Facilitating Care Coordination and Transitions in an ACOWayne Pan, MD, MBASanta Clara County IPA

SCCIPAA Pacific Partners Medical Group

take-aways• focus on the patient• fix processes first• empower providers and

the care team• clinical must lead

technology initiatives• focus on the patient

Whycarecoordinationandtransitions?

because of these

too many of these

MIND THE GAP

source: SF Jencks et al., Rehospitalizations among Patients in the Medicare Fee-for-Service Program, New England Journal of Medicine, 2009;360:1418-28.

$17Bsource: SF Jencks et al., Rehospitalizations among Patients in the Medicare Fee-for-Service Program, New England Journal of Medicine, 2009;360:1418-28.

4processes

communication

collaboration

coordination

PCPs

Specialists

Patients

CaseManagers

anticipation

4dimensionaldata

financial

administrative

clinical

retrospective

reactivecare

behavioral+

predictive

proactivecare

provideclinicaldata

@pointofcare

@home

thecareteam

thecarecontinuum

Santa Clara County1,304.01 sq. miles

1,781,642 (2010)$74,335

5 PCP80 Specialists

57 PCP104 Specialists

173 PCP343 Specialists

11 PCP30 Specialists

SCCIPAfounded in 1986physician-owned, physician-governed800+ physicians - 240+ PCPs, 550+ specialistsall 9 hospitals - including a tertiary care center9 health plans (Commercial and Medicare Advantage)

outpatientcapitation

professional servicesoutpatient services

DME/injectables

people, processes, platform

hospitalistsSNFists

onsite case managerscomplex case managers

utilization review staff

hospitalistsavailable 24/7

evaluation of patients for possible redirection to SNFaggressive use of observation status

annual coding/documentation training for risk adjustmentnotification of PCP of admission/discharge

discharge summary faxed to PCP

SNFistsevaluation of patients to reduce rehospitalization

notification of PCP of admission/dischargedischarge summary faxed to PCP

onsite case managersdaily review of patients based on Milliman guidelines

actively involved with discharge planningall discharge needs authorized/arranged prior to dischargepost-discharge follow-up on all patients with DME/HHC needs

complex case managerswarm hand-off between onsite and ccm

use of clinical and non-clinical staff to assistpatient and family caregivers with care coordinationinsure follow-up with PCP/specialist within 2 weeks

utilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with PCPs/specialists/ccm to facilitate care coordination

compliance with regulatory guidelinesgenerate official documentation regarding medical necessity decisions

physician performance and quality reportingidentification of potential quality issues

continuous process improvement

platform

common web-based communication platformfacilitates administrative functions

rules-based management of processesintuitive user-interface

embed quality reminders into office/provider workflowprovider feedback

provide clinical data at point of careallow patients to access their own data

allow patients to provide feedback and enter their own data

more than an EHRmore than an HIE

clinical integration engine

virtually integrated healthcare delivery system

ourresults

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improve the patient experience,

population health,

reduce cost per capita

engage the patient,

use evidence-based guidelines,

efficient processes

discussion

thankyou

wpan@ppmsi.com

SCCIPAA Pacific Partners Medical Group