components of an integrated delivery system of an integrated delivery system managing populations in...

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PAT TERRELL, EXECUTIVE DIRECTOR • TERRY CONWAY, MD, DIRECTOR OF CLINICAL PRACTICE • DOUG ELWELL, DIRECTOR OF FINANCE ART

JONES, MD, DIRECTOR OF FINANCE • GREG VACHON, MD, DIRECTOR OF CLINICAL PRACTICE MEGHAN KIRKPATRICK, ADMINISTRATOR

Components of an Integrated Delivery System Managing Populations in a Safety Net Environment

June 2013

Terry Conway, MD

Greg Vachon, MD

Linda Follenweider

Lori Weiselberg

Contributing Authors:

Gina Eckart, Doug Elwell, Susan Greene, Art Jones, Meghan Kirkpatrick, Maurice Lemon, Pat Terrell, Linda Trowbridge, Elliot Wicks, Deborah Zahn

HealthManagementAssociates–AccountableCareInstitute 2|P a g e

TABLEOFCONTENTS

ContextandIntroduction___________________________________________________________________________________4

AccountableCareManual ________________________________________________________________________________4

LegalandGovernance_______________________________________________________________________________________5

Finance_______________________________________________________________________________________________________6

InfrastructureandCapacityBuilding______________________________________________________________________8

AdministrativeInfrastructure____________________________________________________________________________8

EligibilityScreening/Enrollment______________________________________________________________________8

AssignmenttoaPCMH_________________________________________________________________________________8

PCMHSupport __________________________________________________________________________________________8

ManagedCareContracting/OtherProgramsRequiredSupport ____________________________________9

FinancialSystems_______________________________________________________________________________________9

InformationTechnology(IT)/Reporting______________________________________________________________9

WorkforceDevelopment_________________________________________________________________________________10

SkillsDevelopment ____________________________________________________________________________________10

PopulationHealth______________________________________________________________________________________10

LeadershipandStaffing_______________________________________________________________________________11

QualityImprovementandCareCoordination _______________________________________________________11

ChangingtheWorkforce_______________________________________________________________________________12

MeasuringandImprovingPerformance________________________________________________________________12

AssignmenttoaHealthCareDeliveryModel ____________________________________________________________13

Patient‐CenteredMedicalHome__________________________________________________________________________14

Team‐BasedCare_________________________________________________________________________________________14

StaffingModel____________________________________________________________________________________________15

Empanelment_____________________________________________________________________________________________15

UsingTechnology ________________________________________________________________________________________16

InitialandOn‐GoingRiskAssessment__________________________________________________________________16

CareManagementwithinthePCMH____________________________________________________________________16

Evidence‐BasedPreventiveCare______________________________________________________________________16

UtilizationTriggersandTransitionCarePrograms_________________________________________________17

Disease‐SpecificManagement________________________________________________________________________17


Self‐CareandSelf‐ManagementSupport_____________________________________________________________17

ComplexCareManagement___________________________________________________________________________17

EnablingServices______________________________________________________________________________________18

PCMHAccess _______________________________________________________________________________________________19

SpecialtyandDiagnosticServices_________________________________________________________________________19

Background_______________________________________________________________________________________________19

SpecialtyandDiagnosticAuthorizationProcedures___________________________________________________19

ExpansionofSpecialtyCareCapacity___________________________________________________________________20

ExpansionofSpecialtyCareAccessviaCommunityPartnerships ___________________________________21

AccesstoDiagnosticandProceduralServices_________________________________________________________21

MonitoringAccesstoSpecialtyCare,DiagnosticTesting,andProcedures__________________________22

SpecializedMedicalHomeandIntegratedCare _______________________________________________________22

BehavioralHealth______________________________________________________________________________________22

HospitalandInpatientCare_______________________________________________________________________________28

Hospitals__________________________________________________________________________________________________28

Long‐TermCare__________________________________________________________________________________________29

SupportforSpecialPopulations___________________________________________________________________________30

Conclusion__________________________________________________________________________________________________31

Appendices__________________________________________________________________________________________________33

AppendixA_______________________________________________________________________________________________33

AppendixB_______________________________________________________________________________________________34

AppendixC _______________________________________________________________________________________________35

MedicalHome(Practice‐Based)CareCoordination‐PositionDescription_______________________35

AppendixD_______________________________________________________________________________________________36

MedicalHome(Practice‐Based)RNCareManager‐PositionDescription________________________36

GeneralDuties__________________________________________________________________________________________36

Authors______________________________________________________________________________________________________39


CONTEXTANDINTRODUCTION

Thepurposeofthisdocumentistoassisthealthcareorganizations,especiallysafetynetorganizationsthatarestrivingtomeetthechallengesofhealthcarereformandthechanginghealthcarelandscape.Theseorganizationsarebeingdirectedandincentivizedtoreorganizetheirdeliveryandfinancingsystemstoimprovequalityofcare,healthoutcomes,andthepatientexperience,whileloweringthecostsofcare.

Concurrentwiththesenewpressuresforchange,healthinsurancecoverageisexpandingforsafetynetpopulations,whichprovidesanopportunityforadditionalrevenueforsafetynetorganizationsthatprovidecaretothepreviouslyuninsured.However,reimbursementisalsotransforming,movingawayfrompaymentforvolumetopaymentforvalue.Thisvalue‐basedpaymentwilllikelyincreasinglybeintheformofcapitation,whichwillentailsomerisktoproviders.Organizationswillbeheldfinanciallyaccountableforhigherqualityofcareandhealthoutcomesofpopulations,ratherthanforjustvolumeofservices.

Whathealthsystemswillsucceedinsuchareformedhealthcarelandscape?Experiencehasshownsystemsthatincludethefullrangeofservicesandprovideintegratedandcoordinatedcarearemorelikelytosucceedinmeetingaccountabilityrequirements.Smallerhealthcareorganizationsarelesslikelytobeabletomeetthesedeliverychallengesaloneandmayhavetojoinwithotherstocreateasystemthatcanprovidecomprehensivecare.Regardlessoftheirsize,safetynetsystemswillalsohavetoredesignandtransformtheircaremodeltoprovideproactive,continuous,andefficientcareforadefinedpopulationratherthanprovidingreactiveandepisodiccare.

Thehealthcaresystemsthatsuccessfullyprovideintegrated,accountablecarewillnotbecastinidenticalformsandstructures.However,someelementsandconstructsarecommontointegratedsystemsthatprovideaccountablecare.Successfulaccountablecaresystems:

• aredevelopedandoperatebasedonadeepandthoroughunderstandingofadefinedpopulation—includingitsdemographics,healthstatusandtrends,andhealthrisks—andthehealthcareandpolicyenvironmentinwhichthesystemoperates;

• arebuiltaroundacoreofcontinuousandaccessibleprimarycarewherethestaffworksinhigh‐functioningcareteams;

• coordinateandintegratecarefortheirpopulationandmeasureandholdthemselvesaccountableforthepopulation’shealthoutcomes;

• useinformationtechnologytoprovideevidence‐basedcaretoindividuals;and• continuallymonitorqualityandcostateverystageofthecaretheydeliver.

AccountableCareManualThismanualpresentsanoverviewof,andapproachesto,designingandimplementingkeycomponentsofintegrateddeliverysystemscapableofprovidingaccountablecare.TheseapproachesarebasedonHealthManagementAssociates’(HMA’s)experienceinhelpingsafetynethealthcareorganizationstransformtheirdeliverysystems.Thismanualisnotahow‐toguide.


Rather,itpresentsanoverviewofthekeyareasthatmustbeaddressedwhendevelopingaccountablecaresystemsandprovidesguidancebasedonwhatHMAhasfoundworksinreal‐worldsettings.

Thismanualspecificallypresumesthatasystemprovidingaccountablecarecontainsthefullcontinuumofhealthcareservicesandthatalloftheseservicesareintegrated.Werecognize,however,thatfewsafetynetorganizationscurrentlyoffertherangeofhealthservicesnecessarytoprovidethefullcontinuumofcareandthatthey,therefore,willneedtopartnerandcollaboratewithotherorganizations.Thismeansthataframeworkmustbecreatedtoshowhowdifferentproviderscanfitintoanintegrateddeliverysystem.Thisisadelicateyetcriticaltask,asmanysystemsincludeproviderswithlittlehistoryofcollaborationorjointplanningforapopulation,eventhoughtheprovidersmayhavecaredforthepatientswithinthatpopulation.Themanualaddressesthecreationofanintegrateddeliverysystemandcallsforincorporatingdifferentlevelsofservices,cultures,andmethodsofpractice.ItalsoincludesamajorfocusonPatient‐CenteredMedicalHomesbecausetheyarethefoundationuponwhicheffectiveaccountablecaresystemsmustoperate.

LEGALANDGOVERNANCE

Acrossthenation,multipleprovidershavecometogethertodevelopintegrateddeliverysystemsthattaketheformofAccountableCareOrganizations(ACOs).ACOsareprovider‐basedentitiesthroughwhichprovidersagreetoworktogetherandberesponsibleforpatientcareforadesignatedpopulationandtoshareinriskand/orsavingsderivedfromimprovedhealthoutcomesandloweredcosts.

WhilethereisnostandardlegalorgovernancemodelrequiredforACOs,somepatternsareemerginginfederalandstatelawsandregulationswithregardtofunctionalrequirements.Thesepatternsprovidesomeguidancefordevelopingaccountablecaresystems.

UnderthefinalMedicareSharedSavingsProgram(MSSP)rule,anACOmustbealegalentityforpurposesofallACOprogramfunctions.Acorporation(profitornon‐profit),partnership,limitedliabilitycorporation(LLC),foundation,oranyotherentityrecognizedunderfederal,state,ortriballawcanbeanACOlegalentity.Therefore,inmanystates,anACOmaytakeonanylegalstructureaslongasitcanperformthefunctionsnecessarytobeanACOundertheapplicablelaw.Entitieswillneedtomakedecisionsaboutwhethertheyneedtocreateanewlegalentityandifso,whatformitshouldtake.ThesedecisionswillbenecessarilyinfluencedbythestatusoftheentitiesthatdecidetoformanACO,aswellasbyfinancialandtaxconsiderationsandapplicablelaw.

ACOscontemplatingparticipationinmultiple‐payerACOinitiativeswillwanttoestablishasinglegovernancestructurethatmeetstherequirementsforallofthem.MedicareoftenleadsthewayforMedicaidandcommercialinsurance,makingitworthwhiletoconsiderwhattheMSSPregulationsrequire.


StateapproachesincludeOregon’sversionofaccountablecarecalledCoordinatedCareOrganizations(CCOs).CCOsmustbelocal,community‐basedorganizationsorstatewideorganizationswithcommunity‐basedparticipationingovernance,oracombinationofthetwo.TheCCOmaybeasinglecorporatestructure,oritcanbeanetworkofprovidersorganizedthroughcontractualrelationships.TheoverarchingthemeofOregon’sCCOsisthattheymustbelocalandtheirgovernancemustincludeconsumerinvolvement.MassachusettsandNewJerseyalsoincludearequirementforconsumerrepresentation.

Safety‐netprovidersmaybesubjecttouniquegovernanceandlegalstructureconstraintsthatmustbetakenintoaccountastheyconsiderparticipationinACOs.Theymustconsiderhowparticipationcouldimpacttheircurrentstructures,allocationofgovernanceandleadership,andhowtoaddressliabilityforlosses.

Inadditiontoconcernsaboutlegalstructureandgovernance,thereareotherlegalissuesforpotentialACOparticipantstoconsiderbeforeembarkingonthispath.ToimplementtheMSSPprogram,thefederalgovernmenthasestablishedcertainprotectionsand“safeharbors”withrespecttofederalanti‐trust,fraud,andabuselaws.However,iftheACOdoesnotparticipateintheMSSP,theseprotectionsdonottechnicallyapply.Inaddition,ACOs(eveniftheyparticipateintheMSSP)mustalsoconsidertheapplicabilityofsimilarlawsatthestatelevel—whichhavenotbeenpre‐empted—aswellasstatelawsconcerninghealthplanregulationandthecorporatepracticeofmedicine.

TherearetwosignificantfactorsforallproviderstoconsiderwhendecidingwhethertoparticipateinanACO:thepotentialbenefitscomparedtothecosts,andtheburdensofparticipation.Thelackoffederalpre‐emptionofstatefraudandabuselaws,aswellastheexistenceofanestablishedregulatoryframework,mayaddanotherlevelofcomplexityandcreatechallengingcomplianceissues.

FINANCE

Safetynetprovidersfaceanuncertainfutureunderpaymentreform.ExistingpaymentmechanismsaresubjecttointensereviewundertheAccountableCareAct.Innovativesafetynetprovidersaretakingtheleadbydevelopingandadoptingvalue‐basedpaymentmodelsthatrequiregreateraccountabilityforquality,healthoutcomes,


andcostsbutalsoenhancetheirabilitytoproducethoseoutcomes.Thereisacontinuumofaccountabilitymodelbasedondegreeofrisk:puresharedsavingswithoutdownsiderisk,two‐sidedriskwithadditionalupsidepotentialinexchangeforlimiteddownsiderisk,partialcapitation,andfullcapitation.Itiscriticalthatsafetynetprovidersprogressgraduallyalongthereimbursementcontinuuminordertobuildtheinfrastructureneededtogeneratesavingsandnotassumeundorisk.Thistransitionusuallystartswithfee‐for‐service(FFS)reimbursementthatissupplementedbycarecoordinationfeesand/orsignificantpay‐for‐performanceincentivesandthepotentialforsharedsavings.Thisup‐frontfundingshouldbeaimedatinitiatingprocessesthatwillgeneratesavings,suchascost‐effectivepharmaceuticaluse,reducedduplicationoftesting,improvedpatientsafety,andimprovedtransitionsofcarethatreduceinappropriateemergencyroomandinpatientutilization.Often,sharedsavingswillnotbegenerated—and,therefore,payable—untilmidwaythroughthesecondyearattheearliest,andlikelylater.Generatingsavingsbyimprovingthemodelofcareusuallytakesayear.

