Managing Population Health: Equity through Person-Centered Care

Linda Alexander, RN, MBA, CCM ● Total Health Care– Chief Clinical Officer ● Plante Moran – Healthcare Consulting ● Detroit Medical Center - Clinical

Operations, Physician Services, and Strategic Post-Acute Integration

● Henry Ford Health System – Nursing, Administration, Quality

● Model 2 Bundling Awardee – DMC 10/9/12

The Era of ACCOUNTABLE CARE---Catalyst for change

Snapshot of Reimbursement in US ● Medicare – 1966 –

Hospital-centric Care ● HMO Act of 1973 –

Managed Care ● Prospective Payment

System (PPS) ● Fee for Service ● PPACA-Healthcare

Reform ● Readmission

Reduction ● Bundled Payment ● ACOs

Change was Inevitable! Without change

our current system is unsustainable

Like Medicare in 1965, PPACA is not perfect but its intent is to move the US healthcare system in the right direction

Modifications may be made, over time, to course correct,

Patient Protection and Affordable Care Act

Full title The Patient Protection and Affordable Care Act.

Acronym PPACA

Colloquial name(s) Affordable Care Act, Healthcare Insurance Reform, Obamacare, Healthcare Reform

Enacted by the 111th United States Congress

Effective March 23, 2010 Specific provisions phased in through January 1, 2018

● The law is the principal health care reform legislative action of the 111th United States Congress.

● PPACA reforms certain aspects of the private health insurance industry and public health insurance programs, including increasing insurance coverage of pre-existing conditions, expanding access to insurance to over 30 million Americans that, financially, is achieved through subsidies by the federal government and increased enrollment in federal health care programs (increasing total national medical expenditures in the short term), and additional policy changes to reduce the long-term cost of health care.

Triple Aim Philosophy PPACA was created with a “triple aim” in mind:

1. Improve the health of patient populations

2. Improve patients’ experience of healthcare

3. Reduce per capita costs of healthcare “The components of ” the Triple Aim are not independent of each other. Changes pursuing any one goal can affect the other two sometimes negatively, sometimes positively” Donald Berwick, Triple Aim: Care,, Health and Cost; Health Affairs; 27, no. 3 (2008)

Three Key Components of PPACA

Accountable Care Organizations

Value-Based Reimbursement

Care Integration

Above components are designed to meet the Triple Aim.

Accountable Care Organizations • Primary Care (wellness & prevention) • Physician/hospital alignment • Quality outcomes • Community stakeholder collaboration • Data sharing/integration • Improved care transitions and

efficiency • Capitated payments

Value Based Purchasing

•Readmission reduction strategies •Integrated care delivery systems •Transparency of information – HIEs •Consumer-driven selection – HCAHPS •Cost containment •Linkages between quality and reimbursement

WHO OWNS THE PATIENT???

ACO/Bundled Payment Linkage

● The ACO is viewed by hospitals & physicians as a key strategy to adapting to changes under healthcare reform.

● Many healthcare executives & thought leaders view ACO’s + Value-based payments as a precursor to bundled payments for episodic care.

● Post-acute entities account for 25-30% of healthcare costs and must be prepared to deliver a “value-based” service that aligns with referring source priorities, as part of the episode of care.

ACO + VBP = SBP

Single Bundled Payment Single Bundled Payment is

defined as the reimbursement of health care providers, which may include post-acute, on the basis of expected costs for clinically- defined episodes of care.

MedPAC 2010

Why Post-Acute is Key

PAC Setting % D/C from Hospital to PAC

Setting

% Readmitted after PAC Setting

% D/C to 2nd PAC Setting

SNF 17.3 22.0 29.3

HHC 15.0 18.1 2.3

Acute Rehab 3.2 9.4 56.8

Hospice 2.1 4.5 2.4

LTACH 1.0 10.0 53.4

Psych 0.5 8.7 25.4

Total 40.0 18.0 19.8

ACO Integration for Post- Acute Post-Acute Providers seeking to

participate in the ACO era must integrate ACO programming goals to counteract the legacy of silo-based care present in the PPS Care Continuum. Clinical accuracy, staff control, and care insight required for value concerns are paramount.

The Silo Effect

The Silo effect refers to the lack of communication and support often found in acute care episodes. Provider types focus primarily on their own goals, often ignoring the needs of others.

