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MassPro February, 2013 2:30p-3:30p Kate Koplan, MD, MPH Director of Medical Management

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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 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
  • 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
  • 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
  • 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
  • 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”
  • 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