Health Care Delivery System Transformation the Adirondack - - PowerPoint PPT Presentation

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Health Care Delivery System Transformation

…the Adirondack Experience

Colleen Florio, PhD, Director Brenda Stiles, RN Care Team Manager, Medical Home Kati Jock, Director Strategic Planning & Network Development

Today’s Panelists

Today’s Agenda

• Adirondack Population Issues
• ADK Region Medical Home Pilot
• Health Home
• ACO
• DSRIP & the “Performing Provider

System”

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Mission: To promote, sponsor, and coordinate initiatives and programs that improve health care quality, access, and service delivery in the Adirondack region.

Adirondack Population

• Older than State Average
• Poorer than State Average
• Greater Chronic Disease Burden
• Rural & Mountainous

– Travel – Communication

Multiple HPSAs: PC, Dental, MH

Collaboration = Key

• Improving Physician Satisfaction and

Retention

• Improving the patient experience of

care (including quality and satisfaction)

• Improving the health of the populations
• Reducing the per capita cost of health

care IHI Triple Aim Plus

ADK Region Medical Home Pilot Goals

Transforming Care in the Adirondacks

Case in Brief: Adirondack Medical Home Pilot

• Five-year pilot to generate health

care value in Adirondack region of Northern New York

• Key objective is to transform

physician practices into NCQA recognized medical homes

• Launched in January, 2010;

previously codified by New York state legislature in 2009

• Supervised by both New York

Department of Health, Department

• f Insurance

Business Confidential: Not for distribution without permission of AHI

4

http://www.adkmedicalhome.org/

Engaging a Multitude of Stakeholders

Pilot Includes Government and Commercial Payers

Adirondack Medical Home Pilot Providers 97 physicians and 127 MLPs spanning 33 individual practices Hospitals 5 hospitals and health systems Patients Population 200,000 105,000 patients Attributed Payers All 7 commercial payers, Medicare, Medicaid

7,000 Square Miles 7 eMR Vendors Regional Health Information Organization (RHIO)

Payer Data Warehouse Treo Health Plans

5 Hospitals 33 Primary Care Practices 3 PPSOs Claims portal Clinical quality portal Clinical care portal

ADT, Meds, Lab/rad/departmental reports (HL7 content) Claims data flow Access to web viewer Web application Clinical summary info (C32 content)

45 Specialty Providers Health Plans 2 GFH Specialty Practices

EHR Data Warehouse( QDC)

Clinical Transaction Content

HIT Infrastructure

Total Attributed Patients 104,022 & Pod Specific Resource Distribution

Resource: 26 sites

• 16 RN Care

Managers

• 2 Social Workers
• 4 Administrative
• 1 Pharmacist

Resource: 8 Sites

• 1 RN Care Manager
• 2 Dieticians
• 2 Patient Educators
• 1 Pharmacist
• 1 Information Tech

Pod #1 14,065 Pod #2 32,933 Pod #3 57,024

Resource: 16 Sites

• 6 RN Care Managers
• 1 Peds Health Coach
• 3 Administrative
• 2 Transition Care
• 2 Patient Navigators

Implementation Issues

Practices

• “Clicks”
• Practice Resources

– Workflow – Remediation – Report Creation – Data Analysis, IT

• Attribution

– Effort – Gaps

• Products
• Changing Insurance

Data

• Utilization

– Timeliness – Pricing – Unpaid Claims

• Clinical

– 7 eMR vendors – RHIO – Standards? – Remediation – Consent – Trigger

Health Home Care Management

• “a care management service model whereby

all of an individual’s caregivers communicate with one another so that all of a patient’s needs are addressed in a comprehensive manner”

http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/

Transitioning TCMs

• Citizen Advocates
• Mental Health Association in Essex

County

• Essex County Mental Health

Services

• Warren-Washington Association

for Mental Health

• AIDS Council of Northeastern NY
• Behavioral Health Services North
• Glens Falls Hospital*

