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Brown and Toland Physicians' Approach to Serving High-Risk, High-Cost Patients to Improve Outcomes at Lower Costs

This case study describes how Brown and Toland Physicians, an independent practice association (IPA) in the Pioneer accountable care organization (ACO) program, serves patients with complex needs and high costs to achieve better health outcomes at lower costs. Brown and Toland's strategy uses a tiered approach to tailor the provision of care-managed services to patients' needs:Ihis experience is valuable to all ACOs seeking to improve health outcomes and costs for a subset of patients with complex health needs.

BACKGROUND AND SUMMARY

Brown and Toland's care management program builds on 20 years of experience contracting with health maintenance organizations to manage risk and to monitor utilization and quality. Early utilization analyses indicated that a small num-ber of Brown and Toland's patients generated a large portion of health care costs.

Patients with complex health needs, particularly Medicare patients, had multiple chronic diseases and behavioral health needs and they struggled with complex medication regimes. In addition, these patients often faced significant life stress-ors and needed assistance with permanent and accessible housing, extended at-home nursing care, and transportation to health care providers. Brown and Toland developed tiered care man-agement programs to target patients' medical and social needs in order to obtain better health outcomes and lower costs.

Brown and Toland customizes the delivery of care management services to meet the particular health needs of patients through three core programs: (1) support through care transitions for those at risk for hospital readmission; (2) outpatient care management for patients with chronic conditions, behavioral health needs, and/ or complex prescription drug treatment; and (3) home-based medical care for frail patients with critical and complex health needs.

Brown and Toland applies the following strate-gies when implementing the care management program:

• Develop strong partnerships with key care delivery organizations, such as physician practices, hospitals, skilled nursing facilities (SNFs), behavioral health providers, and home health care and community services agencies

April 2015

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• Use multiple methods to identify a subset of patients for whom complex care management has the potential to improve health outcomes and reduce costs

• Integrate the provision of care across delivery sites through regular communication and exchange of information

• Maintain a system of feedback and monitoring to identify promising strategies

Brown and Toland joined the Pioneer ACO program in January 2012 and currently has approximately 18,000 aligned benefi-ciaries. The Pioneer ACO Model is operated by the Center for Medicare &Medicaid Innovation and designed for health care organizations and providers that are experienced in cwoordinat-ing care for patients across care settings. In comparison to the Medicare Shared Savings Program, the Pioneer program enables ACOs to move more rapidly from a shared savings payment model to a population-based payment model.

ORGANIZATION

Brown and Toland Physicians is a San Francisco-based net-work of independent physicians who came together in 1992 to provide a comprehensive network of physicians for health maintenance organizations and to create administrative efficien-cies among the physicians. The physician-owned IPA consists of 550 independent primary care and 1,172 specialty care physi-cians, many of whom work in small practices with one or two other providers. Collectively, Brown and Toland physicians serve 300,000 patients, more than half of whom are covered under some form of risk-sharing agreement.

IDENTIFYING HIGH-RISK, HIGH-COST PATIENTS

Brown and Toland combines multiple diverse methods to identify a wide range of patients who will benefit from complex care management, whether enrolled in Medicare, Medicaid, or a commercial health plan. The patient identification approaches incorporate the results of predictive modeling, recent acute care or emergency department (ED) visits, and physician referrals. In combination, these approaches identify a subset of patients who are likely to benefit from complex care management.

Identifying Patients from an Acute Event

Brown and Toland identifies most high-risk, high-cost patients during an inpatient hospital stay or ED visit. To find these patients, Brown and Toland's hospital-based care managers review daily reports of all hospital and ED utilization and screen patients to identify those who meet a combination of the following criteria: history of acute admissions in the past

six months, inpatient readmission in the past 30 days, diagnosis of congestive heart failure or chronic disease (such as diabetes), treated with complicated medication regimes, and poor social support. To facilitate this review, Brown and Toland partnered with hospitals that serve a large portion of their population to flag Brown and Toland patients in their electronic health record (EHR) system. "We get notified between 24 and 48 hours at the latest," said Dr. Marcus Zachary, Brown and Toland's vice presi-dent of population health, rather than wait two to three months for claims data to become available. After receiving notification that the hospital treated a Pioneer patient, the care managers use read-only access to review the patient's' EHR and discharge plan. The care managers, located at the hospital, are also well positioned to coordinate with discharge planners to establish a successful transition plan.

