caring for children with disabilities: the view from ...accountable care organizations (acos) are...
TRANSCRIPT
………………..……………………………………………………………………………………………………………………………………..
Caring for Children with Disabilities:
The View from Inside
an Accountable Care Organization
American Academy for Cerebral Palsy and
Developmental Medicine, 2014, IC21
Garey Noritz, MD, FAAP, FACP
Nationwide Children’s Hospital
The Ohio State University
Columbus, Ohio
………………..……………………………………………………………………………………………………………………………………..
Disclosures
I have no financial disclosures.
This presentation will not include discussion of pharmaceuticals
or devices that have not been approved by the FDA.
………………..……………………………………………………………………………………………………………………………………..
What's an ACO?
Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare/Medicaid patients.
The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.
When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare/Medicaid program.
-CMS.gov
………………..……………………………………………………………………………………………………………………………………..
ACOs vs. HMOs1. ACOs are about creating value, not withholding service.
2. ACOs are local. Where HMOs created large bureaucracies that
layered in cost and complexity, ACOs are designed to directly
manage healthcare in small, manageable settings.
3. Incentives are aligned. HMOs invested in improving the health
of members without reaping the long-term benefit. For ACOs,
financial upside is more immediate.
4. Physicians are now more accepting of integration.
5. ACOs offer an array of payment models.
6. Information technology has transformed the capability for
population health management.
6. ACOs may not avoid high risk patients.Bob Edmondson, VP
Innovation, West Penn
Allegheny Health
System | May 10, 2011
• ACO Affiliated with Nationwide Children’s Hospital
• Full risk contracting for Central/Southeast
• Includes all children on Medicaid Managed Care aged 0-18
Partners For Kids
6
Flow of Funds
$
Ohio Department of
Medicaid
Plan B Plan C Plan D
ODM pays the Medicaid Managed
Care Plans an age-sex adjusted per
member amount each month for all
CFC members in their regions
Plan passes the capitation for members 18 and
under less a small amount for administration
(reporting, member service, claims processing)
Per Member Per Month
capitation payments with
risk
NCH employed physician
group paid per member
per month capitation
payments
Community member
physicians paid fee-for-
service @ % over
Medicaid
Other providers (non-
members) paid fee-for-
service @ % of Medicaid
PAA
$ $ $
PFK provides care coordination,
population health initiatives, credentialing,
network management
Plan EPlan A
For children covered under Aged,
Blind, Disabled (ABD), this
capitated amount is significantly
higher.
7
Financial Incentives
Primary Care Pay for Performance
Access
Practice Improvement—Medical Home recognition,
quality collaborative
Paying for
Quality
OutcomesSelected HEDIS measures
• Well Child Visits
• Appropriate treatment of URI
• Asthma medication
8
Partners for Kids StructurePhysician-Hospital Organization formed in 1994.
• Ohio taxable, not for profit private entity
• Joint venture between Nationwide Children’s Hospital, its
employed physicians and contracted community physicians
• Approximately 95 employed and 180 community PCPs, 480
employed and 50 contracted community specialists
(approximately 900 physicians in total)
Ohio Department of Insurance considers PFK to be an
“intermediary organization”---accepts financial risk but not a
health plan. Must maintain reserves and stop loss coverage.
9
Evolutionary Growth
0
50000
100000
150000
200000
250000
300000
350000
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
Patient Membership
Contracting Strategy
Managed Care Strategy
Accountable Care Org.
