St. Vincent’s Health Partners, Inc.Dr. Michael G. Hunt

CMO/CMIOBridgeport, CT 06606

203-275-0201michael.hunt@stvincentshealthpartners.org

http://stvincentshealthpartners.org/

Clinical Integration, Network Development, Physician-Hospital Organization, ACO: Ask the Same Question…

To HIE or not to HIE?

A PHO is a legal entity generally formed by physicians and one or more hospitals with the intention of negotiating contracts with payers and sharing in the financial rewards of controlling costs while delivering high-quality care.

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What is a Physician Hospital Organization (PHO)?

“Physicians working together systematically, with or without other organizations or professionals, to improve their collective ability to deliver high quality, safe, and valued care to their patients and communities”.

Alice Gosfield, J.D.

What is a Clinically Integrated Network?

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An active and ongoing program to evaluate and modify practice patterns by the network’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality.

This may include: Establishing mechanisms to monitor and control utilization of health care

services that are designed to control costs and assure quality of care Selectively choosing network physicians who are likely to further these

efficiency objectives The significant investment of capital, both monetary and human, in the

necessary infrastructure and capability to realize the claimed efficiencies

Clinical Integration

SOURCE: FTC/DOJ - Statements of Antitrust Enforcement Policy - 1996

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Levels of Integrated Care

Harold Miller: How to Create Accountable Care Organizations 2009

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Attributes for Clinical Integration

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St. Vincent’s Health Partner’s Membership

SVHP

HospitalsSkilled Nursing

Facilities / Rehab / HHC

PCPs Specialists

HospitalMember(s)

PhysicianMembers

1 Flagship Hospital – St. Vincent’s Medical Center370 Providers (Physicians, PAs, APRNs)52 offices > 40 specialties

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ServiceProvision of medical care from a provider/facility directly to

the patientManaging all elements of individual patient care

ManagementPopulation Health

Defining the operational roles of care coordinationEnterprise level

Defining the operational role of case managementFacility level

SVHP Operationalizing Medical Management and Service

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Participate in Care Coordination services across the clinically integrated network while utilizing existing case management services in the hospital, ambulatory, ED, urgent care centers and SNF’s by identifying the additional Care Coordination needs and develop processes across the continuum for a seamless transition of care.

SVHP Playbook Identified more than 140 care transitions and established baseline requirements for data portability Details quality metrics agnostic to Payer Reference for Care Guidelines – Preventative and disease management Organizational polices and plans

SVHP Care Coordination Process

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Goal:Meet Patient Needs and Preferences in Delivery of High-Quality,

High-Value Care

Bridging the gaps between:Primary CareSpecialty Care InpatientMental Health ServicesLong-Term CareMedical HistoryTest Results

Bridging the GapsTransitions of Care

Home Care Informal Caregivers Patient/Family Education and

Support Medications/Pharmacy, and Community Resources

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Operationalization of Care Coordination

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Disaggregation of Data

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Current Health Information Exchange

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Legacy Data from disparate Practice Management Systems

DataHospital(s)Laboratory

Local and national companiesInsurancePatient specific (EMR)ImagingPharmacy

What PHOs Need

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Optimize preventive and chronic disease management Primary and specialty care

Reduce variations of care Care Coordination

Focus the right treatment at the right time for the patient Identify and develop cost-effective management strategies Support initiatives

Patient Centered Medical Homes Participation with ACO Maximize reimbursement

P4P, PQRS, etc. Achieve clinical integration and physician adoption

Share Data Between professionals and institutions With the patient Public transparency

PHO Goals/Strategies

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Membership value to participate Priorities of membership Respect clinical workflow

Just another tool not well utilized Cost and Budget

Limited financial resources Quality and performance demonstration

Use of available data

PHO Information Exchange

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Data typesLabs not based on LOINC

Need for mapping between organizationsData receptivity

Format HL7 CCD Flat file

Patient transition and patient-specific information transfer Intramember patient communication Extrainstitution patient communication Competing priorities between stakeholders Technology

System oriented versus independent members

Our Challenges

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If you do not measure it, you cannot improve it.

IT is the backbone of the CI network's value proposition and is critical to improving coordination and connectivity between providers of care.

