The Trinity Pioneer Story

1. The Trinity Pioneer Story Living Between No Longer And Not Yet Pamela Halvorson Chief Operating Officer, Trimark Physicians Group Executive Sponsor, Trinity Pioneer ACO Lori Weih Administrator – OSC Regional Operations, UnityPoint Health

2. The Trinity Pioneer Story Objectives Describe the financial, clinical and population health impetus for the Pioneer ACO. Illustrate the care coordination needs, development and barriers to deliver the right care for complex needs. Describe the necessary infrastructure, culture creation and partnerships. Outline performance to date and the priorities in care coordination in 2013.

3. The Trinity Pioneer Story And

4. The Trinity Pioneer Story UNITING AROUND THE VISION The financial, clinical and population health impetus for the Pioneer ACO

5. The Trinity Pioneer Story “When we can let go – for a minute – of the fee-for-service model, and ask ‘what would it look like?’ That leads us to the ‘ah-ha’ and ‘well duh’ insights. We find that it becomes very simple. The ACO waivers freed us up to think differently.” Sue Thompson Chief Executive Officer, Trinity Health System

6. The Trinity Pioneer Story Care at Home

7. The Trinity Pioneer Story Using Data Illustrate the care coordination needs, development and barriers to deliver the right care for complex needs. Outline performance to date and the priorities in care coordination in 2013.

8. The Trinity Pioneer Story Demographics PY1 Data

9. The Trinity Pioneer Story Patients with Complex Needs Beneficiary Risk and Chronic Conditions: Number of high risk and priority risk beneficiaries: 1,709(25.3% of total ACO population of 6,744) Patients with Diabetes: 1,725 (25.6% of total ACO population of 6,744) Patients with Congestive Heart Failure – CHF: 244 (3.6% of total ACO population of 6,744) Patients with Coronary Artery Disease – CAD: 1,115 (16.5% of total ACO population of 6,744) Patients with COPD: 510(7.5% of total ACO population of 6,744) Total Patients with Claims over $100K in 2012: 26 ($3.56 million in claims)

10. The Trinity Pioneer Story Patient with Complex Needs

11. The Trinity Pioneer Story Palliative Care Physician integrated Inpatient and Outpatient Palliative Care stats YTD December 2012: Inpatient Initial Palliative Care Consults YTD = 391 Total Inpatient Palliative Care Consults YTD = 472 Outpatient Palliative Care Admissions YTD = 141 Rolling YTD Readmission rate = 3.53% patients seen in Outpatient Palliative Care

12. The Trinity Pioneer Story ED High Utilizers Story

13. The Trinity Pioneer Story SILO BUSTING Describe the necessary infrastructure, culture creation and partnerships

14. The Trinity Pioneer Story One Team The conversations in Year 1 began with asking who was, could or wanted to do certain aspects of care for a population. No assumptions were made about what an organization could do. Examples of questions include: Who touches patients in significant ways? Who is willing to engage in care coordination? Who is ready with resources to do this work?

15. The Trinity Pioneer Story One Team Partnerships among diverse members developed over time “It gets down to relationship and culture building which doesn’t happen overnight; it is about trust, communication, listening, and energy about a new approach to care” Sue Thompson Chief Executive Officer, Trinity Health System

16. The Trinity Pioneer Story Team Growth Growth of the teams over the time period From 6 in the beginning to 68 and growing. What it means to be a member of the team Bringing people and skills together toward care coordination The analysts to the care givers Keeping patients safe in their homes and community Physicians and the team

17. The Trinity Pioneer Story NEEDS BASED TEAMS AND PARTNERSHIPS Describe the necessary infrastructure, culture creation and partnerships. Illustrate the care coordination needs, development and barriers to deliver the right care for complex needs. Outline performance to date and the priorities in care coordination in 2013.

18. The Trinity Pioneer Story Partnerships Critical Access Hospitals Public Health Long Term Care Facilities Community Pharmacies Parish Nurse Services Emergency Medical Services Schools

19. The Trinity Pioneer Story Public Health Story “Standing in the river looking for water”-Sue Thompson

20. The Trinity Pioneer Story Needs Based Teams and Work Programs Across the Continuum Palliative Care Health Risk Assessment My Care Profile Advanced Medical Team for High Risk Patients Care at Home to Support Transitions Telephonic Disease Management Pilot for Diabetes Care Long Term Care Collaborative Medication Therapy Management with Community Pharmacies Pediatric Partnership with Public Health Behavioral Health ACT Iowa Physician Order for Scope of Treatment to Honor End of Life Choices Our Common Language Across the Continuum Adaptive Design for Ideal Care Integrated Chronic Care Disease Management Teach-Back and Ask Me Three One Team

21. The Trinity Pioneer Story 2013 Priorities Implement Patient Centered Medical Home Hardwire current population health programs to the Medical Home Spread the Health Risk Assessment Implement My Care Profile for high risk patients Spread AMT Spread Telephonic Disease Management Spread behavioral health and palliative care through use of technology Spread IPOST Implement Medication Therapy Management Use data to inform decision making Engage more physicians in guiding the work in the Organized System of Care Continue to collectively learn what gets in the way of ideal patient care

22. The Trinity Pioneer Story TRINITY PIONEER