(Population Health)
10
Data Acquisition, Maintenance and Use
Partners for Kids
Data Warehouse
Financial
reporting
Quality
monitoringPhysician
Incentives
Program
Development
Population
Management
Plan B Plan C Plan D
Eligibility
Capitation
Claims
Eligibility
Capitation
Claims
Eligibility
Capitation
Claims
Plan E
Eligibility
Capitation
Claims
Plan A
Eligibility
Capitation
Claims
11
Tools
Accountable Care
Organization
Technology
Web Tools
Financial
Incentives
MOC Credit
Collaborative
Learning
Data Sharing
Partnerships with
Other Organizations
PCMH
Certification
NCQA
Increased
Access
Home Care
Outreach
Standardizing
Care
Distance
Medicine
PFK Care Coordination
12
Physician - Hospital Alignment
16 Board Members• 50% of the board are hospital appointees (2 of which are community
physicians)
• 50% are member physicians elected by their peers
Extensive involvement of both community and employed
physicians in setting up programs and engaging in quality
initiatives---alignment with Hospital’s strategic plan
Committees include:• Internal: Executive, Credentialing, Physician Incentive, Clinical Oversight
• Wellness: Asthma, Better Birth Outcomes, Diabetes, HNHF
• Ad hoc and other hospital-based committees
13
Population Management Tools
AsthmaHealth
SupervisionObesity
Preterm
BirthPharm.
Provider Focus
Collaborative Learning
Standard care
Technology
MOC Credit
Certification
Partnerships
Incentives
Patient Activation
Care Coordination
………………..……………………………………………………………………………………………………………………………………..
Expand the PFK Model
New Geography: Akron region (8 more counties)
New Population: Aged/Blind/Disabled (SSI + <60% FPL)
Shared Savings agreement with state
Focus on certain clinical groups
Behavioral Health
Complex Care
BUT
Many of the most complicated patients are excluded from or may opt out of PFK
14
HCIA Grant – PFK Expansion
………………..……………………………………………………………………………………………………………………………………..
Exclusions from PFK
Children who are:
• On Medicaid Waivers
• In Foster Care (some)
• In Long-Term Care Facilities
• In the Juvenile Justice System
Patients who receive Title V Funds (in Ohio, Bureau for Children
with Medical Handicaps) may opt out
Opportunities: New Geographies
Adams
Allen
Ashland
Ashtabula
Athens
Auglaize
Belmont
Brown
Butler
Carroll
Champaign
Clark
Clermont
Clinton
Columbiana
Coshocton
Crawford
Cuyahoga
Darke
Defiance
Delaware
Erie
Fairfield
Fayette
Franklin
Fulton
Gallia
Geauga
Greene
Guernsey
Hamilton
Hancock
Hardin
Harrison
Henry
Highland
Hocking
Holmes
Huron
Jackson
Jefferson
Knox
Lake
Lawrence
Licking
Logan
Lorain
Lucas
Madison
Mahoning
Marion
Medina
Meigs
Mercer
Miami
Monroe
Montgomery Morgan
Morrow
Muskingum
Noble
Ottawa
Paulding
Perry
Pickaway
Pike
Portage
Preble
Putnam
Richland
Ross
Sandusky
Scioto
Seneca
Shelby
Stark
Summit
Trumbull
Tuscarawas
Union
Van Wert
Vinton
Warren Washington
Wayne
Williams
Wood
Wyandot
Opportunities: New Kinds of Patients
RN/SW Case Managers
Telehealth
Unlicensed Staff
Complex Care Clinic
Nationwide Childrens Akron
Focus Area Existing CMMI Existing CMMI
Prematurity X X
DM X
Asthma X X
Health Supervision X
Obesity X
Complex Care NEW X X
Behavioral Health NEW X X
Infrastructure X X X
Centers for Medicaid & Medicare Innovation
(CMMI) Award
19
Grant Awarded 7/2012 to improve quality/reduce cost
$13.1M awarded over 3 years
Funding key initiatives:
• Expanding the PFK model to Akron Children’s
• Focusing on children with complex needs• care coordination
• weight management
• standardization
• Focusing on children with behavioral health needs• reducing readmissions—transition care/care coordination
• appropriate drug management
• support through Parent Partners
Health Care Innovations Award
Major Challenges
• Feeling comfortable with the risk when you don’t have a lot of control!
• Regulatory issues---changing Medicaid landscape with little ability to influence, no seat at the table
• Maintaining managed care plan relationships and ongoing collaboration
• Competing priorities
• Data management
• Many children excluded whom we want to impact
21
Although informal in the past, now officially
delegated to do care coordination for:
• Molina
• Buckeye
• Paramount
Working on United---may be delegated by mid year.
