TRANSITIONING CARE TO AN INTENSIVE OUTPATIENT CARE … · CBO 2018 Infographic Innovation Care Partners –Confidential Information 3 Healthcare is 25% of the Federal ... Mobile Physician

Innovation Care Partners – Confidential Information

TRANSITIONING CARE TO AN INTENSIVE OUTPATIENT

CARE NETWORK:

TOOLS AND TACTICS

Karen R Vanaskie DNP, MSN, RN

Chief Clinical Officer Innovation Care Partners

March 9, 2019

Innovation Care Partners – Confidential Information 2

Introduction

• This session will cover:

- Best practices in transitioning care from inpatient to outpatient setting.

- Successful program model

- Communication platform between transition and care coordination

- Post Acute networks role

oBPCI-A

- Outcomes

2

Innovation Care Partners – Confidential Information 3CBO 2018 Infographic

Healthcare is 25% of the Federal

Budget


Employer and

Employee

Costs Rising

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits


Healthcare Costs in the Elderly Drive US

Costs

http://blogs-images.forbes.com/danmunro/files/2014/04/hccostsbyage.png

Hagist; Kotlikoff. Working Paper 11833 National Bureau of Economic Research Dec 2005

Fischbeck, Paul. "US-Europe Comparisons of Health Risk for Specific Gender-Age Groups.” Carnegie Mellon University: September 2009

http://blogs-images.forbes.com/danmunro/files/2014/04/hccostsbyage.png


What is Innovation Care Partners (ICP)?

• CI - Legal mechanism that allows practices to remain independent but work together to provide coordinated quality care

• MSSP – Participant in CMS Medicare Shared Savings Program

Clinical Integration (CI) and Accountable Care Organizations (ACO)

HonorHealth

Innovation

Care Partners

Scottsdale Health

Partners MSSP

Commercial and

Medicare Advantage Plans

Wholly owned

Innovation

Physician

Organization (IPO)

Physicians must be

members of IPO

to participate in ICP


Innovation Care Partners Strategic Framework


Innovation Care Partners is Physician Driven

ICP Board of Managers

Physician Chair

Operations, Finance,

Contracting

Physician Chair

Quality

Physician Chair

Clinical

Physician Chair

IT

Physician Chair

Membership

Physician Chair

Executive Committee

Physician Chair

Over 90% of Committee Members are Physicians


Multiple Value Based Products

• Medicare

- MSSP

- MA (BlueCross, Humana, UnitedHealthcare)

• Commercial

- Banner|Aetna, Cigna, HonorHeath Employee Plan

• Marketplace

- Oscar Health

• AHCCCS(Medicaid)

- UnitedHealthcare Community


101,000 covered lives

0

20,000

40,000

60,000

80,000

100,000

120,000

21,90223,672 23,938

26,15930,355 31,427

34,25936,933

39,09442,623

60,076

70,087

81,322

85,743 86,90090,475

96,76499,102 100,264 100,848

2014Q1 2014Q2 2014Q3 2014Q4 2015Q1 2015Q2 2015Q3 2015Q4 2016 Q1 2016Q2 2016Q3 2016Q4 2017Q1 2017Q2 2017Q3 2017Q4 2018Q1 2018Q2 2018Q3 2018Q4

