the abcs of acos for mch may 30, 2013 for assistance: please contact cmccoy@amchp.org or for web...

The ABCs of ACOs for MCHMay 30, 2013

For assistance:Please contact cmccoy@amchp.org

or for web support 888-447-1119 option 2

Brief Notes about Technology

Aud io

Audio is available through your computer

speakers or earphones.

For assistance, contact

cmccoy@amchp.org or for web support

888-447-1119 option 2

2

Brief Notes about Technology ContinuedQues t ions

To submit questions at any time

throughout the webinar, type your

question in the chat box at the lower left-

hand side of your screen.

•Send questions to the Chairperson (AMCHP)

•Be sure to include to which

presenter/s you are

addressing your question.

3

Technology Notes Continued

Re c o r d i n g

Today’s webinar will be recorded

The recording will be available in a week on the AMCHP

National Center for Health Reform Implementation website

at www.amchp.org

A PDF version of the presenters' slides will also be available

on the AMCHP website

4

Evaluation

Attendees will receive a link to a survey evaluation upon

completion of this webinar. Please take a few minutes

to share your feedback.

Objectives

Webinar attendees will: 

1) Increase their knowledge of ACOs and ACOs that

include MCH populations

2) Increase their understanding of how public health

can play a role in ACOs 

3) Will be able to identify strategies and resources to

collaborate with, ACOs in their state

Featuring:

Colleen A. Kraft, M.D., FAAP, Carilion Clinic, VA

Cate Wilcox, MPH, Maternal & Child Health Section

Manager, Public Health Division, Oregon Health Authority

Don Ross, Policy & Planning Section Manager, Division of

Medical Assistance Programs, Oregon Health Authority

Marilyn Hartzell, M.Ed., Director, Oregon Center for

Children and Youth with Special Needs

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The ABCs of ACOs: Making

Them Work for Maternal-Child Health

Colleen A. Kraft, M.D., FAAP

Family-Centered Medical Home

Child and Family

Developmental Services

Home-visitingnetwork

Early Intervention

Child CareResource &ReferralAgency

Early HeadStart& HeadStart

Early ChildMental Health Services

Prevention,BuildingHealth

Acute Care

Chronic Care

Developmental Services

Parenting Support

Lactation Support

Vulnerable children and

families

Medically Complex Children

Accountable Care Organizations

ACO

Hosp

PCP

Spec

Coordinates carefor shared patients

Medicare, MedicaidOr private insurer

Financial bonusfrom savings

ACO Attributes• Coordinates care for shared population of patients with the goal of

meeting and improving on quality and cost benchmarks• Hires an administrator and establish a formal legal structure to work with

payers, monitor performance, and collect any shared savings• Receives a financial bonus that is divided among its participants

according to their agreement.

Traditional Medical Care and Financing“Un-accountable” care

Low Cost Care • Primary Care• Preventive Care—Screenings, Immunizations, Anticipatory Guidance• “Gatekeeper”• Health/Lifestyle counseling• Home-based care• Home visiting• Primary Care access for evenings and weekends

No Coordination of Care

• No incentive for communication and collaboration• No care coordinators• No measurement of outcomes• No comparative effectiveness Research• No focus on population health• No co-location of services• No self management services• No transportation

High Cost Care

• Hospitalizations• Procedures• Duplication of labs, studies, procedures• Transportation = Ambulance• Complications of Chronic Disease• End of life care in an ICU

Low Cost Care Payment poor =No incentive

Transparency of Finances?Outcome Measures?Quality Reporting?Aligned incentives?

High Payment =Plenty of Incentive

Accountable CareReduce Cost

of Care • Develop robust primary care access•.Streamline administrative tasks• Co-management between primary care and subspecialty to avoid hospitalization• Greater use of palliative care• Greater use of home care and home visiting• Patient/Family portals• Avoid duplication of care/HIT

Improve Coordination of Care--Investments

• HIT that promotes communication and interaction• Office Care Coordinators• Home Visiting/Home Care• Primary Care-Ancillary Health co-location, including therapists, dieticians, psychology• Electronic portal for patient communication/collaboration• Support for advanced primary care and Q/I initiatives• Data management infrastructure to evaluate processes and outcomes

Improve Quality of Care

• Improving Scientific Basis of Healthcare Decisions • Based on Comparative Pediatric Effectiveness Research• Measurement of Outcomes• Longitudinal data collection and evaluation

• Payment Tied to Patient Outcomes • Based on Quality Measures

Fair Payment for Low Cost Care

Transparency of ACO FinancesPatient/Family-Centered Investment in Infrastructure

Shared System SavingsAligned Incentives

Improved Outcomes

Accountable Care “Three-Part Aim”

Better Care

Better Health

Lower Cost

Pediatric Accountable Care

Prevention of Adult Disease

Optimize Health and Development

Reduce High Cost Care

Factors Affecting Child Health

SOURCE: Healthy People 2010, US Department of Health and Human Services, 2000.

