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St. Vincent’s Health Partners, Inc.Dr. Michael G. Hunt
CMO/CMIOBridgeport, CT 06606
(203) [email protected]
http://stvincentshealthpartners.org
Medical Management/Population Medical Management/Population
Health: Making it OperationalHealth: Making it Operational
Accountable Care Congress 2014
mailto:[email protected]
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2
California Healthcare
Foundationhttp://www.chcf.org/publications/2013/09/data-viz-hcc-national
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3Kaiseredu.org
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4
From the Institute of Medicine September 2012
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5
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6
Institute of
Medicinehttp://resources.iom.edu/widgets/vsrt/healthcare-
waste.html
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7
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A PHO is a legal entity generally formed by physicians and one
or more hospitals with the intention of
negotiating contracts with payers and sharing in the financial
rewards of controlling costs while delivering
high-quality care.
8
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An active and ongoing program to evaluate and modify practice
patterns by the network’s physician participants and create a high
degree of interdependence and cooperation among the physicians to
control costs and ensure quality.The coordination of patient care
across conditions, providers, settings, and time to achieve care
that is safe, effective, efficient, and patient focused.
This may include:
Establishing mechanisms to monitor and control utilization of
health care services that are designed to control costs and assure
quality of care
Selectively choosing network physicians who can further
efficiency objectives
Investing in physical and human capital to develop
infrastructure capable of realizing the claimed efficiencies
Source: FTC/DOJ ‐
Statements of Antitrust Enforcement Policy,
1996
9
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URAC’s clinical integration standards provide the key components
that providers can follow to develop clinical and financial
integration.URAC’s Clinical Integration Accreditation program
aligns to Federal Trade Commission antitrust guidelines for
ensuring that providers collectively collaborate to improve patient
care and control/contain cost.By earning URAC accreditation,
providers within clinically integrated networks demonstrate they
are improving quality and patient outcomes, setting the framework
to seek incentive-based payments.
10
1996 Department of Justice (DOJ) and Federal Trade Commission
(FTC) Statements of Antitrust Enforcement Policy in Health Care
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• First organization in the country to receive URAC
accreditation for Clinical Integration
• Perfect score on all elements
• Leading the industry and setting the bar for the
competition
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Source: Harold Miller: How to Create Accountable Care Organizations, 2009
12
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SVHPSVHPSVHP
HospitalsHospitalsSkilled Nursing
Facilities / Rehab /
HHC
Skilled Nursing
Facilities / Rehab /
HHC
PCPsPCPs SpecialistsSpecialists
Hospital
Member(s)
Hospital
Member(s)
Physician
Members
Physician
Members
1 Flagship Hospital – St. Vincent’s Medical Center370 Providers
(Physicians, PAs, and APRNs)52 Offices40+ Specialties
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Service◦
Provision of medical care from a provider/facility directly to
the patient◦
Managing all elements of individual patient care
Management◦
Population Health◦
Defining the operational roles of care coordination (Enterprise
Level)◦
Defining the operational role of case management (Facility
Level)
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Inpatient◦
Readmission rates◦
Medication reconciliation◦
Care coordinationOutpatient◦
Preventive HealthWellness examsImmunizationsMammograms/pap
smears
◦
Chronic diseaseDiabetesCHFAsthma/COPD
15
InpatientLength of stayAntibiotic usageBlood
products/transfusions
OutpatientInappropriate ER useInappropriate advanced
radiologyCosts PMPM for ED, pharmacy, inpatient, outpatient,
radiologyAmbulatory Sensitive Conditions
ER and inpatient
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16
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17
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18
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19
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20
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22
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Provide care coordination services across the clinically