Will likely not be delegated by CareSource
Delegated Care Coordination
22
KEY DRIVERS
A. Cost = By 6/2015:
• Reduce per member per month by 1.1%
for TANF and 2.0% for Disabled
• Reduce 60 day PFK behavioral health
readmissions by 30% from 9.8 to 6.9%
• Decrease hospital days of tube fed
children by 10%
• Reduce Summit County neonatal days by
10%
Payment Reform
Health Information
Technology
Patient, Family,
Community
Engagement
Patient Centered
Medical HomeCare
Coordination/Case
Management
Expand PFK model to reduce costs,
improve care and enhance outcomes for
Medicaid children in Ohio
Data Capture,
Analysis &
Reporting
Home Care
Technologies
Risk Model &
Contracting
Specialty Network
Performance &
ExtendersImprovement Science
and Implementation
SECONDARY DRIVERS
SPECIFIC AIMS:
B. Quality = By 6/2015:
• Increase completed 30 day outpatient
PFK medical follow up after behavioral
health hospitalization from 29% to
65% by 6/2015
• Proactive care plan implemented for
children with feeding impairment and
neurodevelopment disorders from 0%
to 85%
• Increase delivery of progesterone to
pregnant women with prior preterm
birth in Summit
County by 20%
C. Health = By 6/2015:
• Decrease Columbia Impairment Scores
from discharge to 60 days post
discharge by 15% for >75% of PFK
patients admitted for treatment of
psychiatric diagnoses
• Increase by 10% proportion of tube fed
kids between 5%ile & 95%ile for
weight on growth chart each year
• Decrease preterm birth rate to 11.6%
from 13.3% in Summit County.
Pay 4 Performance Contracts
Resource Consultation Line
Telemedicine
• Clinic
• Home
Care Coordination and Plans
Managed Care Orgs/PFK
Contracts
Quality Collaboratives
INTERVENTIONS
Progesterone Promotion
Cervical Screening
Parent Training, Advocates
GLOBAL AIMS:
HCIA Grant – PFK Expansion
23
KEY DRIVERS
Cost: By 6/2015
• Reduce 60 day PFK
behavioral health
readmissions by 30% from
9.8 to 6.9%
Payment Reform
Health Information
Technology
Patient, Family,
Community
Engagement
Care
Coordination/Case
Management
Prevent Psychiatric Youth
Crises
Improvement Science
and Implementation
SPECIFIC AIMS
Quality: By 6/2015
• Increase 30 outpatient
follow up after behavioral
health hospitalization from
29 to 65%
Health: By 6/2015
• Decrease Columbia
Impairment Scores from
discharge to 60 days post
discharge by 15% for >75%
of PFK patients admitted
for treatment of psychiatric
diagnoses
Pay 4 Performance Contracts
Consultation Line
• Pediatric Psychiatry
Network
Telehealth
• Telepsychiatry
• Teletherapy, e-therapy
• Healthspot
Care Coordination
Managed Care Orgs/PFK
Contracts
PCP Collaboratives
• ADHD Collaborative
• Building Mental Wellness
INTERVENTIONS
Parent Partner Initiative
GLOBAL AIM:
Mental Health and
Primary Care Access
Public awareness and
education
• Triple P Program
Second opinion program for
medication use
HCIA
PFK
NCHKEY
Behavioral Health
………………..……………………………………………………………………………………………………………………………………..
Parent Partners Intervention
Primary goal
Provide support to parents and families coping with children with behavioral problems
Secondary goals
Assist parents in identifying their own needs and concerns
Education and teach skills focused on coping, self-care, crisis management, problem solving, and personal skill development
Provide emotional support and facilitate sharing of experiences and social connections to other parents
Facilitate the empowerment of parents in decision-making
24
Behavioral Health
………………..……………………………………………………………………………………………………………………………………..
ADHD Medications
………………..……………………………………………………………………………………………………………………………………..