Post-Acute Benefits to Accountable Care

Pre-PPACA : Focus to reduce LOS Follow hospital plan Payment for readmits Minimal transparency Poor coordination with post-acute

Post-PPACA : Integrate care with

continuing care partners Improve patient experience Decrease post-acute care

costs (SBP) Penalties for readmits Payment for quality

(episode) Increase transparency Selective network partners

Hospital Readmissions

Hospital Readmissions ●Symptom of expensive/uncoordinated system

●Hospitals benefit fiscally from readmits

●2 million-30 day readmits - $17.5 billion

●71% of hospitals penalized 2012 - $280 mil

●Penalties doubled 10/13 increase again 10/14

●Promote safe patient passage from acute care

●Viewed as a new indicator for quality

An acquired, transient period of vulnerability and risk in the critical first 30 days after DC. This period of clinical risk is connected as

much to the stresses of the inpatient admission as it is connected to lingering

effects of the original illness. Patients are not only recovering from their illness, but they are also in a phase of generalized risk for a series

of adverse events. NEJM, 2013

Post – Hospital Syndrome

Equity through Person-Centered Care

Managing the Population vs. Managing an Encounter

Population Health Management Person-centered approach to

care Episodic Care Delivery - looks at

continuum, not merely hospital stay

Holistic assessment and care management

Integrates hospital and community care providers

Evaluates outcomes for chronic disease management

Considers other factors (psychosocial, community) affecting population health

Episodic Care Delivery

The re-engineering of the acute episode derived from acuity-based expectations of patient care requirements, devoid of Provider preference, and driven by the least restrictive/costly care environment.

Critical Success Factors Plethora of theories emerging. Common themes include: Ability to improve patient behavior Establish trust in the community in which you want to

serve Ability to align health continuum partners Ability to leverage risk Access to care-systematic evaluation Talent to execute strategy** **Due to siloed care delivery systems, many healthcare leaders have segmented experience. Each segment of the continuum has unique challenges, payment systems, etc.

What can hospital leaders do today?

Integrated Care Network ICN, IHS, ICS, ACOs, IDN, CCN….. “A network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population served.” Stephen M. Shortell, Ph.D. Dean – School of Public Health University of Cal-Berkley

Benefits of an ICS Additional revenue stream to offset volume reductions Hospitals can acquire new lines of business Risk-sharing to downstream providers can offset cost of

reducing utilization

Opportunity to lean into the curve, yet minimize risk Deliver better care, better outcomes Improve patient satisfaction Flexibility to start at your own pace Establish/expand accountability beyond hospital (take

ownership of patient care continuum)

Getting Started Adoption of Accountable Care Concepts Monitor care for an extended period of time (i.e. 30 days) Clinical care protocols, based on indicators vs. volume It is ok to start small!

Accountability and care coordination with downstream partners

Including quality as a key factor for selection of partners Consider risk-based models to drive change (shared savings) Be sure to include Behavioral Health

Integrating Care……Works! Bundled Payment Pilot Program Acute + Post-Acute for 30 day episode Joint Replacements Reduction of readmissions to 2% Savings of $600k during pre-pilot phase! Coordination with downstream/community partners Culture shift from “encounter” to “episode” Patient/caregiver engagement Physician alignment

Downstream Accountability is Critical Home Care: Start of care within 24 hours or less Shift care focus to self-care determination from dependence Clearly define clinical vulnerabilities and strengthen them Identify system/process for communication and coordination Data integration for sharing of clinical information Outcomes measurement and reporting – transparency Assist with education/development Develop processes for when things go wrong Home to SNF Visiting physician Easy outpatient access

Downstream Accountability, Part 2 SNF/Extended Care: Know the capabilities of your partners (frequency of

physician visits, competency level of staff, etc.) Ensure discharge orders are clear and complete Nurse to nurse report Physician oversight Establish goals of care prior to transfer Process to monitor goal-attainment and when to transition to

home or community LOS is based on clinical indicators not reimbursement

Community Connections Primary care coordination Behavioral health assessment and treatment Psychosocial wraparound services Area Agencies on Aging Community agencies Faith-based organizations

Patient education to support self-determination Support groups Maximize hospital-based case managers (i.e. Navigators)

In closing….. Healthcare Reform, driven by rising costs, seems to be here to

stay Post-acute and community integration is key for hospitals to

manage populations, including behavioral health Integrated Care Networks is one way that hospitals can begin

the shift from volume to value Leveraging risk can create alignment with physicians and

downstream providers

Innovation takes Courage “One isn’t necessarily born with courage, but one is born with potential. Without courage, we cannot practice any other virtue with consistency.” Dr. Maya Angelou, USA Today, 1988

Linda Alexander RN, MBA, CCM Lalexander@THCmi.com

313-269-0438

Follow me on Twitter: @JAlex4Health

Thank you!