Innovations in Integrated Care Management: How to Adapt Lessons from - - PowerPoint PPT Presentation

Innovations in Integrated Care Management: How to Adapt Lessons from Spain for the US

Webinar Slides April 17, 2018

OVERVIEW OF SPANISH INNOVATIONS: INDIVIDUAL AND COMMUNITY

CARE PLANS, INTEGRATION IN EMERGENCY CARE AND IN SOCIAL AND HEALTH CARE

Núria Mas

IESE Business School Jaime Grego Chair of healthcare Management

CATALAN HEALTH CARE PLAN 2011-2015

Program of Prevention and Attention to Chronicity (PPAC) Integrated Health and Social Plan (PIAISS)

DIVERSE REALITIES

Socioeconomic differences Rural and urban realities

CARE PATHWAYS

GOALS:

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To obtain the best possible care for the population Proactive: attention to early identify and anticipate crisis Efficiency: use the available resources in the best possible way to achieve the population health goal IDENTIFICATION OF POPULATION SHARED INFORMATION SHARED INDIVIDUAL INTERVENTION PLAN (SIIP) LOCAL AGREEMENTS

CONTINUUM OF CARE FOR CHRONICITY WITH SPECIAL FOCUS ON COMPLEX AND ADVANCED PATIENTS

IDENTIFICATION OF THE TARGETED POPULATION

§ Targeted population: patients with complex chronic conditions (CCP) & patients with palliative needs (MACA) § Proactive identification, with clear targets. Initial target of the Plan: 25,000 CCPs identified by 2015. There were 150,000 CCPs identified by May 2015! § WHO CAN IDENTIFY: it can come from anywhere in the system. However, the GP has the final call on the “oficial”codification as such. The primary care team validates and labels. § IDENTIFICATION GUIDELINES: guideline document for professionals § Unique experience objective (algorithm) risk adjustment models and clinical judgement § Once identified, the primary care team has to guarantee that the patient and her family are informed § Labeling in digital platforms §

6 BASQUE COUNTRY: population screening based on algorithms. 43 items in hospital/community module and 23 items in emergency module

ONCE, IDENTIFIESD THE LABEL CAN BE SEEN IN ALL DIGITAL PLATFORMS

4 KEY ENABLERS OF SUCCESS

8 IDENTIFICATION & LABELING SHARED INDIVIDUAL INTERVENTION PLAN (SIIP) STABLE CRISIS

SHARED INDIVIDUAL INTERVENTION PLAN (SIIP)

§ Personalized care plan § Global evaluation of the patient. Takes into account the individual´s physical, social, and psychological needs. § It also takes into account the patient´s values and preferences § Elaborated collaboratively between the GP, the different health-care and social-care professionals (specialist, geriatrician…), and in many cases (for instance, when the patient is highly dependent) the patient´s family. § It is materialized as a dynamic document that gathers all the main medical and social data on the patient that is to be shared. Periodic review depending on the situation of the patient § For MACA patients it contains advanced healthcare directives. § The SIIP is included in the Shared electronic medical records. § It includes care instructions to facilitate decision making among the professional teams that will be treating the patient. Instructions during stable phases and during crisis

4 KEY ENABLERS OF SUCCESS

10 IDENTIFICATION & LABELING SHARED INDIVIDUAL INTERVENTION PLAN (SIIP) STABLE CRISIS § Contact phones, § Relation with the case management nurse § Revision of medication § Proposed follow-up services § Recommendations to sustain the stable situation for as long as possible § Patients and family know about the SIIP and they can communicate so when the patient is being visited by a provider § DURING WORKING HOURS ‒ First respondent: primary care team ‒ If necessary, patient will be transferred to a specialist team ‒ Hospital admission, day-hospital, emergency care ‒ All the providers can access the action plan through the shared clinical records § NON-WORKING HOURS ‒ Call 061, the health hot line ‒ If there is a SIIP, the 061 will act accordingly

SIIP– WHAT DOES IT INCLUDE?

• f diagnosis, severity.

