Congratulations, You’re an ACO Now What? Terrence O’Malley, MD

1. Congratulations, You’re an ACO Now What? Terrence O’Malley, MD Medical Director Non-Acute Care Services Email: tomalley@partners.org

2. Disclaimers • I have no • Conflicts of interest • Financial support or • Commercial ties to declare • Further Disclaimer: • The opinions expressed here are my own and do not necessarily represent those of Partners HealthCare

3. Our Current Efforts Continue • Keep working on all the issues needed to run a network : • Governance • Funds flow • Performance measurement • Quality improvement • IT • Adapt current systems to the new realities • Build the foundation for an ACO

4. Now What? • What do we need to do that we haven’t done before? • Identify high risk/high cost patients: the most medically, functionally and behaviorally complex • Provide longitudinal coordination of care (LCC) for the 5% of patients who are at highest risk • Improve Transitions of Care (ToC) • Bring Long Term and Post Acute Care (LTPAC) into the ACO

5. Format • Why is this issue important: • What are the potential benefits to the ACO: • What are the key questions: • How to do this: • Unresolved issues:

6. High Risk Patients: Why it’s Important • Focus on “Value”: V= Quality/Cost • Value goes up with increasing quality and decreasing cost • High risk patients use the entire spectrum of care. • They are high cost • They experience lower quality because of long and frequent contact with the health care system

7. 60 % total cost 5% members Figure 1. Typical pattern of health care expenditures among a health plan’s membership. Adapted and reproduced by permission of the publisher and author from: Halvorson GC, Isham GJ. Epidemic of care: a call for safer, better, and more accountable health care. San Francisco (CA): Jossey- Bass; 2003.1:p41 (This figure was based on data obtained from the Milliman 2001 Health Cost Guidelines-Claims Liability Distributions.) From “Managing High Risk, High Cost Patients: The Southern California Kaiser Permanente Experience in the Medicare ESRD Demonstration Project” P Crooks. Permanente Journal, Spring 2005, Volume 9, No. 2 , 93-97

8. High Risk Patients: Benefits to the ACO • Highest impact on cost • These patients are a stress test for the system • Bite sized piece • Lessons learned will apply to other groups with greater than average risk/cost • Improved processes and systems will benefit all patients

9. High Risk Patients: Key Questions • How do we find high risk patients before they become high cost patients? • What do we do when we find them? • Who are they? • How do we know if we’re finding the right ones?

10. High Risk Patients: How to do this • Select a risk assessment tool • Identify a target population • Select Interventions • Intensive care coordination • “Disease Management” • Caveat • Hospitals and PCMHs can’t do this alone

11. High Risk Patients: Unresolved Issues • How to manage “difficult patients”: • “AMA” • Disengaged • Unrealistic • Mismatch between expectations and prognosis • General principles • Keep your arms around these patients or someone else will • Management indifference is not a strategy • How to keep patients in network when they can go anywhere they want • The “Green Grass” strategy

12. LCC: Why It’s Important • Most of us haven’t done it before • We need a platform to: • Catalog all health concerns requiring management • Identify all team members and the problems for which they are responsible • Communicate among team members • Reconcile new information and produce a new plan reflecting changing priorities, goals and outcomes • Key to managing high risk patients

13. LCC: Benefits to the ACO • Provides the platform for managing high risk/ high priority patients • Provides a base for patient centered care: the patient’s goals shape the interventions and the team that oversees them • Patient engagement becomes an essential component of successful LCC • Harnesses the skills of care providers that previously were difficult to engage, more efficiency

14. LCC: Key Questions • Do we currently collect the essential information required for LCC • Goals of care • Current active problems • Active Team members • Interventions matched to problem and team member • What outcomes should we measure • ED visits, Admissions and Readmissions • Patient-centered quality metrics • How should we measure them

15. LCC: How to start • Do it for one high risk patient • Assemble the information needed • Patient goals of care • Current health concerns • Team Members • Develop a process for bringing this together • Connect the dots

16. LCC: Unresolved Issues • How to measure quality across an episode of care? • For a given set of conditions have all of the essential elements of care been provided during the episode? • Has the care provided been consistent with the patient’s goals of care? • What are the outcome measures that matter to patients? • Time until return to usual activities • Number of days in the past 90 spent in a facility

17. Transitions of Care Clinical Transition: The transfer of clinical responsibility between clinicians or teams of clinicians with the information necessary to insure safe and appropriate care for patients moving from one site of care to another.