Medical Services

10%

Environ-ment20%

Genetics20%

Health Behaviors

50%

Health Innovation can be funded through an ACO

• Extension of the Medical Home• In-home care management

– Early Childhood– Oral Health– Prenatal– Asthma– Development/Behavioral Health

Carilion Clinic-Aetna Partnership

17

Carilion Clinic

ACO

Carilion Clinic

Physicians

Private Practice

Physicians

Update: 12/08/2011

Virginia Medicaid Regions

ACO System Savings

• Co-management between primary care and specialty

• Less duplication of services• Tracking of “high utilizers” with care

coordination to provide proactive care• Access to primary care, less use of ED and

hospitalization

CORE Predictive Modeling from Aetna

Mbrs who are Top 1%

Mbrs who are High Risk ED

Mbrs who are Medium/High

Risk IP

A Venn diagram, combining top 1% general risk with ED and IP risk, is used to help illustrate what risk groups a member falls into, and are they falling into multiple groups…

Members who are Top 1%

AND high risk for an ED

visit next 12 mos.

Members who are Top

1% , high risk for an ED

visit, AND medium/high

risk for IP admit next 12

mos.

Members who are top 1%

general risk AND medium/high

risk for IP admit next 12 mos.

Members who are high

risk for an ED visit AND

medium/high risk for IP

admit next 12 mos.

Personalize the Profile for Medical HomesIncreasing Medical and Behavioral Complexity

Group 3:•Ave age 33

•72% female

•PMPM $962

•5 ED visits, 0.2 admits

•32% asthma prevalence; 25% med adherence (asthma)

•85% MH prevalence

•58% co-occurring mental health and substance abuse

•52% with 5+ Rx classes

•5 Specialist visits

•10 PCP visits

Group 4:•Ave age 49

•PMPM $3908

•2.6 admits

•12 IP bed days

•7 ED visits

•51% diabetes prevalence

•73% MH prevalence

•87% with 5+ Rx classes

•20 Specialist visits

•10 PCP visits

Group 6:

•Ave age 43

•PMPM $2425

•1.6 admits

•7 IP bed days

•6 ED visits

•Low medical disease prevalence

•85% MH prevalence

•62% co-occurring MH and SA

•12 Specialist visits

•9 PCP visits

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4Group 5:•Ave age 53

•PMPM $3202

•2 ED visits

•2 admits

•10 IP bed days

•56% diabetes prevalence

•41% MH prevalence

•84% with 5+ Rx classes

•19 Specialist Visits

•7 PCP visits

5

ED Risk Only

ED Risk/IP Risk OnlyTop 1%/

ED Risk/IP RiskTop 1%/

IP Risk Only

Home Visiting Partner

• Child Health Investment Partnership of the Roanoke Valley

• Home Visiting with a Health Focus– Parents As Teachers– Oral Health– Asthma Management– Pregnant Moms– Behavioral Health

Home Visiting

• Pediatric Asth 

Care Management Design

• Home Visiting Contract– Paid per member/per month

• “High Touch”, in-person, in-home• Data Collected in home

– HEDIS metrics– Health Outcomes– Reduced costs

Medical Home

Child and Family

Shared In-basket with EHR

Electronic Referral to CHIP

Transport to visits

Develop Screening results shared

Anticipatory Guidance reinforced

in-home

Oral Health Ed and Fluoride

Oral Health and Fluoride Varnish

• Begin with a Grin!

Asthma Case Management

• Assess environment, modifications

• Smoking cessation• Observe inhaler use• Asthma control

assessment• Asthma action plan and

education• Transportation to visit

Behavioral Health

• Prenatal to age 7• Perinatal/postpartum

depression screening• Connection to services

for parents and children at-risk and diagnosed

• Transportation to visits

Results

100% children have a Medical Home

90% 2yr olds UTD on well visits and immunizations

100% children are screened for lead, Hgb, development

100% children have a Dental Home

66% of children have had a dental visit by age 3

97% have had an oral health assessment and fluoride

varnish

145 children in program 2011-2012

84% well controlled84% minimal inhaler use90% decrease in ED visits82% decrease in school absence due to asthma

In-Home Screening

Ready for School?