Patient Volume Growth > 10%


ICP Physician Membership

Physician

TypeTotal

Family Medicine 218

Internal Medicine 45

Pediatricians 27

PCP Total 290

Specialist Total 1,567

Grand Total 1,857

Pending Total 50

Allergy 15

Anesthesiology 134

Bariatrics 4

Breast Surgery 22

Cardiac Electrophysiology 8

Cardiology 82

Cardiovascular Surgery 7

Colon and Rectal Surgery 4

Dermatology 39

Ear, Nose & Throat 22

Emergency Medicine 139

Endocrinology 22

Fertility 6

Gastroenterology 43

General Surgery 40

General Surgery/Trauma-Crit 2

Gynecologic Oncology 8

Hand Surgery 19

Hematology-Oncology 65

Hospitalists 96

Intensivists 6

Nephrology 82

Neuro-hospitalist 2

Neurology 27

OB/GYN 39

OB/GYN-Perinatal 2

Oncology – Clinical Trials 8

Ophthalmology 67

Oral Surgery 3

Orthopedic Surgeon 128

Pain Management 39

Physical Medicine and Rehab 10

Plastic Surgery 14

Podiatry 39

Pulmonary-Critical Care 15

Pulmonology 24

Radiation-Oncology 27

Radiology 76

Rheumatology 3

Urology 73

Vascular Surgery 6

Other 100


ICP is a Pluralistic ACO

• ~ 400 health system employed physicians

• ~ 1400 independent private practice physicians

• ~ 58 health system employed practices

• ~ 403 independent private practices

• > 60 different EMRs

• Most EMRs not yet integrated into ICP’s private health

information exchange


PCP Practice Meetings

Inserts

Citizenship Metrics

Medication

Substitution Lists

RAF & Data Gap

Initiatives

MSSP

Communications

MSSP Measures

MSSP Quality

Scores


Innovation Care Partners - What We Do

1. Engage Physicians

2. Care Coordination and Transitional Care

Management

3. Improve access to data for clinicians

4. Improve provider communications and coordination

5. Manage the health of our populationLeads to…

• Improved quality

• Reduced cost

• Improved patient satisfaction


ICP TECHNOLOGY 101Creating the future of healthcare


Core ICP Technologies

Innovation Care Partners Technologies

“Innovation Exchange”Health Information Exchange

By Orion Health

Reference

Labs

Community

Practice

AEMRs

Labs

Payers

Home Health

Cardiology

HonorHealth

Hospitals

SMIL

ED

Radiology

HonorHealth

ICP / Community

Care

Managers –Risk Management Analytics

By McKesson

Provider Portal

By Orion Health

Secure Text

By TigerText

eReferrals

By par8o

Community

Practice

AEMRs

Community

Practice

AEMRs

Community

Practice

EMRs

Quality Exchange Care Coordinate

ICPHealth.com

Public Website

ICPHealth.net

Physician Website

ICPPatients.com

Prior Auth Website


Data in Innovation Exchange

• AZHeC

integration

coming soon

• Adding more

practice

EMRs

• Surrounding

state

controlled

substances

coming soon

Transcribed Reports

Lab Results

Radiology Reports

RadiologyImages

Encounter Events

Patient Demo’s

Vitals Immun.Controlled Substances

East Hospitals

1/12 1/12 1/12 1/12 1/12 10/15

West Hospitals10/16 10/16 10/16 10/16 10/16 10/16

Medical Group - East 1/12 1/12 1/14 10/15

Medical Group – West 10/16 10/16 10/16 10/15

1/12 10/15 1/12 1/12

6/17 6/17 6/17

6/17 6/17 6/17

12/14

1/12

Arizona Controlled S Substances 9/16


Innovation Exchange

• Robust private health

information exchange

• Easy to use

• Longitudinal patient

record combining

patient data from

multiple disparate

sources


Controlled Substances Search


Innovation Exchange Patient Searches

Over 14,000 patient searches per month!


Reporting and Research

• Example Reports

- Inpatient Pharmaceutical Costs

- Patient-Providers Heat Map

Visualizations

- Specialist Network Utilization

and Cost Dashboards

- Interactive ICP Cost and

Utilization Dashboards by Payer


What data is in Risk Manager?

• Finalized, post adjudicated claims data

- Includes all claims for a patient population for a given payer

• HL7 Lab data from the HIE (Health Information Exchange) –

known as Innovation Exchange

• Payer Data in RM:

- Medicare:

oSHP MSSP (CMS-Fee for Service {FFS})

o JCL ACO MSSP (CMS-FFS)

oBCBS – Medicare Advantage (MA)

oHumana – MA

- Commercial:

oHonorHealth Employee Plan (HHEP)


What is Risk Manager?

• Risk Manager (RM) is a software and data warehousing service that

Change Healthcare provides to ICP

• Risk Manager is used for:

- Reporting

o Emergency Room Utilization

o Patient Risk

o Pharmaceutical Utilization (Brand vs. Generic)

o Detailed Patient Level reports (SmartViews)

o Data cubes to provide insight into utilization and cost

o Dashboards to review network performance overall and at the practice and provider levels

- Data warehousing

o The data warehouse (DDW) contains all our payer claims data in organized fashion for

customized reporting (Using SAS or SQL programs)

- Attribution for HHEP


Example Dashboard


Referral Management

par8o will be a mandatory technology in July, 2018

• ICP has used Crimson Medical Referrals since

2012

• ABC changed their strategy so the

product/service no longer meet ICP’s needs


Care Compass – Search Results

• Specialist closest to your

patient, that accept their

insurance appear first

• Enhanced features include the

ability to rank specialist based

on our networks needs and

goals;

- Including their response rate

to referrals

- Scheduling within urgency

- Being active online vs. fax


Secure Text Messaging

Vendor: TigerConnect

Time to Implement: 1 month

Go-Live: March, 2013

Purpose: Secure provider to

provider, asynchronous

text messaging

Users: Over 2,756 users and

counting


Secure Text Messaging Adoption and UseOver 50,000 Messages Per Month!