Oncetheyareavailable,sharedsavingspaymentsshouldbedistributedbasedonaformulathattakesintoconsiderationmembership,thesourceofsavings,theprincipaldriversofthesavings,andachievementofqualitymetricsthatdetectinappropriateunder‐utilization.Aportionofthosesharedsavingsmusteventuallypayforsubsequentcarecoordinationfeesandpay‐for‐performanceincentives.

Providersshouldalsoretainsomeoftheirsavingstocreatethereservesnecessarytoassumedownsideriskandeventuallytransitiontocapitation.Thisisbecausesharedsavingswithdownsiderisk,partialcapitation,orfullcapitation,shiftsfinancialriskbeyond“performancerisk”to“insurancerisk.”Insuranceriskentailsassumingfinancialresponsibilityforhealthservicecostsand,therefore,requiressubstantialcapitalreservesintheeventofunanticipatedmedicalexpenselosses.Experienceshowsthatexplicitregulatorysafeguardsandfinancialreservesrequirementsarenecessarywhenentitiesassumeinsurancerisk,quitepossiblyalongthelinesthatCMSpromulgatedinthelate1990sforProviderSponsoredOrganizationsorthatstateslikeCaliforniarequireforprovidersassumingfullrisk.

ACOswillbesuccessfulonlyiftheycanmeettheirfinancialbenchmarksandqualitystandards.AnACOmustperformbetterthanitsbudgetarybenchmarktoqualifyforsharedsavingsor,underthefullcapitationmodel,haverevenuesthatexceeditscosts.QualityscoreswillaffectsharedsavingspaymentstoACOs,withpoorperformancetriggeringfinancialconsequences.

Paymentreformwillnotbesuccessfulunlessitiscoupledwiththenewinnovationsinthehealthcaredeliverymodelthatitaccommodates.Newpaymentanddeliverymodelsmustbedesignedandimplementedinwaysthatdeliveronthepromiseofcoordinated,patient‐centeredcarethatgeneratesimprovedvaluefordollarsspent.


INFRASTRUCTUREANDCAPACITYBUILDING

AdministrativeInfrastructureHealthreformwillmandatenewrequirementsforensuring—anddocumenting—qualityandeffectiveness.Safetynetpublicsystemshaveseldomhadtheresourcesavailabletoprivatesystemstoinvestinthereportinganddatasystemsthatdocumentqualityandutilization.Healthreformwillrequirenewsystemsbeputinplacetofacilitatebettermanagementofpatientsacrosscaresettingsandtoimplementnewpaymentmethodologies.

Thesepublicsystemsmustestablishnewinfrastructuresandnewapproachestoadministrativefunctions.Thisrequiresnewskillsandtools.Formany,thiswillbeatotalsystemtransformation.Asintegratedhealthsystemsdevelop,theywillhavetodecidewhethertobuildorbuytheseessentialadministrativecomponents.Thekeycomponentsandconsiderationsaredescribedbelow.

EligibilityScreening/EnrollmentAllpatientsthatentertheintegratedsystem,whetherthroughtheEmergencyDepartment(ED)orawalk‐inclinic,mustbescreenedtodetermineiftheyareeligibleforMedicaidoranythird‐partyinsurancecoverage.ForthosethatmaybeMedicaidorMedicareeligible,thehealthsystemmustfacilitateenrollmentintotheappropriateplan.Forthoseineligibleforthird‐partycoverage,thesystemshould“enroll”theuninsuredintothehealthsystem(andaPatient‐CenteredMedicalHome[PCMH]),thusprovidingaccesstoamanagedsystemofcare.Itisalsoimportantthattheeligibility/enrollmentscreeningbeaone‐stopprocess,ratherthantriagingpatientstovarious“offices,workers,orrooms”basedontheprogramforwhichtheyareeligible.Whoeverbeginsthescreening/enrollmentprocessshouldbeequippedtohandleallenrollmentoptionsandcompletetheprocess,regardlessofprogrameligibility.

AssignmenttoaPCMHAspatientsaccesshealthcareservices,theinfrastructureinplacemustbeabletofacilitateassignmenttoaPCMH,withpatientinputweighingintotheselectionprocess.Aspartoftheassignmentprocess,patientsshouldreceiveinformationaboutwhataPCMHisandhowbesttoaccessservices,andaPCMHteammembershouldhelpmaketheinitialappointment.Forthesystem’sexistingpatientbase,thehealthsystemshouldhaveanongoingsetofpoliciesandproceduresandcorrespondingdataflowthatresultsin(1)eachpatientbeingabletoidentifyhisorherprimarycareprovider(PCP)andcareteamand,(2)thesystembeingabletoidentifywhosepanelthepatientison.

PCMHSupportForthePCMHmodeltofunctioneffectively,thehealthsystemmustprovidetheadministrativecomponentsrequiredtosupporttheteam.ThePCMHteamworkstoguaranteeallassignedpatientsgettherightservicesandsupportsattherighttime,intherightamount,andforaslongastheyneedthem.Examplesofsupportinclude:

• verifyingPCMHassignmentforinternalandexternalproviders


• managingPCMHchangesatpatientrequest• managingpanels(open,closing,monitoring)• 24‐hourcallcenter,utilizinganautomatedcalldistributorsystem,sopatientsandtheir

PCMHcancommunicatewitheachother• aweb‐basedportalforpatientstoaccesstheirhealthinformationandcommunicatewith

theirPCMH(requestappointments,sendandreceivenotices,etc.)

ManagedCareContracting/OtherProgramsRequiredSupportAssafetynetsystemsmovetowardsparticipationinACOs,carecoordination,andmanagedcareplans,theywillneedtoacquirethetechnicalexpertisetonegotiateagreementswithManagedCareOrganizations.Moreover,theprocessmustdirectlyinvolvePCMHteammembersandotherclinicians.Withouttheirdirectparticipation,thehealthsystemmaynotbeabletotakefulladvantageof,orsuccessfullymanage,suchagreementsorprograms.ItiscriticalthatthePCMHteamsandothercliniciansunderstandeachmanagedcareagreement(andotherprogramagreements)andhaveinputintodecisionsaroundwhethertoparticipate.OncefinanceandPCMHteamshaveamutualunderstandingoftheircontractualobligations,itwillbepossibletoalignhealthsystempoliciesandincentivestofullybenefitfromthesearrangements.

FinancialSystemsHealthsystemsmusthavethecapacitytoevaluatetheemergingalternativereimbursementmodel’simpactontheirsystem,bothintheshortandlongterm.Safetynetprovidersthatarecash‐strappedmustrecognizetheabsolutenecessityofbuildingtheinfrastructuretomovegraduallyalongtheriskreimbursementcontinuum.Doingsowillgeneratesavingsandavoidundorisk.Thecorrectfinancialsystemsmustbeinplacetomonitorthistransitionandprovidefeedbacktothesystemalongtheway.

InformationTechnology(IT)/ReportingITcapacitymustbesufficienttosupportintegrateddeliverysystems.ThisincludesITsystemstosupportcarecoordinationanddeliveryacrosssettings,aswellastotrackanddocumentcaredelivered.Itincludesgeneratingfinancialreportingtotracknewreimbursementmethodologieswhilemonitoringcosts.Safetynetprovidersmustrecognizetheneedtomonitorandreportperformance,notonlyforinsuredpopulations,butalsoforthosethatremainuninsuredevenaftertheAccountableCareActisimplemented.ProvidingITsupportforthePCMHfunctionsisrequired.Thissupportmayinclude:

• apatientregistrythatislinkedtothePCMHteamandempanelmentdatabase• theabilitytogenerate“dayofcareplans”thatdisplaypatientrisklevel,alertsforgapsin

care,andtrendsinkeyclinicalmeasures• theabilitytoproducereal‐timeinformationthatenablesPCMHmanagementoftransitions

ofcare

Thisexpandedinformationtechnologycapacitywillbecriticaltototalsystemtransformation.Theadministrativefunctionslistedabovearenotall‐inclusive,buttheydemonstratethenecessityof


alignmentbetweenstrategy,deliverysystemdesign,performancemonitoring,andfeedbackthatarerequiredtomoveforwardsuccessfully.

WorkforceDevelopmentSkillsDevelopmentIntegrateddeliverysystemshavestartedtotransformthehealthworkplaceinwaysthathaveimportantimplicationsforhealthcareprovidersandworkersofalltypes.Coordinatedcareinitiativesinbothoutpatientandinpatientsafetynetsettingshaveresultedinnewjobtitles,responsibilities,andcombinationsofjobsinhealthteams.

Thedevelopmentofnewskillsinthehealthworkplaceisdrivenbyseveralinterrelatedfactors.Healthprovidersandstaffmustperformnewtaskstoprovideeffectivepopulationhealthcareandhigh‐qualitypersonalcare.Newskillsetsincommunication,technology,andprocessimprovementareincreasinglyrequired,andareunlikelytobepartofpasthealthworkertraining.Tohelpmanagethesechangesrequiresnewleadershipskillsforadministrativeandcarecoordinatorsinoutpatientandinpatientsettings.Resourcelimitationshaveoftenpreventedsafetynetsystemsfromprovidingup‐to‐datetrainingandexperientiallearningtoenhancetheseskills.

PopulationHealthIncreasedaccountabilityforcareofapopulationemphasizestheneedforawidevarietyofsupportstohelpprovidersdevelopnewskillsinpatientcare,outreach,andeducation.Healthcareprovidersandstaffneedtobereorganizedsotheytransitionfromindividuallyfocusedworktoteam‐basedwork.Theprovisionofpatientcarebyasingleindividual,soprizedinearliergenerationsofhealthcareproviders,isnowsupersededbyexpectationsthatprovidersfunctionandenhancecareinamultidisciplinaryteamsetting.Tofacilitatethischange,explicitjobexpectationsandrolesneedtobespecifiedforeachteammembertoensurebothaccountabilityandefficiencyofoperations.

Managinganentirepopulation’shealthplacesincreaseddemandsonpracticemanagementskills,bothwithinthehealthcaresettingandwhenreachingouttopatients.Manypatientsinadefinedpopulationdonothaveregularcontactwithhealthcareproviders,sohealthworkersmustnowbetheleadersincontactingandcommunicatingwithpatientsandreinforcingamoreproactiveandpreventativeapproachtocare.Inaddition,withinthegroupofmemberscurrentlyserved,moreintensivecontactwithpatientsmayoftenbenecessary.Itiscriticalthathealthworkerspossesstheskillsneededtoaccomplishthesetasks.

Withthisvarietyinpopulationneeds,somespecificskillsetswillbemostuseful:

• communicationinavarietyofmedia• datamanagementskillsandacquaintancewithIToutputinterpretation• implementationofevidence‐basedprotocolsforcare

TheabilitytoregularlyassessskillefficacywithaPlan‐Do‐Study‐Act(PDSA)methodologywillbeneeded.


LeadershipandStaffingThegoalsofstaffingwillbetoprovideflexibilityandcomprehensivesupporttoproviders.Avarietyoftoolsrecentlyhavebeendevelopedtoassessstaffingeffectivenessintheoutpatientclinicalsetting.Thougheachpatientpopulationisdifferent,sothatstaffingneedswilldiffer,theabilitytoprovideappropriatestaffingguidancewillbeafirststepinorganizinganeffectiveapproachtoworkforcedevelopment.Benchmarksarestartingtobecomeavailableforsomesettings.

Therolesofofficeandsupportstaffwillneedtobeenhancedtoincreasethescopeandcapabilitiesofhealthworkerstoperformhigher‐levelfunctions.Forexample,clinicalassistantswillhaverolesingatheringdata,providinginterventions,andinteractingwithpatients,therebyfreeinglicensedclinicalstaffforhigher‐levelinterventionswithpatientsandfamiliesrequiringmoreattention.

Theincreasingroleofinformationtechnologytobettercoordinatecareisalsoimpactinghealthworkers’roles.Thetechnologyrequiredtomanagepopulationshasincreasedthedemandforhealthworkerswhoarefamiliarandcomfortablewithinformationtechnology.Everylevelofthehealthcareworkforceinteractswithelectronicdataandcommunications,arealityheightenedbythegrowingspreadofelectronicmedicalrecords.

Leadersofthesemultidisciplinaryteamsmusthavehands‐onskillsandmanagerialabilities.Akeyleadershipskillistheabilitytoorganizeflexiblestaffingthatcanberealignedtofocusonimprovinghealthoutcomes.Leadersmustpossesstheabilitytoleadperformanceimprovementprocessesandhelpeveryworkerperformatthehighestlevelallowedbytheirlicenseorcertification.Ensuringthatallstaffisperformingattheirfullpotentialiscriticaltoefficientresourceutilization.

QualityImprovementandCareCoordinationThefocusonqualityisakeypartofcoordinatedcare.Qualitymanagementisamajorpartofeachpieceoftheintegrateddeliverysystem.Identifyingandrespondingtoqualitymetricsisacrucialelementofmanyhealthworkers’tasks,fromtheofficeassistanttothephysician.Effectivelyaddressingqualityissuesreliesonperformanceimprovementmethodology.Healthworkersneedtobefamiliarwithprocessimprovementteamsandfunctions.

Althoughcurrentprovidersandstaffmustacquirenewskills,newcategoriesofhealthworkerswillbeneeded.Chiefamongtheseisthecarecoordinator.Peoplewiththeseskillsareoftengivendifferenttitlesindifferentsettings,including“carecoordinator,”“casemanagers,”and“caremanagers.”Allofthemcanfunctioninavarietyofsettings.Forexample,carecoordinatorsarefrequentlyusedinintegrateddeliverysystemsasmanagersofapracticepopulation.(SeeAppendixCforasamplecarecoordinatorjobdescription.)