• f drug and active ingredients,

• bjectives for the patient and

EMERGENCY CARE AS PART OF THE INTEGRATED CLINICAL PATH 24/7

§ 061 Respondents can see the patient label (CCP/ADS) § Qualified 061 professionals (doctors/ nurses) can have access to the SIIP and to the electronic shared medical records § Participate in the local agreements and care pathways § Number of patients for whom 061 has accessed HC3 (2016)

4 KEY ENABLERS OF SUCCESS

16 IDENTIFICATION & LABELING SHARED INDIVIDUAL INTERVENTION PLAN (SIIP) SHARED CLINICAL RECORDS

Shared clinical records

• They include the labeling of the patient

(CCP or ACD)

INDIVIDUAL PORTAL

4 KEY ENABLERS OF SUCCESS

19 IDENTIFICATION & LABELING SHARED INDIVIDUAL INTERVENTION PLAN (SIIP) SHARED CLINICAL RECORDS LOCAL AGREEMENT

LOCAL AGREEMENTS

Integrated Care Pathways and local agreements

§ An ICP is a way to organize all people involved in the care process § The strongest feature of the ICP is its flexibility to adapt to the different characteristics of the territory

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Elaboration process

§ A group of experts at the national level set the conditions to target § A second group of experts in a local level use this core key elements and then add ad hoc § The final pathway is transmitted to CatSalut

§ SUCCESS DEPENDS ON THE PATH MORE TAN ON THE

• PROTOCOL. It is based on the functional integration of all the agents in

the territory. § Local focus and collaboration as the key to implement best practices § Development of Integrated care pathways (ICP) § Local written and formal agreements between local leaders

CURRENT STATUS

Criteriaavailability of intermediate care units % of regions Explicit written agreement 87% Agreement between agents to respond to crisis 90% Description of a model of home care 48% Description of a model of long-term-care facilities 29% Explicit agreement of care during transitions 80% Availability of “day hospital” units for chronic patients 90% Availability of expert units to assist primary care in complex cases 79% Availability of intermediate care units 72%

RESULTS(I)

.7 .8 .9 1 1.1 2008 2010 2012 2014 2016 Year Osona synthetic control unit

45% Reduction

Avoidable hospitalization rate: Osona vs. synthetic control

Source: Mas & Masllorens (2018) “Impact on Health Outcomes from Integrating Health and Social Care”

RESULTS (II)

Source: Mas & Masllorens (2018) “Impact on Health Outcomes from Integrating Health and Social Care” .8 .9 1 1.1 1.2 2008 2010 2012 2014 2016 Year Osona synthetic control unit

9% Reduction

30 days readmission rat: Osona vs. synthetic control

State Innovations and Payment Reform

Center for Medicare and Medicaid Innovation April 17, 2018

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“The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished to individuals under such titles.”

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The CMS Innovation Center Statute

Three scenarios for success from Statute: 1. Quality improves; cost neutral 2. Quality neutral; cost reduced 3. Quality improves; cost reduced (best case) If a model meets the statutory requirements for expansion, the statute allows the Secretary to expand the duration and scope of a model through rulemaking.

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Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system.

Focusing on the way we pay providers, deliver care, and distribute information

Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.

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Pay Providers Deliver Care Distribute Information

FOCUS AREAS

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Focus Areas CMS Innovation Center Portfolio Pay Providers Test alternative payment models § Accountable Care ‒ ACO Investment Model ‒ Pioneer ACO Model ‒ Medicare Shared Savings Program (run by the Center for Medicare) ‒ Comprehensive ESRD Care Initiative ‒ Next Generation ACO § Primary Care Transformation ‒ Comprehensive Primary Care Initiative (CPC) & CPC+ ‒ Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration ‒ Independence at Home Demonstration ‒ Graduate Nurse Education Demonstration ‒ Home Health Value Based Purchasing ‒ Medicare Care Choices ‒ Frontier Community Health Integration Project ‒ Medicare Diabetes Prevention Program Expanded Model § Bundled payment models ‒ Bundled Payment for Care Improvement Models 1-4 ‒ Oncology Care Model ‒ Comprehensive Care for Joint Replacement § Initiatives Focused on the Medicaid ‒ Medicaid Incentives for Prevention of Chronic Diseases ‒ Strong Start Initiative ‒ Medicaid Innovation Accelerator Program § Dual Eligible (Medicare-Medicaid Enrollees) ‒ Financial Alignment Initiative ‒ Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents ‒ Medicare-Medicaid ACO Model § Medicare Advantage (Part C) and Part D ‒ Medicare Advantage Value-Based Insurance Design Model ‒ Part D Enhanced Medication Therapy Management Deliver Care Support providers and states to improve the delivery of care § Learning and Diffusion ‒ Partnership for Patients ‒ Transforming Clinical Practice § Health Care Innovation Awards § Accountable Health Communities § State Innovation Models Initiative ‒ SIM Round 1 & SIM Round 2 ‒ Maryland All-Payer Model ‒ Pennsylvania Rural Health Model ‒ Vermont All-Payer ACO Model § Million Hearts Cardiovascular Risk Reduction Model Distribute Information Increase information available for effective informed decision- making by consumers and providers § Information to providers in Innovation Center models § Shared decision-making required by many models