CARE MANAGEMENT

PROGRAM


Cost Strategies Across the Population Pyramid

• Highest Risk Patients (5% of population but 50% of cost; Multiple simultaneous

illnesses and socio economic barriers)

- Care coordination across continuum

- Address psychosocial issues with medical issues

- High touch, high continuity care

• Medium Risk Patients (40% of the population, 40% of cost & Single stable

chronic conditions and acute illness)

- Reduce variation using- Evidence based medicine & Effective Team

Based Care

• Low Risk (55% of population, 10% of cost)

- Wellness and prevention and minor acute illness


Central Care Management Department

Innovation Care Partners

Care Management Model

Honor Health Hospitals:

• Shea

• Osborn

• Thompson Peak,

• North Mountain

• Deer Valley

MD

MD

MD

Payor

Services &

Programs

MDMD

Transitional

Care Manager

Care

Coordinator

Care

Coordinator

Care

Coordinator

Post- Acute

Transitional

Care Manager

Medical

Management

Program


ED

Inpt

SNFOutPt

Home


Care Management Programs

Transitional Care Management

(Hospital/Post-Acute Setting)

• Available for ICP physicians/patients

• Assist with the transitional needs of ICP patients in the

hospital

• ICP Notification of admission, discharge, and emergency

room visits

• Focus on maintaining clear communication to primary care

physician about treatment plan

• Leverages TigerConnect and Innovation Exchange to

communicate across the continuum of care


Real-Time Secure Smart Phone Notifications

HonorHealthICP / Community

ADT

Messages

Scrubbed

Notifications

EHRs

HonorHealth

CDR EMPI

Integration

Engine

ICP CareConnect

A patient for whom you are

recorded as Ordering MD and

Primary Care Provider has

had

recent activity sent to ICP

CareConnect.

Bob SMITH (unique identifier

00011111111) was admitted as

an inpatient with the MED

specialty a facility SHC (ward

SHC) on May 30, 2015.

Hospital: Shea

Room: 2412

Bed: 1

Challenges:

- Redundant ADT

messages sent for

each admission

- PCP data is

manually entered


Post Acute SpectrumA Variety of Services Form the Post-Acute Care Spectrum

ICP uses a Vetting Process focused on:

• Strong Quality Record

• Ease of Transition to Facility

• Highly collaborative relationship building

• Prepared for a truly innovative and integrated delivery system

• Efficient care/services delivered

In-Home

Care

Mobile

Physician


Preferred Post-Acute Engagement Process

1 2

Meet

and Test

o ICP CM team met to

review services,

programs, etc.

o ICP CM Team test

service delivery on

current cases

Discussion with ICP

Physicians Covering

• Onsite visit

Determine Preferential

Relationships thru ICP

Council

o Post-Acute entities sign

ICP Post-Acute Care

Coordination

Agreement

o Sign agreement to

communicate with

TigerText

3 4

Performance

Data Review

o Send survey to ICP

physicians

o Quality data assessment

on facilities (CMS

reported)

o Obtain performance

feedback from ICP

contracted payers

5

Ongoing Collaboration

o JOC – quarterly

o Vendor fair

Evolution of Emergency Care

In-home care delivery addresses the:

• Healthcare needs of the on-demand

consumer

• Access challenges of at-risk patients

• Requirement to extend the reach of

traditional ER in order to provide higher

acuity and better value care than

competitors

• Need to maintain a patient within a

network of services and providers


The Evolution of Bundled Payment Programs

BPCI Advanced aims to build upon knowledge gained under the BPCI

program to further improve the efficiency and quality of patient care.

BPCI BPCI Advanced

Participation Voluntary Voluntary

Episode Initiators Hospitals, Physician Groups, Post-Acute Hospitals and Physician Groups

Bundles 48 Inpatient29 Inpatient,

3 Outpatient

Pricing Retrospective Prospective

Reconciliation Quarterly Semi-annually

CMS Discount 2% 3%

Quality No formal quality component Quality affects payment amount

MACRA Status No Advanced APM Status Advanced APM

Innovation Care Partners – Confidential Information|

Levers for Success in BPCI AdvancedRemedy incorporates the four care redesign levers that are critical

for success in bundled payment programs.