Identifting Patients Through Physician Referrals

Brown and Toland identifies high-risk, high-cost patients that are treated in an outpatient setting through physician referrals. The physician referral method evolved early when Dr. Zach-ary realized cold-calling high-utilizing patients failed. Instead, Brown and Toland provides primary care providers with lists of their patients that have been identified as potential care man-agement candidates based on predictive modeling. The model incorporates a variety of data sources, including medical claims, prescription drug utilization, labs, and diagnosis codes. The pro-viders review the list to identify patients who can benefit from complex care management. In describing early conversations with providers, Dr. Zachary said: "I wasn't in there saying, 'Who are the people who need to go into complex care management and who are the people who are homebound?' but rather 'Here's a list of folks that we identified as being in the Pioneer program. Can you take a look at this list and see if there is anybody that you would like us to partner with you to help them with their care?'"This strategy leverages physicians' personal insight into patients' health needs, resource availability, and social supports. "There's no substitute for that," Dr. Zachary said.

Brown and Toland reduced the burden associated with physician referrals by developing a "no wrong door" policy stating any physi-cian can refer any patient and the complex care team will provide services for that patient. Care coordinators then assess the needs of identified patients, align care management or referral services (if needed), and communicate the care plan to the physician. Another strategy to reduce the burden on physicians involved modifying the EHR system. Physicians can quickly see which patients are attributed to the Pioneer program and submit refer-rals for care management services through the click of a button.

Brown and Toland fosters partnerships with physicians, both to improve the appropriateness of referrals and to provide continu-ity of care delivery when care management begins. Within a

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week of receiving a physician referral, Brown and Toland care coordinators call the physicians to discuss the patient's plan of care. Dr. Zachary emphasized that this establishes "a positive

cycle ... it is human nature that if [the physicians] don't hear

from you, they're going to assume that you're not thinking about their problem; that they wasted their time." Over time, physicians have become more knowledgeable about the type of patient who benefits from complex care management. "If we cre-ate a positive cycle and they see you as the 'that was easy' button,

then you're going to get access to the office in a way that you haven't before," he said.

DELIVERING COMPLEX CARE MANAGEMENT

Brown and Toland's approach to its care management pro-

gram tailors service provision to patients' particular needs. The

program consists of three approaches, each supported by a care

management team centralized within Brown and Toland. These three approaches are distinct in service provision, intensity, and

duration (see Table 1).

Brown and Toland designed the three approaches to meet

the patients' different levels of need. Based on their evolving

health status, patients can move from one level of care manage-ment to another. Most patients first engage in transitional care

management, which meets their needs within four weeks. If the

care transitions team determines a patient would benefit from

additional care management, the team collaborates with the out-

patient complex care management team to smooth the patient's

transition to the next level of care management. Other patients are engaged in outpatient complex managed care based on

physician referrals. The team enrolls patients in the home visit

program who have difficulty leaving their homes, are frail, have complex needs that are difficult to manage, or require frequent

visits with a health care provider.

Teams consisting of nurses, care coordinators, and social workers support all three care management approaches. The team-based

approach builds continuity and trust with patients and primary

care providers, while enabling Brown and Toland to spread care management resources across multiple provider practices.

The teams generally work virtually, often communicating with

patients and providers by telephone and recording care manage-

ment provision using a shared software platform. The technology

system enables the care management teams to build on informa-tion collected from the initial patient assessment through each

patient encounter and facilitates ongoing communications with

the patient's providers. In addition, the teams use this informa-tion when transitioning patients from one care management

track to another as patients' health care needs evolve.