18. Improve ToC: Why it’s Important • Transitions of care are what connect different parts of a system • High failure rate • Most common “procedure” (and if we had another procedure with a similarly high failure rate we’d stop doing it)

19. Transitions Touch Everything Readmissions Bounce backs Patient flow Work flow Capacity Capital TRAINING Non-standardized process Cost effectiveness Cross training Low scores on discharge Re-admissions THROUGH-PUT PATIENT SATISFACTION Transitions COST SAFETY Work-around Near misses Errors Sentinel Events Liability Efficiency Re-work Staffing intensity Task assignment Staff satisfaction QUALITY Content Timeliness “No dropped balls”

20. ToC: Key Questions • Where do you start • Where do you stop • What is the process

21. ToC: How to do this • Ask the receivers what they need • Ask the senders what the receivers need to know (DK2) • Agree on process, format, timing, content • Use the TJC Targeted Solutions Tool (TST) http://www.centerfortransforminghealthcare.org/tst_hoc.aspx

22. ToC: Unresolved Issues • Difficult to measure impact on outcomes: safety, quality, efficiency • How to detect near misses, omitted treatment, unnecessary treatment due to omission • Proxy measures such as decrease in the number of rapid response calls to serve as measures for improved hand-offs • How to measure impact on efficiency: • Can measure “defects” in the hand-off process but have to separately report the impact of these defects on efficiency by asking receivers what they had to do to make up for the defect

23. Measurable Safety Goals • Improve safety • Fewer Sentinel events • Fewer Bounce-backs to sending site • Fewer Readmissions within 30 days • Fewer Adverse events • Fewer Rapid Response calls within 2 hrs of transfer • Fewer Work-arounds to make up for missing information • Fewer Delays in treatment • Fewer Occurrences of Inappropriate treatment

24. Measurable Efficiency Goals • Improve Efficiency • Reduced cost per unit of care • Reduced variability in process • Improve information flow • Content • Format • Delivery • Reduce time spent reconciling conflicting information • Reduce time spent mitigating the effects of adverse events • Reduce time Sender needs to complete a transition • Reduce time Receiver needs to get information • Reduce call backs

25. Process Measures • Reduce “defective” transitions • All essential information is provided • All information arrives at the right time • All transitions use the agreed upon process • All information is in the agreed upon format

26. LTPAC Within: Why it’s Important • 20% of discharges go to SNF • 30% go to HHA • Accounting for ~ 1/3 of total cost • Often LTPAC is outside the control of the ACO • 3rd party vendors • Limited influence except through market forces • Independent/unaffiliated clinicians • No standard quality, performance metrics

27. LTPAC Within: Benefits to the ACO • Control quality, access, readmissions and utilization • Create lower cost options for care • SNFs direct admissions in lieu of Observation or Admission • Bring services to the patient rather than patient to the services • More flexible matching of patient needs by “flexing” services from high cost to low cost sites • Home care as a platform for delivering chronic disease management as an extension of or replacement for the PCMH

28. LTPAC Within: How to do this • “Within” doesn’t necessarily mean “own” but it does mean “under ACO management” • Shared incentives • Shared risk/reward • Shared performance and quality metrics • Buy vs Build vs Lease vs Joint Venture • De-couple staffing from physical plant operation • How are “investments” shared between the ACO and LTPAC

29. LTPAC Within: Key Questions • How much is enough • How much is too much • How much goes for ACO use • How much for FFS • How are “system” investments determined • How to align incentives

30. Aligning Incentives

31. LTPAC Within: Unresolved Issues • Staffing in LTPAC • Lower pay scales: constant RN draw from LTPAC to acute care hospitals • Physician staffing must shift towards full time away from part time community PCP coverage • Payment • Facilities need incentives for quality and reduced utilization • Nursing staff needs parity • Clinical staff needs different incentives to increase throughput and quality while reducing LOS

32. "Every system is perfectly designed to get the results it gets.“ Dr. Paul Batalden

33. Build the New System • Identify and manage high cost/high risk patients • Create ability to provide longitudinal coordination of care • Improve transitions of care • Include LTPAC in your network

34. It won’t be easy being an ACO But it will be interesting.