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The CMS Innovation Center Portfolio Aligns with Broader CMS Goals

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CMS Innovation Center’s Range of Impact

Beneficiaries touched CMS Innovation Center models impact over 18M beneficiaries1,2 in all 50 states Providers participating Over 200,000 health care providers and provider groups2 across the nation are participating in CMS Innovation Center programs

and Medicaid (as Medicare-Medicaid enrollees), CHIP, and Medicare Advantage) and individuals with private insurance, including in multi-payer models

Source: Innovation Center Report to Congress, December 2016

> 18 million > 207,000

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ACOs PCMH Bundled Payments Initiatives

States can drive multi-payer alignment across initiatives for: Goals Incentives Targets Metrics

Medicaid Commercial Payers Medicare Payers The Innovation Center partners with states to align payment and delivery system reforms across payers in order to reduce burden on providers

State-Level Alignment Can Reduce Provider Burden

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Unique State Environments Drive Change

State Innovation Models provide financial and technical support to states to test the ability of state governments to use their regulatory and policy levers to accelerate health transformation*

The State Innovation Models (SIM) initiative has partnered with states to invest nearly $1 billion in local, state-led health system transformation

*From State Innovation Model Funding Opportunity Announcement, Round 2

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SIM has supported 38 states* representing nearly two thirds of the U.S. population Round 1: § 19 model design/pre-test, 6 model test states (three and half year award started April 2013) § $300 million awarded ($250m for Test, $50m for Design) Round 2: § 11 model test states (four year award started February 2015) § 21 model design states (one year award started February 2015) § $660 million awarded ($622m for Test, $42m for Design)

17 Test states Non-SIM states 21 Design states and territories

*Includes 3 territories and the District of Columbia

SIM Awarded Funds in 2 Rounds

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SIM gives states flexibility to design and test innovative approaches that can be tailored to meet state-specific needs in return for meeting specific programmatic requirements.

Examples of Customized State Approach

• Idaho is developing virtual PCMHs in rural and frontier

areas

• Connecticut provides ACOs with evidence-based

interventions for asthma and hypertension SIM Program Area

• Michigan links communities with PCMH practices

through Community Health Innovation Regions

SIM States Customize within Defined Program Elements

Population Health Plan Health Care Delivery System Transformation Plan Payment/Service Delivery Model Leveraging Regulatory Authority Quality Measure Alignment Stakeholder Engagement Monitoring and Evaluation Alignment with State/Federal Initiatives

• Ohio created 2 new rules to enable PCMH payments

and provider eligibility in Medicaid

• Rhode Island developed a core measure set to be

used by all payers to reduce provider burden

• Iowa developed a state-wide alert notification system

(SWAN) of admissions/discharges/transfers

• Colorado convenes cross-cutting workgroups on multiple

topics to disseminate information to stakeholders

• New York partners with New York Academy of Medicine

to evaluate the impact of SIM

• Washington aligns SIM and TCPI to support providers in

VBP environments and to avoid duplication of funds/efforts

Health Information Technology

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§ Scale targets to disseminate reforms across states’ payers and providers § All-payer financial targets to ensure state’s healthcare costs across payers grow at a sustainable level § Medicare financial targets to generate cost savings to Medicare § Population health targets to tie success to actual improvements in the health and quality of care for residents

The Innovation Center provides custom, state-specific Medicare flexibilities to test 3 novel models in return for state accountability on both all-payer cost growth and population health measures. These models are closely aligned with the goals of SIM, and that synergy is especially clear in Vermont as a SIM Test state.