A common patient engagement approach links all three care

management approaches. The team's engagement goals include: assessing and understanding the patient's unique health, social,

and welfare needs; managing and coordinating needed care; and

addressing patient-level barriers that drive poor outcomes and

Table 1

Three Approaches to Care Management

Care Management Approach Description Caseload

Transitional care management

Supports patient through transition from hospital to SNF or home, with service duration of one month or less

Each month, up to five registered nurses and two care coordinators make

roughly 1000 calls to approximately 400 members

Outpatient complex care management

Provides care management for patients with multiple chronic conditions and complex health and social needs, with average service duration of three to six months

Six registered nurses and six care coordinators together managed around 1,300 cases in 2014

Home visit program

Coordinates and delivers care to patients who are frail and benefit

from home-based medical care provided; of the three tracks, the home visit program is the most intensive and can continue for an indefinite time

Each of the two nurse

practitioners has a caseload of about 70 patients.

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high utilization. Brown and Toland trains staff to develop skills based on a foundation of motivational interviewing, a goal-oriented approach to behavior change that focuses on building intrinsic motivation, understanding each patient's unique needs and challenges, and helping to remove or mitigate obstacles to achieving better outcomes in more appropriate care settings. Additional training includes strategies to have difficult con-versations with patients, either virtually or in person. Ms. Ann Marie Molyneaux, director of clinical services, found that with experience and consistent mentoring by nurse supervisors, care managers become adept in handling difficult tasks. For example, they learn the best ways to introduce and lead conversations about patients' end-of-life wishes, or they know when they have to allow people to make their own choices, even if that means a mentally competent elder returns to less than optimal living arrangements.

The care management team also engages with family members and caregivers that patients have identified as key members of their support network. This engagement provides a more com-plete assessment of patients' care needs, financial challenges, and living environment. In addition, social workers are cognizant of the demands facing patients' caregivers. Social workers identify opportunities to support family members and caregivers so that they may be able to continue caring for patients on an ongoing basis, for example enabling a caregiver to have an occasional respite from the daily challenges of caring for a loved one.

In addition to engaging patients directly, the care management team partners with key providers to affect positive changes in service delivery and patients' lives. These providers generally serve a high volume of Brown and Toland's patients and include primary care practices, hospitals, SNFs, and home health agencies. The basis of these partnerships is a high degree of communication throughout care provision, from streamlining the referral process to integrating care plans. For example, Brown and Toland recog-nized that one SNF treated many of its patients but had a higher percentage of hospitalizations after SNF discharge than other SNFs. Brown and Toland partnered with the SNF to increase medical support to serve patients and developed clearer commu-nication methods between the hospital and the SNF.

The partnerships are a mechanism to increase engagement with patient and caregivers and to enable the care management team to build on established physician—patient relationships. Brown and Toland promotes use of a common EHR platform across partner hospitals and primary care practices, both to facili- tate communication and enable care team members to access patients' information in real time.

Transitional Care Management

Transitional care management focuses on supporting a patient from hospital or ED discharge through the first follow-up

appointment with his or her primary care provider. The primary care provider appointment usually occurs with seven to fourteen days of discharge, though the team might provide continued support for another three to four weeks until the patient's health stabilizes. The teams, composed of registered nurses and unlicensed, highly skilled care coordinators, are located within hospitals treating a large portion of Brown and Toland patients.

After identifying patients appropriate for transitional care management, the team assigns the patient to a care management team member with expertise appropriate for the patient's needs, such as a care coordinator or a registered nurse for medically complex and high-risk patients. The care management team then works with hospital discharge planners to review recent medical records, consider patient needs that might arise after discharge, and anticipate issues that might increase the risk of readmission. For example, the care coordinator might discover that a married man who would typically be discharged home requires assistance because he has limited family-based support after his wife's recent stroke.

The care coordinator could determine that the patient would benefit from review by the registered nurse care manager. For example, the patient might have been prescribed a complicated medication regime, either before or during the hospital stay. The registered nurse would review the medications, perhaps with a Brown and Toland staff pharmacist or medical director, to recommend that the prescribing physician simplify or adjust the medication treatment. In addition, the care coordinator may also work with the home health care nurse, when involved in patient care, who also complete medication reconciliations.

After discharge, the care coordinators contact patients, arrange for office visits with patients' primary care providers, align refer-rals, and ensure patients have at-home supports to remain in stable condition. Completing initial outreach soon after an acute event is most effective because patients are receptive to help when feeling stressed or overwhelmed by their treatment plans. In the initial post-discharge telephone call, care coordinators ask patients open-ended questions about their hospital experiences, their understanding of their treatment plans, and whether they have any questions or concerns:The goal of the care coordina-tor's outreach, notes Ms. Molyneaux, is to complement hospital staff's discharge education by providing patients with an oppor-tunity to focus on what is important to them and identify issues that can affect their ability to heal.

