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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
LafayetteGeneral.com
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
PayorContracts
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
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
Carilion Clinic
- efforts in population health
& accountable care
Michael P. Jeremiah, MD, FAAFP
Carilion Clinic1,026 Licensed Beds
49,000 Admissions877,000 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
AQC
Care
Transitions
Group
SNF
Collaboration
Taskforce Extensivist
Clinic
Tele-Health
ED Case
Management
Pay 4
Performance
TeamAdvance
Care
Planning
CHF
Transitional
Visits
Employee
Health Plan
Accountable Care
Transition Team
CCMH
Central Care
Coordination
DOCTORS CONNECTED
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 CareCarilion 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 ScreeningPercentage 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 VaccinationPercentage of patients >65 years of age
with a pneumococcal vaccination
67.6% 78.0% 80.0% 71.7% 18.3%
Tdap ImmunizationPercentage 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.
Medical Home Impact on ED Utilization(All Patients with 1 or more ED Visits before Medical Home Engagement)
n = 139229
153
103
0
50
100
150
200
250
One Year BeforeMedical HomeEngagement
One Year AfterMedical HomeEngagement
Two Years AfterMedical HomeEngagement
Nu
mb
er
of
ED V
isit
s
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
33%
55%
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
UH Rainbow Care Connection
Integration of Primary Care into a Pediatric ACO
Todd J. Walker MBABusiness 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
Payer Partners
► Insurers
► Employers
► States
► CMS
• Improve health of the population• Enhance patient experience of care• Reduce / Control per capita cost of care
© 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
0
80
3
78
52
99
0
100
PBF Baseline
PBF 4 month
BMI
All HEDIS
measures
% o
f elig
ible
child
ren r
eceiv
ing targ
ete
d s
erv
ices
Fluoride
Varnish
Lead
screening
50
0
80
3
78
52
99
0
100
PBF Baseline
PBF 4 month
BMI
All HEDIS
measures
% o
f elig
ible
child
ren r
eceiv
ing targ
ete
d s
erv
ices
Fluoride
Varnish
Lead
screening
50
© 2015 University Hospitals Health System, Inc.
Practice Tailored Facilitation:Quality
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
Year
1
Year
2
Year
3
Year
4
© 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.
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
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
37
Source: Steckler, Feldman and Watts. A Physician-led Accountable Care Organization: From Award to
Implementation. American Journal of Managed Care September 24, 2015
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
39
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
Five Highlighted Organizations
40
Adirondacks ACO - Northern New York
Anne Arundel Medical Center - Eastern Maryland
Bon Secours Medical Group - Virginia
Hennepin County Medical Center – Minnesota
WellSpan - Pennsylvania
Common Themes
41
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
Common Themes
42
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
Common Themes
43
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
Policy Implications
44
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
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