AHI Health Home Service Providers

Patient-Centered Medical Homes

 Hudson Headwaters Health

Network

 Champlain Valley Health Network

State ICMs

 Saint Lawrence Psychiatric Center  Capital District Psychiatric Center*

AHI Health Home Patients Served 2014

Care Management Agency Average Members Per Month: January- May 2014

AIDS Council of Northeastern New York 60.4 Behavioral Health Services North 302.6 Champlain Valley Health Network 42.8 Citizen Advocates/Northstar Behavioral Health 312.6 Essex County Mental Health Services 33.8 Glens Falls Hospital N/A* Hudson Headwaters Health Network 394.4 Mental Health Association of Essex County 65.4 Warren-Washington Association for Mental Health 92.8

Grand Total 1304.8

* Glens Falls Hospital will be merging with AHI's Health Home effective 7/1/14. In May 2014, Glens Falls Hospital had 230 members. Number excluded from Grand Total.

Data Drives Triple Aim

• Improving the health of

populations.

Quality

• Improving the patient experience
• f care, including access to care

and satisfaction with their care.

Patient Experience

• Improving efficiency & reducing

the per capita cost of health care.

Cost Savings

Data Uses

• Share pertinent patient information with other providers

to improve health outcomes and reduce redundant or unnecessary services (interfaces, RHIOS, shared care plans, etc.)

• Monitor progress toward utilization, clinical quality and

patient experience goals

• Determine success of new initiatives such as Care

Management and Transition Care

• Identify patients who may benefit from a focused

intervention

• Identify unaddressed barriers to care including psyco-

social determinants

Transparency

• Performance Dashboard
• n The Hweb -

http://hweb/Departments/home.cfm?Me nuID=5136&OldCFID=178261

 Network Quality Measures  Pediatric Quality Measures  Patient Satisfaction  Utilization Measures  Provider Level Reports

• Workgroups

 Chronic Disease  Pediatric  Prevention  Advocacy/Advisory

Patient Centered Primary Care A Team Based Approach

Brenda Stiles, RN CDE

Care Team Manager Northern Adirondack Medical Home September 22, 2014

Engaging a Multitude of Stakeholders

• Pilot Successfully Includes Wide Range of Payers, Providers

Adirondack Medical Home Pilot Participants

Adirondack Medical Home Pilot Providers 97 physicians and 127 mid-levels spanning 33individual practices Hospitals 5 hospitals and health systems Payers All 7 commercial payers with Medicare, Medicaid Patients 105,000 patients3

Committing to Substantial Practice Redesign

• Major Changes in Practice Operations and Investments

Key Requirements to Join Pilot

Participate in quality measurement and improvement activities Join regional health information exchange Coordinate care across continuum Implement evidence-based care Create disease management Achieve medical home recognition (level 2 or level 3) Implement same day access Adopt e-prescribing system Accept assignment as patients’ personal provider

Practice Transformation

Person Centered Medical Home Primary Care Provider & Patient/Family Practice Change Team Based Care Disease Management Access to care 24/7

25

Transitional Care Supports

Improving Patient Outcomes and Reducing Hospital Readmissions

RN meets patients in hospital for introduction of supports available RN provides 48-72-hour phone call or home visit for follow-up Medication reconciliation with pharmacist dedicated to Medical Home patients Work with patient and PCP to ensure that follow-up appointment

• ccurs 7 – 10 days

post discharge RN Care Manager review daily admissions & readmissions to determine those patients at highest-risk

Adult Mental Health Transitional Care

• May 2014
• Health Home Care Manager began providing transitional care supports to all patients

discharged from Adult Mental Health Unit

• Follow up call to ensure patient was able to obtain medications, transportation to

follow up appointments, etc.

• Ensure that Primary Care Provider aware of the recent hospitalization, along with

medication changes

Health Home Care Management

An Evolving Role

Pediatric Transitional Care

Pediatric Mental Health Transitional Care

• March 2014
• Medical Home Team began providing transitional care supports to children and families

discharged from the CAMU

• 72 patients have received transitional care supports
• 31 active patients currently receiving supports

72 41 31 10 20 30 40 50 60 70 80 Total Admissions Closed Active

CAMU Transitional Care

7% 7% 8% 4% 7% 9% 6% 7% 9% 8% 8% 11% 9.50% 0% 5% 10% 15% Q1 Q2 Q3 Q4 Year Average