Medicare flexibility Maryland Vermont Pennsylvania

Provide a custom Medicare ACO model, based on CMMI’s NextGen ACO model. Allow global budgets to determine Medicare payment amounts to Maryland hospitals Allow global budgets to determine Medicare payments to participating Pennsylvania rural hospitals

Multi-payer model Novel test

Hospital global budgets to decouple hospital revenues from volume and incentivize prevention and wellness In a low cost state, bring ACOs to scale statewide to incentivize value and quality under the same payment structure throughout the delivery system Hospital global budgets for rural hospitals (already at low spending levels), and a deliberate plan to improve quality and efficiency across services and service lines

State accountability

Unique State Partnerships Test Novel Multi-Payer Models

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The Maryland All-Payer Model has seen early successes using hospital global budgets

• Medicare has saved $300M* in hospital

expenditures, driven by 3% decline in inpatient admissions and a large reduction in

• utpatient expenditures
• Incentivized to prevent avoidable

utilization, hospitals have engaged in several activities:

• Improved care continuity and

management, discharge planning, and treatment adherence

• Enhanced focus on behavioral health
• Changed hospital administrative and
• rganizational structures
• Shifted service sites
• Enhanced clinical staff management

State determines the total, all- payer revenue target (global budget) for each hospital to decouple hospital revenue from volume and incentivize prevention Maryland All-Payer Model design Preliminary actuarial results of first two years demonstrate reduced Medicare cost growth

*Based on actuarial results from HSCRC. More information available at: http://healthaffairs.org/blog/2017/01/31/marylands-all-payer-model-achievements-challenges-and-next-steps/

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The Vermont All-Payer ACO Model strives for APM scale and explicitly focuses on health outcomes

§ State and ACO-level accountability for explicit and specific health outcomes will incentivize collaboration between the care delivery system, public health, and community resources. 70% of all VT residents, including 90% of VT Medicare beneficiaries, attributed to an ACO § State and ACO-level targets on SUD and suicide deaths; access to care; chronic condition prevalence (i.e., hypertension, diabetes, COPD) § Financial targets of no more than 3.5% per capita annualized healthcare cost growth across payers and 0.1-0.2% points below annualized national Medicare per beneficiary cost growth The Innovation Center’s first test of a total cost of care (TCOC) APM in which all the payers within an entire state incentivize value and quality, with a focus on true health outcomes, under the same payment structure for providers throughout the delivery system. Scale ACO scale throughout the state will allow Vermont providers to reach the tipping point where redesigning the entire care delivery system is a rational business strategy. Each payer will continue to have independent ACO programs but key design elements will be aligned. Accountability The Vermont All-Payer ACO Model is in its first year and will conclude in 2022.

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Payment model and scale Rural hospitals will receive global budgets for all inpatient and outpatient services, to produce lower revenue but higher margin § Global budgets will cover 90% of each hospital’s revenue by year 2 § 30 hospitals will participate by year 3 (45% of all rural PA hospitals) § Payers will include Medicare FFS, Medicaid managed care, and commercial payers (including Medicare Advantage) Care delivery redesign Hospitals will redesign their delivery system based on local health needs § Hospitals will build partnerships with other providers through care coordination and referral patterns to promote population health § Hospitals may also reduce excess beds, change service delivery lines, or transition to become an outpatient centers § The state will review the hospital plans to ensure access and quality

The PA Rural Health Model aims to improve financial viability and reduce health disparities

Financial targets § At least $35M in Medicare rural hospital savings § No more than 3.38% all-payer rural hospital cost per capita annualized growth rate

• Pop. health

targets § Increase access to primary and specialty services § Reduce deaths related to substance use disorder (SUD) and improve access to

• pioid treatment

§ Improve chronic disease management and preventive screenings in target areas: cancer, cardiovascular disease, and obesity/diabetes The Pennsylvania Rural Health Model is in its first year and will conclude in 2023.

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SIM Supports States to Achieve Better Health and Value

Improve quality and accessibility of care Improve health outcomes and put patients first Improve value and affordability Strong partnership between states and the Innovation Center reduces provider burden through alignment, and accelerates sustainable, nationwide health system improvement in order to:

State Innovation Successes The Future of Medicaid

MaryAnne Lindeblad, BSN MPH Medicaid Director, Washington State Health Care Authority April 17, 2018

HCA: purchaser, innovator, convener

HCA purchases health care for over 2.2 million people, with a $10 billion annual spend.

