Transcript Dr. Steven Strongwater, Atrius Health, Morning Plenary

Transformation
Atrius Health
Steve Strongwater, MD
President & CEO
September 2016
CT Practice Transformation Network Congress
Atrius Health
Transforming care to improve lives
The Northeast’s largest nonprofit independent medical group recognized as a national leader in delivering highquality, patient-centered coordinated care.
Patients: Providing care for 675,000 adult and pediatric patients in
eastern Massachusetts
Medical Staff: 1300 clinicians, 750 physicians across 32 clinical
sites in over 35 specialties
Multi-Specialty Medical Groups:
Dedham Medical Associates, Granite Medical Group, Harvard
Vanguard Medical Associates
VNA Care Network Foundation: Home health, palliative care and
hospice, private duty nursing
Financial Performance: $1.9B annual revenue
Pioneer ACO
Quality scores ranked #1 in New
England and #3 nationally for 2014. Top
performer in 2015 ($6.8M savings)
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Rapid Transformation is Underway!
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What’s Next?
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Stages of Change
Cost Inefficiency In Healthcare
PriceWaterhouse
Coopers, $1.2T*
Institute of Medicine
$765B**
*Premier’s Waste Dashboard, 1/22/12
**IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously
learning health care in America. Washington, DC: The National Academies Press.
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Population Health
Advanced Illness. Top 2%
High Risk Poly. Chronic 3%
Rising Risk, next 15%
Risk Prevention & Reduction
Remaining 80%
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Tight coordination of 5% highest risk patients
Close medical management at end of life
Management of chronic conditions
Preventative care and risk reduction
Local Implementation
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•
Practices at different starting points.
Central support
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Top
5%
Keys to Success
Leadership and Facilitation
• Create data-based hypothesis
• Use evidence-based best
practices
• Develop standards & tools to
close care gaps
• Measure and track outcomes
• Fidelity to a process
Core Competencies
• Small teams with operational
credibility
• Diverse clinical expertise
• Shared resources brought
together (no silos)
• Med Home for shared values
• Exploratory mindset
• Laser focus on triple/quad aim
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Where to start…
High Effort
Low Effort
Low Reward
High Reward
Own hospitalists
Tele visits
NCQA PCMH Certification
1.
2.
3.
4.
Establish Medical Home
Reduce Clinical Variation
End of Life Care management
Integrated Primary/Specialty chronic disease
mgmt. including BH
5. Identifying Rising Risk Patients
6. Moving more care to the home
7. MIH
8. Home infusion
9. Hospital at Home
10. Referral management
1.
2.
3.
4.
5.
6.
7.
8.
Data Analytics to identify High Risk pts
Case Managers/facilitators
Pop Health facilitators
SNF’ists to reduce ALOS in SNF’s
Transitions of care managers to reduce
readmissions (remote and in EDs)
Expanded office hours (to accommodate
urgencies/convenience/access)
Identification and Management of preferred
vendors (SNF/DME/VNA)
MD compensation/incentives
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Target Unjustified Practice Variation
Commonly Overused Clinical Services
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MRI for low back pain
Imaging for headache
Nuclear stress tests
Serial PFTs for COPD
EGD for GERD
Arthroscopy
Pre-op evaluations
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Cancer screening for elderly
Vitamin D testing
Echo for benign murmurs
PSA testing
PAP smears
Mammography (?)
Derm referrals for moles
Non-generic drugs
And a lot more!