Care coordinators also screen for health needs that would benefit from involvement by other members of the care manage-ment team. In the rare instance when a patient's health needs appear to be too complex to manage through telephone calls, a registered nurse or social worker makes a home visit. If the home visit identifies potential prescription medication prob-

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lems, the nurse can complete a medication reconciliation by comparing the patient's understanding of the prescribed drug treatment with data recorded in the EHR. The registered nurse may conclude the care plan requires adjustment and connects with the patient's primary care physician to consider alternate treatment strategies.

The care transitions team can continue to provide care man-agement for the patient for up to one month after discharge, collaborating with SNFs, home health agencies, and/or primary care providers to ensure patients have continuity of care. The ongoing support can address transportation barriers that limit the patient's ability to get to follow-up appointments, such as limited access to a car or difficulty maneuvering steep San Francisco stairways. The care team might discover that crucial equipment, such as oxygen tanks, are not delivered when sched-uled or that family caregivers who are present in the first days after discharge must return to work. The care transitions team determines if a patient requires ongoing support and refers the patient to the care management program focused on complex management in the outpatient setting.

Outpatient Complex Care Management

The outpatient complex care management program serves patients with multiple chronic conditions and complex health needs that drive utilization. Care management includes support and coordination of medical care, identification and mitigation of barriers to good health outcomes, and connection with social services. Patients generally receive complex care management for three to six months, until the care management team determines the patients no longer requires their services. Occasionally, the team finds patients are stable within the six month window and can be supported by the primary care physician with infre-quent check-ins by the care management team. More complex patients, such as those in the beginning stages of dementia, may require ongoing care management.

The complex care management team includes registered nurses, unlicensed care coordinators, social workers, and a supervisor to mentor the team and troubleshoot issues. The team is organized into small groups, called pods, which are associated with specific physician practices. This structure supports the development of relationships among the care management staff, the physician practice, and the patients treated by each physician practice.

To initiate complex care management, a care coordinator calls the patient as the representative of the primary care physician's office and relays that the physician believes the patient might benefit from additional assistance. "This approach has been vital to gaining patients' trust," says Dr. Zachary, noting that patients are often skeptical about care management and fear it is an attempt to limit services. Care coordinators who make the

initial patient contact can be selected based on their proficiency with foreign languages; Brown and Toland enrollees' primary languages frequently include Cantonese, Spanish, or Tagalog.

After initial contact, registered nurse care managers connect with patients to establish an in-depth understanding of their health care needs and ensure the involvement of all appropriate providers in the care plan. The nurses develop this understanding by performing a number of screenings and assessments related to activities of daily living, family and social support, medica-tion therapy management, depression, and end-of-life plans (if appropriate). Depending on the results of these assessments, the nurses and care coordinators will contact the patient's primary care physician, specialists, a social worker, a pharmacist, and/or a home health care agency. In addition, nurses work closely with care coordinators, who support patients who have billing and logistical questions.

Over time, the care coordinator remains in contact with patients through telephone calls to continue to build relationships, assess evolving medical and social needs, refine the care plan, and con-nect patients with community services such as Meals on Wheels or the health insurance advocacy programs. "Providers regard them as an extension of their office staff," says Ms. Molyneaux, offering an example of providers requesting care coordina- tor assistance for patients struggling to manage their insulin regimens. Throughout these communications, care coordinators remain alert for indications that the nurse should also connect with the patient, such as unmanaged pain, medication confu-sion, or symptom escalation. In those situations, the nurse may determine that the patient would benefit from a home visit.

The care management team can involve social workers to iden-tify behavioral challenges that compromise health improvement or contribute to increased utilization. For example, a patient with chronic obstructive pulmonary disease requests an ambu-lance for an ED visit up to five times in a week. In a 45-minute telephone conversation with the patient, a social worker and nurse discovered that the trigger for the ED visits was anxiety, not the patient's medical condition. Over a series of phone calls the care management team educated the patient about anxiety and convinced her to use her prescribed anti-anxiety medication, which halted the frequent ED visits.