Complex Patients
A child with
• One of about 60 neurologic conditions* AND
• A feeding tube
*These neurologic codes were selected by our team from ICD-9 as
those diseases most likely to result in functional dependency
(For a list of these codes, please email me at
KEY DRIVERS
SPECIFIC AIMCost
Decrease hospital days
per 10,000 member
months for tube fed
patients from 24.8 to 22.3
days for 12-month period
ending 6/30/2015*
Care
Proactive Care
Coordination will be
provided for 85% of
children with feeding
impairment and
Neurodevelopment
Disorders from a baseline
of 0% by 6/30/2015
Health
Increase by 10% annually
the proportion of
NCH/ACH tube fed kids
between the 5th percentile
& 95th percentile for
weight on standard CDC
growth charts
INTERVENTIONS
Virtual Care
Management Support
infrastructure
Home Management
Support
Improve Health of
children at risk with tube
feedings or other
technologies
GLOBAL AIM
• Home visits for tube mechanics and
training
• G tube insertion/removal protocol
• Telemedicine Tube Advice
• PCP Training on Complex Care
• Resources provided to PCPs for
Complex Care Patients
• Self Management resources (e.g.
Home medication list) for Care Plan
• Centralized Medical Care
Coordination as needed in
cooperation with PCP
Tertiary Care
(Hospital-based care)
• Scheduled formula evaluations
• Family-Centered Care Planning
Complex Care
27
HCIA Self-Monitoring DashboardComplex Care: May 2014
AIM #1: Decrease by 10% NCH Inpatient Hospital Days/ 10,000 PFK Member Months over 12-Month Period for Tube-Fed Children
Initiatives:
Modify ‘Feeding Tube Placement’ orders in EPIC to establish provider responsible for nutrition management
Construct ‘Complex Feeding Smart Form’ in EPIC to organize feeding tube related information for providers and families
Parent Education: journey board, workbook, videos, webpage, app, Family Resource Center kiosk
9/6/2014 28
HCIA Self-Monitoring DashboardComplex Care: May 2014
9/6/2014 29
Secondary Program Aim for June 30, 2015 Baseline Results this Month Goal
Decrease the average length of stay for tube-fed children at
NCH by 10% from a baseline average of 6.7 days for Jul2011-
Jun2012 to average of 6.0 days for the 12 months ending June
30th, 2015.
6.7
days
12 month average through May 2014: 4.8 days
(28% ↓ from baseline)
6.0
(↓ 10% from
baseline)
Group Avg: Discharge or to-date LOS for all admissions in the month; admission months containing patients still in the hospital as of June 15, 2014
are color-coded red and are subject to change in upcoming months until patients are discharged
Group Size: Admission month for those with a tube-fed related visit (any patient class) in the prior 12 months.
Month with patient(s) yet to be discharged
Desired Direction of
Change
Care Coordination
Expanded
Med. Dir. of Comprehensive Health
Care Service (CCHCS) Starts
HCIA Grant Awarded/Feeding Tube Task Force
Formed
Dietician & RN Join CC
Team
HCIA Self-Monitoring DashboardComplex Care: May 2014
9/6/2014 30
Secondary Program Aim for June 30, 2015 Baseline Results this Month Goal
Decrease the # of tube-fed children admitted to NCH by
10% from a baseline average of 15.5 admissions/100 cohort
patients for Jul2011-Jun2012 to an average of 13.9
admissions/100 cohort patients for the 12 months ending
June 30th, 2015.
15.5
admissions/
100 cohort pts
12 month average through May 2014:
13.4 admissions/100 cohort patients
(13% ↓ from baseline)
13.9
admissions/100
cohort patient
(↓ 10% from
baseline)
Desired Direction of
Change
Care Coordination
Expanded
Med. Dir. of Comprehensive Health Care Service (CCHCS)
Starts
HCIA Grant Awarded/Feeding Tube Task Force
Formed
Dietician & RN Join CC
Team
HCIA Self-Monitoring DashboardComplex Care: May 2014
9/6/2014 31
Process Measures
Meets Expectations Mitigation in Progress Requires Attention Not started
Program Aim for
June 30, 2015
Monthly Process
MeasureResults Goal Notes Status
Decrease by
10% NCH
inpatient
hospital days
per 10,000 PFK
member months
over a 12-month
period for tube-
fed children.