39

1. Next Site of Care Optimizing utilization of appropriate care setting

2. Performance NetworksUtilizing top performing SNF/HHA

providers in your market

3. SNF Length of Stay Optimizing length of stay based on

patient needs

4. ReadmissionsPreventing readmissions through

proactive care management


From the time of admission, what can be done to ensure a patient can transition to

home for recovery?

Physician• Guide clinical plan of care

• Lead NSOC discussion

Patient/Family/Caregivers

• Identifying goals of care and “What

Matters to Them”

• Identifying concerns and needs

• Recovery at Home

Nursing• Assessing, planning, implementing

nursing plan of care and patient

stated goals

• Establish early mobility plan

Therapy• Assessing, planning and

implementing therapy functional plan

of care and patient stated goals

40

Entire Clinical Team• Establish and monitor progress of

clinical plan of care

• Patient engagement, i.e., “What matters most”

to the patient

• Communicate early and often with patient/

family/ caregivers

• Discuss, review and refine next site of care

plan early and often

• Identify and address risks for readmission

• Educate patients/ families/ caregivers

Refocusing the Efforts of the Interdisciplinary Team

Care Management• Identify clinical needs, services for

recovery and transition planning

• Identify and develop the “capable caregiver”

knowledge and confidence

• Identify formal and informal community

support services

• Align and optimize financial resources


Skilled Nursing Facilities

1. Assign a SNF Designee

2. Utilize ELOS guidelines -Set tentative DC dates upon admission.

3. Involve Home Health Agency Early

4. Utilize evidence-based readmission reduction protocols

5. Perform Root Cause Analyses

6. Conduct Early Initial Discharge Planning Discussions– Identify potential discharge challenges and

set LOS expectations with patient and family within 72 hours of admission to the center

7. Collaborate on Utilization Review (UR)

8. Share Clinical Information – Update the Partner(s) on patient progress toward DC planning goals

9. Actively Communicate Challenges

10. Share Outcomes Data and Quality Measures – Including current readmission, LOS metrics and

others as appropriate.

11. Communicate Clinical and Operational Capabilities and Challenges


Benefits of a Home Recovery

Lower risk of complications• Less likely to develop infections or delirium

• Lower risk of falls and of being readmitted

Better patient satisfaction• More private, quiet, and familiar environment

• Better access to friends and family

More judicious use of Medicare benefit• Save SNF days for when they’re really necessary

• Once benefit is used, patient must pay out of

pocket

Faster recovery,

better long term

outcomes and

happier,

healthier, more

secure patients.

42


Home Health Care Roles & Responsibilities

1. Ensure a smooth Post-Acute Care Transition

2. Start of care within 24 hours of discharge

3. Provide daily encounters for the first three days (visits or phone)

4. Primary Physician appointment within 5 days of discharge

5. Arrange Social Work patient visit within 1 week of admission to services

6. Assess risk of readmission upon admission and implement intervention protocol based on

risk score utilizing evidence-based practices


Readmission Prevention


Care Management Programs

Comprehensive Care Coordination ICCC)

(PCP Office Setting)

• Intensive outpatient care program using well trained care

manager embedded in a high – performing primary care team

• Based on IOCP Model testing at Boeing, PBGH, CMMI

• Creates close relationships with medically complex patients

and delivers highly individualized and accessible primary

care

• Develops a patient-specific, goal orientated treatment plan

• Geared to use mostly MA level staff to economically reach

more people with the same budget

• Power by ICP CareCoordinate


PBGH / CMMI Grant Results on Health Status:

15,000 Medicare Beneficiaries Across Western US

• 3.6% increase in patient engagement (PAM)

• 33% improvement in depression symptoms (PHQ 9)

• 3.4% improvement in mental health functioning (VR 12)

• 4.1% improvement in physical health (VR 12)

21% reduction in total cost of care for high risk patients over a 18

month period of time starting 1 month after enrollment

55% decrease in emergency department visits from the quarter

before a patient entered IOCP to the third quarter a patient was

enrolled in IOCP.


Comprehensive Care Coordination

• Primary care based for predicted moderate to high risk patients

• Specially trained care coordinators

- Behavioral modification interviewing

- “Supervisit” process

- Medication Management

- Assessment tools:

o SF-12 (VR-12) – measure health related quality of life and estimated disease burden

o PAM - tool that measure patients engagement in their health care (Levels 1-4)

o PHQ–2 & PHQ-9 – tool used to screen, diagnose, monitor, & measure severity of

depression

• Mutually agreed upon “Shared Action Plan”

• High level (face to face) contact with patients and providers.