Readmission Rates

Readmission Rates

• All Medical Home Primary Care Providers
• Patients discharged from CVPH and Alice Hyde Medical Center
• May 2011 - Readmission Rate – 14.9%

260 444 372 470 1546 323 478 299 339 1439 483 514 997 500 1000 1500 2000 Q1 Q2 Q3 Q4 Total 2014 2013 2012

Total Patients

31

Care Management

Focusing on Critical Need

• Practice Based RN Care Managers focus on:
• Chronic Disease, i.e.: Diabetics who are not managed well with HbA1c >9
• Patients who need additional supports to manage their chronic disease
• Patients who have social barriers that prevent them receiving adequate care
• Care Managers utilize health coaching model, determine needs through motivational

interviewing, readiness to change; review areas of prevention

• Empower and educate patients/care givers on self managing their healthcare through

personal goal setting, self-management tracking tools and educational materials

• Barrier identification and assistance with resources available in the community
• Referral to Social Worker as needed to reduce barriers to improved health outcomes

Adult Care Management

Behavioral Health Professional

Several practices have Clinton County Mental Health available in practice to meet with patients. Exercise Specialist Community Resource Advocate

In House Referral

Primary Care Provider Referrals Care Manager

Nutrition Educator

Diabetes Care Management

1363 786 577 200 400 600 800 1000 1200 1400 1600 Refferals Accepted Refused

Diabetes Referrals

444 227 115 50 100 150 200 250 300 350 400 450 500 Decrease - 56% Same - 29% Increase - 15%

Change in A1C

Community Resource Advocate Referrals

2013 - 2014

Pediatric Care Management

Role of the Patient Navigator

All referrals sent via EMR to

Patient Navigator Pediatric Care Manager, RN

Pre-Diabetes HTN Hyperlipidemia Complex Medical Needs Asthma Newborn High Risk

Nutrition Educator

BMI > 85% Nutrition Education

Community Resource Advocate

Behavioral/Mental Health Needs Follow up discharge CVPH MHU Barriers to care (ie: transportation, insurance issues, etc.) Once referral is complete, if further assistance is identified referral will be sent to the appropriate person / community resource

Behavioral Health Professional

Several practices have Clinton County Mental Health available in practice to meet with patients. Primary Care Practice

240 58 50 100 150 200 250 300 Practice A 1/29/14 Practice B 4/25/2014

Patient Navigator Referrals

Building Community Collaboration

Care Management Support Network

Accountable Care Organization: The Next Logical Step

ADK Medical Home Pilot set to “sunset” 12/31/14

• ACO model will shape the future while sustaining the platform

established through the pilot Person-centered Medical Home infrastructure supports ACO development

• Advanced primary care that will utilize population health management

resources for optimal

• Chronic Disease Management
• Care Transition to Home
• ED diversion solutions

Overlap between PCMH, Health Home, ACO and Clinically Integrated Primary Care Providers

Clinically Integrated PCPs PCMH Pilot In ADK ACO and Pilot ACO Network Health Home Specialists Hospitals

Adirondacks ACO, LLC Stakeholders

Augmenting the Relationships Established Through Medical Home Pilot

Adirondacks ACO, LLC Providers/Medical Homes Hospitals Patients Payers

42

• Provider-led organization with a strong base of primary care and hospital

systems

• Collectively accountable for quality and total per capita costs across the

full continuum of care for a population of patients

• Payments linked to quality improvements that also reduce overall costs
• Reliable and progressively more sophisticated performance measurement

to support improvement and provide confidence that savings are achieved through improvements in care

Creating an Accountable Care Organization

The Adirondacks ACO

A seven county accountable care organization (ACO) comprised of an extensive network of providers to manage the health care for Medicare beneficiaries: New York

• Clinton
• Essex
• Franklin
• Hamilton

Comprised of more than 500 primary care providers:

• Fletcher Allen Partners
• Adirondack Health/AMC
• Alice Hyde Medical Center
• Glens Falls Hospital
• Irongate Family Practice
• Hudson Headwaters Health Network (FQHC)
• Independent Community Primary Care Practices
• Warren
• Washington
• Northern Saratoga County