Home Visit Program

Brown and Toland provides home-based medical care to frail patients with complex, critical health needs. The home visit care team provides highly individualized services, customized to meet the goals and care preferences of the patients, families, and pri-mary care providers. Many of the patients enrolled in this care management track would likely have moved to custodial care if not for the support of involved caregiving from family members.

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In collaboration with a patient's primary care provider, the home visit care team delivers medical care and services in the patient's residence to maximize functionality and alleviate suffering. Some patients will regain functioning and return to receiving all their primary care from their office-based providers, whereas others continue to receive treatment from the home visit care team for the rest of their lives or until the patient transitions to hospice care.

Brown and Toland has two distinct home visit care teams, each consisting of a nurse practitioner and a social worker, that travel to the patients' homes. The teams include care coordinators who are located within Brown and Toland's central offices, are skilled in customer service, and serve as a conduit for communication among the care team, patients, and families. In this role, the care coordinators act as the glue for the team by managing referrals; coordinating appointments; serving as a consistent contact for patients' families to discuss care preferences and health needs; and aligning care from other providers, such as home health nurses, physical therapists, and medical equipment suppliers. For both care teams, Dr. Zachary acts as a medical director and provides clinical oversight. Should he be unavailable, the care team contacts a designated back-up physician.

To initiate care, the nurse practitioner and social worker visit the patient's home together and spend about two hours com-pleting a full assessment of the patient's needs and supports and identifying the patient's goals. The social worker identifies behavioral health issues, considers the adequacy of the patient's support systems, and considers issues that might negatively affect health outcomes. The nurse practitioner completes medical assessments, performs prescription and medication management, and provides care in the home. Together, the nurse and social worker identify barriers to better care, which can include a lack of transportation, inadequate support, and gaps in the patient and family's knowledge. Newly enrolled patients often require intensive medical treatment because mobility issues limit their ability to access office-based medical care. Based on this initial visit, the nurse practitioner and social worker work with the patient and family to create a comprehensive care plan.

The home visit care team implements the care plan and man-ages patients' chronic conditions and treatment on an ongoing basis within their residences. They coordinate this care with the patients' primary care providers and other specialist providers by taking the following actions:

- Coordinate in-home care delivery by other providers, such as home health agency visits for minor wound care, behav-ioral health treatment, or physical and occupational therapy

- Order in-home labs, x-rays, and durable medical equipment

- Explore end-of-life wishes and complete related forms

- Respond to emergent medical issues

- Manage prescription drug treatment

The team also aims to reduce caregiver burden by supporting and linking caregivers to counseling and other community resources. For example, one team made a referral to speech therapy for a patient suffering from multiple sclerosis who had trouble speaking and swallowing. The team also aligned support for the patient's husband, who served as the main caregiver and had difficulty managing the burden.

Throughout care provision, the nurse practitioner remains in close contact with the patient's primary care provider. Recently, Brown and Toland implemented information technology enhancements to enable the nurse practitioners to access and input into the charts in the patient's EHR, further integrating the home visits with the patient's broader care team.

MONITORING AND EVALUATION

To continue refining and improving the care management program, Brown and Toland calculates trend analyses of utilization, quality, and patient satisfaction measures. The trend calculations reflect changes in care delivery for all Brown and Toland patients, including Pioneer-aligned beneficiaries. Taken together, these early analyses provide an indication that Brown and Toland's care improvement initiatives, including the care management program, enable patients to receive higher quality care in the outpatient and home settings and reduce unnecessary inpatient and ED treatment.

Between 2012 and 2014, Brown and Toland found the number of acute care and ED admissions among patients over 64 years had decreased. The number of acute care admission per thousand senior patients dropped from 239 to 178 and the number of ED visits dropped from 325 to 274 (Figure 1). At the same time, patients' length of stay for acute and rehabilitative care in the inpatient setting also decreased, from 1,179 to 1,057 days per thousand senior patients (see Figure 2, on the following page). Looking beyond the inpatient setting, Brown and Toland also found that patients' length of stay in skilled nursing facilities reduced from 1,033 to 881 days per thousand senior patients.