integrated network that complement the existing case management
services, such as:◦
Identifying gaps in care and transition◦
Empowering the use of evidenced based care◦
Developing processes across the continuum for seamless care
transition
The SVHP Playbook◦
Identified 140+ care transitions and established baseline
requirements for data portability
◦
Details quality metrics agnostic to Payer◦
Reference for Care Guidelines – Preventative and disease
management
◦
Organizational polices and plans
23
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The Goal – Meet patient needs and preferences in delivery of
high-quality, high-value careThe Process – Bridging the gaps
between◦
Primary Care ◦
Specialty care◦
Hospital based (ED, IP, OP)◦
Mental Health Services◦
Skilled Nursing Facilities◦
Long-term Care◦
Home Health Care ◦
Medical History◦
Test results◦
Care Givers (Family education support, formal and informal)◦
Medication/Pharmacy◦
Community resources
24
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25
Source: Navigant Consulting
Hospital Disaggregation Risks
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Practice Management System Claims DataMSG - SVMCUCC –
SVMCGoldfarb Ranno & Assoc.Allergy & Asthma Care,
LLCPulmonary & Internal MedicinePrimary Care of
SheltonEndocrine Associates, LLCEhrlich BariatricsOpthalmic
Consultants of ConnecticutFamily Podiatry CenterDr. Reuvin
RudichDr. R. Levin & Dr. L. Fliegelman
McKesson Population Manager –
SaaS/Cloud
Secure File Transfer Protocol (SFTP) Claims Feed
Quest Diagnostics
HL7 Interface Results Feed
Clinical Lab Partners
.CSV Results File Upload
Physician Quality ReportingPoint of Care Technology (Future)
Physician Offices
Physician Hospital Organization (PHO)
&
PHO Hospital Partner
26
Data SourcesData Sources
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27
Data Types◦
Labs not based on LOINCNeed for mapping between
organizations
◦
Data ReceptivityFormat – HL7, CCDA, Flat File
Transitions Team◦
Members of SNF, Home Health, Pharmacy◦
Patient transitions and patient-specific information
transfer◦
Communication (patient and
professional)Intra-organizationExtra-institution
PHO member priorities◦
Technology PHO versus member needs (EMR, Data Warehouse
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28
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• Manage cost and utilization•
Manage practice pattern
variation
• Identify high‐risk patients•
Identify and manage
network leakage
• Model and manage
incentives programs
• Manage drug spend
•
Provider‐oriented assessment & care planning•
Manage patients and care holistically •
Managing complex, chronic patients•
Blended case management & disease‐specific
assessments
• Readmission reduction •
Transitions management
• Enterprise patient registry•
Aggregate clinical data from
multiple settings
• Close gaps in care•
Enable care coordination•
Reduce variation in care
delivery
• Support Clinically
Integrated Networks
ICD/CPT/Lab/Rx/EHR Claims/CPT/Lab/Rx/EHR
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35
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36
SmartHealth
Queue: Attribution Data
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37
SmartHealth
Queue: Rx Data
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38
Low Risk High Risk
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Secure Message all reports electronically◦
Allows onsite staff to “handle” data at highest skill
On-site data review and collaboration◦
Review of complex patient cases◦
Review dashboards/report cards◦
Investigate and solve barriers
Continuous communication for high profile patients◦
ED and inpatient admission
All inpatient discharges followed-up within 7 daysHigh risk ED
discharges followed-up within 14 daysHigh readmission
riskUtilization
39
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40
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• Focus on:• Preventive work• Focus on establishing a PCP and
building relationships• Promoting healthy habits• Health
education
• Majority of patients will fall into this category
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• Focus on:• Disease/Condition Education• Ensuring proper
testing and follow-up work
• i.e. Quarterly A1c testing for diabetics with poor control•
Care Coordination across a handful of settings/providers
• Between 15-25% of patient population
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• Focus on:• Intensive case management• Coordinating care across
several providers/settings• Managing ED utilization•
Disease/Condition management
• Between 5-10% of patient population
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Oct 13 Apr 14 Jul 14
Acute and chronic
31.60 26.00 46.00
Improvement 40.00 40.00 50.00
Preventive Care
56.67 66.67 56.67
Utilization Metrics
43.98 48.35 47.42
49
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