Vermont

• Grand Isle
• Chittenden

Hudson Headwaters Health Networks

CVPH

Glens Falls Hospital Physician Group Entity (PGE) Adirondack Health/ AMC

Board of Managers Corporate Membership (Ownership) Operations and Technology Provider Participants

FAHC

Required Members

Fletcher Allen Partners

Fletcher Allen Partners 2 Seats 2 Seats 2 Seats 6 Seats 2 Seats 4 Seats

Irongate Family Practice

1 Seat

The Adirondacks ACO

DSRIP ~ $6.42 billion

New York’s opportunity to make significant investments over a 5 year period to address underlying challenges to the healthcare delivery system

• Lack of primary care
• Weak healthcare safety net
• Health disparities
• Transition to managed care challenges

Goal = 25% reduction in avoidable hospital visits.

Incentives Over Time

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4

Avoidable Hospitalizations Project Specific Outcomes Process Metrics Financial Stability

Project Design Grant Applications

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip_design_grant_applications/

• 50 Project Design Grant Applications

1 1 1 1 5 5 1 3 20 8 4

AHI: 9 Counties ~ 694,000 people

82,054 39,309 51,698 55,358 4,835 219,832 112,060 65,700 63,108 Clinton Essex Franklin Fulton Hamilton Saratoga

• St. Lawrence

Warren Washington

SOURCE: U.S. Bureau of the Census; "2008-2012 American Community Survey" Complied by the Community Health Care Association of New York State in March 2014, using the Census Bureau's American Fact Finder and the Missouri Census Data Center's Dexter interactive query tools.

9.1% 16.3% 17.5% 11.3% 20.9% 15.2% 0% 5% 10% 15% 20% 25% Persons without Health Insurance With Medicaid / CHP Alone or in Combination with Other Coverage With Medicare Alone or in Combination with Other Coverage Service Area New York State

Health Insurance Status: Service Area Compared to State

SOURCE: U.S. Bureau of the Census; "2008-2012 American Community Survey" Complied by the Community Health Care Association of New York State in March 2014, using the Census Bureau's American Fact Finder and the Missouri Census Data Center's Dexter interactive query tools.

Health Insurance Status

50000 100000 150000 200000 250000

Clinton Essex Franklin Fulton Hamilton Saratoga

• St. Lawrence

Warren Washington

Medicaid / CHP Alone or in Combination Non-Medicaid

109,000 Covered by Medicaid

SOURCE: U.S. Bureau of the Census; "2008-2012 American Community Survey" Complied by the Community Health Care Association of New York State in March 2014, using the Census Bureau's American Fact Finder and the Missouri Census Data Center's Dexter interactive query tools.

Engage Partners Submit LOI Project Design Grant Application Final Project Plan

AHI ~ DSRIP Year 0

April December June

• 5 Open Forums
• 100+ Partners
• 9 Counties
• Project Survey
• PAC Established
• 2 PAC meetings
• Assessment
• Project

Development

• Work Plan
• Governance
• Financial Model
• Value tied to

payment

• Partner network =

attribution

PAC Project Selections

• D2: System Transformation (2 - 4)
• Integrated Delivery System
• Medical Village – hospital
• Medical Village – nursing home
• Care Coordination / Transitions
• Connecting Settings (navigation)

* Telemedicine project to be incorporated into integrated delivery system, or

• thers

PAC Project Selections

• D3:

Clinical Improvement (2 - 4)

• Primary Care / Behavioral Health

Integration

• Community Crisis Stabilization
• Ambulatory Detox
• Palliative Care, IHI Conversation

Ready Model

PAC Project Selections

• D4:

Population-Wide (1 - 2)

• Strengthen Mental Health /

Substance Abuse Infrastructure Across Systems

• Increase access to chronic

disease preventive care & management – COPD

Community Needs Assessment

• Medicaid focus
• Build on CHA / CSP Process
• Access
• primary care, PCMH, long-term & home-based,

behavioral health / substance abuse treatment, care management, transitional care

Governance

 Shared model  Variety of options

currently under consideration

 PAC (Project Advisory

Committee) is advisory, includes management & workforce representation (union/staff seats)

AHI DSRIP News

www.adirondackhealthinstitute.org

DSRIPahi@adkhi.org

Questions?