FLAACOs 2014 Conference - Improving Outcomes and Reducing Costs Through Active Care Coordination and...

FLAACOs Business Partners

Improving Outcomes and Reducing Costs Through

Active Care Coordination and TEAM Based Care

TEAM of Care Solutions

Alan Gilbert

Ph 855.602.6800

Email [email protected]

mailto:[email protected]


What was the Old Way To Coordinate Care?

Through the Rear View Mirror

Leveraging Outdated Claims Data

No Formalized Plan of Care in Any Setting

Minimal Coordination Communication Among Providers and Specialists

Minimal Patient Input Into Treatment Options and Care Delivery

Lack of Formal Initiatives for Patient Satisfaction Outside the Hospital


What is the Goal We are Trying to Achieve?

Source: Identifying and Quantifying the Cost of Uncoordinated Care: Opportunities for Savings and Improved Outcomes,

Mary Kay Owens, R.Ph.,C.Ph, Institute of Medicine, 2009.


Potentially Avoidable Complications Consume a Large Portion of Spending


Emergency Departments Are Over Utilized

Source: CDC/NCHS, National Hospital Ambulatory Medical Care Survey.


What is the Problem to Creating System Performance for ACOs?

Problem: Lack of Infrastructure Between Participants to Assure Bonus

Payments

Coordinate Care Between Sites of Care

Manage Multi-Site Performance to Lower Cost

Manage Multi-Site Performance to Improve Quality


What Makes a Great TEAM?

Working Towards a Common Goal

Improved Care Outcomes and Reduced Costs of Care

Bonus for Achieving Program Goals

TEAM-Work

A TEAM of Care Across All Care Settings

Clinical Integration among Providers

Every TEAM Member Does Their Part

Specific Actions Needed to Achieve the Goal

Actionable does not equal ACTIVE


Lessons Learned

If you have seen one ACO, you have seen one ACO

Importance of an infrastructure inclusive of all transitions

Achieving buy-in from multiple stakeholders will take time

Analytics and reporting do not change provider behavior

Establish a Foundation for performance


ACO Care Coordination Philosophy

Tighten Integration Across the Entire Continuum of Care

Integrated TEAM of Care

Not Replacing the Care TEAM: Coordinating Their Efforts

Create a Unified View of the Patient and Their Care

Unified Coordination Plan

Synchronize Orders and Actions

NOT replacing the EMR (clinical system of record)

Manage the Actions that Improve Outcomes and Reduce Costs

Task and Action Tracking

Prioritize Actions and Resources

Close the Gaps Before They Occur


Learning Objectives

Why do you need a platform to manage and coordinate the care activities

inside and outside of your organization, across the entire continuum of

care?

Lack of IT infrastructure between providers

Care Coordinators typically use combination of multiple technology systems and

manual processes to coordinate care

Many physicians are in the process of changing EMRs

Not all EMRs can generate an automated CCD

Most EMRs do not have all the fields for ACO Quality Metrics

EMR tasks are not Care Coordination workflow

Paper will persist

Typically need to integrate to internal or external Health Information Exchange

(HIE)


Set Foundational Requirements that Create Momentum to Performance

Agreement on Goals

Patient Centered Medical Home Certification (PCMH)

Agreement on Practice Standards

Engage Entire Continuum of Care

Require Meaningful Use Certified EMRs

Commitment to Active Care Coordination

Establish Care Coordination Technology Infrastructure


Foundation: Agreement on Goals

ACO Enterprise Performance

Business Operations

Clinical Performance

Cost Management

Productivity

Growth

Adoption of Medicare Shared Savings

Program (MSSP) Metrics

Cost

Quality

Compliance


Foundation: Patient Centered Medical Home

PCMH demonstrates PCP commitment to Triple Aim Goals

Focus attention on aspects of primary care the improve quality and reduce costs

TEAM-Based approaches to care

PCMH practices have already begun the culture change

Source – NCQA Standards Workshop – Patient-Centered Medical Home – PCMH 2011 – Part 1:

Standards 1-3


Foundation: Agreement on Practice Standards

Create Clinical Work Groups to Set Coordination Pathways

NQF Metrics, primarily Outcomes

Establish a Common Coordination Plan across the ACO

Initially Focus on Specific Conditions Used to Quality Metrics

Diabetes

COPD

CHF

CAD/Hypertension/Ischemic Vascular Disease

Depression

Preventative Health


Foundation: Engage Entire Continuum of Care

PCP Acute Post

AcuteHome



PCP Acute Post

AcuteHome

18%35%

7%

14%

9%

6%

9%



PCP Acute Post

AcuteHome

221624 303


Foundation: Require Meaningful Use Certified EMRs

Real-Time EMR Data is Critical to Active Care Coordination and ACO

Performance

Qualifying for MU Incentive is a MSSP Quality Metric

Core Objectives for Meaningful Use align with the ACO Quality Metrics

Report ambulatory clinical quality measures to CMS

Generate list of patients by specific conditions

Provider of care should provide summary care record for each transition of care

or referralSource:

www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/eP-Mu-tOC.pdf

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/eP-Mu-tOC.pdf


Foundation: Commitment to Active Care Coordination

Patient Navigators: Care Coordinators Embedded in Care Settings across the

Care Continuum (e.g. Hospital, Physician Office, Nursing Home, etc)

Care Coordination has to be in the clinical workflow

Share care plan, care coordination tasks, and secure messages in a

standardized format

Proactive preventative, acute, chronic, and end of life care

Establish a Common Language: Care Coordination Lifecycle Status

Claims Data is Two Months Old: Too Re-Active for Care Coordination



Chronic Disease Management (CDM) Interventions

Identify and Take Action on Gaps Before They Occur

Create Care Plans Around Individual Goals

Create Shared and Unified Coordination Plan

Prioritize Actions using Satisfaction, Risk, and Cost Scores



Transition of Care Interventions

Get Patients and Families involved in their own healthcare management

Unified Care Plan with Coordination Activities

Systematic Follow Up Tasks and Alerts

For example, Contact w/in 48 hours/PCP visit w/in 7 days



Emergency Interventions

Notifications at time of Emergency Room Registration

Opportunities Abound

Initiating Quality Care

Diverting of Care

Cost Containment

ACO Contacts Emergency Room to

Provide context and historical information

Participation in the decision making

Engage patient and patients family/caregivers


Foundation: Establish Care Coordination Technology Infrastructure

· Care Coordination / ACO Performance Management System

· Private Health Information Exchange

· Document Management System

· Data Analytics System

PCP

SNF

Public Health Information Exchange:

ADT & Continuity of Care Document (CCD)

Acute

Acute

ACO Ecosystem

Non-ACO Inpatient Ecosystem Non-ACO Outpatient Ecosystem



Care Coordinators

Primary user

Manage Care Plans Continuity Between Providers and Patients

Transition of Care Between Sites

Providers

Rapid Visibility into Care Plan Process

Task Queue Directly Embedded in the Workflow of the EMR

Referral Management Between PCPs and Specialist

Administrators

Program Performance Management

Workflow Management


Reach UsTEAM of Care Solutions

Alan Gilbert, MPA, FHIMSS

Ph 855.602.6800

Email [email protected]

Website www.TEAMofCare.com

mailto:[email protected]

http://www.teamofcare.com/

FLAACOs 2014 Conference - Improving Outcomes and Reducing Costs Through Active Care Coordination and...

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