Atrius Health as an ACO/PCMH:
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Atrius Health as an ACO/PCMH: Strategies to coordinate with our patients across the continuum (Hospitals, SNF’s, Home Care). MassPro February, 2013 2:30p-3:30p Kate Koplan, MD, MPH Director of Medical Management Atrius Health. Atrius Health – Background.

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Atrius Health as an ACO/PCMH:Strategies to coordinate with our patients across the continuum (Hospitals, SNF’s, Home Care)


February, 2013


Kate Koplan, MD, MPH

Director of Medical Management

Atrius Health

Atrius health background
Atrius Health – Background

Non-profit alliance of six leading independent medical groups

Granite Medical

Dedham Medical Associates

Harvard Vanguard Medical Associates

Reliant Medical Group

Southboro Medical Group

South Shore Medical Center

Provide care for ~ 1,000,000 adult and pediatric patients in almost 50 ambulatory sites

1000 physicians, 1450 other healthcare professionals across 35 specialties

NCQA-Level 3 Certified Patient-Centered Medical Home at all Groups

  • Long history with global payments, currently managing 50% of our patients with global payments.

  • Strong infrastructure to manage risk

  • One of first to sign BCBSMA Alternative Quality Contract (AQC) and One of 32 Medicare Pioneer ACOs nationally

Elements of patient centered medical home
Elements of Patient Centered Medical Home

  • Personal physician

  • Physician-led care team

  • Whole person orientation

  • Coordinated Care Across Continuum  HOSPITAL/SNF/HOME CARE

  • Enhanced access

  • Quality

  • Safety

  • Patient and family centered

Comprehensive aco pcmh work must extend to the continuum
Comprehensive ACO/PCMH work must extend to the “continuum”

  • ~20% of Medicare patients hospitalized at least 1x/yr (Medicare Preferred and ACO)

  • They require services at discharge:

    • 20-45% hospital discharges lead to SNF or Rehab stay

    • 1/3 receive Home Health

    • 1/10 receive outpatient/ambulatory therapy

Preferred hospitals will have at least two of the following
Preferred hospitals “continuum”will have at least two of the following:

  • Unique contracting relationship

  • High-volume or at least a regionally high-volume

  • Site or Group preference, with supportive communication strategy

  • Formal collaborative relationship between Atrius Health and Hospital, including steering, clinical collaboration, and IT committees

  • Standards and metrics agreed upon and regularly reviewed, including discharge coordination and use of Atrius’ preferred network

  • Mutual agreement that Atrius and Hospital will collaborate on IT interoperability, including Atrius patient identification at registration and notification to primary team of admission and discharge

  • Atrius Health and Hospital physician and administrative leads to guide relationship

Preferred snf facility standards
Preferred SNF Facility Standards “continuum”

  • General:

    • Staffing/HR requests, incl. credentialing

    • Facility agrees to use Atrius Health preferred providers (DME, VNA, specialists)

  • Pre-Admission:

    • Patient screen and bed availability streamlined

    • Patients are identified as Atrius Health patients

    • Able to accept direct admits from home/ER/clinician office.

  • During stay:

    • Facility comfort for pts and staff

    • INTERACT tool (or comparable quality tool)

    • Therapies are available seven days per week; Mental Health coverage

    • Team and care planning meetings; facility case manager responsibilities

    • Radiology, Lab, Pharmacy expectations

  • At Discharge and Post-Discharge:

    • Patient experience survey

    • Atrius preferred vendors utilized for DME, Home Care, Home Infusion, Hospice, etc.

    • D/c planning based on checklist, incl. med list, sharing ACP directives, teach back

Preferred snf provider standards
Preferred SNF Provider Standards “continuum”

  • Discharge Planning

    • Templated summary; sent w/i 24h to Atrius Med Records

    • Ensure that f/u care is appropriate and that patient returned to Atrius Health PCP

  • 24/7 coverage by experienced and responsive clinicians

  • Timely communication to PCP if unexpected change in patient’s status

  • Newly admitted patients seen w/i 48h of admission by physician

  • Utilize Atrius Health preferred providers during stay

  • Participate in team and family meetings

  • Participate in quality and INTERACT or other related readmissions reviews

  • Comply with all payer minimum requirements

Pioneer aco snf based collaboration
Pioneer ACO SNF-based Collaboration “continuum”

  • Representatives from the five Eastern Massachusetts began regular meetings in November 2012.

  • The group has recently expanded to include representatives from Leading Age and Mass. Senior Care Federation.

  • The first initiative was to create expectations for both SNF Facilities as well as for SNF Providers. So that SNFs would have one set of common expectations and not five.

  • Expect that they will be released in the next few weeks.

  • The next effort will be develop a set of expectations for hospitals when transferring a patient to a SNF.

Standards and metrics to define our hospital snf strategy
Standards and Metrics to Define our Hospital/SNF Strategy “continuum”

  • Relationship structure

  • Care coordination, including case management and transitions of care

  • On-site functions

  • IT interoperability

  • Unique contracting opportunities

  • Preferred providers/vendors post-dischargee

Improved care coordination work across continuum
Improved Care Coordination & Work across “Continuum” “continuum”

  • Differential process for discharge to SNF, home with services, and home without services, plus care coordination’s link with elder care services

    • Standards & Metrics, incl. IT interoperability

  • Post ED and hospitalization follow up within 7d, w focus on medication reconciliation and care coordination

  • “Call First” campaign – encourage follow-up at our facilities if ambulatory-sensitive, or use of our preferred inpatient facilities, if level of care is appropriate

  • Data: post-facility f/u, readmissions trending (3d, 7d, 30d), high risk patient reviews, etc…

  • Direct liaison with our hospital/SNF/homecare partners

Open time
Open Time “continuum”