Pediatric Asthma

Home Visiting Intervention Pilot

Home Visiting = In-Home Prenatal Care Management

IDEA• Poverty is a risk factor for

poor maternal and newborn outcomes.

• What if every mother with Medicaid had a Home Visitor to provide support, education, transportation?

• How would this impact health of the next generation?

AIM STATEMENT• Reduce the number of

infants born at <37 weeks gestation and low birth weight (<2500 grams) by 30% by December 2012 utilizing home visitors as in-home case managers.

National Benchmark=March of Dimes

Virginia• “C” grade for premature

birth• Total prematurity = 11.3%• Late preterm (34-36 wk) =

8%• Uninsured = 17.2%• Maternal smoking = 15.2%

Roanoke/Allegheny • Metrics worse for this

region• Prematurity = 12.2%• Late preterm (34-36 wk) =

10.1%• Uninsured =15.6%• Maternal smoking = 24.4%

MeasuresMeasure Health Care Cost

Percent of infants born at < 37 weeks gestation O

Percent of infants born between 34 and 36 weeks gestation (late preterm) O

Birth weight term infants <2500 grams O

Percent of Pregnant Moms participants who smoke that stopped smoking O

Percent of Pregnant Moms participants who start prenatal care in the first trimester P

Percent of Pregnant Moms participants who attend all the recommended prenatal visits P

Percent of Pregnant Moms participants who are uninsured P

Percent of Pregnant Moms participants identified with depression P

Percent of Pregnant Moms participants connected to treatment for depression P

Cost of Care C

1st Trimester—Goal =90%

PercentGoal = 90%

All Visits-Goal = 60%

Percent Goal = 60%

Reduce Maternal Smoking by 1/3

PercentGoal = 16%

Perinatal Depression

Reduce Percentage of Infants born <37 weeks by 30%

<37wk34-36 wk

Goal

Reduce Percentage of Term Infants born < 2500g by 30%

Cost of Care

Note: One premature infant March 19-May 10

Next Steps• Continue current project, data analysis• Continue Home Visiting Contract after birth• Expand Asthma and Behavioral Health HV models• Assess

– HEDIS measures– Compliance with Asthma guidelines, ER and hospital

admissions, missed school and work days– Co-locate HV teams in OB and Pediatric practices– Feasibility of project replication as ACO expands– Development and school readiness of birth cohort

Other Outcomes

• 92% of children with asthma are well controlled with minimal inhaler use

• 90% of all pregnant mothers attended all their prenatal visits, starting in first trimester

• 57% of pregnant moms who smoked were able to stop smoking

• 100% of children with behavioral health problems improved on PECFAS

Care Connection for Children

Special Families

Special Families

• 42 families with successful IEP meetings• 10 families connected with waiver services• 10 hospitalizations avoided due to connection

to home health services• 8 support group meetings• Special Families facebook page• Respite program

Accountable Care

• Health of a population– Pregnancy outcomes?– Decrease in hospitalizations and ED visits?– School attendance, grades?– Parental education and employment– Function and performance of the Medical Home

CONCLUSION:

It is easier to build strong children than to repair broken men.

Frederick Douglass

Don RossOregon Division of Medical Assistance Programs

Cate WilcoxOregon Public Health Division

Marilyn HartzellOregon Child Development and Rehabilitation Center,

OHSU

Coordinated Care OrganizationsHealth System Transformation and

Opportunities for Preconception Health

What we’ll talk about today

Basics of Coordinated Care OrganizationsPublic Health Role in CCOs (ACOs)

MCH MetricsPreconception Health (One Key Question)

Opportunities for Children and Youth with Special Health Care Needs to work with CCOs (ACOs)

www.health.oregon.gov

Oregon Health Plan

53

50% of babies born in Oregon

16% of Oregonians

85% of Oregon providers

11% percent of total state budget

Fastest growing portion of state budget

www.health.oregon.gov

Triple Aim: A new vision for Oregon

www.health.oregon.gov

56

Changing health care delivery

Benefits and services are

integrated and coordinated

One global budget that

grows at a fixed rate

Local flexibility

Local accountability for health and

budget

Metrics: standards for

safe and effective care

www.health.oregon.gov

Benefits & services are integrated and coordinated

Physical health, behavioral health, dental healthGet better outcomes:

Health equityPreventionSocial determinants of health: education,

employmentMH: Supported Employment

Community health workers/non-traditional health workers

Collaborate and Integrate with other health and human services (e.g. long term care; public health; schools)

www.health.oregon.gov

Global budget

Current systemMCO/MHO/DCO/FFSPayments based on actionsNo incentives for health outcomes

CCO global budgetOne budgetAccountable to health outcomes/metricsLocal vision, shared accountability, shared

savingsFlexibility to pay for the things that keep

people healthywww.health.oregon.gov

CCOs: governed locally

State law says governance must include: Major components of health care delivery systemEntities or organizations that share in financial riskAt least two health care providers in active practice

Primary care physician or nurse practitionerMental health or chemical dependency

treatment providerAt least two community membersAt least one member of Community Advisory Council

www.health.oregon.gov

ACOs vs CCOs-What’s Different?

ACOs have distinct features: ACOs developing around health systems, not payersACOs in the ACA are aimed primarily at Medicare savingsProviders in ACOs share in Medicare savings in:

Medicare Shared Savings ModelAdvance Payment ACO ModelPioneer ACO Model

CCOs are accountable to the state, and local communityMedicaid enrollment in CCOs is required

www.health.oregon.gov

Community Advisory Council

Majority of members must be consumers.Must include representative from each county

government in service area.Duties include Community Health Improvement

Plan and reporting on progress.

CCOs and public healthVariety of requirements in statute:

o State shall require and approve agreements between CCOs and publicly funded providers for payment for certain services (immunizations, STIs and other communicable diseases)

o State shall allow CCO enrollees to receive family planning and HIV and AIDS-related services from fee-for-service providers, as well as maternity case management if CCO cannot do it

o State shall encourage and approve agreements between the two entities for authorization and payment of other services including maternity case management, prenatal care, school-based clinics, services provided through schools and Head Start programs, screening services for early detection of health problems in vulnerable populations

www.health.oregon.gov

CCOs and public health (2)Variety of requirements in contract:

o Collaborate with local public health authority, local mental health authority, community based organizations and hospital systems for community health assessment and development of community health improvement plan

o Actively promote screenings with A or B grades from USPSTF, or recommended in Bright Futures guidelines

o Contribute to implementation of state’s plans for physical activity, healthy nutrition, tobacco prevention, suicide prevention, and local public health and health promotion planning efforts

o Partner with local public health and culturally, linguistically and demographically diverse community partners to address the causes of health disparities.

www.health.oregon.gov

Accountability Metrics for CCO’s

Reduction of disparities - report all other metrics by race and ethnicity

Member/patient Experience of care Health and Functional Status among CCO

enrollees Rate of tobacco use Obesity rate Outpatient and ED utilization Potentially avoidable ED visits Ambulatory care sensitive hospital admissions Medication reconciliation post discharge All-cause readmissions Alcohol misuse – SBIRT Initiation & engagement in alcohol and drug

treatment www.health.oregon.gov

Accountability Metrics for CCO’s

Mental health assessment for children in DHS custody Follow-up after hospitalization for mental illness Effective contraceptive use among women who do

not desire pregnancy Low birth weight Developmental Screening by 36 months Planning for end of life care Screening for clinical depression and follow-up Timely transmission of transition record Care plan for members with Medicaid-funded long-term

care benefits

www.health.oregon.gov Metrics in bold can be applied to Preconception Health

Initial MetricsDesigned to achieve quick return on

investment to meet the federal requirements

Maternal and Child Health is imbedded in many, but not necessarily called out

www.health.oregon.gov

Second Phase of Metrics

Important to be at the table—we have a lot to offer!

MCH brings the sustainability factor MCH brings the lifelong wellness factor

www.health.oregon.gov

Possible MCH metrics

Look at a broad range of standards of care/practiceHP2020, Bright Futures, USPSTF, Title V

priorities

Include Adolescent measures

Look for means of coding/tracking the measure

www.health.oregon.gov

Possible MCH metrics

Targeted measures for MCAH populationsOral HealthPositive ParentingSleep hygienePositive Youth DevelopmentFamily violence preventionSafety/Injury preventionPregnancy intendedness

www.health.oregon.gov

Example: One Key Question

Do you plan on getting pregnant in the next 12 months?

