ACOS: Where Are We At?

Accountable Care Organizations: Where Are We At?

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)

Presented by:

Kris Mastrangelo, OTR/L, LNHA, MBAPresident & CEO

Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2

“Widen Your Gaze”~Sherlock Holmes


The learner will be able to summarize goals of ACOsThe learner will be able to identify and articulate examples of the ACO processThe learner will be able to identify strategies for interdisciplinary management of ACOs

Objectives

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Accountable Care Organizations

“It is not the strongest of the species that survive, nor the most intelligent that survive. It is the one that is the most

adaptable to change.” ~Charles Darwin

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Accountable Care Organizations

“Voluntary groups of physicians, hospitals, and other health care providers that are willing to assume responsibility for the care of a clearly defined population of Medicare beneficiaries attributed to them on the basis of patients’ use of primary care services.

If an ACO succeeds in both delivering high-quality care or improving care and reducing the cost of that care below what would otherwise have been expected, it will share in the savings it achieves for Medicare.”

The New England Journal of Medicine (NEJM), October 20, 2011Making Good on ACOs’ Promise – The Final Rule for the Medicare Shared Savings ProgramDonald M. Berwick MD, Administrator, CMS


Team Medicine

First building blocks of integrated team medicine: Model, data and leadershipCreate a care team that maximizes impact for patientsBuild a physician culture of multidisciplinary practice


Team Medicine

1. An integrated, flexible physician model

“Multispecialty group medical practice maximized physicians’ abilities to care for patients through doctor-to-doctor consultation, through the training and mentoring of young physicians, and through the inherent quality controls built into the group”


Team Medicine

2. Physician-Friendly DataYields evidence-based medicine


Team Medicine

3. Rethink physician leadership“We recruit physicians with a sense that we’re a group practice. We stand for quality. We measure quality and results. We think it’s important that we tell patients we’re going to give them the kind of quality they deserve. You then orient, evaluate, and promote people based on the same set of values and expectations. Eventually you end up with a culture that is very comfortable with a focus on quality, measurement, comparison, and improvement.” Jack Cochran, MD


Healthy Bones:Tests and Prescriptions to Prevent

Problem: In 2010, osteoporosis was the ninth most costly major illness among the top 5% highest cost Medicare beneficiariesIn 2005, 2 million fractures cost the United States $17 billion for both acute and long-term care. By 2025, the annual fracture rate is expected to increase by 50% to about 3 million at a cost of $25 billion per year.On average, 24% of patients presenting with a osteoperosis-related fracture die within one year, and the mortality rate of men exceeds womenOnly 21% of women age 67 or older who have had an osteoporosis-related fracture had a bone mineral density test or a drug prescription to treat or prevent osteoporosis in the six months after the fracture

* Information provided by Kaiser Permanente


Healthy Bones

Solution: Care managers, primary care physicians, and surgeons use daily reports generated from the electronic health record to identify members at risk for osteoporosis and fracturesCare managers coordinate care for these patients to close care gapsWorking together, the team provides patients with education, screening, treatments, and monitoring as needed. The multidisciplinary team includes:Orthopedic surgeons, endocrinologists, gerontologists, family practitioners, internists, rheumatologists, gynecologists, physical therapists, disease/care managers, radiologists and member education


Healthy Bones

Impact: Annual bone density screening rates increased by 474% from 2002 to 2009 People on anti-osteoporosis medications increased by 214% from 2002 to 2009Over 45% reduction in rate of hip fractures (preventing >1400 hip fractures) by 2010If the Healthy Bones approach were adopted in the United States, the country could achieve a 25% reduction in the rate of hip fractures, preventing 75,000 hip fractures per year


Improvement Standard

As the New York Times reported on its front page Tuesday, Reuters (10/24, Morgan) reports that the Obama Administration has proposed a settlement to a class-action lawsuit, promising to broaden current Medicare regulations to allow coverage to "maintain the patient's current condition or ... prevent or slow further deterioration." Previously, beneficiaries had to demonstrate improvement to continue to receive coverage, the change will likely benefit thousands of Americans with degenerative conditions like multiple sclerosis, Parkinson's, and cerebral palsy.

An HHS spokeswoman said the settlement merely "clarifies" current policy, and continued, "We expect no changes in access to services or costs."