Today the industry is inundated with tools to assist with monitoring and reporting the care provided to a patient. Two types of data sharing sources

Health records patient registries

repository that holds clinical information specific to a disease, disease process, implant, drug, etc Sources

physician office Hospital ancillary care facility ambulatory care facility

Information Technology

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Component Definition Method of Measurement

Process Manner to ensure that care is given

Clinical pathwaysReadmissionsRate of preventive testing

Infrastructure Facilities, personnel and equipment used in the healing process

Patient satisfaction survey

Outcome Results of patient care ComplicationsCost of careLength of hospital stay mortalityMorbidityDisease-specific function tools

What are the Quality Components

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InpatientReadmission ratesMedication reconciliationCare Coordination

OutpatientPreventive Health

Wellness exams ImmunizationsMammograms/pap smears

Chronic diseaseDiabetesCHFAsthma/COPD

Quality Metrics

Acute and Chronic Care Management Measures

Appropriate testing for children with pharyngitis Appropriate treatment for children with URI Appropriate antibiotic treatment for acute bronchitis New episode of depression: acute phase treatment New episode of depression: continued treatment AMI: persistence of beta-blocker treatment after a heart attack CAD: ACE inhibitor/ARB therapy Complete lipid profile for patients with CV conditions Heart failure (HF) : beta-blocker therapy PDC: for HTN (ACEI or ARB) PDC: for cholesterol (Statins) Diabetes: eye exam Diabetes: hemoglobin A1c testing Diabetes: lipid profile Diabetes: urine protein screening PDC: oral diabetes Annual monitoring on persistent medications: ACE/ARB Annual monitoring on persistent medications: anticonvulsants Annual monitoring on persistent medications: digoxin Annual monitoring on persistent medications: diuretics Arthritis: disease modifying therapy in rheumatoid arthritis Osteoporosis management in women who had a fracture Use of appropriate medications for asthma

  Preventive Care Measures Breast cancer screening Cervical cancer screening Childhood immunization status: MMR Childhood immunization status: VZV Chlamydia screening in women Glaucoma screening in older adults Adolescent well visits: 12-21 years Well-child visits in the first 15 months of life Well-child visits: 3-11 years

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InpatientLength of StayAntibiotic usageBlood products/transfusionsReadmission rate

OutpatientInappropriate ER useInappropriate advanced radiologyCosts pmpm for ED, Pharmacy, inpatient, outpatient, radiology

Ambulatory Sensitive ConditionsER and Inpatient

Utilization Metrics

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McKesson Population Manager – Population Management

McKesson Risk Manager – Risk Management/Value Based Contracting

Clinical Informatics Systems – EHR/EMR/PMS/HIE/Pharmacy/Lab

Health Information Technology: Clinical Integration at SVHP

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Practice Management System Claims DataMSG - SVMCUCC – SVMCGoldfarb Ranno & Assoc.Allergy & Asthma Care, LLCPulmonary & Internal MedicinePrimary Care of SheltonEndocrine Associates, LLCEhrlich BariatricsOpthalmic Consultants of ConnecticutFamily Podiatry CenterDr. Reuvin RudichDr. R. Levin & Dr. L. Fliegelman

McKesson Population Manager – SaaS/Cloud

Secure File Transfer Protocol (SFTP) Claims Feed

Quest Diagnostics

HL7 Interface Results Feed

Clinical Lab Partners

.CSV Results File Upload

Physician Quality ReportingPoint of Care Technology (Future)

Physician Offices

Physician Hospital Organization (PHO)

&

PHO Hospital Partner

Data Sources

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Data Types and Sources

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Data Type Source

Primary Practice Mgmt / Billing System(s)

At each practice and not centralized.

Clinical Events EMR systems.

Providers Multiple sources. One provider could be in more than one source. TaxID & NPI’s are available for each provider (mid-levels too).

Lab Hospital, Quest, Labcorp, CLP, POC labs

Radiology Inpatient & Outpatient, may be different sources. POC radiology.

Pharmacy Possibly Surescripts.

Processed Claims Claims from insurers.

Other

Data sources include: Demographic, ICD-9, CPT, CPT-2 from

Practice Management Systems Prescription history from Surescripts HIEs Lab results from hospital, local labs,

LabCorp, Quest EMRs Hospital State sources (Immunization Registry) Survey Data Payers Data entered on-line

McKesson Population Manager:Robust Data Acquisition

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Every night, registry processing runs automatically:PCP AssignmentRegistry AssignmentResponsible Provider

Medical ExclusionsRegistry PurgeCompliance Calculation

McKesson Population Manager:Registry Processes

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McKesson Risk Manager

ProvidersHierarchies

Payer Medical

& RxClaims

MembershipEligibility

DataSentinel

Rhapsody

Data Mart

DataEnteredOn line

Lab Results

EMR, HIEData

Patient & Population Risk Management:

Predictive ModelsRisk Stratification

Pharmacy MgtWorkflow Engine

MD Attribution & Correction Workflows

Episodes of CareManagement

Capitation ManagementPMPM & Utilization

Benchmarks

HEDIS & STARManagement

DCGsETGs

EBM Connect

Quality Rules

P4P RulesFormulary

FDB

MPIAttribution

Organization Hierarchy

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Full Spectrum Reporting

Across the continuum of care: inpatient, outpatient and pharmacy

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McKesson Risk Manager:Quality Dashboard

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McKesson Risk Manager:Predictive Modeling Report

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Attribution

Questions?

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American Hospital Association’s Center for Healthcare Governance

Lakeshore Health Network Case Study, 2013

References

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