Session 33

Improving Outcomes in a Value-Based Environment:Holistic Care Management for Complex Medical Conditions

Kyle Grunder, MBADirector of Provider Operations CKRI, Allina Health

Jill Henly, MSW, LCSWManager, Care Coordination and Social WorkCRKI, Allina Health

Learning Objectives

• Recognize how advanced care management can help people with disabilities, injuries, or complex medical conditions achieve the highest possible degree of health, functioning, and quality of life, while also lowering costs.

• Recall how this breakthrough approach serves as an organization’s innovation lab for the emerging value-based reimbursement model.

• Define the role analytics plays in creating a new care model.

2

3

15% Impacts

approximately

of citizens in the United States. An essential element to

maximize the quality of life for patients with disabilities.

Poll Question #1

4

How important is rehabilitation to your organizations’ ability to manage its populations?

1) Not important2) Somewhat important3) Moderately important4) Very important5) Extremely important6) Unsure or not applicable

Allina: Region’s Largest Healthcare OrganizationAllina Health is dedicated to the prevention and treatment of illness and enhancing the greater health of individuals, families, and communities throughout Minnesota and western Wisconsin.

Allina Health• 13 Hospitals.• 82 Clinic sites.• 3 Ambulatory care centers.• Pharmacy, hospice, home care,

medical equipment.• 26,000 employees. • 5,000 physicians.• 2.8 million+ clinic visits.• 110,000+ inpatient hospital

admissions.• 1,658 staffed beds.• 3.4B in revenue.• 32% Twin Cities market share.

Courage Kenny Rehabilitation Institute

Largest Rehabilitation Provider in the Upper Midwest

Locations45

Employees1,500

Volunteers2,000

Lives Touched Each Year95,000 +

The Courage Kenny Rehabilitation Institute

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Background

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• Services for the disabled often exist in silos.• Lack of care coordination results in a less than

ideal support relationship. • A whole person approach is needed, including a

greater focus on preventative care.

• A very complex population. • Average patient has 7-9 medical conditions in

addition to disability(ies).

• Allina needed to be better stewards of resources.

• Prepare for pay-for-outcomes (value-based) reimbursement model.

Complex Population

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Income

Dual 34%

MA Only 37%

Medicare Only15%

Private 14%

Payers

Arthritis 4%

Brain Injury/CVA

45%Spinal cord Injury 20%

Musculoskeletal13%

Cerebral palsy8%

Neurological 7%Other 3%

Diagnosis

Courage Kenny Rehabilitation Institute

Above 200%

poverty, 20%

Below 200%

poverty, 35%

Below poverty,

45%

The Opportunity

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• Comprehensive services and skilled providers were needed to address the needs of this complex population.

• Rehabilitative care has many inherent challenges including:• Lack of coordinated care from inpatientÆ rehab Æ

outpatient.• Inconsistent offering of support services for patients

once they are discharged. • Use of care coordinators was not consistently applied. • Community services engagement.• The need to focus first on what is right and best for

the patient, while considering the Triple Aim associated with caring for its population.

Turning Point

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Allina Health saw the need to:1. Create a new model for

rehabilitation care that focuses on the whole person—looking beyond just medical to address vocational, social, community, and emotional needs.

2. Increase collaboration to enable comprehensive and seamless care across the continuum while preparing the organization to operate in a value-based, at-risk environment.

Results

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• Creation of an innovative care management model and culture that optimizes patients’ quality of life.

• Annual community cost savings of $11.2 M.• Savings resulted from significant reductions in

many areas, including hospitalizations, length of stay, and emergency department (ED) visits.

• For example, up to 76 percent reduction in hospitalizations and 53 percent reduction in ED visits, for specified programs.

Community Cost Savings

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Courage Kenny Program Annual Total Cost of Care Reductions in 2015 Primary Drivers

Advanced Primary Care(Healthcare Home)

*DHS population only$4,500,000

Hospitalizations reduced 37%.Hospitalization days reduced 66%.Readmissions reduced 79%.

Residential Pain Program $180,000Hospitalizations reduced 76%.Emergency department (ED) visits reduced 53%.Pharmaceutical use reduced 83%.

Stroke Care Coordination $525,000

Hospitalizations reduced 15%.Hospitalization days reduced 2%.ED visits reduced 43%.Secondary stroke reduced 8%.Mortality per 1000 strokes reduced from 40 to 0.

Independent Living Skills (ILS) $100,000Hospitalizations reduced 22%.Primary care physician visits increased 28%.

Adult Rehabilitative Mental Health Services (ARMHS) $430,000

Hospitalization days reduced 53%.ED visits reduced 15%.

Vocational Services $930,000 Benefit to Minnesota's economy for every dollar invested (MN State Rehabilitation Council annual report).