Thebackgroundandtrainingacarecoordinatorneedswilldependonthepopulationserved.Oneofthekeyconceptsforintegrateddeliverysystemsisimplementationofriskassessmentandriskstratificationforindividualpatients.Staffingmustbematchedtotheidentifiedneedsofthepatientpopulation.FormostgroupsofpatientsseeninthePCMH,aclinicalbackgroundasanursewillbemostappropriateforacarecoordinator.Forotherpopulations,suchastheseriouslymentallyill,abackgroundinsocialworkmaybemoreadvantageous.Forgenerallyhealthypopulations,astrong


clinicalbackgroundmaybelessnecessary.Forsafetynetpopulations—whichtypicallyhavecomplexmedical,behavioralhealth,andsocialproblems—carecoordinatorsneedadditionalskillsinidentifyingtheappropriateclusterofproblemsandmarshalingtheoften‐limitedcommunityresourcesthatthepatientneeds.

ChangingtheWorkforceNochangesintheworkforcecanbeexpectedwithoutcontroversyandevenresistance.Developingnewhealthcarerolesisperhapstheleastcontentiousissuebecauseitrepresentsanexpansionofopportunitiesforemploymentinhealthcare.Ontheotherhand,changesinthejobdutiesandexpectationsofcurrentstaffmayprovokeconcerns.Forexample,needsforflexibilityandcross‐trainingforcertainfunctionsmaycollidewithorganizationalorunionconcernsaboutdiminishingopportunitiesforsomestafforchangesinstaffingneeds.Carefulattentiontocommunicationwithcurrentstaffandeducationabouthowchangingjobfunctionsallowhealthworkerstocontinuetostayrelevantinthenewhealthcareworkplaceisimportant.Ofgreatusearewell‐preparedtrainingmodulesthatallowstafftocomfortablyreachcompetencyintheskillsetsdemanded.

AnumberofacademiccentersacrosstheU.S.haveacquiredexperienceandproficiencyintrainingworkersforthesenewfunctions.Thekeyeducationalphilosophyisoftenbasedonacompetency‐basedcurriculumthatmatcheseducationalprogramstoneededskillsintheworkplace.Skillsmustbetransferable,butthereareseveralsetsofskillsthathavebeenconsistentlyidentified.Theyincludeskillsincommunication,healthinformationtechnology,processandqualityimprovement,interdisciplinaryteamtraining,populationhealthmanagement,andpatienteducation.

Avarietyofformatsarebeingtried.Theconceptofcompetency‐basedtrainingemphasizestheneedtocloselymatchtrainingtojobneed.Modularformatshavebeenusedtodevelopfacultyandlearningmaterialfordiscretesubjectareas.Earlyworkoneffectivenessassessmenthasbeenpublishedinanumberofcenters.

Amongthekeystosuccessarepartnershipsbetweenworkplacesandeducationaltrainingvenuestoverifyskillacquisition.Examplesincludeacademicinstitutionssuchasnursingschools,residencyprogramsforphysicians,andothereducationalfacilitiesforlicensedproviders.Vocationaltrainingschoolsarepartnersforcertifiedmedicalassistantsandotherstaffprovidinghands‐onexperience.Providerinstitutionssuchashospitalsandmedicalcentersshouldhavethestrongestcommitmenttothistrainingbecausethesuccessoftheirworkforcedependsonthequalityoftraining.

Insafetynetinstitutions,resourcesfortrainingareoftenlimited,sopartnershipsarevital.Payers,suchascommercialinsuranceplans,maybegoodresourcesfortrainingincarecoordinationskillsinbetter‐compensatedhealthsettings.Thefederalgovernmentandstates,aspublicfundersofMedicaidandMedicare,haveexpressedinterestinnewworkforcetrainingmodels,buttheyarejuststartingtooffersupporttoworkplacetraining.

MeasuringandImprovingPerformanceAnintegrateddeliverysystemwillhavetodevelopmeasuresandmethodsformonitoringandreportingperformance,aswellaspoliciesandproceduresforensuringcontinuousimprovement.


Performancemonitoringandthecommunicationoffindings/trendsshouldbeperformedbyanexecutive‐levelpersonthatreportsdirectlytothehealthsystemCEO.

PerformancemeasuresmustaddressthedomainsoftheTripleAim,aframeworkthatdescribesanapproachtooptimizinghealthsystemperformance.ThegoalsoftheTripleAimareimprovingthepatientexperienceofcare(includingqualityandsatisfaction),improvingthehealthofthedefinedpopulation,andreducingthepercapitacostofhealthcare.

Examplesofperformancemeasuresinclude:

• utilization/cost(bypayerclass):o hospitalizationratesforempanelledpatientso 30‐dayand7‐dayre‐hospitalizationratesforempanelledandnon‐empanelled

patientso EDuseper1,000patientso specialtyvisitconsultationsperprovider,per1,000patient‐equivalents(definedin

registrysection)o rateofnon‐genericdruguseperprovidero chargesperpatientbyproviderperapplicablepayerclass

• improvedhealth:o percentofpatientswithbloodpressureatgoalatlastmeasuremento percentofpatientswithA1c>9byprovider,bysiteo percentofdiabeticpatientsinreasonablecontrol(BP<140/90,A1c<9,LDL<130)

andinnearidealcontrol(BP<130/85,A1c<7.4,LDL<100)o processoutcomes:influenzavaccinationrate,rateofmetforminuseper100

diabetics,rateofACEinhibitor/ARBuseper100diabetics,retinalscreeningfordiabetics,mammography

• patientexperience:o satisfactionperprovider/persite

Performancemeasuresthataredeterminedtobeatasubstandardlevelaretargetedforqualityimprovementefforts.Somehealthsystemsmaybenefitfromaquality/researcharmandfundingtosupporttestingofnewinnovationsandimprovementefforts.

ASSIGNMENTTOAHEALTHCAREDELIVERYMODEL

Becausepatientshavedifferentneedsandutilizeservicesdifferently,itisimportanttoassignpatientstoaspecificmodelofcare.Withinintegrateddeliverysystems,therearegenerallythreecaredeliverymodelstowhichapatientcanbeassigned:

• Aspecialty‐onlymodelforpatientsthathavenon‐contractedprimarycarebutneedspecialtyservicesonly,orforwhomitisappropriateforthespecialisttoactastheprimarycareprovider.


• Anepisodicprimarycaremodelforpatientswhoaregenerallyingoodhealthanddonotneedregularcoordinatedcare.

• APatient‐CenteredMedicalHome(PCMH)modelforpatientswhoneedongoingcoordinatedcare.(Seenextsectionforamoredetaileddescription.)

Optimally,asystemwouldbeabletoprovideaPCMHforallpatients.However,ifresourcesarelimited,itisacceptabletoassignpatientstoepisodiccareaslongasitisdoneinanorganizedandintentionalmanner.

PatientswhoarenotalreadyassignedtoaPCMHareassignedbasedonresultsofabriefsetofquestionsandpatientdata.IfaPCMHmodelisappropriateforthepatient,thenheorshewillbeassignedbasedfirstonchoiceandthenbygeographytoaninternalPCMHortoanexternallycontractedPCMH.

Forservicesprovidedbyasystem(ratherthanexternally),patientaccesswillnotvarybypayerbutbyhealthcaredeliverymodel.Forexample,theremaybeformularyrestrictionsforthosereceivingepisodiccareorspecialtycareauthorizationprocessesforexternalPCMHs.Forservicesnotprovidedbythesystem—butrathercontracted,suchasbehavioralhealthservices—patientaccessmaydifferbybothhealthcaredeliverymodelassignmentandpayersource.

PATIENT‐CENTEREDMEDICALHOME

ThefollowingsectionsdescribeoperationsofkeyelementsofinfrastructureandcareforpatientsassignedtoPatient‐CenteredMedicalHomes(PCMHs).

Team‐BasedCareTeam‐basedcarewithinaPCMHisasignificantdeparturefromtraditionalmethodsofcaredelivery.Itcanbedefinedasthe“provisionofcomprehensivehealthservicestoindividuals,families,and/ortheircommunitiesbyatleasttwohealthprofessionalswhoworkcollaborativelyalongwithpatients,familycaregivers,andcommunityserviceprovidersonsharedgoals,withinandacrosssettings,toachievecarethatissafe,effective,patient‐centered,timely,efficient,andequitable.”1

Teamscanbeconfiguredinavarietyofways,butthegoalistomoveawayfromrelyingsolelyonphysicianstodelivercare.Instead,rolesandresponsibilitiesaredistributedamongdifferenthealthprofessionalsandstaff,includingnurses,medicalassistants,licensedpracticalnurses,caremanagers,behavioralhealthproviders,andcommunityhealthworkers.Teamsareassembledaccordingtoastaffingmodel,withindividualteammembershavingdefinedrolesandresponsibilitiesthatalignwiththePCMHmodelofcare.

Inorderforteamstooperateefficiently,allteammembersshouldbeoperatingatthe“topoftheirlicense”(i.e.,eachproviderandclinicalstaffpersonisfocusedontheworkthatisatthehighest

1NaylorMD,CoburnKD,KurtzmanET,etal.Team‐BasedPrimaryCareforChronicallyIllAdults:StateoftheScience.AdvancingTeam‐BasedCare.Philadelphia,PA:AmericanBoardofInternalMedicineFoundation,2010.


levelofhisorherqualifications,expertise,andprofessionallicense).Teammemberscoordinatetheircarethroughateam“huddle”priortopatientsessionsandthroughelectronicregistryalertsthatassignindividualstaffmemberstocarryoutpopulationmanagementactivities.PCMHclinicteamsareconsistentlyscheduledtoworktogethertothegreatestextentpossible.

StaffingModelThestaffingmodelfordeliveryofcareiscritical.Laboristhesinglelargestexpenseforhealthcareorganizations,accountingforclosetohalfofhealthcaredeliverycosts.Ahealthcareorganizationwillnotsurviveintheneweraofaccountablecarewithoutanadequatenumberofstaffproperlytrainedtoreliablyhitqualitytargetswhileprovidingexcellentpatientservice.Ontheotherhand,overextendingstaffingbeyondthepointofpositivereturnoninvestmentwillquicklyleadtopoorfinancialperformance.Ensuringthatstaffmembersworktothetopoftheirlicenseisasimportantasthenumberofstaff.

ThePCMHmustplantodeterminehowmanyemployeeswitheachtypeoflicense,training,andfunctionareneededwithinthemodelofcaredelivery,anditmustthenmonitoremployees’abilitytomeetoutcomesstandards.Thisplanningneedstobeglobal(e.g.,howmanynursesneedtobehiredintotal),granular(e.g.,howmuchofaparticularnurse’stimeneedstobespentwithaparticularphysician),andrelatedtoactivities(e.g.,howmuchtimeaparticularnon‐licensedstaffperson,suchasamedicalassistant,needstospendincarecoordination).Thistaskisachallengingbutnecessarysteptoaccuratelyassesstheoutcomeofahiringandtrainingplan.(Seetheworkforcedevelopmentsectionforadditionaldiscussion.)

Manyfunctionsneededforthedeliveryofprimarycarealsomustbeaddressed,includingadministrativefunctionssuchasmaterialsmanagement,timeandattendance,andbudgeting,aswellasbasicfunctionsforsupportingclinicalflow,suchasre‐stockingrooms.

Staffschedulingisalsocriticalfordefiningrolesandresponsibilitiesofteammembersanddeployingtherightnumberofeachtypeofstaff.APCMHneedsastructuredprocessforimplementingateam‐focusedschedule.(SeeAppendixAforastaffmodelworksheetatthe“currentrealitystage”andAppendixBforastaffingworksheetforanindividualprovider.)

EmpanelmentEmpanelmentistheprocessofcreatingandmaintainingarelationshipbetweeneachpatientandaprimarycareprovider(PCP).Empanelmentisthecornerstoneinthefoundationofclinicalandfinancialaccountability.ThegoalofempanelmentistoensurethateachPCMHcareteamhasagroupofpatientsforwhomtheyareresponsibleandthateachpatientcanidentifytowhomtheycanturnfortheirhealthcareneeds.Itisaprovenmethodforcreatingcontinuityforprovidersandpatientsandensuringthatpatientpopulationhealthismanaged.(SeeHMA’sEmpanelmentGuide:http://www.healthmanagement.com/assets/Publications/Empanelment‐Implementation‐Guide‐January‐2013‐FINAL.pdf.)


UsingTechnologyTechnologyhelpsorganizeandfacilitatePCMHoperations.KeytechnologiesforPCMHsareelectronicmedicalrecords(EMR)andanelectronicregistry.ThedifferencebetweenanEMRandaregistryisthatanEMRcontainsapatient’sentirehistory,whereasaregistryisfocusedonaggregatingandorganizingalimitedsetofinformationwithanemphasisoncertainconditions,populations,and/orhealthcareactivities(e.g.,ahospitalization).Registriesarecriticaltomanagingthecareofpatientsandpopulations.

InitialandOn‐GoingRiskAssessmentAstandardizedapproachtocaredeliveryrequiresthatcaremanagementactivitiesbedefinedanddrivenbyriskassessmentforempanelledpatients.UponassignmenttothePCMH,aninitialriskassessmentisconductedforeverypatient.Riskisreassessedinresponsetodefinedtriggereventsthatrevealchangesinpatients’conditionsandrequireadefinedresponse.

Oncepatientshavecompletedariskassessment,theyareassignedalevelofrisk.Thelevelofriskisusedasanindependentvariabletodrivecaremanagementactivities.Forexample,ahigh‐riskpatient(e.g.,apatientwithahospitaladmissionforcongestiveheartfailureinthepastyear)whomissesanappointmentwillgetacallwithin24hours,whereasalow‐riskpatient(e.g.,onewithwell‐controlleddiabetes)willnotgetacallafteramissedappointmentuntilascreeningtestisoverdue.

