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Transforming Care For Alternative Payment

Iowa PCA Annual MeetingOctober 2019

o Integrated Public Health, Mental Health, Primary Care, Dental Services

o Public entity FQHC with Benton County sites; • Corvallis (includes admin, Mental Health & Public Health)• South Corvallis (also a School-Based Health Center)• Monroe (also a School-Based Health Center)• Alsea

o Sites in Linn County• Lebanon• Sweet Home

o Served 9,800 patientsin 2018

CHC of Benton & Linn Counties

CHC Services o Medical: Patient Centered Primary Care Home• Primary Care• Family Planning• School Based Health Center (Lincoln & Monroe)

o Behavioral Health: Integrated & Specialty• Behaviorists• Adult Behavioral Health• Children’s Behavioral Health• Addiction Services

o Dental• Adult & Children’s Treatment• Varnish & sealant program• Adult hygiene• Van & voucher program

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OHA/OPCA APM Piloto Started July 1, 2014 o OHA (Oregon Health Authority) pays the

‘wrap’ (PPS) on a monthly PMPM (per member per month) rate for all engagedMedicaid patients

o Required reporting on toucheso Quarterly reconciliationo Accountability plan requires meeting 4 of 5

quality metrics outcomes

CCO Alternative Payment Piloto Started January 2015o Methodology for payment

• Paid a monthly PMPM for enrolled OHP patients• Rate of PMPM based on the rate group the

member is assigned by OHAo Monthly member reconciliationo Quarterly reporting

• Access, Outcome, & Utilization Metricso Pay for Performance on Clinical Quality Metrics

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Transforming Care DeliveryPatient Centered Primary Care Home (PCPCH)

Patient Centered & Team Based

Access Cost

Quality Equity

o Accountability for Access• Patient-centered (PCPCH) & Team-based • Patient panels• Care coordination • Outreach & Navigation program• Addressing Social Determinants of Health

o Accountability for Quality Outcomes• Data & reporting• Quality Metrics• Quality Improvement tools• Training & work flows

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Shift Focus From a Billable Provider Visit To:

Early Phase: Plan, Prepare, & Reorganize

Team Based CarePatient Panels

OutreachQuality, Data, & Reporting

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Team Based Careo Right Size Team

Core Team• Providers (2)• Medical Assistants (2)• Scheduler

Additional Members• Panel Manager• RN Care Coordinator• Behaviorist• Clinical Navigator• Clinical Pharmacist

’

Support Access to Integrated Services

Team Based Careo Shared office spaceo Designated consult roomso Define Roles & Responsibilities

• Panel manager role• Supported working at ‘top of license’• Identified care coordination

responsibilitieso Team Communication

• Scrubbing & huddles

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Patient Panelso Assess assignment process

• Access member data from the CCO & match clinic patients to CCO lists

• Established a process for provider transitions

Patient Panelso Managing Panels

• Set expectation for panel size at 1,200• Identified basic elements of identifying

complexity;Race/ethnicity, Age, Co-occurring conditions

o Scheduling process• # of new patients• 30% scheduled; 70% same day

Patient Panelso Proactive Care

• Prevention & Screening

• Recall system for follow-up of chronic conditions

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Outreach & Health Navigationo Types of Health Navigators

• Outreach & Enrollment

• Clinical Navigators – based in clinic

• Community Navigators – based in schools & community settings

Outreach & Health Navigationo Roles

• Outreach in communities/neighborhoods• Enrollment in Insurance & Safety Net programs• Access to primary care & specialty services• Appropriate utilization of health care services• Connect to social services & community

resources• Patient engagement through effective self-

management• Facilitate language and culture differences;

health literacy

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Data & Reportingo Assessed EHR capability to generate

needed reports

o Added staff to data team

o Developed Panel reports

• Capture of face-to-face visits

• Defined ‘Care steps’ performed by non-billable team members

Types of interaction

Qualityo Inventory of all reported metrics

o Prioritized metrics• Providers selected 4 to focus on

o QI tools & training

Benchmark January 2018 December 2018 % of change

Well Adolescent Visits 43.90% 39.08% 51.54% 12.46%

ColorectalCancer 50.60% 29.40% 46.14% 16.74%

Diabetes -Poor Control 24.60% 28.58% 28.51% -.037%

(lower is better)

Hypertension 72.60% 61.11% 68.62% 7.51%

Quality: Clinical Outcomes (All patients)

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Middle Phase: Redefine & Refine

Team Based CarePatient Panels

OutreachQuality, Data, & Reporting

Team Based Careo Continue Refinement of Roles &

Responsibilities

o Matching team member expertise to the panel characteristics

o RN Care Coordination for ED utilization & follow-up from hospitalization

o Referral management (Closed loop referrals)