2021

90%

state-financed

50%

commercial

Tools to accelerate VBP and health care transformation

• 2014 legislation directing HCA to implement VBP strategies
• SIM Round 2 grant (Healthier Washington), 2015-2019
• Medicaid Transformation, 2017-2021
• Medicaid (Apple Health)

– 1.9 million clients

• Public Employees Benefits

– 370,000 covered lives

• School Employees Benefits (2020)

– 144,000 more covered lives coming

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A healthier Washington through innovation

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Getting to a healthier population

Change the way we pay for care: value-based health options and innovative programs Use data and evidence-based recommendations Educate and engage people and their families Integrate funding with shared resources Leadership support for integration as driving model of operations Physical and behavioral health needs treated collaboratively for all persons Consistent communication and collaboration Roles and cultures that blur or blend

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Health is more than health care.

The 20/80 rule

Adapted from: Magnun et al. (2010). Achieving Accountability for Health and Health Care: A White Paper, State Quality Improvement Institute. Minnesota.

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Strategies that address the other 80%

• Medicaid Transformation

– Diversion intervention (measuring: % homeless, % arrested) – Support of ACES (adverse childhood experience intervention) – Support of community health workers

• New Medicaid eligibility categories

– Long-term services and supports

• Supporting unpaid family caregivers
• Supporting people who need long-term services and are at risk of

spending down to impoverishment

– Foundational community supports

• Helping those with complex health needs obtain and maintain housing

and employment

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Clinical/community linkages through Accountable Communities of Health

Focus on:

• Addressing health

issues through regional collaboration

• Community,

stakeholder, provider engagement

• Integration of physical

& behavioral health

• Medicaid

Transformation

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System redesign: whole person care

• Health reform must address accountability for cost

and outcomes

• This imperative is driving system design that:

– Focuses on social, physical, and behavioral health needs – Emphasizes coordination of care across sectors – Requires financial flexibility, shared data, and collaborative leadership

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Process challenge: “Whole person – whole system”

• Teams

– Availability of trained personnel – Roles and expectations – Communication and coordination (“co-location is not collaboration)

• Data collection and registries

– Measurement – Population-based care: tracking and reporting

• Connection to community

– Social determinants of health

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Measurement goals: Capturing “whole-person” outcomes data

• Improved health status including recovery/resilience
• Increased participation in meaningful activities like

employment and education

• Reduction in ED, hospital and crisis services
• Reduced involvement in criminal justice system
• Enhanced safety and access to treatment for forensic

patients

• Increased housing stability

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Health Home program

• Services include

– Comprehensive care management – Care coordination – Health promotion – Transitional care planning – Individual and family supports – Referrals to community and social support services

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Is it working?

YES……

• Health Home services are changing lives
• Health Home services are reducing health care costs
• Dual eligible Medicare savings from the first 30

months of Health Home program: ü Preliminary gross Medicare savings of $67.5 million over two years*

*Report for Washington Managed Fee-for-Service, Final Demonstration Year 1 and Preliminary Demonstration Year 2 Medicare Savings Estimates, Centers for Medicare & Medicaid Services, July 2017

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Payment drives system transformation

• Fragmented clinical and financial

approaches to care delivery

• Uncoordinated care and transitions
• Unengaged people left out of their own

health care decisions

• Variation in delivery system

performance, cost, and equity with no clinical or financial accountability and transparency

Status quo

• Integrated systems that pay for and deliver

whole person care

• Coordinated care and transitions
• Engaged and activated people who are

connected to the care they need and encouraged to take a greater role in their health

• Standardized performance measurement

with clinical and financial accountability and transparency for improved health

• utcomes

Transformed (value- based) system

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Examples of state VBP efforts

PEBB – State Employees Apple Health - Medicaid

• Accountable Care Program, ACO model

with up and downside risk to incentivize clinical and quality accountability

• Total Joint Replacement Bundle and

Center of Excellence

• Contracts with HCA require bidders to
• ffer substantially similar ACO program

(risk sharing and care transformation approaches) to spread VBP in the marketplace

• 1% MCO premium withhold based on

quality and provider VBP arrangements

• Behavioral and physical (financial)

health integration in Southwest WA, statewide by 2020

• Exploring a value-based model for

rural settings

• Medicaid Demonstration: regional VBP

goals tied to incentive payments

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• Washington state is transforming the way it

purchases health care.

• HCA is aligning its business with national movement

away from fee-for-service to payments based on value.

• Medicaid Transformation demonstration continues

through 2021.

• End result is better care, healthier people, and lower

costs for Washington residents.

Where we are and where we’re going

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Questions?

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