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

FLAACOs Business Partners
Improving Outcomes and Reducing Costs Through Active Care Coordination and TEAM Based Care
TEAM of Care Solutions
Alan Gilbert
Ph855.602.6800
Email Alan.Gilbert@TEAMofCare.com

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Leveraging Outdated Claims Data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 allthe 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
Acute
Home

PCP Acute Post
Acute
Home
35% 18%
7%
14%
9%
6%
9%

PCP Acute Post
Acute
Home
24 16 22 303

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 referral
Source: 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 SystemPCPSNFPublic Health Information Exchange: ADT & Continuity of Care Document (CCD) AcuteAcuteACO EcosystemNon-ACO Inpatient EcosystemNon-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 Us
TEAM of Care Solutions
Alan Gilbert, MPA, FHIMSS
Ph855.602.6800
Email Alan.Gilbert@TEAMofCare.com
Website www.TEAMofCare.com

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

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