Transitional Rehabilitation Program $3,200,000 Transitions to home, reduced healthcare facility utilization.

Outpatient Physical Therapy Utilization $1,400,000 Deliver at, or better than, national average outcomes with fewer therapy visits than national averages.

Cumulative Community Savings $11,200,000

Serving patients with the most critical needs & achieving improved outcomes results in fewer, higher cost services

Three key ingredients to the results we achieved. 1. Care Delivery Transformation.

2. Analytics.

3. Specialized Programs.

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Our Innovative Approach

Care Delivery Transformation

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CKRI exists to help people with disabilities, injuries, or complex medical conditions achieve the highest possible degree of health, functioning, and quality of life.

• Specific objectives addressed included: • Early identification of patients in need of CKRI services.

• Better coordinated interdisciplinary care for inpatients.

• Consistent use of care coordinators.

• More effective care transitions—ED → inpatient → rehab → home.

• Providing support services for patients post discharge – including more consistent and better use of community support services.

• Focused on the best care for each patient to achieve the highest quality of life – not driven by cost or reimbursement considerations.

Analytics

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The new coordinated care model is supported by analytics, helping CKRI overcome the identified challenges.• Implemented an EDW and analytics platform to integrate clinical, demographic, cost,

claims, functionality and satisfaction data to:

� Identify, target and monitor populations for different initiatives.

� Evaluate clinical processes and business operations.

� Manage care and support across the continuum.

� Measure patient outcomes.

� Demonstrate improved outcomes for services provided to payers and the community.

Poll Question #2

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How effective is your organization at identifying patients with disabilities who need special support?

1) Not effective2) Somewhat effective3) Moderately effective4) Very effective5) Extremely effective6) Unsure or not applicable

CKRI Analytic Tools

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Tabs support views of care and functionality levels across the continuum. Ability to filter by group,

location, diagnostic code, patient and

provider and time period.

Toggle between different outcome measures.

Specialized Programs

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CKRI serves a vast population for both chronic and episodic rehabilitation needs, with more than 11 different specialty programs.

Today we will highlight three key specialty programs:• Advanced Primary Care Clinic.• Stroke Care Management.• Transitional Rehabilitation Program.

Advanced Primary Care

Medical Home Model Delivers on the Triple Aim

The Advanced Primary Care Clinic• Providing the best care for patients with disabilities…

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Background

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• This group is part of the five percent of the US population accounting for 47.5% of all healthcare spending.

• A disability knowledgeable primary care clinic was suggested as a way to resolve poor access to healthcare resulting in high cost and poor outcomes.

difficulty in accessing

health-care providers’

offices.

22% 12.9%

unfair treatment at a provider’s office.

As a result, frequently use hospitals and emergency rooms.

Persons with disabilities who report:

The Opportunity

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• Individuals with disabilities have complex health needs, face profound issues of access to basic health services, and are four times more likely to be hospitalized than the general population.

• Addressing this challenge requires an investment in non-traditional primary care to understand and meet the needs of the population being served currently within the rehabilitative service line.

The Turning Point

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Recognized the need to redefine historical roles

(including primary care) and create

new roles.

Needed to make appropriate data

available to achieve Triple Aim.

Required an “innovation center” to

foster new care models and allow

learning in preparation for a value-based reimbursement

model.

Results

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• Created a disability-knowledgeable care environment. • Providers knowledgeable about living with a disability.• Resources to address the medical and social challenges of disability.

• Overall improved experience for patients.

• Improved access to care through nurse care coordinators.

30%REDUCTION

66%REDUCTION

79%REDUCTION $4.5M

SAVED

in hospitalizations. in hospitalizations days.

in 30-day readmissions days.

over one-year period.

Value Realized

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Calculations based on 193 CKRI Advanced Primary Care patients covered by Medicaid only or dually eligible. Hospitalization tracked 3 years prior to enrollment, and through their enrollment into the clinic.

10.6

3.6

0

2

4

6

8

10

12

Before medical home enrollment After medical home enrollment

Hos

pita

l Day

s

Hospital Days ReductionEquates to

$2.96 million for all Medicaid or dually-eligible patients for

2015.66% reduction in

hospital days, equivalent to

$1,277 in savings per patient per month to Allina.

Poll Question #3

Does your organization have a primary care environment that is specifically designed for patients with disabilities?

a) Yesb) Noc) Unsure or not applicable

1. Certified medical home (CMH).

2. Whole person care management.

3. Analytics.

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Our Approach to Supporting the Needs of Medically Complex Patients

Certified Medical Home (CMH)

Effective Care Management model• Fully accessible clinic.

• Hour long appointments.