Cumulative
percent of
feeding-tube
patients in
the cohort
with
information
in the
Complex
Feeding
Smart Form
in EPIC
EPIC Complex
Feeding Form
Rollout
milestones:
• 10/1:
Available to
providers in
CP Clinic,
Complex Care
and IDF
• 11/1:
Available to
all providers
# of families
assessed for
tube feeding
competence
in the Family
Resource
Center
5 families
Complex Feeding Smart Form Usage in EPIC
0%
5%
10%
15%
20%
25%
30%
35%
40%
Oct
-13
No
v-1
3
De
c-1
3
Jan
-14
Feb
-14
Mar
-14
Ap
r-1
4
May
-14
Cu
mu
lati
ve
% o
f P
atie
nts
in
th
e F
ee
din
g-T
ub
e C
oh
ort
wit
h In
fo
In S
mar
t Fo
rm S
ect
ion
/Fie
ld
Procedure Detail Section Care Team Section
Last Nutrition Assessment Field Weight at Goal Field
HCIA Self-Monitoring DashboardComplex Care: May 2014
AIM #2: Provide Proactive Care Coordination for 85% of Tube-Fed Children with A Neurodevelopment Disorder
Initiatives:
Global Care Coordination with Complex Care Flag
Health Care Assessment Every 6 Months
Care Plan
Post Inpatient and ED Discharge Follow-Up
9/6/2014 32
HCIA Self-Monitoring DashboardComplex Care: May 2014
9/6/2014 33
Program Aim for June 30, 2015 Baseline Results this Month Goal
Proactive Care Coordination will be provided for 85% of
children with a feeding tube and neurodevelopment
disorder(s).
0% May 2014: 55% 85%
Patients with A Feeding-Tube Dx/Px in Prior 12 Months and A Neuro Code As early as Jan 2010, Ages 0-18
Feb-14 Apr-14 May-14
Cohort N* 594 571 557
# Offered Care Coodination 263 273 306
# Discharged from Care Coordination 49
# Actively Enrolled 185
# Outreach but No Care Coordination 72
# No Care Coordination Activity 251
* Excludes deceased patients
HCIA Self-Monitoring DashboardComplex Care: May 2014
AIM #3: Increase by 10% Annually, the Proportion of NCH Tube-Fed Children between 5th and 95th Percentile for Weight on Standard Growth Charts from Baseline
Initiatives:
Construction of the ‘Complex Feeding Smart Form’ in EPIC
Standardizing RD involvement for patients with a feeding tube
Complex Care App with Feeding Journal targeting patients with low weights
9/6/2014 34
HCIA Self-Monitoring DashboardComplex Care: May 2014
9/6/2014 35
Program Aim for June 30, 2015 Baseline Results this Month Goal
Increase by 10% annually the proportion of NCH tube-fed
children between the 5th percentile and 95th percentile for
weight on standard growth charts.
59.5%
12 month average through May 2014: 63.4%
(0.2% chg from last month; 6.4% ↑ from baseline)
Month of May14: 63.5%/72.5% with Accept Wt Pts
79.2%
(↑ 33% from
baseline)
Care Coordination
Expanded
Med. Dir. of Comprehensive Health Care Service (CCHCS)
Starts
HCIA Grant Awarded/Feeding Tube Task Force
Formed
Dietician & RN Join CC
Team
Note: Beginning June 2012, the baseline shifted upward from 59.5% to 62%
*Number of patients who were in weight range PLUS patients out of weight range but with acceptable weights per dietician notes in Apex patient registry
or in EPIC Nutrition Smart Form
………………..……………………………………………………………………………………………………………………………………..
Transition- Challenges
Ensuring Continuous health
coverage after age 19 (or 26).
Continue care management
Transfer to adult systems as
appropriate.
Staying on Medicaid (Ohio)
• On Waiver OR
• On SSI OR
• Income based
………………..……………………………………………………………………………………………………………………………………..
Conclusions
An ACO is a workable model for organizing the care of children
with disabilities.
An ACO can improve care while reducing costs.
The Successful ACO requires:
• Close collaborations between physicians and organizations
• A family-centered approach to health care
• A vision that values outcomes over throughput
• A willingness to take financial risk
• A significant investment in data management