To supplement the utilization analyses, Brown and Toland looks to survey data of patient experience and quality data from the HEDIS and STAR Metrics. Between 2012 and 2014, Brown and Toland found a steady improvement in the mean patient satisfaction score. In addition, 2013 and 2014 quality data indi-cate improvement in multiple areas. For example, the percent of patients receiving colorectal and nephropathy screenings increased, as did the percent of patients receiving appropriate

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• ACO Learning System Case Study

Figure 1

Number of Admissions for Brown and Totand's Senior Patients, 2012 — 2014

Figure 2

Length of Stay Measures for Brown and Toland's Senior Patients, 2012 — 2014

management of hemoglobin Alc and the percent of women with osteoporosis management following a fracture.

LESSONS LEARNED

Brown and Toland's layered approach to patient identification and care management has evolved over time, based on feedback from providers, the experiences of the care management teams, and insight gleaned from data analysis. Some lessons learned to date include the following:

• To identify patients appropriate for care management,

provider insight into patients' needs should supplement

predictive modeling results. Early outreach attempts based on predictive modeling alone resulted in a 10 percent patient engagement rate in the outpatient care management program. Brown and Toland made a number of process changes to increase the recruitment, including increasing collaboration with patients' primary care physicians to understand which patients were most appropriate for complex care management. Likewise, Brown and Toland's hospital-based care managers work with discharge planners to identify good candidates for the transitional care program.

• Partnerships with providers improve patient

engagement and enhance the effectiveness of care

management. To increase the patient engagement and the effectiveness on ongoing care management, care management

teams establish close connections with patients' primary care providers. Brown and Toland found that when care coor-dinators call patients as representatives of the primary care physicians' offices, patients view the team as an extension of their physician relationships and engagement rates improve. Once patients begin receiving care management services, care management teams continue to coordinate with providers, for example to arrange for office visits, align referrals, or complete medication reconciliations.

• Harness information technology to facilitate

communication within the care management team

and to increase continuity of care. When beginning the Pioneer program, Brown and Toland spent months improv-ing communication networks and building the information technology tools to better manage care for Pioneer-aligned patients. "What we did early on, which I think helped us greatly, was spend a lot of time, and a lot of energy, invest-ing in connectivity and information technology to get these patients integrated within our already-existing systems," says Ms. Stephanie Mamane, vice president for payor contracting and accountable care. In addition, Brown and Toland created a shared software platform for the care management team to document information about patients' needs, note care provided, and record the results of screenings and assessment. The teams use these data in communications with providers, to smooth the transition between care management programs, and to limit repetition of screenings and assessments.

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SUMMARY

Dr. Zachary summarized Brown and Toland's work for

patients with complex needs and high costs: "We provided care

coordination ... in such a way that we eliminated unneces-

sary transitions. We eliminated medical errors. We improved

communication. We improved access. And we have somebody

who's watching the whole thing, to be captain of the ship for

care coordination. And that is what drives the outcomes and

ultimately the savings."

ABOUT THE ACO LEARNING SYSTEMS PROJECT

Mathematica Policy Research and its partners—the Institute

for Healthcare Improvement, Health Services Advisory Group,

Premier Inc., Telligen, and TransforMED—are conducting this

project for the Center for Medicare & Medicaid Innovation. The

project team creates a structure for peer-to-peer learning to help

Medicare ACOs achieve better care for patients, better health

for populations, and lower health care costs. The team is grateful

to Brown and Toland Physicians for its valuable contributions to

this case study, specifically Marcus Zachary, M.D., vice president

of population health and senior medical director; Ann Marie

Molyneaux, R.N., director for clinical services; and Stephanie

Mamane, vice president for payor contracting and accountable

care. We particularly appreciate their careful review of this brief

and the time they devoted to answering our many questions

during our interviews. Cory Sevin, Catherine Craig, and Sonya

Streeter wrote this case study. The observations in the case study

represent the views of the authors and do not necessarily reflect

the opinions or perspectives of any state or federal agency.

For more information, contact ACO Learning System at PioneerLearningActivities@mathematica-mpr.com .

Follow us on: gra tOr Mathematice is a registered trademark of Mathematica Policy Research, Inc.

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