• Set goals that meet individual patient needs.

• Focus on early intervention techniques—including appointment scheduling, follow up, and arranging accessible transportation.

• Coordinated medical and social services.

• Management of chronic conditions preventive services.

• Large referral network of community-based services.

• Co-located physiatry, psychiatry, and pain services.

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Whole Person Care Management

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RN care coordinators are assigned to meet patients’ highly individualized health and social needs.

• Develop comprehensive care plans for each patient.• Perform medical assessments, triage, referrals, medication

refills, labs, immunizations, and health education. • Maintain contact with the patient on average of two times

per week.• Assist with non-medical needs, that if left unaddressed can

hinder patients from keeping to their care plans (e.g., financial challenges, housing, legal issues).

Analytic Tools Track Opportunities

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Various filters (based on location, service line, diagnostic code, etc.) to identify disability patients for CKRI consult within 24 hours of admission.

Results for a search for disability patients with seizure disorders at Allina’s Abbott Northwestern Hospital.

Tracking Key Metrics

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0.2

0.4

0.6

0.8

1

1.2

1.4

Nov'12

Dec'12

Jan '13 Feb'13

March'13

April'13

May'13

June'14

July'14

Aug'14

Sept'14

Oct '14 Nov '14

Dec'14

Jan '15 Feb'15

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May'15

June'15

July'15

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Sept'15

Oct ‘15 Nov ‘15

Dec ‘15

FinalData

Hosp PMPM Pre Enroll Hosp PMPM Post Enroll

66% reduction in hospital days over a three year period

Advanced Primary Care Clinic - Hospitalization Days Per Member Per Month

Quick Break:5 minute stretch

Stroke CareCare Management Strategy

Improves the Lives of Stroke Patients

Background

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Stroke kills ~130,000

Americans yearly—1 out of every 20

deaths.

On average, one American dies from

stroke every 4 minutes—795,000 deaths annually.

Stroke costs the U.S. an estimated $34 billion each

year.

Stroke is a leading cause of serious

long-term disability in the United

States.

Table Discussion

At your table, discuss the challenges you have encountered in your organization caring for stroke patients… ...if you are not a care provider or do not have experience in stroke care, discuss the challenges you have witnessed by family members or friends who have experienced a stroke or other serious disability.

The Opportunity

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• Stroke patients needs are complex and challenging. • Recovery depends on many factors, from early administration of

treatment to comprehensive, tightly coordinated care post-discharge.

• Allina identified a number of challenges related to stroke care. • Early intervention and treatment essential for best outcomes. • Patients not achieving maximum physical and cognitive recovery.• Key transitions not being managed as well as they could be. • Need for better patient education.• Inadequate data regarding post-stroke functionality.

• This led to higher readmission rates and poor outcomes.

The Turning Point

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Allina Health believed that readmission rates and other challenges facing stroke patients could be significantly reduced with comprehensive, coordinated care across inpatient teams, rehab services, and social support services.

Results

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reduction in stroke mortality.

Mortality per 1000 strokes reduced from

40 to 0.

Saved $154,000

over one year.

56%

reduction in hospitalizations.15%reduction in hospitalization days.2%reduction in emergency department visits.

43%

Care coordinator program proven successful for stroke patients.• Supports patients and their caregivers to

understand and navigate through what can be a complex care delivery.

• Strengthens care team relationships and coordinates patient care with care guides, social workers, inpatient teams, and rehabilitation care support services.

Analytics Helps to Identify, Monitor, and Manage Patients

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Care Coordinator and Care Guide view list of individuals on care team, appointments, and no shows.

Ability to filter by discharge date, location, and disposition.

1. Care model.

2. Education.

3. Analytics.

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The Three Keys to Achieving Results

Care Model & Education

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Whole person care model to deliver seamless care across the continuum.

• Care manager (funded by grants).• Experienced RNs assigned to help patients navigate the delivery system. • Available from diagnosis through treatment.• Work with a care guide and a social worker to collaborate patient’s support

needs.

• Stronger relationships between inpatient teams and support services.• Clinical care and rehab services coordinated to assure efficient care

delivered in a timely manner.

Improved patient and provider education. • Videos, stroke camps, connect through storytelling, peer visitors, and

support groups.

Analytics Platform

Analytics help to prove value of care management model through improved outcomes (PROMIS, secondary stroke,

readmission, missed appointments, etc.) for post stroke patients that

were supported by the care manager.

Ability to filter by group, location, diagnostic code, patient and provider, and time period.

Dashboard view for a specific outcome measure.

Functional values and improvements by patient.

Integrated clinical, demographic, cost, claims and patient functionality data from across the enterprise. • Analytics used to:

• Identify, monitor and manage patients.• Measure financial impact of care

management model; for example, how preventative measures save the system money.