CareManagementwithinthePCMHCaremanagementwithinthePCMHincludesevidence‐basedpreventivecare/healthmaintenance,utilizationtriggersandtransitioncareprograms,anddisease‐specificmanagement,outlinedbelow.Alsowithinthescopeofcaremanagement(andaddressedinthissection)areself‐care,self‐managementsupport,complexcaremanagement,enablingservices,andtele‐monitoring.PositiondescriptionsforPCMHpractice‐basedcarecoordinatorsandRNcaremanagersarepresentedinAppendixCandD,respectively.

Evidence‐BasedPreventiveCareTheelectronicpatientregistryproducesaDay‐of‐CarePlan,whichisaprintablesummaryofpatientdatawithdirectionstothecareteamabouttheactivitiesthatneedtobecompletedforthepatient.Thisalertstheteamtoaddressissueshighlightedintheplan.Forexample,ahealthscreeningmaybeindicatedasoutstandingontheDay‐of‐CarePlan.Theteammemberisalertedandconductsthescreening.Oncethescreeningiscompleted,theteammemberdocumentstheresultofthescreeningtestintotheEMR.InterfacedwiththeEMR,theregistrypullsthisdatatoalerttheteamthenexttimethepatientisdueforthisscreening.

Standardregistryreportsforcancerscreening,diagnosticscreening,andbehavioralhealthscreeningareusedtomeasureoverallPCMHperformanceinreachingpreventivecaregoalsforPCMHteams.

Forpatientswithoutascheduledappointment,theCertifiedMedicalAssistant(CMA)printsstandardreportsofpreventivemeasuresdueforempanelledpatientsbythefirstofeverymonthto


identifypatientsinthepanelthataredueforparticularpreventivescreeningandotherhealthmaintenancemeasures.Whenpatientsaredueforscreening,ateammembercontactsthepatientbymailortelephonetoscheduleascreeningappointment.Follow‐upcareforpatientswhoscreenpositivefollowscurrenthealthcenterprotocols.

UtilizationTriggersandTransitionCareProgramsUnplannedhospitaladmissionsandEDvisitsarelinkedtopooroutcomesformanypatients.DuringthecaretransitionbetweenthehospitalandthePCMH,opportunitiesforerrorandincompletecommunicationcanleadtoadverseeventsorreadmissiontothehospital.Topreventthis,astandardprocessisrequiredtoassureatimelytransitiontothePCMHafterhospitaladmissionsandEDvisits.TheregistryflagsPCMHpatientswhohavebeenseenintheEDoradmittedtothehospitalandpushesanalerttothecaremanagementnurseassignedtothatpatient.

Post‐DischargeProtocolsThefocusoftransitioncareistoavoidreadmissions.Anumberofevidence‐basedinterventionshavebeenshowntoreducereadmissions.Theyincludemedicationreconciliationandadherence,caretransitionwithfollow‐up,andpatientactivationandengagement.APCMHwillneedasysteminplacetonotifythemwhentheirpatientsaredischargedfromthehospital,aswellasdefinedprotocolsforallfollow‐upinterventions.

Post‐EmergencyDepartmentVisitProgramAPCMHalsowillneedasysteminplacetonotifythemwhentheirpatientshaveanEDvisit,alongwithprotocolsforallfollow‐upinterventions.

Disease‐SpecificManagementAPCMHneedstohaveevidence‐basedprotocolsforthemanagementofpatientswithspecificdiseases.Conditionsthatwarranthighpriorityforprotocoldevelopmentincludediabetes,congestiveheartfailure,hypertension,asthma,anddepression.

Self‐CareandSelf‐ManagementSupportSupportforself‐careandself‐managementisakeyresponsibilityofthePCMHteam.Self‐careincludespreventivehealthmeasuressuchassmokingcessation,healthfuleating,andexercise,aswellashealthsystemnavigation(e.g.,howandwhentoaccesscareatthePCMHduringandafterclinichours,whotheirPCMHteamis,andhowtocontactthem).Patientswithchronicdiseasessuchasheartfailure,asthma,ordiabetesareprovidedwithself‐managementsupport.Areasofemphasisincludeunderstandingthediseaseprocessandtreatmentplan,medicationadherence,recognitionofsignsandsymptomsofworseningillness,andskillsformanagingaparticularcondition.Allmembersoftheclinicalteamparticipateinequippingpatientswithnecessaryskillsandprovidingongoingsupportforpatientsinself‐careandself‐management.

ComplexCareManagementNowhereisthelinkbetweencostandqualitymoreclearlydemonstratedthaninthecareofthemedicallycomplexpatient.Patientswhoarepoorlymanagedaremorelikelytobehospitalized,whichresultsinpoorhealthoutcomesanddrivesuphealthcarecosts.Infact,thetwo‐thirdsof


Medicarebeneficiarieswithmultiplechronicconditionsaccountfor96%ofMedicareexpenditures.2

Inadditiontopatientswithmultiplechronicdiseases,patientswithcomplexhealthneedsincludepersonswithdisabilities,frailelderly,andpatientswithseriousmentalillness.AmongMedicarepatientsintheU.S.,itisestimatedthatone‐thirdhavefourormorechronicconditions.3Medicallycomplexpatientsareatthehighestriskforthemultitudeofpooroutcomesassociatedwithfragmentedcare.Thesepatientsaccesstheirhealthcareservicesacrossmultiplesettingswithmultipleprovidersofcare.Theyhavehigherriskforadversehealthoutcomes,includingdeath,functionallimitationanddisability,frailty,nursinghomeplacement,diminishedqualityoflife,treatmentcomplications,andavoidableinpatientadmissions.4

CaringformedicallycomplexpatientswithinaPCMHcreatesaparticularsetofchallengesandopportunities.Forexample,thePCMHmodelrequiresthatthemajorityofthepatient’shealthneedsandproblemsbeaddressedandtreatedwithinthePCMH.Forcomplexpatients,forwhomthismaynotbepossible,thePCMHneedstomanagecareprovidedoutsidethewallsofthehealthcenter,particularlyduringtransitionsincare.

Ongoingmonitoringandscreeningforhealthriskandchangesinfunctionalhealthstatusinformcareprioritiesanddrivedecision‐makingandinterventions.

Carecoordinationandmanagementformedicallycomplexpatientstypicallyrequiresaregisterednurseorlicensedsocialworkercaremanager,whopartnerswiththepatientandthePCMHteaminthedesignanddeliveryofthepatient’sindividualizedcareplan.Thecaremanagerworkscloselywiththepatientandthepatient’scaregiverstoidentifythepatient’svaluesandcurrenthealthstatusandtosetrealisticgoalsforthepatient.

AddingthecomplexcaremanagementcomponenttothePCMHallowsmedicallycomplexpatientstobemanagedwithinaprimarycaresettingbytheirprimarycareprovider.CaredeliverythroughthePCMHmodelhasthepotentialtosignificantlybenefitthispopulationbyprovidingimprovedqualityofcareatalowercost.

EnablingServicesPCMHswithinintegratedcaresystemsalsoneedwaystoprovideenablingservicessuchastransportation,interpretation,andhomevisitstopatients.Thisisespeciallycriticalforsafetynetpopulations.FederallyQualifiedHealthCenters(FQHCs)arerequiredtoprovideenablingservicesaspartoftheirfederally‐definedscope.However,integratedsystemsneedtodeterminehowtheseserviceswillbeprovidedregardlessofwhetherornotanFQHCparticipatesinthesystem.

2ChronicConditions:MakingtheCaseforOngoingCare.September2004update.JohnsHopkinsandtheRobertWoodJohnsonFoundation'sPartnershipforSolutions.Availableat:http://www.partnershipforsolutions.org/DMS/files/chronicbook2004.pdf3Ibid4InterventionsforImprovingOutcomesinPatientswithMultimorbidityinPrimaryCareandCommunitySettings.SmithSM,SoubhiH,FortinM,HudonC,O'DowdTCochraneDatabaseSystRev.2012;4:CD006560.


PCMHACCESS

PCMHsneedtoensureappropriateaccesstoservicesanddefinehowtheywillmeasureandmonitorpatientaccess.WaystosupportpatientaccessthatareconsistentwiththePCMHmodelincludethefollowing:

• anadvancedphonesystem,whichmayinclude“CentralScheduling”withroutingcapabilityandamechanismforhandlingcallsafterhours

• extendedhealthcenterhourstoensureeveningandweekendhours• patientschedulingapproaches,suchas“SimplifiedPatientScheduling,”whichallowfor

same‐dayandnext‐dayappointmentaccess• minimizingno‐showratescreatedbylimitingtheamountoftimebetweenbooking

appointmentsandactualappointmentsandbyconsistentlymakingremindercalls• enhancedworkflowandthroughputandsystematicidentificationandeliminationof

bottlenecksinpatientflow• longerappointmentintervalsforpatientswithgoodchronicdiseasecontrol,whichcould

includenon‐visitfollow‐upviaphoneorothermeansiffeasible,includingsecuree‐mailortextmessaging

• non‐providervisitsforselectedissues(e.g.,nursevisitstoimplementsteppedtherapyforchronicdiseasecontrolandstandingordersforimmunizations)

• evidence‐basedgroupvisitsforpatients

SPECIALTYANDDIAGNOSTICSERVICES

BackgroundAccesstospecialtyconsultationanddiagnosticservicesisanintegralcomponentofthesafetynetdeliverysystem.However,gainingthataccesscanprovechallenging.AsMedicaidexpansionsmoveforward,previouslyundiagnosedoruntreatedconditionsthatrequirespecialtyconsultationsanddiagnosticevaluationswillbeidentified.Theresultingincreaseddemandforreferralswillfurtherstressalreadyburdenedspecialtyanddiagnosticentities.

Integratedhealthsystemsmustworkaggressivelytooptimizeprocessesforreferrals,appointments,pre‐visittesting,appointmentreminders,follow‐upappointments,anddischargefromspecialtycare.Specialtyandprimarycareproviderswillneedtobettercoordinatecaretoensurethebestuseofvaluable—andsometimeslimited—specialtycareanddiagnosticresources.Integratedhealthsystemswillhavetosolicitoutsidepartnersforkeyspecialties,diagnostictests,andproceduresthatthesystemcannototherwiseprovideinatimelymanner.

SpecialtyandDiagnosticAuthorizationProceduresIntegratedsystemsneedtoemployanevidence‐basedsetofclinicalreferralrulestoensureatightlymanagedauthorizationprocess.Theseruleshelpensureapatientisaccuratelydiagnosedwithaclinicalproblem,assignedtoreceivetheappropriatetests,andisreferredtotherightspecialist.


Thesereferralrulesmaybeoperationalizedthroughaweb‐basedportal.Anidealspecialty/diagnosticreferralsystemaccomplishesthefollowingfunctions:

• clarifiesreasonsforthereferral• providesapatientcondition‐specificdialogwiththeorderingproviderconcerningthe

reasonforreferralandthespecificquestiontobeanswered• identifiesandensuresacompletework‐upbytheprimarycareproviderpriortothe

specialtyconsultation• communicatesstandardsforappropriatereferralsinthenetwork• directsreferralstothemostappropriateservice• assignsprioritiesbasedonclinicalconditionsandensureshighprioritycasesarequickly

addressed• identifiesandmanagesdocumentationrequirements

Referringproviders’patientsmayormaynotbegrantedanappointmentiftheirconditiondoesnotmeetstandardsforappropriatereferral,oriftheproviderdidnotperformapre‐referralwork‐up.Thisrestrictionhelpsprimarycarephysiciansmakeappropriatereferrals.Often,whenapre‐referralwork‐upisperformed,theprimarycareprovider’sconcernisansweredorresolved.Aninappropriatereferralisavoided,andtheprovidergainsvaluableinsightforfuturereferrals,ultimatelyenhancinghisorherpractice.

Thereferralsystemalsoprovidesadministrativedecisionsupportbygeneratingusefulreports.Reportscontain:

• totalvolumeofreferralorderstraffickedacrosstheuser’snetwork• theaverageelapsedtimetoprocessreferralrequestsandthenumberofordersthathave

exceededthetargetprocessingdeadline• real‐timeperformancetrackingofthetotalunscheduledbacklog• sourceofreferralanddemandgenerated• withinageneratingclinic,asummaryofeachprovider’sordersoveranyspecifiedtime,with

linkedaccesstothedetailsofanyindividualorderdetail

ExpansionofSpecialtyCareCapacityIdeally,processimprovementsandserviceenhancementsfocusonhigh‐demand/low‐capacityservices.Schedulingtemplatesforallpriorityoutpatientspecialtyclinicsaremodifiedtoensureahighpercentageofallappointmentslotsarededicatedtonewreferrals.Follow‐upvisitsarelimitedtoonevisitunlessmorearespecificallyauthorized.Ifthepatientmaintainsongoingconsultantcare,theintervalbetweenfollow‐upvisitscanbelongerasthepatientisco‐managedwiththePCMH.

Patientsaredischargedfromthecareofspecialtyclinicstoprimarycareproviderswithathoroughcareplan.Trackingnewreferralschedulingandthenumberofdischargedpatientsiscriticalfordeterminingwhethertheutilizationofspecialtycareisappropriate.

Inhigh‐priorityspecialtyclinics,patientsneedtobecontactedwithpre‐visitcalls/texts/e‐mailstoremindthemofappointments,ensuretheyintendtokeeptheappointment,andtodetermineif


orderedtestshavebeencompleted.Pre‐visit“scrubbing”(i.e.,cancellingappointmentsforpatientsnotpreparedforavisit)maximizesshowrates,reducesneedlessoverbooking,allowsotherpatientstofillcancelledappointments,andreducesineffectivevisitsforpatientswhohavenothadorderedtestscompleted.Pre‐visitcontactwithpatientscanreducethenumberofunproductivevisits,creatingadditionalcapacityforspecialtyconsultation.