Levels of Activation


Care Coordination Growth + 63%

81

225

439

1599

2602

0

500

1000

1500

2000

2500

3000

2014 2015 2016 2017 2018

Cumulative Enrolled and Discharged Patients

4,946

enrolled

patients

since

program

inception


Behavioral Modification Interviewing Training

ICP Care Management Program

BMIT class…….Care Coordinators

learned more effective communication

style to engage patients in their health

care


Patient Case Story

• White, 66-year-old male with Multiple COPD exacerbations with hospitalizations

• Enrolled in Care Coordination on 8/2/16 - patient did not have a pulmonologist except at the

hospital.

• Got him a prior authorization from BCBS ADV to continue to see Pulmonologist from the hospital for

continuity of care.

• Weekly and bi-weekly calls to patient for support.

• Established with Pulmo, Trilogy vent was suggested and obtained working collaboratively with

Pulmo.

• Established a good relationship with patient and PHQ9 went from 20 down to 7.

• Patient has difficulty clearing mucous-worked together with Pulmo, Respiratory Technician, and

BCBS to get an airway clearance vest approved. Had to go through level one appeals and we

finally got it.

• Patient - PAM score improved from Level one to Level four.

• Patient has not readmitted for over a year.

• Patient went on a vacation for the first time in 5 years to granddaughters birthday.


Cost Savings

Cost Information for Patient XBU

Metric6 Months Before Care

Management Enrollment

6 Months After Care Management

Enrollment

Overall Amount Paid $45,772.28 $10,494.92

Medical Amount Paid $43,453.98 $4,351.19

Pharmacy Amount Paid $2,318.30 $6,143.73

Number of Inpatient Stays 5 0

Total Inpatient Days 17 0

Number of Readmissions 3 0

Number of Emergency Room

Visits 0 0

Number of Office Visits 8 5

Calculated Annual Savings:

$70,554.72


Patient Web Site


OUTCOMES


ICP – Transitional Care Management Team Readmissions

5.8%

7.3%

4.1%

5.4%4.8%

4.3%

6.4%

5.1%

8.9%

14.3%

10.7%

5.4%

11.6%

7.2%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Jan, 2018Feb, 2018Mar, 2018Apr, 2018 May,2018

June,2018

July,2018

Aug,2018

Sept,2018

Oct, 2018 Nov,2018

Dec,2018

Jan, 2019 Avg YTD

Total Readmission Rate 2018 - 2019 (YTD Avg – 7.2%)


Care Coordination OutcomesDemonstrated improvement in patient activation depression and function

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline Follow-Up

23.2%17.6%

20.8%

17.4%

27.3%

32.0%

28.7%33.1%

% of Members by PAM Level for Baseline and Follow-up -

February 2019

Level IV

Level III

Level II

Level I

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline Follow-Up

4.0% 1.6%

9.6%4.1%

14.9%

9.0%

44.7% 68.3%

26.8%17.1%

% of Members by Depression Level

Baseline and Follow-Up -February 2019

Mild depression

Minimaldepression

Moderatedepression

Moderately severedepression

Severe depression

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

Mental Mean Score Physical Mean Score

47.9

30.8

48.6

31.5

Average Scores for Members who completed the VR12 Survey

- Baseline and Follow-Up -February 2019

BaselineFollow-Up


Outcomes after 6 Months in Care Management

Program

% Of Patients with

Severe Depression:

59% lower

Mental VR12 :

1.5% improvement

Physical VR12:

2.5% improvement

Patients highly engaged in

their own care:

15% increase


SHP Has Held Spending Growth Compared

With National ACOs and All FFS Medicare


SHP Has Lowered SNF and Rehab Spending


SHP Has Lowered SNF Day Utilization


SHP Has Reduced ED Utilization


SHP Has Reduced Admissions


SHP Has Reduced Readmissions


SHP MSSP Trends vs. National ACOs and FFS

•


SHP MSSP Trends Over Time

$9,000.00

$9,200.00

$9,400.00

$9,600.00

$9,800.00

$10,000.00

$10,200.00

$10,400.00

$10,600.00

$10,800.00

$11,000.00

2015 2016 2017 2018

Benchmark Spend


Conclusions

• Macroeconomic forces are driving providers to adopt value-

based payment models while keeping fee for service models

in place

• CINs are an important tool to allow a community to make this

transition

• Physician engagement is the most important focus of

successful CINs

• CIN maturation takes time and resources and is influenced

greatly by local environments

66


Thoughts or Questions ???

Documents

TRANSITIONING CARE TO AN INTENSIVE OUTPATIENT CARE … · CBO 2018 Infographic Innovation Care Partners –Confidential Information 3 Healthcare is 25% of the Federal ... Mobile Physician