• Measure and improve patient satisfaction.

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Making Lives Work for Stroke Patients

Transitional Rehabilitation

Transitional Care Helps People with Disabilities

Achieve Highest Possible Quality of Life

Background

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• Common for patients to experience changes in physical function resulting from disease, injury, surgery, or increasing frailty.

• Disability is one of the nation’s most important public health issues impacting approximately 13%-15% of U.S. citizens.

• For the ill or injured, a comprehensive rehabilitation program is an essential element required to achieve a high level of functionality.

• The Transitional Rehabilitation Program (TRP) is a nationally recognized 44 bed skilled nursing facility (SNF) inpatient program that has been serving people with disabilities since 1976.

The Opportunity

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• In 1999, the state legislature passed legislation providing financial support to meet TRP’s unique needs.

• In 2012, the state legislature repealed this critical financial support as a deficit reduction measure.

• In 2013, TRP was operating at an unsustainable deficit.

• $110 per resident per day ($1.4 million annually).

The Turning Point

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TRP recognized the need to be better stewards of resources and to demonstrate that their services result in improved patient outcomes and long-term cost savings for the state.

Results

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20%improvement in impairment in brain injury patients (MPAI-4)

84% 14%improvement in spinal cord independence measure (SCIM)

improvement in patient-reported physical health (PROMIS 10)

13%improvement in patient-reported mental health (PROMIS 10)

20% $3.2Mpoints greater success than traditional SNFs in discharging to community

Saved over a one-year period.

Successful reinstatement of state legislation to close funding gap

High-Quality Data and Analytics

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Critical components to effectively managing services

Filters show physical and mental health ratings—time 1 and time 2.

Ability to filter by group, location, diagnostic

code, patient and provider and time period.

Table Discussion

At your table, discuss the types of patient-reported data you collect and how you use it.If you are not currently collecting patient-reported data, what are the obstacles you face in implementing this practice?

1. Analytics platform.

2. Care model.

3. Reimbursement legislation.

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Key Elements to Achieving Results

Analytics Platform

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Leveraging Allina Health’s EDW and analytics platform, TRP was able to monitor the cost of care, track patient outcomes, and identify TRP candidates.

By continuously reviewing patient data, it served those with the biggest need to maximize cost savings to the community.

• TRP analytics provides: • Costs and patient clinical, functional, and satisfaction outcomes. • Outcomes relative to like patients who do not receive the same intensive

therapies and services offered by TRP. • Patient reported outcomes.� Physical independence, mobility, social integration, occupation and mental, and physical health.

• Health outcomes reported using nationally recognized ratings.� Mayo-Portland Adaptability Inventory (MPAI). � Spinal Cord Independence Measure (SCIM).

• Outcome data to justify improved state funding support.

Care Model and Reimbursement Legislation

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Leveraging the whole person care model used across Allina Health, TRP was able to better manage patients’ full continuum of care.

Reimbursement legislation critical to TRPs work. • Minnesota Department of Human Services recognized

CKRI’s TRP special services required above-the-norm reimbursement.

• TRP needed to become better stewards of resources and prove that it helped people with disabilities achieve their maximum cognitive and physical functionality.

• Data and actionable analysis was the answer to prove value for its services and lobby for critical reimbursement adjustments.

The Present and Future of

CKRI

The CKRI Story…

CKRI has successfully implemented a highly collaborative and multi-disciplinary approach to comprehensive rehabilitation

characterized by a holistic view of health. This new data-driven care model features an effective blend of health system and

community services in support of patients, focusing not only on patients’ medical needs, but also on their vocational, social, and

emotional needs.

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Lessons Learned

• Service line value proposition driven by Sr. Leadership.• Creation of a multidisciplinary Value Oversight Committee to design,

implement, and manage the new care model.• A commitment to standardization, programmatic support, and outcome

measurement among frontline clinicians and leaders across a large health system.

• A strong culture of learning and innovation.• A high degree of patient involvement and advocacy.• Expansion of care team roles outside of traditional healthcare

(independent living skills, telemedicine, care guide, volunteers).

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Future Plans for CKRI

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Continue to improve the model with hopes

of being able to expand its services to support even more individuals.

The organization is working continuously to refine its

ability to manage its populations effectively, as well as to apply lessons

learned to help rehabilitation services

operate more effectively under a value-based, risk-

based reimbursement system.

Focus on enhancing processes for

collecting necessary clinical, utilization,

functionality, and cost data from across the

continuum into integrated analytic

environment.

Analytic Insights

AQuestions &

Answers

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What You Learned…

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Write down the key things you’ve learned related to each of the learning objectives after attending this session

Thank You

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