Low Value Care
28 low-value medical services cost $32.8 million for 1.46 M adults (2013) or 0.5% of total
spending for commercially insured or > $22 per person/year. N Sood, JAMA 2016
Target Unjustified Practice Variation
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Define best practice guidelines
Disseminate the evidence, existing guidelines
Data-sharing (performance) and facilitated conversations
Assure EMR support (alerts, order sets)
Align incentives (rewards and penalties)
Monitoring and feedback of data
Atrius Health Foundational Care Model
Strategy
• Roster Reviews. Multi-disciplinary, focused on cohort of medically complex patients
• Care facilitators & pop health managers who provide proactive highly integrated care &
outreach
• Integration with tertiary/specialty colleagues
Medically or psychosocially complex cohort
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Complex chronic disease
Multiple specialist involvement
Significant disability
Time and/or resource intensive families
Psychiatrically complex families
*Patients cross all payers and all sites
1.5 % of HVMA pts in Pediatrics
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ATRIUS HEALTH PC MEDICAID CARE MODEL
System
Case
Management
Population Health Management
Region
• Program
Development
• Oversight
Specialty
Leadership
Pediatric
Nurse Case
Management
•Peds
•IM/FM
•BH
Community
Health
Workers
Regional Leadership
Site
Site
Leadership
Triads
Peds
IM/FM
PCP Team
PCP Team
Care Facilitator
Population Manager
Ambulatory RN Case Manager
Shared Social Worker
Behavioral Health Triage
High Risk Patient Strategic Model
Community
Insurers
Case Management
Family
School
Ancillaries
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Skilled Nursing: - VNA, ECF
Therapies : - OT, PT, Speech, ABA
DME
DCF
Specialists
Medically
Complex
Patient
PCP
Hospital
Team
Care Facilitator
Dashboard
Management
Social Worker Assigned
CM Assessment
CM Enrolled
BH Contact
Roster Review
Care Plan
High Risk Patient Roster Review
Confirm diagnoses
Review medications
Address quality measures
Social assessment
Care needs assessment
PCP-Led Team
Advance directives
Palliative care discussion
Care plan documentation
& orders
Typical Participants
PCP
Primary Nurse or Medical Assistant
Population Manager
Care Manager
Geriatric Champion or Palliative Care Specialist
Social Worker
VNA representative
Clinical Pharmacist
“Each site may choose to have any
number or combination of participants
so long as the goals of high risk roster
reviews are being met.”
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Patient Care Checklist
For each….
• Review current state, best practices
• Choose an assessment tool, develop workflows
• Develop EMR tools and trackers
• Set targets
• Measure and track performance
©2015 Atrius Health, Inc. All rights reserved. Not for distribution.
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Depression Screen & Fall Risk Assessment
Reset FRA, PHQ Checklist
Implemented EMR checklist
Behavioral Health is essential to TME
management
©2015 Atrius Health, Inc. All rights reserved. Not for distribution.
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Roster Review. CKD Dashboard
Primary Care Dashboard: Merge of EPIC and Claims Data
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Lab Result Based Total CKD Population
Laboratory Screening (Ca, Phos, CBC, UA, Vit D, PTH)
Clinical Outcomes (BP, LDL, HgA1c)
Referral to Nephrologist Specialist
Visit to Nephrologist
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©2015 Atrius Health, Inc. All rights reserved. Not for distribution.
CKD Problem List Rates: Site
Transitions of Care. SNF Opportunities
• ↑Patient & provider satisfaction
• ↑ Clinical Outcomes
• ↓TME
“Outer Space”
Approx. 240 Facilities
ALOS: 22.3
Readmit rate: 10.9%
% of admits: 30%
# of admits: 1,023
TME per case $11,249
↓2.0 LOS = $2M
↓2% Readmit Rate = $ .5M
Preferred
Facilities
Facilities w Atrius
Clinicians
Facilities: 20
ALOS: 15.8
Readmit rate: 8.4%
% of admits: 30%
# of admits: 1,026
TME per Case:
$9,395
Facilities:16
ALOS: 13.9
Readmit rate: 8.3%
% of admits: 40%
# of admits: 1,380
TME per SNF Case: $7,624
Data is for TMP and Pioneer patients thru November 2014 and is for the three Atrius Health Moving
Forward practices; does not include Commercial insured patients)
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Choluteca Bridge
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APPENDIX
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TME Management
Acute
Illness
Healthy
• Prevention
• Referral
mgmt. &
triage
• Rx mgmt.
• Imaging
Utilization
mgmt.
• Preferred
ASC
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Urgent
Care
Telecom
Telemed
Mobile Int.
Health
IHB
PreHab to
Surg to
home
Self
directed
care
(rescue
kits)
Hospital
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•
•
•
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Avoidable
hospitalization
SNF waiver
Preferred
Hospitals
Integrated
protocols
Hosp @ Home
Case Mgmt.
Preferred VNAC
Recovery
• Preferred
SNFs
• VNA Care
Monitoring
Chronic
Illness
• Pop Health
Mgmt.
• Variation in
practice
• Care
Bundles
• Care gap
closure
• Active
monitoring
• EOL
planning
• MOLST
Actionable/ Real time data + Data analytics/ Forecasting tools
• The project described was supported by
Funding Opportunity Number#
1L1CMS331459-01-00 from the U.S.
Department of Health & Human Services,
Center for Medicare & Medicaid Services.
The contents provided are solely the
responsibility of the authors and do not
necessarily represent the official views of
HHS or any of its agencies.
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