If yes, preconception health careIf no, contraceptive health care

www.health.oregon.gov

ACA, Public Health, & Data

Pay attention to Electronic Health Record requirements in the ACAThe concept of “Meaningful Use” introduces

more complex reporting to public health by Electronic Health Record users.

Public health needs to be ready to be able to receive data from providers.

Public health needs to be ready to be able to provide data to providers.

www.health.oregon.gov

Opportunities for Children and Youth with Special Health Care Needs to

work with CCOs (ACOs)

Join the conversation – get to know the ACOs/CCOs

Educate ACOs about the population of children with special health care needs

Who are CYSHN?ComplexBroad and inclusive definitionCommonalities of needs across the population of

individuals

Educate ACOs about how to identify CYSHN within a system of care

ScreenersComplexity Scales

www.health.oregon.gov

Opportunities for Children and Youth with Special Health Care Needs to work with CCOs (ACOs) …and their families

Family-Professional Partnerships

Patient Engagement is not Family-Professional Partnership

Family Professional Partnerships involve: Shared knowledge and expertiseMutual respectCollaborative problem solving

www.health.oregon.gov

Opportunities for Children and Youth with Special Health Care Needs to

work with CCOs (ACOs)

Advocacy and Education Encourage family leaders, F2F HICs,

community leaders to join the Advisory Committees

Support family leaders in their work with ACOs

The Family Voice

#1:  Nothing about us without us!#2:  Decisions made under

Parent/professional partnership involves compromise for both!

#3:  Please listen to our concerns.www.health.oregon.gov

Opportunities for Children and Youth with Special Health Care Needs to

work with CCOs (ACOs)

Effective Systems of Care for CYSHNFamily Centered Care Early and continuous screening Medical home with care coordinationEase of Use of Community-based servicesYouth Transition to adult health care (think

specialty care too!)Health care finance

Be a resource to ACOs

www.health.oregon.gov

Opportunities for Children and Youth with Special Health Care Needs to

work with CCOs (ACOs)

Public health programs support ACO aims & metricsImmunizationsFlu vaccinationAnnual well-child visitsAnnual dental visitsReduced ER usage

Build partnership with ACO to help achieve the 3 aims

Remember – there are 3 aims!

www.health.oregon.gov

Opportunities for CYSHN to work with CCOs (ACOs) - An expanded model for statewide care coordination

Tertiary-based Care Coordination Team CYSHN are assigned to when they are identified through the

hospital or clinics CC Team serves as single point of contact for families in the

targeted group of childrenCC Team nursing, social work, family navigator, psychology

– according to the needs of the child and familyRegional Unit of Care Coordination (Senior Nurse

Coordinator) Regionally based senior nurse coordinator (expert nurse with

CYSHN)Child/family referred to/through back into community-based

careLinks family with PCP and community-based care

coordination as neededSenior Nurse Coordinator provides connections between the

tertiary care coordinators, PCPs and the community public health services

Community-based Care CoordinationChild identified within the community through public health

nursing or primary care settings; goals identified by PHN and/or PCP

Linked to Senior Nurse Consultant for input, and behavioral specialist when needed

For More Information:

Don Ross, Manager

Policy and Program Unit

Division of Medical Assistance Programs

Oregon Health Authority

Donald.ross@state.or.us

503-945-6084

www.health.oregon.gov

Marilyn Hartzell

Director, OCCYSHN

OCCYSHN / Oregon Center for Children and Youth with Special Health Needs

Institute on Development and Disability (IDD) at OHSU

Hartzell@ohsu.edu

503-494-6961

Cate Wilcox, Manager

Maternal and Child Health Section

Public Health Division

Oregon Health Authority

Cate.S.Wilcox@state.or.us

971-673-0299

Question & Answer

80

•Please submit questions through the chat feature and direct them to the chairperson

Thank you for attending “The ABCs of ACOs for MCH”

Colleen A. Kraft, M.D., FAAP, Carilion Clinic, VA

Cate Wilcox, MPH, Maternal & Child Health Section Manager, Public Health Division, Oregon Health Authority

Don Ross, Policy & Planning Section Manager, Division of Medical Assistance Programs, Oregon Health Authority

Marilyn Hartzell, M.Ed., Director, Oregon Center for Children and Youth with Special Needs

The recording will be posted on www.amchp.org