosaic behavioral health consultant for her anxiety
and depression. Additionally, the Mosaic RN Care Coordinator started checking in
with her monthly to help her manage her diabetes
With all these team efforts, Rebecca’s mental and physical health started improving
drastically. The behavioral health consultant and the CHW went so far as to work
with Rebecca’s new housing manager to help her keep a dog for mental health
support in her new apartment. Rebecca is also successfully checking her own blood
sugar for the first time in many years.
Central Oregon Complex Care Strategy –
Centered Around the Patient
Customized
Comprehensive
Eval
Team-based
Care
Proactive,
between
visit care
Shared
Action Plan
Pharmacy
Management
Community Collaborative
Actionable data
in the hands of
caregivers
Patient
Socio-behavioral Risk
Modification
Multi-faceted Approach
Transitions of
Care
Patient
Education
Specialist
Coordination
Nutrition
Counseling
Virtual
Visits
Developing a Complex Care Strategy:
Serving Rebecca, Addressing Community Opportunity
Healthcare Spend Limiting Resources:
Healthcare costs continue to increase;
reducing resources for education, housing,
security and other public services.
Unique Stakeholder Dialogue: Of the spend,
50% of the expenditures account for 5% of the
population. X percent of the spend is
considered “waste” or avoidable costs.
Common pain points and recognition of need
for sustainable economics has brought new
collaboration energy
Bridges Health
Opportunity to Catalyze: Catalyze
community partnership. Provide a starting
point for innovation: evolving central and
distributed complex care competencies
(hub and spoke)
Growing Evidence Base: Multiple initiatives
suggest significant outcome improvement
and cost reduction opportunity in focused
complex care center:
- High levels of quality outcomes – 90th percentile HEDIS measures,
improvement on chronic disease markers
- High levels of patient experience (CG-CAHPS), SF12
- 10-20% per capita spending below comparison group or regional
average
A Community Vision
Central Oregon
collaborating within the
existing strong
healthcare infrastructure
to develop innovative
care models to address
community-wide
challenges
Taking on the challenge
of complex care head
on – building an
integrated strategy to
better manage complex
(and costly) Medicare,
Medicaid, Commercial
and Uninsured
populations
Developing custom
solutions that facilitate
concentrated complex
care services and
community wide
distributed complex care
services
Part of a journey towards better health and sustainability for Central Oregon
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Bridges Health
Supporting Patients and Providers
Vision: World class complex care center coupled with strong distributed network of
services to provide community with comprehensive model
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Primary Care referral center for complex and intensive care (Ambulatory ICU):
Comprehensive care for patients including primary care, behavioral health, social
work, physical therapy, pain, nutrition, education, etc.
An “Innovation Hub”; Starting point for a robust community strategy: developing
workforce and competencies --- helping the medical groups build internal
competencies; delivering high dose of intervention in the central location, and
expanding to a distributed model
A Community Referral Point - Patients would be referred by their primary care
physician to seek care at the Complex Care Center – where they would meet a
physician and integrated team to address health (and life) needs. Strong
communication processes with the referring physician would be hardwired
Patient-led: A spirit of patient-centeredness would be embodied in the care model,
the staffing, cultural sensitivities. More formally, a patient advisory council is being
formed
The Basics
What: Develop a comprehensive complex care strategy, a component of which is a
dedicated outpatient complex care clinic called Bridges Health
When: Open Bridges Health in August 2013, with evolution of community distributed
complex care services between now and go live
Who: A community collaborative, with an investment from PacificSource and Mosaic as an
operating partner. Led by advisors to guide the innovation and spread.
How: Two pronged approach:
• Centralized: a center with physicians, nurses, health coaches, behavioral health
specialists, pharmacy, community health workers, and pain specialists providing
comprehensive complex care to 1600-2000 members of our community
• Distributed: provision of community resources to support complex care needs within
community practices in more dispersed geographic areas
Where: PacificSource Building, near the St Charles campus, directly above the St. Charles
Family Care clinic
Bridges Health Benefits for the Patient
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A dedicated Bridges Health team member to:
– Engage with the patient and support their care needs, concerns, answer
questions and provide education
– Support care and partner with the patient in providing comprehensive access to
meet their healthcare needs
– Facilitate and enable effective communication across the continuum for the
patient
– Be a health coach and guide the patient in meeting his/her goals, motivating the
patient to take steps towards improved health
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Additional team resources include behavioral health, pharmacy, pain management,
community health coaching, etc. – all with partnership with the Bridges Health Medical
Directors
24/7 access to Bridges Health team via phone, email or in person
Bridges Health enables an engaged community of family / caregivers
Holistic care that centers on bettering the patient as a whole – physical and mental
health, community resources, family services, etc.