Manypatientsreferredtospecialistsdonotneedanin‐personappointment.Electronicmessagingandelectronicconsultshaveproventobeeffectivewaysforpatientstoconsultaspecialistataconvenienttime,withouttheneedforaformalofficevisit.Suchelectronicconsultationscanbesecureandcanincludeaneffectivewaytodocumentthereferralrequestandconsultation.Thee‐consultprocessisaneffectivecommunicationtoolthatallowsthespecialistandprimarycareprovidertoco‐manageapatient.Theimprovedcommunicationbetweenthespecialistandtheprimarycareprovidercanexpandin‐officeappointmentcapacity.

ExpansionofSpecialtyCareAccessviaCommunityPartnershipsTomeetaccessstandards,integratedsystemsneedtodeveloppartnershipswithhospitalsorspecialtygroupstofillgapsinservices.Thesespecialtycarepartnersshouldbecarefullyselectedusingcriteriathatinclude:

• location• easeofreferral• abilitytoreferuninsuredandinsuredpatients• effectivecommunicationofspecialtyreportstoreferringproviders• useofaneffectiveelectronicreferralsystem• agreementonafinancialmodel

Establishinganeffectivepartnershiprequiresintegratedplanofficialstomonitortherelationshiptoensurethatcontractrequirementsarebeingmetandutilizationpatternsareappropriate.

AccesstoDiagnosticandProceduralServicesItisimportantthatspecialty(andprimarycare)providersreceivetheresultsofindicateddiagnostictestsandproceduresinatimelymanner.Appropriateaccesstotestsandproceduresproducesbetterpatientoutcomes,reducesineffectiveandunneededspecialtyvisits,andexpeditesthereturnofpatientcaremanagementtothePCMH.

Referralstodiagnosticandproceduralservicesthatareexpensiveanddifficulttoaccessshouldrequiremorerigorouspriorauthorization.Utilizationpatternsofindividualandgrouppracticesthatmakethesereferralsshouldalsobecarefullyreviewed.Combineduseoftheempanelmentprocessandthepatientregistrymakesitpossibletocalculateandcompareutilizationratesforallproviders—forexample,CTscansper1,000patientsperyear.Priorauthorizationshouldbeinstitutedforhigh‐utilizingprovidersandshouldbestandardforprovidersreferringfrompartnerorganizations.


Tomeetaccessstandards,thehealthsystemmayneedtoformpartnershipswithhospitalsorotherdiagnosticcenterstofillgapsindiagnosticservices.Thesepartnershipsaredevelopedandmonitoredasdescribedabove.

MonitoringAccesstoSpecialtyCare,DiagnosticTesting,andProceduresAnenhancedclinicalutilizationreportingsystemmonitorsaccesstospecialtycareanddiagnosticandproceduralservices,aswellastheirusage.Thehealthsystemneedstotracknewappointments,dischargesfromspecialtyclinics,specialtyserviceproductivity,anddiagnostictestingandproceduralserviceproductivity.Trackingaccessandutilizationratesofpartnershipsitesforspecialtycareanddiagnosticsisalsonecessary.Reportsneedtobepreparedandformattedtoeasilyallowcomparisonofwaittimes,productivity,andutilization.Adashboardtrackskeyelementsoftheprovisionofspecialtycare,diagnostic,andproceduralservices.

SpecializedMedicalHomeandIntegratedCareToooften,appointmentsmadewithspecialistsarefollow‐upappointmentsthatmightbeappropriatelyhandledwithinthePCMHwithspecialtysupport.Inaddition,patientsmaywanttocontinueseeingthespecialtycareproviderstheyhavebeenseeingexclusively.

Therearetwoapproachesfordealingwiththeseproblems.ThefirstistheSpecialtyMedicalHome,wheresubspecialistsserveastheprimarycareprovider,andthespecialtyclinicbecomesthepatient’sPCMH.Thesecondapproachistodeliverthespecialtyandprimarycareinbothsettingsasappropriatetothepatientpopulation.Theinfluenzavaccine—typicallyaprimarycareresponsibility—maybeadministeredinthespecialtysetting,whileanassessmentofcomplexdiseasecontrol—typicallyperformedbythespecialist—maybedoneintheprimarycareoffice.Thisparticulartypeofintegrationfocusesonsharingcareresponsibilities.Thesecondapproachismostcommonlyusedforpatientswithsevereandpersistentmentalillness.Regardlessofthemodelused,itisnecessaryforthedifferenttypesofspecialiststodefinetheirrole,ashasbeendoneforprimarycare.

Specialist‐basedPCMHsshouldhavetomeetthesamestandardsasprimarycare‐basedmedicalhomes.Thisincludesrequirementsforprovidingfirst‐contact,continuous,andcomprehensivecare,andusingsystematicprocessestoimprovethehealthofapractice'spatientpopulation.

ThePCMHpopulationandavailabilityofspecialtymentalandbehavioralhealthserviceswilldictatehowmentalhealth,behavioralhealth,andprimarycareareintegrated.Evidence‐basedmodels,suchastheIMPACTmodelfordepressioncare,orotherdemonstrationsconductedbytheNationalCouncilonCommunityBehavioralHealthCare,willhelpdeterminetheapproach.

BehavioralHealthIntegrateddeliverysystemsneedtoprovideforthebehavioralhealthneedsoftheirpopulation,includingmentalillnessandsubstanceabuseservices.Althoughthenatureofbehavioralhealthservicesvariesbystate(partlybecauseofstateregulation)orbyorganization,therearecommonelementsanysystemadoptingaccountablecarepracticemustaddress.


Whenstartingtoplanforbehavioralhealthservices,anintegrateddeliverysystemmustassessthelikelyprevalenceofmentalillnessandsubstanceabusedisordersamongitspopulation.Itisestimatedthat20%ofthepopulationintheUnitedStateswillneedsomebehavioralhealthinterventionortreatmentyearlyandthat5%ofthepopulationsuffersfromseriousandpersistentmentalillness.However,theprevalenceofmentalandbehavioralhealthdisorderswilldifferwidelyamongdifferentpopulationsdependingonfactorssuchasage,race,socio‐economicstatus,andethnicity.Assessmentofthepopulationwillrevealtheamountandtypeofresourcestheintegrateddeliverysystemmustbeabletoprovide.

Mostmentalhealthorsubstanceabuseconditionsarecurrentlymanagedwithinaprimarycaresetting.Itiswidelyacknowledgedthattheseconditionsareunderdiagnosedandinadequatelyaddressed.Everypatientinanintegrateddeliverysystemshouldbescreenedtoidentifybehavioralhealthconditions.Theintakeassessmentshouldidentifypasthistoryofdiagnoses,hospitalizations,ortreatmentfortheseconditions.Screeningshouldberepeatedroutinelytocapturechangesinpatients’needs.Becauseofthehighprevalenceofdepression,allmembersofaPCMHshouldbescreenedannuallyforthiscondition.OneusefulinstrumentisthePHQ9,althoughothersmaybeused.Beyondscreening,aPCMHmustbeadequatelypreparedtoprovideevidence‐basedclinicaltreatmentofidentifiedneeds,aswellascaremanagementandcarecoordinationappropriateforbehavioralhealthissues.

Collaborativecareisperhapsthemosteffectivemethodforprovidingmentalhealth,behavioralhealth,andsubstanceabuseserviceswithinprimarycare.TheImpactModelisthebestexampleofcollaborativecarefordepressioninprimarycare;however,thisapproachcanbeappliedtootherconditions,suchasPost‐TraumaticStressDisorderoranxietydisorders.Inthismodel,universalprimarycarescreeningforspecificbehavioralconditionsisfollowedbyabrief,standardizedprimarycarediagnosticassessmentforthosewhoscreenpositive.Themedicalhometeamfunctionsintwomainways:1)theindividual’sprimarycarephysicianworkswithacaremanager/behavioralhealthspecialisttodevelopandimplementatreatmentplan,and2)thecaremanager/behavioralhealthspecialistandprimarycareproviderconsultwiththepsychiatristtochangetreatmentplansifindividualsdonotimprove.Aregistryisusedtopromptfollow‐upsessionsandoutreachandtotrackbehavioralhealthoutcomes.

Providerstreatingeitherprimarycareorbehavioralhealthpatientsshoulduseavailabletoolstoscreenforsmokingandsubstanceabuse.Theyshouldprovidebriefinterventionseffectiveintreatingpatientsidentifiedwithproblematicorriskysubstanceuse.

ElementsofCollaborativeCareofDepression

RoutineScreeningforDepressionCaremanager/behavioralhealthspecialistwhoprovidesandmonitorssuccessofevidence‐(stepped)basedcounselingandtherapywithprimarycarephysician.

Consultationbyapsychiatristwhoreviewscasesperiodicallyandconsultsonthoseresistanttotherapy.


Patientswithsevereandcomplex,persistentmentalillnessarereferredtothesubspecialtymentalhealthresourceswithintheintegrateddeliverysystem.Itisimportantthatthementalhealthsectoroftheintegrateddeliverysystememployevidence‐basedmodelsofcare,suchastheMedicationManagementApproachesinPsychiatry,IllnessManagementandRecoverymodel,andAssertiveCommunityTreatmentteams.Accesstoadditionalresourcesforcrises,housing,andsupportivecareareobtainedthroughthesubspecialtysector.

Toimprovehealthandcontrolhealthcarecostsforpatientswithseriousbehavioralhealthconditions,itiscriticaltorecognizethatthesepatientsarealsolikelytohavechronicphysicalconditions.Severementalillnesses,suchasschizophreniaorbipolardisorders,areassociatedwithexcessivemorbidityandearlymortalityfromphysicalconditionssuchasheartdiseaseandcancer.Likewise,theeffectsofunrecognizeddepression,anxiety,andsubstanceabuseareamongthemostprominentcontributorstopoorcontrolofchronicphysicalillness.

Unfortunately,thebehavioralhealthandphysicalhealthneedsofpatientstraditionallyhavebeenmanagedandtreatedinseparatesystemswithinadequatecoordinationforaperson’stotalcare.Practitionersinbothprimarycareandmentalhealthfeelunpreparedtoaddresstheclinicalissueswitheachotherandlacktimeandreadilyavailablemethodstocommunicateacrosstheirprofessionalboundaries.Inaddition,mentalhealthpractitionerscapableofmanagingcareforthesickest,mostcomplexpatientsareinshortsupply,especiallyinpoorcommunities.Forpatientswithco‐occurringconditions,thisfragmentedapproachgeneratesexcessiveuseofhealthcareandhighcosts.

IntegrationofBehavioralandPhysicalHealthandtheHealthHomeIntegratingbehavioralhealthandprimarycarecanimprovehealthoutcomesandhelpavoidexcesscostforpatientswithbehavioralhealthissues,especiallythosewithco‐occurringchronicconditions.Itishelpfultohaveaconceptualmodeloftreatmentbeforeproceedingtoactualintegrationwithinadeliverysystem.

Completeintegrationofprimarycareandbehavioralhealthintoonehealthcareunitoffersthemostpotentialfordeliveringthehighestquality,lowestcostofcare.However,usuallytheprimarycareandspecialtybehavioralhealthresourcesandservicesoperateseparatelywithindifferentorganizations.Thechallenge,then,istodesigncaredeliverythateffectivelyidentifiespersonswithco‐occurringconditions(usuallyfromscreening)inbothphysicalandbehavioralhealthsettings—anddeliverstheneededcare.

Achievingthisgoalwillrequire:

1) planningwherepatientsreceivecareforeachcondition

IntheNationalComorbiditySurvey(2001‐2003),68%ofadultswithmentalhealthdisordershadchronicphysicalillness,and29%ofadultswithmedicalconditionshadseriousmentalhealthdisorders.


2) ensuringthatthereiscoordination,communication,andcollaborationbetweeneachclinicalsiteinvolved

3) providingasystemofcaremanagementforthispopulation

OnemodelfordoingthisistheHealthHome,atermusedforaPCMHthathasbeenenhancedtomanageorcoordinatethebehavioralhealthneedsofitspopulationthroughcoordinating,co‐locating,orintegratingwithbehavioralhealthservices.Likewise,theHealthHomemaybeabehavioralhealthfacilitythatcoordinatesormanagestheprimarycareneedsofitspopulation.Itisalsoresponsibleforcoordinatingallofthepatient’s/client’scare,isacontinuoussourceofcare,andensurestheentirecontinuumofcareisavailable.

IdentifyingWhereanIndividualReceivesCare

Where is the Health Home?

Withinanintegrateddeliverysystem,itisassumedthateachmemberhasaMedical/HealthHome.However,forpatientswithbothphysicalandbehavioralconditions,careforbothconditionsmustbeprovidedatonemainsite.Thisfacilitywillbetheentitywheretheclient/patientspends—orchoosestospend—themosttime.Theprimarysitecoordinatescareandisthesiteofaccountability.TheFourQuadrantIntegratedModel(shownbelow)isahelpfulplanningtool.Whileitisnotprescriptive,itcanhelpguidethedecision‐makingprocessforwherecaremightbestbeprovidedforpersonswithbothphysicalandbehavioralconditions.

FourQuadrantIntegratedModelI.

LowMentalHealthNeeds/LowPhysicalHealthNeeds

II.HighMentalHealthNeeds/LowPhysicalHealthNeeds

III.LowMentalHealthNeeds/HighPhysicalHealthNeeds

IV.HighMentalHealthNeeds/HighPhysicalHealthNeeds

Traditionally,personsinQuadrantsIandIIIarethemostappropriatecandidatesforHealthHomecareprovidedinaPCMH.PersonsinQuadrantIIaremostappropriateforaHealthHomewithinbehavioralhealth.PersonsinQuadrantIVrepresentaparticularchallengesincetheyhavesevereandpersistentbehavioralhealthissuesaswellassevere,complex,andchronicphysicalillnesses.InterpretersoftheFourQuadrantmodeloftenindicatethatspecialtybehavioralhealthcentersaretheidealHealthHomeforthoseinQuadrantIV.Managingthecareforpersonswithcomplexillnessesisachallengeinanysetting,butthebesthealthoutcomesforpatientswithseverebehavioralandphysicalconditionshavebeenachievedinintegrateddeliverysystems.

