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Care Coordination in the ACO EraPresented by:
Anne Meara, RN, MBA
July 9, 2015
The Bronx
• 1.4 million residents in the poorest
urban county in the nation
• Median household income $34,000
• 54% Hispanic, 37% African-
American
• High burden of chronic disease
• Per capita health expenditures 22%
higher than national average
• 80% of health care costs paid by
government payers
Who We Are• Children’s Hospital at Montefiore
• Montefiore Einstein Center for Cancer Care
• Montefiore Einstein Center for Heart and
Vascular Care
• Montefiore Einstein Center for Transplantation
• Clinical
• Translational
• Health
Services
• ~1,323 Residents & Fellows
• ~420 Allied Health Students
• ~1,552 Graduate &
Undergraduate Nursing
• ~200 Home Health Aides
• ~100 Social Workers
ResearchTeaching
• Home Health
Programs
• Primary Care
• House Call
Program
• 8 Campuses
• 7 Hospitals
• 2,200 Beds
• 150 Skilled
Nursing Beds
• 1 Freestanding
ED
HomeCare
Hospitals
• Clinical
support
• Network
applications
• Finance
• Legal
• Planning
• Purchasing
• Compliance
• Marketing
• Human
Resources
• Care
Management(>300K Covered Lives)
• Disease
Management
• Care Coordination
• Telemedicine
• Pharmacy
Education
Information Technology
CorporateFunctions
CMO
• Health Education
• Community Advocacy
• Wellness
• Disease Mgmt.
• Nutrition
• Obesity Prevention
• Physical Activity
• Reduce Teen Pregnancy
• Lead Poisoning Prevention
Population Health
• ~23,000 Employees
• ~3,450 Integrated Provider
Association Physicians
• ~1,800 Employed MDs
• ~4,270 RN/LPN
• ~3,300 NYSNA RNs
• ~10,280 SEIU/1199
Workforce
Community
AcademicHealthSystem
Notable Centers of Excellence
Primary & Specialty
Care
• Advanced Primary
Care
• Sub-specialty Care
• Dental
• School Based
Health Centers
• Mobile Health
• Neuroscience
• Orthopedic
• Ophthalmology
• OB/GYN
Population Health Infrastructure
• Formed in 1995• MD/Hospital Partnership• Supplies network of par
providers committed to cooperation in care improvements
• Accepts some full risk capitation from health plans
• Established in 1996
• Wholly-owned subsidiary of Montefiore Medical Center
• Performs care management delegated by health plans
• CMO performs most functions for MIPA
• 1000 staff
CMOMontefiore Care
ManagementMontefiore IPA (MIPA)
3
Overview of Value-Based Payment Arrangements at Montefiore
Goal: To reach 1,000,000 covered lives
Source 2015 Population
Risk Contracts 221,000
Shared Risk 170,000
Medicaid Health Home
(Care Coordination)10,000
Totals 401,000
1996 Established the
Montefiore IPA and
CMO to facilitate risk
contracts
2000Major expansion of
risk membership
2011Montefiore
selected
as
Pioneer ACO
2012Formation of
Montefiore-led
Medicaid
Health Home
Program
2013Creation of
Montefiore
HMO (MLTC)
and
expansion of
Pioneer ACO
2009Montefiore
leads creation
of
Bronx RHIO Development of
care management
infrastructure;
extension of care
management core
competencies
into network
2014 -2015DSRIP
planning and
implementation;
development of
commercial
ACOs
Montefiore’s Journey to Accountable Care
Sunset of NYS all-payer hospital
reimbursement
Affordable Care Act
Performance-Based Culture
Managed Care Expansion
Identify & Prioritize
Enroll
Assess Needs
(Baseline and Ongoing)
Develop Personalized Care Plans
Stratify into Programs
Monitor &
Update Care
Plans until
Discharge
Patient
Primary CareProvider,
PCMH
Care Management Process Lifecycle
7
Care Planning
Develop Personalized Care Plans
• Accountable
care manager
assigned
• Stratification of
service levels
• Care plan
developed
(based on
problem list)
Initial engagement
Enroll
• No contact • Opt out
• Make contact
• Opt-in to care
management
• Self-
management
• Customized
assessments
• Access to
information as
needed (e.g.,
PHR, general
health info)
b
Care Management Process Lifecycle: High-Level Workflow
Preliminary identification of cohorts
High utilizers/ High risk
Functionally ill
Healthy/worried well
Identify & Prioritize
• Conduct
analytics to
segment
attributed
populations
• Segment
based on
utilization,
cost, and
available
clinical
information
Comprehensive needs assessment
Assess
Needs
• “Problem list” developed
• Telephonic
interview to
determine
medical and
psycho- social
needs
Care Guidance
Ongoing component
Monitor &
Update Care
Plans
• Inter-disciplinary
team assigned
Care team• Accountable Care Mgr
(RN, LPN, SW)
• Behavioral Care Mgr
Support resources• Clinical SMEs
o MD
o Pharmacist
o Disease-specific
SMEs
• Programs
o SNF
o Palliative Care /
Hospice
o House Calls
Community Services
Specialists
8
• Analyst,
utilizing the
following
enablers:
– Patient list
from State
– Claims,
administrative,
clinical data
– Risk
stratification
software/
applications
Preliminary identification of cohorts
Identify & Prioritize
• Coordinator
• Non-clinical staff
with minimum
high school
education
• Knowledge of
community
members,
sensitive to local
needs
• Bilingual
preferred
Initial engagement
Enroll
• Interviewer
• Trained and
experienced in
motivational
interviewing
• Clinical
background
(RN, LPN, SW)
Comprehensive needs assessment
Assess
Needs
• Accountable
Care Manager
• Clinical
understanding
and knowledge
of local
community
resources
• Clinical
background (RN,
SW)
Care Planning
Develop Personalized Care Plans
Care Management Process Lifecycle: Resources requiring varying skill sets
Care Guidance
Monitor &
Update Care
Plans
Care Team• Accountable Care
Mgr (RN, LPN, SW)
• Behavioral Care Mgr
Support resources• Clinical SMEs
o MD
o Pharmacist
o Disease-specific
SMEs
• Programs
o SNF
o Palliative Care /
Hospice
o House Calls
Community Services
Specialists
Analytics alone will not be able to
identify underlying drivers of medical
expense
• Unstable Housing
• Substance Abuse
• Mental Health
• Financial Distress
“Big Data” Is Not Enough
8% Generate 55% of Medical Expense
10
Social Determinants of Healthcare Costs
Based on results of over 4,000 assessments of high-risk
patients conducted at Montefiore CMO
Montefiore: An Introduction – Revised 5/2012
Medical/Behavioral ConditionsFood · Housing Finances
Education Transportation
FoodHousingFinancesEducation
Transportation
Medical/
Behavioral
Conditions
Care Coordination
Community Based Services • Care Transitions • Intensive Care Mgmt • Chronic
Care Mgmt • Palliative and Hospice Care • Behavioral Health Mgmt • Telemonitoring
The Provider View The Patient View
Aligned Priorities and Goals
Care Management Bridges the Gap
Montefiore: An Introduction – Revised 5/2012
Lessons Learned
• Skill set to manage complex psychosocial issues does not reside in traditional health care setting
• Data is a means to an end, not the end
• No one discipline/organization has all the requisite expertise/resources to manage a complex population
• Care coordination is a dynamic process requiring constant review and improvement
• Collaboration is key to success