Kim Olmedo, LCSW, CCM CSW-G Social Work Manager, Silverback

Care Management

According to AARP, about 8000 people turn 65 every day

The Medicare Trustees have estimated that Medicare will run out of money in 2026

The “good news”: this date is 2 years later than anticipated, in part due to slowed spending, primarily for skilled nursing care

Creation of the CMS Center for Innovation in 2009 • Accountable Care Organizations (ACOs) A platform for doctors, hospitals and other health care

providers to come together to decide what is best for the Medicare beneficiaries they serve

The Challenge • Medicare has significant challenges in program

management and sustainability Our Opportunity

• To be a part of the solution—to come together to help shape the future of Medicare

The Model—Pioneer ACO • Health care organizations and providers that are

already experienced in coordinating care for patients across care settings

Texas Health Resources and North Texas Specialty Physicians submitted an application to CMS in August 2011

Pioneer ACO status was granted in October 2011

Plus became operational January 1, 2012

Patients • 41,000 traditional Medicare beneficiaries • Primarily in Tarrant, Johnson, Parker, Dallas, and

Collin counties • Patients are aligned based on the physicians

who provide the plurality of their care Physicians

• 600 NTSP physicians; about 200 are PCPs • 140 Texas Health Physicians Group (THPG) PCPs

and 40 THPG physician extenders

Save Medicare dollars Provide quality health care

All ACOs must adhere to 32 quality metrics mandated by CMS

Managing a previously unmanaged population

Care management plays an integral role in the ACO model

CMS shared claims data with Plus This allowed Plus to see where Plus

beneficiaries were getting their care, and the type of care they were getting

In 2012, UM services were provided by Gordian.

All providers were asked to notify Gordian of services being provided to Plus members, including hospital admissions (acute care, LTAC and Rehab), home health services, skilled nursing admissions and DME requests

In April 2013 this service was brought back under the auspices of NTSP through a new company, Silverback Care Management

Plus members are still traditional Medicare beneficiaries

They still have the choice to use any health care provider, even providers not on the Plus Preferred Provider list

We still ask all providers to notify Silverback, so that we know the services our members receive, and so our case managers can assist when needed

Developed preferred providers These providers go through a formal

process that looks not only at costs based on claims data, but that also looks at a variety of quality measures

Costs are weighted based on RAF scores, which is a risk adjustment index

Care management team was gradually implemented during 2012 • Initially there were 2 nurses doing a Discharge

Transitions program from THFW • One nurse embedded in THFW Emergency

Department on the weekends to do ED Diversion • 2 social workers by the end of the year,

monitoring patients at THSW and assisting with discharge planning, as well as providing community case management

Nurses identified patients in the hospital who were at the highest risk of being re-hospitalized within 30 days

Following discharge, the patient received at least weekly phone calls from the nurse

Nurse embedded in ED By identifying Plus patients in the ED, she

was able to prevent some admissions by identifying other services, such as SNF placement when qualified, or direct admission to inpatient rehab

This team now includes 7 social work case managers and 3 RN case managers

We can do: • Home visits • Referrals to community services • Provide services across the care continuum • Coordinate care between health care providers • Assist discharge planners in hospitals and

skilled nursing facilities

A three-tiered predictive modeling system helps us identify patients who might be in need of care management services

These are healthy patients, or those with a stable chronic disease state

Patients are engaged, and receive most care at the primary care level

Patients with more PCP visits than ED visits

No hospitalizations in the past 12 months

These patients are at risk for moderate to serious health issues

Have had between 2-5 ED visits in the past 12 months

More ED visits than PCP visits At least one hospitalization in the past 12

months

These patients have established disease states and/or may be in the terminal stages of chronic illnesses

5 or more ED visits in the past 12 months More than 2 acute care admissions in the

past 12 months Multiple system of care contacts

Plus is on pace to save $10 million annually in Medicare spending

Plus is meeting all quality metrics

At this time, Plus has notified CMS of our intent to withdraw from the Pioneer ACO program, due to possible substantial penalties

At this time, we are still a Pioneer ACO, and as recently as Friday we were still in talks with CMS on how we might remain in the Pioneer ACO program

It is very likely that traditional Medicare will have some level of management

There are still 23 Pioneer ACOs, and more and more shared savings ACOs are being created

Medicare supplement products are attempting to manage their members, and United Healthcare is demonstrating savings with this population in 5 cities across the country