Patient Panelso Alternative access

• Team members interaction (face-to-face, phone, e-mail)

• Group visits• Home visits

o Reaching out to assigned but not engagedo Monitoring ‘leakage’o My-Chart utilization

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Outreach & Health Navigationo Expanded Team

o Developed a training hub for certification

o Uniform data capture & reporting ‘Care Steps’

Care Steps

Outreach & Health Navigationo Patient and community voice

• Hired a Communication & Engagement Coordinator

• Community and population based focus groups

• Patient stories

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Data & Qualityo Continued refinement & use of reports

o Implemented Quality Awards

o Implemented a Trainer to focus on work-flows & consistency

o Foster staff engagement in testing change

Data & Analytics: Access to Care Report Example

Data & Analytics: Quality Metrics Report Example

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Advancing Phase: Focus on Complexity

Patient PanelsQuality, Data, & Reporting

Patient Panelso Risk Stratification/Segmentation

• Advancing risk scores from medical diagnosis only

• Social Determinants of Health

o Care Plans

SDOH Pilot

Using the PRAPARE tool ◦ Completed once a year by patients◦ Resource referrals from Health

Navigation, as desired◦ Engagement opportunity for care team

Screening in 3 clinics currently◦ Slow with clinic driven criteria ◦ Fast with ‘everyone’ approach AND it’s

doable!◦ One site is looking only at food security

questions

Funding from InterCommunity Health Network Coordinated Care Organization supports this work.

Image credit: First Nations Health Council

http://www.nachc.org/research-and-data/prapare/

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Veggie Rx

3 validated questions about food security Ability to get food (access) Running out of food (financial need) Healthy food (prevention)

Stand open Tuesday and Thursday at Benton Health Center from 2:00-4:30 pm

Tokens can also be used at the Corvallis Farmers’ Market Wednesday and Saturday

$20 provided initially, opportunity to renew monthly from May- October

Engagement and use by staff, community, neighbors, other county employee's

Testing the financial model/sustainability Access point to improve consumption of local, fresh,

organic foods for everyone

Done in partnership sourcing, staffing, and logistics from the Corvallis Environmental Center

Data & Analytics

Data & Qualityo Hired Data Analytics Manager

o Developed data analytics strategy

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People* Senior Leadership Sponsors* Data Stewardship * Clinical & Business Analysts* Data Driven Culture

Process* Data Strategy

* Data Governance* Performance Measurement* Data Quality* Analysis of Data* Acting on Results

Technology* IT Tools and Support * Integration* Self Service Analytics

Data Analytics Strategy: Factors to Consider

2020 Reports: Adolescent Well Care Visits

683

430

210

576

51.5%

48.8%

52.38%

51.39%

0

100

200

300

400

500

600

700

800

Organization - Wide CCO Patients Trillium Patients APCM Patients

Adolescent Well Visits (AWV) 12-21yrs.

Total Adolescent Patients Total Patients Screened

Highest Benchmark:  65.2%

Jan Feb March April May June GAP

2020 Reports: Adolescent Well Care Visits

79.17%

0.00%

20.00%

40.00%60.00%

80.00%

100.00%Indiana Jones

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Lessons Learned

Clinical Impact of APMo Detached payment from a provider

visit/schedule

o Increased reliance on team

o Supports alternatives to access & care coordination

o Enhanced focus on quality & outcomes

o Resources for innovation & integration

Benefits of APMo Financial predictabilityo Resources for innovationo Better patient care; improved health

outcomeso Improved accesso Enhanced focus on patient and community

needs

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Feedback From Providerso “ Team based care has been helpful for me as

now I have a whole team who can care for my patients, no longer relying on just the provider”

o “ My life got easier because I can just focus on the physician patient relationship”

o “ It decreases my administrative burden, as other team members such as MA’s and CSR’s learn to interact with the medical record as they are able”

Feedback From Patientso “I feel as though a real team makes this ship function.

In the short time I’ve seen my PCP, I feel more managed than I ever did at my other doctor’s office”

o “Provider genuinely care about my condition, When I’ve needed referrals they have been made as soon as possible. I have gotten help with getting healthcare, food stamps, and other services”

o “ My doctor takes the extra time to get to know me and make you comfortable with your health/treatment. Thanks to all of you as a great team”

Feedback From Patientso “ My doctor takes the extra time to get to

know me and make you comfortable with your health/treatment. Thanks to all of you as a great team”

o “Dr is awesome! The girls are awesome! They know us by my name. I love coming to the clinic. I know that my and my family’s needs are taken care of!”

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Be Preparedo Staff time in preparing for & implementing

changeso Increase staffingo Invest in reporting through technology &

staff timeo Lots of change• Work flow adjustments• Roles & responsibilities• Multiple areas of focus