Improving Care for High-Need, High Cost PatientsDemonstration Project & Learning Initiative

Institute for Accountable Care

November 27, 2018

Build the evidence base on the impact of accountable care delivery strategies to support care transformation and inform public policy

Mission

VisionBecome a nationally respected resource for developing, synthesizing and disseminating practical actionable research and analysis supporting value-based care.

ACO Linkages

Broad Data Warehouse

IMPACT

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About the Institute

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Addressing the Needs of HNHC Populations

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85 percent of ACOs have programs targeting HNHC patients Multiple methods for identifying patients

⏤ High spending and utilization (high cost)⏤ Predictive analytics (high-risk)⏤ Clinician referral (high need)

Multiple programs deployed in many ways⏤ Nurse care management, care transition programs most common⏤ Designated HNHC clinic, community health worker, extensivist less common

Primary impact measure is change in service use/cost Respondents believe programs have positive impact but don’t know which

programs are most effective

HNHC Initiatives in ACOs: NAACOS Survey Toplines

Adults with High Needs Have Higher Health Care Spending and Out-of-Pocket Costs

$702 $1,157 $1,669$4,845

$7,526

$21,021

Note: Noninstitutionalized civilian population age 18 and older.Data: 2009–2011 Medical Expenditure Panel Survey (MEPS). Analysis by C. A. Salzberg, Johns Hopkins University.

Total adult population231.7 million

Three or more chronic diseases, no functional limitations

79.0 million

Three or more chronic diseases,with functional limitations

(high need)11.8 million

Exhibit 1

Source: S. L. Hayes, C. A. Salzberg, D. McCarthy, D. C. Radley, M. K. Abrams, T. Shah, and G. F. Anderson, High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? The Commonwealth Fund, August 2016.

Average annual out-of-pocket spending

Average annual health care expenditures

$1,154 $3,688 $10,710

$4,362 $8,194

$26,376

$11,738 $17,218

$51,380

$20,895 $27,573

$73,087

$55,962 $61,500

$133,083 Median Top 25% Top 10% Top 5% Top 1%

Total adult population Three or more chronic diseases, no functional limitations

Exhibit 2

Health Care Spending Was Higher at Every Level for Adults with High Needs Than for Adults with Multiple Chronic Diseases Only

Three or more chronic diseases, with functional limitations

(high need)

Source: S. L. Hayes, C. A. Salzberg, D. McCarthy, D. C. Radley, M. K. Abrams, T. Shah, and G. F. Anderson, High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? The Commonwealth Fund, August 2016.

Note: Noninstitutionalized civilian population age 18 and older.Data: 2009–2011 Medical Expenditure Panel Survey (MEPS). Analysis by C. A. Salzberg, Johns Hopkins University.

Adults with High Needs Have Unique Demographic Characteristics

17%

52%

67%

16%

30% 28% 26%31%

58%

77%

14%

27%

41%38%

55%

63%

72%

28%

52%

83% 83%

Age 65+ Female White race Nohigh school

degree

Income below200% FPL

Publicinsurance

Fair or poorhealth status

Notes: Noninstitutionalized civilian population age 18 and older. Public insurance includes Medicare, Medicaid, or combination of both programs (dual eligible).Data: 2009–2011 Medical Expenditure Panel Survey (MEPS). Analysis by C. A. Salzberg, Johns Hopkins University.

Exhibit 3

Source: S. L. Hayes, C. A. Salzberg, D. McCarthy, D. C. Radley, M. K. Abrams, T. Shah, and G. F. Anderson, High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? The Commonwealth Fund, August 2016.

Total adult population

Three or more chronic diseases, no functional limitations

Three or more chronic diseases, with functional limitations (high need)

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9

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Improving Care for HNHC Patients in ACOs: A Demonstration Project

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Form ACO Advisory Group Select preferred interventions Develop detailed specs and

implementation support plan Create evaluation strategy Recruit 10 – 15 ACOs

Timeline: Implementing HNHC Initiatives in ACOs

Home Visit Program

ExtensivistModel

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1. Support ACO implementation of programs to improve care for high-need, high-cost individuals by providing technical assistance, training, systematic learning opportunities and evaluation of what works and what doesn’t.

2. Generate protocols, tools and education that will help other ACOs deploy programs effectively

Project objectives

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Two Initiatives on Separate Timelines11/2018 5/2019 11/2019 5/2020 11/2020 5/2021

Home Visit Program

Learning Collaborative

Evaluation Implementation Planning ProposalReview

ProposalReview

Proposal Implementation Extensivist

Model

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Objectives of home visits⏤ Develop trusting relationship with HNHC individuals⏤ Identify and address social determinants of health⏤ Build effective linkage with primary care team⏤ Provide home based medical services (selected models only)

Personnel⏤ Community health worker; paramedic; registered nurse; nurse practitioner

Desired outcomes⏤ Close care gaps⏤ Address social needs⏤ Reduce avoidable hospitalizations/ED visits/post-acute care

Home Visit Program

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Extensivist Model Multi-disciplinary care teams providing intensive outpatient management

and home-based services for frail high risk patients with complex medical conditions.

Objective: stabilize and manage high risk patients to reduce avoidable institutional care, improve quality of life and support independence

Multiple potential models⏤ Extensivist clinic⏤ Virtual/mobile extensivist model⏤ Clinic within a primary care clinic⏤ Post-discharge clinic⏤ Ambulatory clinic providing hospital-level care

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Help identifying HNHC patients (algorithms, screening tools) Analytic support: profile of ACO’s high-risk patients and spending

profiles using NAACOS Medicare data warehouse Program startup support (job description, training modules, patient

assessment forms, checklists/protocols for home visit staff. Training/boot camps (for operational staff or care teams) Forms/formats for data collection Program evaluation support

⏤ Did your project reduce spending/improve outcomes⏤ Building internal capacity for program evaluation

Technical assistance

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Separate collaboratives for home visit and extensivist initiatives Likely two in-person meetings and monthly virtual meetings over 9 –

12 months (likely support for travel) Guidance from expert faculty from ACOs with experience deploying

successful programs Structure for sharing best practices and collaborating with peers on

process improvement and troubleshooting

Learning collaboratives

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How Do I Get Involved?

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Institute StaffRob Mechanic, Executive DirectorJennifer Perloff, Director of ResearchTeresa Litton, Senior Advisor

Advisory Group MemberAmy Russell, MD, Chief of Community Medicine, Mission Health

Thank You