Improvement StandardThe case, Jimmo v. Sebelius, resulted in a focus on skilled service delivery in the context of maintenance programs

Historically, patients with chronic conditions and anticipated functional deterioration were considered skilled for the establishment of a maintenance program

This settlement now allows for coverage of the actual delivery of maintenance therapy by licensed nurses and therapy professionals



Current Medicare skilled guidelines state:

The services must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time,

Or the services must be necessary for the establishment of a safe and effective maintenance program



The Proposed Settlement:

“Instead, providers, contactors, and adjudicators must recognize “maintenance” coverage and a beneficiary’s need for skilled care that is performed or supervised by professional nurses and therapists.”

The manual revisions will clarify that, under the Skilled Nursing Facility, Home Health, and Outpatient Therapy maintenance coverage standards, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program

Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program



Quality Care is our number one objective

Harmony embraces the OBRA 87 regulations which require facilities to provide services to meet “the highest practicable physical, medical and psychological well-being” of every resident

This practice has been our standard since its inception. This new Improvement Standard, further supports our core values as providers of specialized services to the post acute care population.


Continuum of Care Post Discharge

“When the asthma attack is done, the patient goes home, and the game’s over. No one is accountable for any of the follow-up care.”

George Halvorson , Chairman & CEO

Kaiser Permanente


Integrated Follow-up

Call patient to make sure they are taking their meds Call patient to make sure they are avoiding any allergic trigger


Prevention

Problem:One in eight women develops breast cancer, and nearly 40,000 die from it every yearRegular mammograms – which can identify breast cancer early, when it is most treatable – can reduce breast cancer deaths by more than 30 percentThe United States Preventive Services Task Force recommends screenings every one to two years for women aged 50-74 years. However, current screening rates fall short of these guidelines, and they have been steadily declining


Prevention

Through the Proactive Office Encounter program, the health care team identifies and targets patients with care gaps (including whether a patient is due for a mammography) or chronic medical conditions and encourages them to actively participate in own care


Proactive Office Encounter and Mammography The program engages all members of the clinical care team in a coordinated and collaborative effort to encourage and support patient health

Automated creation of care checklists for all patients whose records indicate gaps in careAt every point of contact with patients, clinical care teams review checklists and help patients get the care they needBased on identified gaps in care, medical assistants during office visits discuss with patients the need for preventive screenings and routine care, such as cancer screenings and tests for abnormal blood sugar or cholesterol levels, and schedule appointments on the spot


Proactive Office Encounter Also Helps

Along with other concurrent improvement initiatives, the Proactive Office Encounter has contributed to:

30% increase in colon cancer screening11% increase in breast cancer screening5% increase in cervical cancer screening13% improvement in cholesterol control


Data, Data, Data

“You cannot make bricks without clay.”~Sherlock Holmes


Better Patient ManagementUsing Evidence-Based Medicine

Patient Registry and Concurrent Tracking System

Identifies all members in the populationRisk stratifies population for targeting interventions and resourcesTracks and monitors each patient for key indicators (lab, pharmacy, encounters, clinical indicators)Easy access (web-based)


Better Patient ManagementUsing Evidence-Based Medicine

Care Management Systems Flags/alertsSupports telephone management and documentationIdentifies all members in the population

Supports Automated Clinical Decision Support and Practice Tools

In-reach/outreach

Health Education and Self-Care Support


Evidence-based Medicine/Prevention

Proactive care instead of reactive carePatients who have the largest “gaps” in recommended care do not routinely visit their primary care physiciansSpecialty clinics must play a role to achieve optimal results. Fewer than 40% of patients needing a mammogram or testing for diabetes visited their primary care physician. Appointments can be made on the spot or referrals generated so gaps can be readily addressed


Beyond the Patient: Widen Your Gaze

Focus on primary care and prevention, and addressing chronic disease requires looking at larger communitywide issues

Behavioral factors are as important as specific treatments: better diet, promoting physical activity, and reducing smoking

Community education for adults and children in recognizing bad health habits and taking action to create a better health outlook


ACOs: Strategies for Interdisciplinary ManagementTo be continued…

To hear more about these introductory slides, and all that is still to come, please join me:

Date: Friday, May 3rd

Time: 10:15 a.m. – 11:45 a.m.

Kris Mastrangelo, President & CEOHarmony Healthcare International

http://www.harmony-healthcare.com/Tweet me your questions! @KrisMastrangelo

http://www.harmony-healthcare.com/



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Health & Medicine

ACOS: Where Are We At?