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Provider Feedback From Initial Eligible Patient
Review
• High burden of clinical conditions
• Significant level of social and behavioral health challenges
• Claims review identifies frequent utilization unknown to PCP
• Significant gaps in care – especially Rx adherence
• Recognition that these patients are challenging and often not progressing in health –
however unclear pathway on how to change that paradigm
• Recognition that many identified patients have “stable chronic conditions”
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Key Success Elements
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Analytics – Data/Metrics – Targeted population
– Patients with persistent and Actionable disease, disease burden or
utilization pattern
– Opportunity for outcomes impact, meaningful patient service and financial
sustainability rests on identifying the right members; predictive model +
clinical intelligence rules + utilization triggers
Other Analytics – Data/Metrics
– Enhanced Data Transparency
– Robust evaluation of the model to understand effectiveness of model
Member Engagement
– Care model to “meet patients where they are”
• clear articulation of value; open access; superb service; “Surprise and
delight” elements, smooth transitions; no additional cost to member
– Primary referral source will be the patients’ community PCP; members
without PCPs may be invited in through other mechanisms
• PCP key referral source and most trusted relationship for most
patients.
• Strong communications key to transitions, co-management of patients
Essential Care Model Elements
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Complex Care Model
– Dedicated Team-Based Care:
• MD + Care Manager + Multi-disciplinary team
– Supervisit
• Initial visit sets shared trust
– Shared Action Plan
• Standard, active, dynamic document keeps everyone on same page
– Rules-based Proactive Care Management
• Ongoing proactive care partnership with patient
Bridges Health Payment Model
– Beyond Fee For Service Reimbursement at Center; Shared Incentive to
Community Providers
Community/Provider Partnership Development
– To facilitate transitions, appropriate use of community resources
Communications
– Thoughtfully developed patient communication materials to achieve
targeted enrollment in Bridges Health
Space Readiness: Design and Buildout
– Develop a patient centered space to achieve optimal patient engagement
Bridges Health Staffing Model
Dedicated Team:
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Bridges Health Medical Director
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Bridges Health Clinic Administrator
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1 Additional Physician
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1 Nurse Practitioner
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3 Care Managers
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4 Community Health Workers
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1 Administrative Assistant
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1 Receptionist
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Social Worker that can provide behavioral health services
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Additional Behavioral Health Specialist with prescribing capabilities
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Pharmacist
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Nutritionist
Bridges Health Patient Identification Process
PacificSource will use specific risk modeling tools to identify eligible Bridges Health
patients using claims data.
Patients will also be referred into Bridges Health by their primary care providers
using specific defined criteria or following a health event (e.g. hospitalization).
Specific variables for risk identification include:
• Diagnostic Criteria
– Comorbid Behavioral Health Accelerators
• Provider Referral
• Patient Wellness Assessments
• Truven Prospective Risk Scores
– Diagnostic detail
– Demographics
– Claims Experience
• Inpatient Experience
• ED Experience
Patient Engagement Process
Patient is identified for opportunity with Bridges Health
information communicated with PCP
PCP refers patient to have a Supervisit at Bridges Health
Patient visits Bridges Health for Supervisit
Bridges Health team reaches out to PCP team before and after visit to align care
Patient receives care with Bridges Health as a specialty resource, ultimately
graduating in most cases upon reaching strong self-management
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Supervisit Philosophy
A key success element for Bridges Health is the initial patient onboarding and first visit with the Care Coordinator, Bridges Health
Medical Director and the Patient
• Provides an opportunity for MD, Care Coordinator and patient to share trust
• Provides platform for deeply assessing patient’s health and multi-domain
assessment of life challenges getting in the way of achieving optimal health
• Enables start of Action Plan
• Allows for longer face-to-face time, which later facilitates email and
telephonic interactions
• Provides (and forces) an intentional, structured opportunity to discuss many
of the patient’s goals/concerns
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Supervisit Timeline - Intensivist Model
Pre-visit
planning
15-20 min
Care Coordinator, Intensivist
and Patient visit
45-60 min
Care
Coord Patient
end visit
15-20 min
Total Time = ~ 1hour and 30 minutes
Patient Time: 60 minutes
Care Coordinator Time: ~90 minutes
Intensivist Time: 45-60 minutes
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Domains for Assessment
A critical goal of the Supervisit is to evaluate the patient for areas of
risk, so that you may over time together develop actions steps to
address risks.