FullyintegratedHealthHometeamshavetheexpertisetoprepareandimplementacareplanthatistrulypatient‐centeredandsharedbyeveryonewhocaresforthepatient.Theyusethesamerecords,plantogether,andworkasoneteam.Often,integratedcareislocatedinalargersystemofcare.Thisprovidesthegreatestopportunityfordeliverydesign,anorganizedchangemanagementmethod,


andinfrastructuretosupporttheintegratedapproach.Asstatedearlier,fullintegrationofbehavioralhealthandphysicalhealthisanexception.Mostdeliverysystemshavestartedtoaddressintegrationonlyrecentlyandareatdifferentstagesofthisprocess.

ModelsofIntegrationThereareseveralmodelsthatrepresentdifferentlevelsofintegration.Experienceineachofthesemodelsoffersinsightabouttheireffectivenessandthekindofsystemredesignneededtoimplementthem.Eachmodelrequiresnewstaffrolesandcompetencies,aswellasretrainingorhiringnewstaff.Thethreelevelsofintegrationare:collaborationofservices,co‐locationofservices,andfullyintegratedmodels.

Collaboration of Services

Thisisthefirstlevelofintegrationbetweenindependentprimarycareandbehavioralhealthentitieslocatedinseparateplaces.Thisshouldbetheminimumrequiredofprimarycareandbehavioralhealthfacilitieswithinanintegrateddeliverysystem.

Atthislevel,thetwoentitiesrelatetoeachotherviareferralswhichtheyusetodelegateaspectsofcare.Thereareagreementsandprocessesthatdefineandfacilitatereferralsinbothdirections,andcommunicationoccursonindividualcaseswithreleaseofinformationsoughteachtime.Inaddition,thereissomeformalattempttounderstandanddefineeachentity’sroleandmodelofcare.Expandeddutiesforeachareusuallyincluded(e.g.,screeningformedicalconditionsinthebehavioralhealthentityorpsychiatricmedicationmanagementinprimarycare).

Caremanagementstaffateachentityhasaparticularroleinfosteringandsupportingthecollaboration.OneentityisdesignatedtheHealthHome.Theotherentityhasmoreofasecondaryroleasaconsultant.Informationtechnology,databases,andmedicalrecordsareseparate.Reimbursementandgovernancearetypicallyseparate,andtruesharingofacareplanisnotcomplete.

Co‐location of Services

Closeconsultationbetweenprimarycareandbehavioralhealthinacollaborativemodelisanimprovementovercurrentpractice.However,manyhealthsystemshavefoundgapsincontinuityandcommunicationthatcannegativelyimpactpatientcare.Whenservicesareseparatelylocated,someduplicationofservicesandcostsareunavoidable.Patientscannotreceivetheirneededcarewithoutsometravelandmustbecomeaccustomedtoasecondlocation’sdesignandprocesses.Asaresult,importantandeffectiveservicescanbemissed.Toaddressthis,systemshaveco‐locatedapractitionerintheothersettingtoservepatientswithco‐occurringconditions.

Oftenaprimarycarenursepractitionerisembeddedinabehavioralhealthsetting,oralicensedclinicalsocialworkerisembeddedinaprimarycaresetting.Thisimprovespatientconvenienceandenhancestheuseofinformalconsultationbetweenstaff.Theembeddedpractitionerprovidescarewiththecollaborationandconsultationofapsychiatristorprimarycarephysicianattheir“home”site.


Theembeddedclinicianmayservetosupportcollaborativecaremodelsorprovidedirecttreatmentandservicetoalimitedcaseload.Theclinicianalsoactsasaliaisonbetweentheentities.Theinformalrelationshipstheclinicianmaintainshelpincreaseunderstandingandcommunication.Patientsaremorelikelytoadheretoscheduledvisitswiththisone‐stoparrangementandawarmhandoffthatcanoccuruponreferraltotheembeddedclinician.Whenconsultationswithsubspecialistsarenecessary,theconsultantisusuallybetterprepared,andtheprocessismoreefficient.

However,thisisnotfullintegration.Medicalrecordsusuallyareseparate,asisbillingandthereportingandevaluationofthepractitionertoanotherfacility.Whilethenursepractitionerorlicensedclinicalsocialworkerisembeddedinanothersetting,theyarenotactuallyfull‐fledgedmembersofthatcareteam.Communicationisimproved,butformalcommunicationapproaches,suchasasharedcareplan,areusuallylacking.OneoftheentitiesistheHealthHomeandisaccountableforpatientcareandcoordinationofcareandoutcomes,nomatterwherethecareisdelivered.Substantialagreementmustoccurbetweenthefacilitiesonpolicies,designationofresponsibilities,availability,andaccess.

Fully Integrated Models

Althoughitisnotwidespread,thefullyintegratedapproachtreatsallpersonswithmentalillness,includingseriousmentalillness,inoneorganizationthatcontainsbothprimarycareandsubspecialtybehavioralhealth. Theseclinicalservicesareintegrated,andthesingleentityisresponsibleforgovernance,administration,andfinancing.Thedesignofintegratedservicesissimplythedesignoftheorganization’smodelofcareandanorganization‐wideeffort.Behavioralhealthandprimarycareprovidersareonthesamestaffandinteractfrequently.Theyshareasinglemedicalrecord,careplan,informationsystem,database,andqualityprogram.

Anintegrateddeliverysystemwithglobalfundingorcapitationforapopulationistheeasiestenvironmentforimplementingtheseintegratedmodels.Inmanyotherinstances,requirementsforbillingforservices,suchascarve‐outsformentalhealth,maybeanobstacletofullintegrationbydenyingreimbursementfortwoservicesthatwouldbeavailabletotwodifferentorganizationsprovidingthesameservices.Confidentialitycriteriainstatelawsandfederalsubstanceabusestandardsneedtobeconsidered,andtheconflictstheyrepresentmustberesolved.

Perhapsthegreatestchallengestointegrationarethedifferentcultures,workstyles,andpracticepacesofbehavioralhealthandprimarycare.Forinstance,primarycarehasdevelopedmuchmoreofapopulationfocus,whilebehavioralhealthismorefocusedontheindividual.AcorecomponentandactivityinthePCMHmodelis“panelmanagement,”whichrecognizesthatapopulationisbeingimpacted,notjustindividuals,whereaspanels(asopposedtocaseloads)aregenerallynotpartofthebehavioralhealthframework.Anotherdifferenceistheroleofconsumerinput.Includingconsumersintheentity’soperations(throughpeertreatment)andgovernance(throughstructuredconsumerinput)isgenerallymorecentraltothecultureofabehavioralhealthinstitution.Whilemanybehavioralhealthappointmentsarenon‐structured,withtheclientdirectingthefocusofthe


time,primarycare’spaceisrapidandfocusesonbrief,effectiveinterventionswithsupportedpatientself‐management.

Movingthetwokindsoforganizationstowardfullerintegrationisnotaneasytask,butevaluationsoforganizationswithhighlevelsofintegrationindicatehealthoutcomesimproveandcostsdecline.

HOSPITALANDINPATIENTCARE

Whileenhancingprimarycareisessentialforaneffectiveintegrateddeliverysystem,hospitalsandinpatientcareareclearlypartofthecontinuumofcare.Thisiswhymostsuccessfulintegratedsystemsownorhaveastrongaffiliationwithahospital.Likewise,long‐termcareisanessentialcomponentofanintegrateddeliverysystem.

HospitalsIntegratinghospitalsintotheorganizationofanintegrateddeliverysystemcanposechallenges.Inthecurrentfinancialenvironment,hospitalleadersfeeltremendouspressuretoensuretheirbedsareoccupied,whichcausesthemtofocusonmaintaininghighvolume.Thisfocusrunscountertothegoalsofofferinghigh‐quality,cost‐effectiveintegratedcare.Howevercriticalitisatcertaintimes,ahospital’scontributiontotheoverallhealthofapopulationislimited.Hospitalizationisanunwelcomeincidentinthelivesofpatientsandisoftenconsideredtobeasymptomoffailurebytheprimarycareandoutpatientsectors.

Itiswellbeyondthescopeofthissectiontoaddressthechallengesofredesigningandtransforminghospitaloperationsoroutcomes.Instead,thediscussionbelowconcerns:1)thehospital’sroleintheintegratedsystem;2)thenecessarycommunicationandcoordination;and3)therequirementthatthehospitalsharethegoalsofandparticipateinthesystemthatisaccountableforcosts,quality,andpatientengagement.Hospitalleaders,includingclinicalleaders,mustunderstandandmutuallysupportthegoalsofthesystem—andperhapsbemembersofitsgoverningbody—ifthosegoalsaretobeachieved.

Oneconditionclearlymustbemetinanintegrateddeliverysystem.ThehospitalEDcannotbethedefaultentrypointforgainingaccesstothesystem.Rather,whenapatientgoestotheED,thefollowingconditionsmustbemet:

• EDstaffreadilyandroutinelyidentifyapatient’sPCMH.• TheEDhasaccesstothepatient’sriskstatus,careplan,andrelevantclinicalinformation

throughanelectronicconnectionsuchasasharedregistryorothersoftware.• Whenappropriate,EDcliniciansdeferdiagnosticsandspecialtyreferralstothePCMH.• EDcaremanagersorutilizationmanagersareresponsiblefortransmittingrecordsand

medicationliststothePCMHandensuringthatthepatientleaveswithanappointmentandthePCMH’scontactinformation.


• Whenappropriate,EDstaffworkwithaPCMHteamtotransferorreferapatienttoskillednursingcare,long‐termcare,orhome‐andcommunity‐basedcarewithouthavingtoadmitthepatient.

Consistentapplicationoftheseconditionscanpreventmanyunnecessaryhospitalizations.

Althoughmanyinpatienthospitalizationsareclearlynecessary,manycouldbepreventedwithappropriateprovisionofprimarycare.Theinpatientserviceofthehospitalshouldparticipateinachievingtheintegratedsystem’sgoalsby:

• understandingthePCMH’scentralroleandfunctionsandcomplementingthemthroughcommunication,deferringpatientcarerisktothePCMH,andreliablyrepatriating

• participatingintheassessmentofthereasonforadmissionorreadmissionofeachpatient• transformingitscurrentinpatientutilizationmanagementstaffintoinpatientcare

managerswhoroutinelyandconsistentlyworkwiththePCMHandthelong‐termcareplanofthepatient

• constructingadischargeplanwiththePCMHcaremanagementstaff,communicatinginformation,andincludingthepatientintheplanningandthehandoff

• providingcentralizedhubsforplacementservices(e.g.,toskillednursingorhomehealth)aswellasorderingservicessuchasdurablemedicalequipmentandtransportationforinpatients,EDpatients,andpatientsinthePCMH

• providingactionableinformationtotheintegratedsystemsuchastracking(e.g.dischargelocations),trending(e.g.ratesofreadmission),andpredictivecapabilities(e.g.riskforreadmissionusinggranularinpatientdata),asclosetorealtimeaspossible

Long‐TermCareLong‐termcare(LTC)isclearlyafundamentalpartofanintegratedsystemwithinthesafetynet.TheappropriateroleforLTCanditseffectsontheefficacy,quality,andcostofcarearecomplexissuesthatgobeyondthescopeofthisdocument.AppropriateuseofLTCcanreducecosts,improvequalityofcare,andenhancequalityoflife.WhenLTCispartofthepatient’scaremix,coordinatingcommunicationamongthepatient,family,andprovidersandamongtheLTCprovider,primarycareproviders,emergencycare,andhospitalcarebecomesmorecomplex.ThedivisionofresponsibilitiesbetweenMedicaidandMedicareincreasethecomplexityofcoordination.Thesystemmusthavemechanismsinplacetoanswerwhy,how,when,andwhereLTCservicesaredelivered.

TypesofLTCservicemightincludehomecarealongwithhomehealthandhomecareservices/communitysupports,suchasall‐inclusiveapproacheslikethePACEprogram.Residentialcareincludesshort‐termskillednursingandlong‐termcustodialsettings,extendingtosupportingendoflife,palliativecare,andhospicecare.AllofthesemustbelinkedtothePCMHwhenpossible,andtheyshouldsharethegoalsandapproachesoftheintegratedsystemtoimprovequality,controlcosts,andengagepatientsandfamilies.Optimally,anintegratedcaresystemwouldhavethefollowingLTCfeatures:


• AsingleentrypointtoLTCservicesthatcanofferaccesstomultipleprovidersandavarietyofserviceswithoutdependingonindividualswithinthesystem(suchashospital‐unit‐basedsocialworkers)whohavelimitedknowledgeofavailableLTCresources.

• Asingleassessmentmeasurementprocess,basedontheclient’sfunctionalautonomy,coupledwithacase‐mixclassificationsystemtodetermineappropriateLTCneeds.

• TheabilitytouseinnovativeLTCapproachessuchasLong‐TermAcuteCarehospitalization,Hospital‐at‐Homeapproaches,andPACE‐likeprograms.

• Individualizedserviceplansintegratedwiththepatient’scareplan.ElectronicmeansshouldbeusedforcommunicatingtheseplansbetweenLTCinstitutionsandthefullrangeofprofessionalproviders,includingthoseprovidingsocialservices,transportation,homehealthnursing,etc.

• Theabilitytoensurethatdecisionsmadebydifferentorganizationsandserviceprovidersarecoordinatedandcompatibleandthatthecaremanagementprocessincludespatientsandfamilies.

• AtransitioncareprogramthatguaranteespatientsaremovedintoLTCefficientlyandappropriatelywhenevernecessary.AcareplanthatseekstomovethepatientbacktoacommunitysettingassoonaspossiblemustbefashionedandsharedamongtheLTCorganization,clinicalproviders,andthePCMH.

• Whenappropriate,treatmentplansshouldincludeend‐of‐lifeplanningsoservicessuchashospiceandpalliativecarecanbeintegratedintotheLTCplantoavoidunnecessary,unwanted,andpainfulhospitalizations.