Examples of risk areas include:
1.
Medical Risk Domains – Complexity of disease, complexity of
treatment, unstable disease, etc.
2.
Behavioral Risk Domains
3.
Social Risk Domains
4.
Utilization/Access Risk Domains
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Functioning Risks: Physical Functioning Risks
6.
Self-efficacy, Confidence Risks (including an assessment of Patient
Activation)
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Different Models that Lift from Supervisit
Patient visits Bridges Health for Supervisit
Comprehensive multi-domain assessment identifies domains of risk and
opportunity
Bend patients go to Bridges Health, patients geographically further dispersed
patients go to distributed model, other PS program or continues with PCP
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Bridges and Referring PCP Have Close
Communication Channels
The Bridges Health team serves as a referral extension to the
community PCP. As such – the Bridges Health team commits to
regular communication and updates to the referring PCP, and also
will look for input and feedback from the referring PCP as the
patient receives care at Bridges.
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Template Referral tool and process
Pre-Supervisit planning agenda
Post-Supervisit communication
Shared Action Plan
Ongoing structured communication
Graduation templated communication
Open access for discussion
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Economics of Complex Care Model
Assumptions
1. Current Annual
Medical Expense for
target population
2. Payor Mix
3. Total Spend for
2,000 Patients in
Complex Care Model
4. Avg. Annual Clinic
Subsidy over 5 years
5. Cost Savings to
Achieve Breakeven
Commercial
$21,410
Medicaid
$16,470
MCR
$45,226
Average
$25,000
Uninsured
5%
Commercial
5%
Medicaid
60%
Medicare
30%
$40 Million
$1.25 Million
3.1%
Where the Savings Accrue
Assumptions
1. Current Annual
Medical Expense for
target population
2. Payor Mix
Commercial
$21,410
Medicaid
$16,470
MCR
$45,226
Average
$25,000
Uninsured
5%
Commercial
5%
Medicaid
60%
Medicare
30%
3. Total Spend for 2,000
Patients in Complex
Care Model
$40 Million
Modeling savings: 600 Medicare members in complex care
Category
Medical Spend (PMPM)
PMPM Savings at 10%
Annual Savings per 600 Members
% of Total Savings
IP Hosp
$ 1,930.00
$193.00
$1,389,600.00
52%
OP Hosp
$399.00
$39.90
$287,280.00
11%
ER
$31.00
$3.10
$22,320.00
1%
Physician
$722.00
$72.20
$519,840.00
19%
RX
$376.00
$37.60
$270,720.00
10%
Other
$285.00
$28.50
$205,200.00
8%
Total
$3,743.00
$2,694,960.00
100%
Complex Care Model
PCP Level Economics for Referrals to Complex Care
FFS Revenue Shift
PSHP Medicare
Top 10%
PSHP Commercial
Top 10%
PSHP Medicaid
Top 10%
$30 PMPM
PCP Practice
Risk Model Economics*
• 5% savings on 1600 Complex Patients =
$2M
• 10% Savings = $2M
• 5% Savings Spread among 400 COIPA
Providers = $5,000/pt.
• 10% = $10,000/pt.
• Payor Mix 60% Medicaid/30% Medicare/
10% Commercial
• $45 PMPM revenue shift
•$540 Annual revenue loss
Estimated return to PCP per patient referral:*
9:1 to 18:1
*Assumes minimum medical loss ratio targets are achieved during contract year
Impact on PCP office
Soft Costs Avoided
• Front office burden
• No show rate and
noncompliance
• Frequent Rx refills and
other requests
• Staff burnout
• Narcotic management