SUPPORTFORSPECIALPOPULATIONS

Integrateddeliverysystemswilleventuallycoverarangeofpopulations,someofwhichmayhaveverycomplexphysical,emotionaland/orsocialchallenges.Examplesincludepersonswithdevelopmentaldisabilities,severementalillness,andthosenewlyreleasedfromincarceration.Asdeliverysystemstakeonincreasedrisk,theywillfacethechallengeofgeneratingcostsavingsandmaintainingqualityofcareforthesepopulations.Mostofthecostsavingswillresultfromreducingunnecessaryemergencydepartmentvisitsandhospitalizations,andassuringthatpatientsarecaredforattherightlevelofcare(outoftheinstitutionandintothecommunityasappropriate).

Amongthemosteffectivewaystocontrolcostsistoensuresmoothtransitionsbetweenlevelsofcare.Successfullycreatingthesetransitionsrequiresexpertisewiththepopulationandongoingsupportservices.Communityorganizationsthatdevelopthisexpertiseandprovidetheseservicescanplayacriticalroleingeneratingcostsavingsandmaintainingqualityofcarefortheintegrateddeliverysystem.However,thesecommunityorganizationsneedtomakethemselvesknowntokeyinstitutionsinthecommunity(e.g.hospitals,long‐termcareorganizations)byadvocatingforwhattheycanbringtothedeliverysystem.Oncetheinstitutionsareinformed,theyshouldwelcometheparticipationofcommunityorganizations,astheyoftendonothavesufficientexperiencewithmanyofthespecialpopulationsidentifiedandwillbenefitfromsuchpartnerships.


CONCLUSION

Mountingeconomicandfiscalpressures—andtherecognitionthatthecurrentreimbursementsystemoftendoesnotproducegoodvalueformoneyspent—spotlightthecriticalneedforcreatingwidelyavailable,viablenewoptionsforthehealthcaresystemthatareabletolowercost,improvethepatientexperience,andenhancehealthoutcomes.Afundamentaltransformationinthewayproviderscoordinateservices,collaborateinplanning,andshareaccountabilityforthepatientstheyserveisrequired.

Positionedbetweenfee‐for‐serviceandtraditionalcapitation,integrateddeliverysystems/ACOsrepresentanimportantnewopportunitytocreatemodelsofcarethatchangeincentivesandprovidethebasisformeasuringbothfinancialandclinicalperformance.

Thisdocumentseekstoprovidesupporttohealthsystems,especiallythoseinthesafetynet,astheymovetowardbuildingintegrateddeliverysystems/ACOs.Itprovidesguidanceongovernance,finance,infrastructureandcapacitybuilding,aswellasatransformationofprimarycare,specialtyanddiagnosticservices,andhospitalandinpatientcarethatisconsistentwiththisapproach.

Integrateddeliverysystems/ACOswillbesuccessfuliftheycanenhancethepatientexperience,improvehealthoutcomes,andreducecost.Therearedifferentaccountablecaremodels,andtheirrelativesuccessisyetunproven.Themodelswillalmostcertainlyrequiresignificantrefinementaspayers,providers,andbeneficiariesgainexperience.


APPENDICESAppendixAMainstaffmodelworksheetatthe“currentreality”stage

INSTRUCTIONS RESULT WHAT THE NUMBER MEANS

Line 1 Enter total Physician Full Time Equivalents 1 Number of FTES (from FTE calculation sheet)

Line 2 Multiply by 9 to get total 1/2 sessions 9 Number of session equivalents

Line 3 (actual sessions may be more w/residents ‐ their 1/2 day session don't have as many patients scheduled ‐ suggest PGY1 0.3, PGY 2 0.5, PGY 3 0.7)

Line 4

Line 5 Enter number of non‐licensed staff that can support clinical flow staff (MA, HA, PCA) 2 Total FTEs of non‐licensed clinical staff

Line 6 Divide line 2 by 10 0.9 Number of unlicensed staff needed to support flow

Line 7 Subtract line 6 from line 5 1.1 Unlicensed staff that can do care coordination

Line 8

Line 9 Enter # of LPNs 2 Number of LPNs

Line 10 If line 7 is positive enter 0; if Line 7 is negative enter the same number without the positive sign 0 FTEs of clinical flow needed from LPNs acting in MA role

Line 11 Subtract line 10 from line 9 2 Number of LPN FTEs to support nurse clinical flow

Line 12 Divide line 2 by 20 (round to one decimal point) 0.5 This is FTEs of nurse clinical flow needed

Line 13 Subtract line 11 from line 12 1.5 LPNs that can support care coordination

Line 14

Line 15 Enter # of RNs 1 Number of RNs

Line 16 If line 11 is positive, enter 0. If line 11 is negative enter the same number without the negative sign 0 FTEs of clinical flow from RNs acting in MA role

Line 17If line 13 is positive, enter 0. If line 13 and 11 are both negative, enter line 12. Otherwise, subtract line 11 from line

12. Whatever value is obtained reduce to Line 15 minus Line 16 if it is above that value. 0 Number of RN FTEs to support nurse clinical flow

Line 18 Subtract Line 16 from Line 15 1 RNs that can support care management

Line 19

Line 20 Enter number of clerical FTEs 4 Total FTEs of clerical staff

Line 21 Divide line 2 by 20 (round to one decimal point) 0.5 Number of FTEs needed to support clinical flow

Line 22 Subtract line 21 from line 20 3.5 Clerical staff that can do care coordination

Line 24 If line 18 is positive, enter 0.5; if negative then enter [line 11 if positive+line 17] divided by 1/10th of line 2 0.50 Nurse clinical flow per session per provider present

Line 25 If line 18 is positive, then divide by line 1; if negative enter zero 0.20 RN Nurse care mangement per FTE

Line 26 If line 16 is zero, enter 1.0, if not zero, then add lines 5, 9 and 16 and divide total by 1/10th of line 2 1.00 Non‐licensed clinical flow per session provider present

Line 27 Add together just positive values in lines 11, 18 & 22, then divide by line 1; if all negative enter zero 6.10 LPN & Non‐licensed care coordination

Line 28 If line 22 is positive, enter 0.5; if negative then enter Line 20 divided by 1/10th of line 2 0.50 Clerical staff per session

Your "Present Reality" Staffing Model per FTE for care management and coordination and per session for clinical flow:


AppendixBStaffingworksheetforindividualprovider

STEPS: 1. Fill in provider type 2. Fill in the orange button boxes with the total per each session 3. Fill in the solid orange with the total across all cells

Name Intructions Mon AM Mon PM Tues AM Tues PM Wed AM Wed PM Thur AM Thur PM Fri AM Fri PM

Provider George Mason, MD Enter FTEs: 0.67per

sessionx x x x x x

Attending NP or PA PGY 3 PGY 2 PGY 1

Provider type for this provider (X in 1) x 1

Main person in role of non‐licensed staff

clinical flow Larry Smith 1 1 0.5 1

2nd Non‐licensed staff clinical flow Sally Jones 0.8 0.5 0

Other staff doing non‐licensed clinical flow Fran Quinn, RN 0.2

1 1 0 0 1 0 1 1 0 0

Main staff doing care coordination

2nd staff doing care coordination

3rd staff doing care coordination

0

Nurse 1 Clinical Flow Fran Quinn, RN 0.1 0.1

Nurse 2 Clinical Flow

0.1 0.1 0 0 0 0 0 0 0 0

Nurse 1 Care Manager

Nurse 2 Care Manager

0

Clerk

Clerk

Enter Value or total

total

across all

cells

per

session

per

session

total

across all

cells

1.0

40.7

0.5

Put an X in the box of the provider type

Put an X in each box the provider is present

per

session

For sessions when provider is

present you will see orange boxes

when too few resources scheduled,

red when too much

1.3




red when too much

0.5

For sessions when provider

is present you will see

orange boxes when too few

resources scheduled, red

when too much

If no resources, then gray. If

too little scheduled, then

orange. Too much time

scheduled and all are red.




red when too much


AppendixC

MedicalHome(Practice‐Based)CareCoordination‐PositionDescriptionThecarecoordinatorworkswithinthecontextofaprimarycaremedicalhome,fromateamapproach,andincontinuouspartnershipwithfamiliesandphysicianstopromote:timelyaccesstoneededcare,comprehensionandcontinuityofcare,andtheenhancementofchildandfamilywell‐being.

CareCoordinationQualificationsThecarecoordinatorshallhave:

• bachelor’spreparationasanurse,socialworker,ortheequivalentwithappropriatepastexperienceinhealthcare

• threeyearsrelevantexperience,ortheequivalent,incommunity‐basedpediatricsorprimarycare,particularlyinthecareandserviceofvulnerablepopulationssuchaschildren/youthwithspecialhealthcareneeds(CYSHCN)

• essentialleadership,advocacy,communication,educationandcounseling,andresourceresearchskills

• corephilosophyorvaluesconsistentwithafamily‐centeredapproachtocare• culturallyeffectivecapabilitiesdemonstratingasensitivityandresponsivenesstovarying

culturalcharacteristicsandbeliefs

CareCoordinationResponsibilitiesThecarecoordinatorwill:

• demonstrateandapplyknowledgeofthephilosophy/principlesofcomprehensive,community‐based,family‐centered,developmentallyappropriate,culturallysensitivecarecoordinationservices

• facilitatefamilyaccesstomedicalhomeproviders,staff,andresources• assistwithorpromotetheidentificationofpatientsinthepracticewithspecialhealthcare

needs(suchasCYSHCN);addtoregistryanduseittoplanandmonitorcare• assesschild/patientandfamilyneedsandunmetneeds,strengthsandassets• initiatefamilycontacts;createongoingprocessesforfamiliestodetermineandrequestthe

levelofcarecoordinationsupporttheydesirefortheirchild/youthorfamilymemberatanygivenpointintime

• buildcarerelationshipsamongfamilyandteam;supporttheprimarycare‐givingroleofthefamily

• developcareplanwithfamily/youth/team(emergencyplan,medicalsummaryandactionplanasappropriate)

• carryoutcareplans,evaluateeffectiveness,monitorinatimelywayandeffectchangesasneeded;useageappropriatetransitiontimetablesforinterventionswithincareplans

• serveasthecontactpoint,advocateandinformationalresourceforfamilyandcommunitypartners/payers


• research,find,andlinkresources,servicesandsupportswith/forthefamily• educate,counsel,andsupport;providedevelopmentallyappropriateanticipatoryguidance;

inacrisis,interveneorfacilitatereferralsappropriately• cultivateandsupportprimarycareandsubspecialtyco‐managementwithtimely

communication,inquiry,follow‐upandintegrationofinformationintothecareplan• coordinateinter‐organizationallyamongfamily,medicalhome,andinvolvedagencies;

facilitate“wraparound”meetingsorteamconferencesandattendcommunity/schoolmeetingswithfamilyasneededandprudent;offeroutreachtothecommunityrelatedtothepopulationofCYSHCN

• serveasamedicalhomequalityimprovementteammember;helpmeasurequalityandidentify,test,refineandimplementpracticeimprovements

• coordinateeffortstogainfamily/youthfeedbackregardingtheirexperiencesofhealthcare(focusgroups,surveys,othermeans);participateininterventionswhichaddressfamily/youtharticulatedneeds5

AppendixD

MedicalHome(Practice‐Based)RNCareManager‐PositionDescriptionPositionDescription:ThePatient‐CenteredMedicalHome(PCMH)NurseCareManager(CM)focusesonapplyingextensiveknowledgeandskillstoconsistentlyprovidecomprehensivecaretopatientsinavarietyofsettings.TheCMdemonstratesanin‐depthunderstandingofhealthandillnessissues/problemsforthepatientandfamily.Possessingavastbackgroundofexperience,theCMrecognizesandrespondstodynamicsituationsbyusingpastexperiencestosynthesizeandinterpretmultiple—sometimesconflicting—sourcesofdata.TheCMperformsanalysestodemonstrateandsupportoptimalpatient,system,andprofessionaloutcomes.

TheCMfocusesoneachcareepisodeinthecontextofthecontinuumofcareforthatpatientandtheiruniqueneeds.TheCMfocusesonasmallpercentageofhigh‐risk/high‐costpatientsatahighlevelofserviceintensity.TheCMcollaborateswithallteammembersaroundtheirfocusareasandfacilitatesdevelopmentandimplementationofacomprehensive,interdisciplinarytreatmentplanfocusedontheambulatorysetting.

GeneralDuties1. Facilitatesassignmentofrisklevelforeachmedicalhomepatient.

a) Reviewsandcollectsinformationonriskfactorsfromthepatientandthepatient’smedicalrecordtoassessriskstatus.

b) Adjustsrisklevelaccordingtoreassessmentofpatientstatus.

5McAllisterJ,PreslerEandCooleyWC.MedicalHome:Practice‐BasedCareCoordination:AWorkbookCenterforMedicalHomeImprovement(CMHI)CrotchedMountainFoundation&RehabilitationCenterGreenfield,NewHampshireJune2007


2. Participatesinthedevelopment,implementationandevaluationofamultidisciplinaryandindividualizedplanofcare(basedonrisk,medicaldiagnoses,clinicalstatus,psychosocialandemotionalneeds,languageandculture)thatincludes:

a) riskcategorization

b) planforeducationandmotivationappropriatetolevelofrisk

c) promptsforevidence‐basedhealthinterventions

d) linkagestootherneededservices

3. Updatesplanofcareaspatients’statuschanges.

4. Actsasaliaisonbycollaboratingandcommunicatingwiththeprimarycareprovider(physician,nursepractitionerorphysicianassistant),patient,familyandothermembersofthehealthcareteam.

5. Facilitatesinterdisciplinaryteamconferencesandconsultations,asnecessary.

6. Preparesandfollowstailoredcaremanagementinterventionsforthefollowingconditions/areasincludingbutnotlimitedto:

a) CHF

b) type2diabetes

c) asthma/COPD

d) coronaryheartdisease

e) depression

f) highED/hospitalutilization

g) transitionsofcare

7. Facilitatespatientengagementwithappropriatemedicallynecessaryservices(e.g.,specialtyanddiagnostics),andcoordinatescommunicationbetweentheseproviders,theprimaryteam,andthepatient.

8. ActivelyparticipatesinthecoordinationofcareforPCMHpatientswhichincludes,butisnotlimited,to:

a) assessingpatientequipmentandserviceneeds

b) discussingneedswithprovidersandobtainingnecessaryorders

c) followingappropriateprocesstofacilitatecoordinationofcareneeds.

Example:communicateswithinternaland/orexternaldepartmentstofulfillpatientneeds

d) followingupwithpatient/responsiblepartytoensurecoordinationofcareneedsaremet


9. Followsuppost‐hospitalization,post‐emergencyroom,andpostprocedures.

10. Providespreventivehealtheducationanddiseasespecificself‐managementsupport.

11. Documentsallpatientencounterswhetherfacetoface,telephone,orotherformsofcommunicationintheappropriateregistryand/ormedicalrecord.

a) ManagesapatientcaseloadusingtheDHSRegistry(patientinformationdatabase),includingtheproperdocumentation:

i. assessments

ii. careplans

iii. tasks

iv. appointmentsandfollow‐ups

12. Ensuresallactivitiesrelatedtoplanofcarearecompletedinatimelymanner.

13. Identifiesthevariancefromestablishedplansofcare,pathwaysandguidelines,andfacilitatesthedevelopmentofplan/do/study/actcyclestodecreasevariance.

14. Collectsavoidableadmissiondataandotherrelevantinformation,andplansfollow‐upinterventionswithteam.

15. Collectsandreportsdataandelevatescriticalconcernstoappropriateleadership.

16. Identifieslearningneedsofcareteamandincorporatestheroleofeducatorintodailyactivities,therebyfacilitatingthedevelopmentofthemultidisciplinaryteammembersintheprinciplesofcaremanagement.

17. Knowledgeableofcommunityresources.

18. Maintainsastrongrelationshipwithhealthcareandcommunityandsocialserviceorganizations.

19. Facilitatesservicecoordinationofpatientswithcommunityresources,suchashousing,employment,nutrition,mentalhealth,andsubstanceabuse.

20. Preparesfor,andparticipatesin,PCMHteamandcaremanagementmeetings:

a) discussesoperational/programchallenges/solutions

b) discussespatientcaseload

c) providesongoingtraining

d) activelyparticipatesinprogramdevelopment/assignedprojectsandreportonprogress

21. Otherdutiesandresponsibilitiesdefinedastheprogrammatures.


AUTHORS

Dr.Conwayhasmorethanthirtyyearsofexperienceasaphysicianinleadershippositionsincommunityhealthcenters,academicmedicalcenters,staffmodelmanagedcareorganizations,aswellaspublichospitalsandhealthsystems.Hehasfocusedondevelopingstrategies,organizationalstructures,providers,andclinicalleadersthatarecapableofmeetingtheneedsofunderservedandvulnerablepopulations.

HispracticeatHMAhasbeentoprovideconsultingassistanceintheareasofhealthsystemdevelopmentandoperations,medicalstafforganization,hospital/medicalschoolrelationships,

behavioral/primarycareintegrationandclinicalapproachestodiseasemanagement,includingafocusonspecialtycareorganizations.InthelastfiveyearsatHMAhehasbeentheclinicalleadforlargestrategicprojectsforthelocalgovernmentsinsuchmetropolitanareasasMemphis,Dallas,NewOrleans,SanMateo,Austin,Miami,LosAngeles,OrangeCountyandSanFrancisco.Hehascompletedoperationalprojectsinclinicalareasspanningfromemergencyroomfunction,inpatientlengthofstay,outpatientsystemqualityandefficiency,operatingroomutilization,andthefunctionofpostgraduatemedicaltraininginacommunityhospital.HehasprovidedmentoringtoChiefMedicalOfficersinseverallargepublichealthcaresystems.Hehasbeenpartofteamsthathaverecommendedchangesinpublichealthsystemgovernance,aswellasclinical/fiscalpolicyrecommendationsforchronichepatitis.Heiscurrentlythedirectorofanefforttoredesignandimprovethecareofchronicillnesseswithinall33prisonswithintheStateofCaliforniaDepartmentofCorrectionsandRehabilitation.

PriortojoiningHMA,Dr.ConwaywastheChiefOperatingOfficeroftheAmbulatoryandCommunityHealthNetwork,CookCountyBureauofHealthServices.HeisanAssociateProfessorofMedicineatRushMedicalCollegeandhasbeentheprincipalinvestigatorconductinginterventiontoimprovecommunitybasedphysicianasthmacaretoinnercitypatients,andhasparticipatedinNIHandAHRQresearchprojectstostudyandchangeminoritypatientbehaviorindiabetesandasthmacare.AtCookCountyheconceptualizedanddesignedawebbasedspecialtyreferralsystemthatimprovedreferralflowandefficiencythroughtheuseofasetofclinicalalgorithmbasedreferralrules.Dr.Conwayhasconductedresearchandpublishedintheareaoftheroleofprimarycareandviolence,predictorsofphysicianattitudestowardsmanagedcare,aswellasanumberoftopicsinpreventioninphysicianpractice.

TERRY CONWAY, MD MANAGING PRINCIPAL

Tel(312)641‐5007Fax(312)641‐[email protected]


LindaisanAdvancePracticeNurse(APN)andboardcertifiedFamilyNursePractitionerwithmanyyearsofclinicalexperience.

LindaworksaspartoftheEmergencyMedicineGroupatAdvocateChristHospitalincarecoordinationinoneofthebusiestEmergencyDepartmentsinthestate.Whilethere,LindaservedontheAdvocateMedicalGroup(AMG)APN/PAAdvisoryBoardaddressingtheincorporationofAPNsintoAdvocatesystemclinicalpractice.PriortoherarrivalatAMG,sheservedastheClinicalDirectorofAsthmafortheBureauofCookCountywhereshecreatedanew

roleforadvancedpracticenursesandlinkageforasthmacareintheCookCountysystem,apopulationmostseverelyaffectedbyasthmaandaccesstocare.ShehasworkedasaNursePractitioner(NP)andtheClinicalServicesManagerforEvercare(adivisionofUnitedHealthGroup),aspartoftheirnewsitedevelopmentteamforIL.Whiletheresheimplementedbestpracticesforvulnerablepatientpopulationsinnursinghomesandchronicdiseasemanagementinthecommunity.LindahasalsoworkedasaNPandtheClinicManagerattheChicagoFamilyHealthCenter(FQHC).LindaalsoservedasaNPattheJolietCorrectionCenterandStatevillePenitentiary,maximumsecurityprisonsinthestateofIL.

LindahasexpertiseinbillingandreimbursementforAPNsbothinpatientandoutpatientandhasservedontheboardofISAPNandtheAPNMulti‐StateReimbursementAlliance.

LindawasnamedtheAdvancedPracticeNurseoftheYearforthestateofIllinoisin2009bytheIllinoisSocietyforAdvancedPracticeNursing.

LindaalsoservedontheboardfortheAmericanLungAssociationofMetropolitanChicago.Lindawasrecognizedin2006bytheAmericanLungAssociationofMetroChicago(ALAMC)andpresentedwithaserviceawardforherworkthathelpedtopassthelegislationthatmadeChicagoandIllinoissmoke‐free.

LindahasservedasGraduateSchooladjunctfacultyforLoyolaUniversity,UIC,RushUniversityandtheUniversityofSt.FrancisinJoliet,IL.

LindaearnedherBachelorofSciencedegreeinNursingandMasterofSciencedegreeatSt.XavierUniversity,andisallbutdissertationandPhDcandidateattheSchoolofPublicHealthdivisionofBiostatisticsandEpidemiologyattheUniversityofIllinois–Chicago.

LINDA FOLLENWEIDER SENIOR CONSULTANT



Dr.GregVachonisaPrincipalwithHMA,providingconsultingassistanceinsystemapproachestopreventionandchronicdiseasemanagementincludingthepatientcenteredmedicalhome(PCMH)modelofcare,paymentstructurestopromotethetripleaimsofquality,accessandefficiency,anddesignandimplementationofclinicalcareinnovations.

Dr.Vachon’sworkinsystemapproachesincludedevelopment,evaluationandimplementationofpatientregistriesforlargehealthsystems,assessmentofinformationtechnologycapacityandrequirementsforACOandACO‐likeentities,andthecreationanduseofpatientempanelmentsystems.Dr.Vachon’s

workhasspanneddevelopingstrategicplans,towritingbusinessrulesforcoding,totrainingstafftousetechnologyeffectivelywithinthepatientcenteredmedicalhome.PaymentstructureconsultationhasincludedworkwithACOandACO‐likeorganizationsinseveralstatesaswellaswithStateleadership.Dr.VachonhasassistedmanyorganizationswithclinicalcareinnovationsandisfounderandCEOofacompanyofferingagroundbreakingwellnessincentivemodel.

PriortojoiningHMADr.VachonservedovertenyearsasMedicalDirectorofAustinHealthCenterofCookCountyinChicago.Therehedevelopedanovelgroup‐caremodelfordiabeticsincorporatingcomponentsofthechroniccaremodelincludingregistryusetomonitorqualityimprovements.AsaChairoftheDiagnosticServicesCommitteefortheAmbulatoryandCommunityHealthNetwork(ACHN)oftheCookCountyBureauofHealthServices(CCBHS),heprovidedlabcontractoversight,improvingqualitywhileloweringcosts.HeservedastheChairoftheInformationTechnologyCommitteefortheCareImprovementCollaborative,aqualityimprovementprojectthatdevelopedcapacityinhealthcentersthroughoutthenetworktoenhancechronicdiseasemanagement.Dr.Vachonwasthe2007PetersonScholarattheUniversityofIllinoisatChicago’sSchoolofPublicHealthwherehefocusedonhealthcareeconomicsandpolicyanalysis.HiscurrentclinicalpracticeisatanFQHConthesouthsideofChicago.

GREG VACHON, MD PRINCIPAL



AsaseniorconsultantwithHealthManagementAssociates,LoriWeiselbergprovidesconsultingassistanceintheareasofhealthsystemdevelopment,approachestodiseasemanagement,andthedevelopmentofpublichealthinitiatives.

Ms.Weiselberghasover20yearsofemploymentexperiencerelatedtotheimprovementofthehealthandhealthcareofmedicallyunderservedpopulationsinbothruralcommunitiesandurbancenters.SheworkedfortheStateofWisconsin’sDepartmentofEducationpromotingacomprehensiveschoolhealthprogramwithemphasisonHIV/AIDSprevention.Shealsodirectedafederally–fundedAreaHealthEducationCenter(AHEC)toimprovethecapacityandqualityofprimaryhealth

careservicesthroughhealthprofessionstraininginNewYorkCity.Ms.WeiselbergworkedwithacityhealthdepartmenttodevelopaprimarycareoutreachcampaignfortheNYCChildhoodAsthmaInitiative.

Ms.Weiselberghasalsoassistedhealthcareproviders,academicinstitutionsandpublic/privateentitiestoimplementdiseasemanagementprogramsforchronicconditionsinunderservedneighborhoodsinChicago/CookCounty.Theprojectsshemanagedinvolvedcommunityengagement,patientempowerment,healthcenterreorganizationandproviderpracticechange.PriortojoiningHMA,shemanagedaNationalCenterofExcellencefortheReductionofAsthmaDisparities.Ms.Weiselbergholdsabachelor’sdegreefromCornellUniversityandaMasterofPublicHealthfromtheUniversityofMichigan.

Ms.WeiselbergworksoutofHMA’sChicagooffice.

LORI WEISELBERG SENIOR CONSULTANT


H e a l t h M a n a g e m e n t A s s o c i a t e sA c c o u n t a b l e C a r e I n s t i t u t e

ACIPat TerrellExecut ive Direc tor

Terry Conway, MDDirec tor o f Cl inical Pract ice

Doug ElwellDirec tor o f F inance

Art Jones, MDDirec tor o f F inance

Greg Vachon, MDDirec tor o f Cl inical Pract ice

Meghan KirkpatrickAdminis t rator

180 North LaSalle Street

Suite 2305

Chicago, Illinois 60601

Telephone: 312.641.5007

Fax: 312.641.6678

www.healthmanagement.com

Health Management Associates (HMA) has amassed a wealth of on-the-ground

experience that is important to share more widely as the nation undergoes the

dramatic changes anticipated over the next several years. To that end, it is forming

the Accountable Care Institute (ACI). The ACI will:

• provide a venue in which to share experiences and best practices from across

the country related to the development of community-specific integrated

delivery systems, new financial strategies to incentivize value, and innovative

partnerships between providers and payers to ensure effective care for the

unique populations they are both trying to serve;

• develop and offer resources to others to help spread lessons learned in the

development of these new approaches to the delivery of accountable care;

• facilitate the training of new leaders in health system change; and

• translate delivery system lessons learned on the ground into policy and policy

into change at the delivery system level, whether financial, legal, clinical or

organizational.

Over the past decade, HMA has been assembling a growing practice of senior

health care clinicians and administrators, finance experts, behavioral health

professionals, managed care leaders, long term care innovators and others

committed to developing new approaches to delivering health care services,

particularly to populations and communities that have traditionally been under-

served. HMA has worked for large health systems, consortia of providers, individual

hospitals and ambulatory providers, states and counties, foundations and managed

care plans to assess current delivery of care, plan new approaches and assist in

implementation. This work has been growing in volume as the country has started

to seriously grapple with how to assure access and quality—and the improvement

of health status—while rolling back the cost trajectory which is universally agreed

to be unsustainable. Expertise in integrated and accountable care as it applies to

the delivery of care to those funded by public dollars is in demand; it is anticipated

that the ACI will provide a vehicle for meeting that demand.