3/16/2016

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Plug & Play-Quality & Care Coordination in a Volume to Value Transition

Lauren Wright, RN/MSN

Leann Richard, RN/MSN

Heather McConnell, RN/BSN

Objectives

• Care Coordination in the Continuum of Care

• Understanding the Transparency in Reporting Quality (Language of Providers & VP’s and how they differ)

• Team Success: Integration of Care Coordination & Quality (Contractual Pitfalls, Patient Needs, & Physician Relations)

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History of Gaston County

• Founded In 1846

• Border Mecklenburg County (Charlotte) & South Carolina

• Covers approximately 350 square miles

• Approximately 205,000 people

History of Gaston County

• Known for our textile mills and tobacco industry

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Gaston County Health RankingsFrom University of Wisconsin – Population Health Institute

Health Outcomes2012 2013 2014 2015

76th 81st 79th 77th

Health Factors2012 2013 2014 2015

65th 65th 60th61st

Gaston County Income

0

10000

20000

30000

40000

50000

60000

UNITED STATES North Carolina Mecklenburg County,North Carolina

Gaston County, NorthCarolina

$53,046 $46,334 $55,444 $42,017

Median household income (in 2013 dollars), 2009‐2013

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Unemployment

=Gaston County Rate =National Rate

Education

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County Health RankingsUniversity of Wisconsin – Population Health Institute

Adult Smoking – 2015 (2006-2012 data)Current Smokers

10 %

30 %

20 %

50 %

40 %

20.3 %

26 %

21 %

26 %

20%

44 %

12 %

Gaston County NC USA NC’14 ’15 ’15’13 Min Max’15

County Health RankingsUniversity of Wisconsin – Population Health Institute

Adult Obesity – 2015 (2011 data)BMI > 30

’14 ’15 ’15’13 Min Max’13 ’15Gaston County NC USA NC

10 %

30 %

40 %

20 %

50 %

29.4 %27 % 28.3 %

31 %29%

40 %

21 %

31 %

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Published Cost Comparisons

Overview of CaroMont Health• Established in 1945

• 435 bed facility

• Non-profit general and acute care facility, including• Level III Trauma Center

• Freestanding ED, Mt Holly

• Gaston Hospice

• Courtland Terrace-SNF & STR

• Cancer Center

• Diabetes Center

• Wellness Center

• Wound Center

• Mobile Mammography

• Oncology Center

• 43 Primary & Specialty Practices

• 2 Urgent Care Facilities

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CaroMont Medical Group23 Specialty Clinics:

Obstetrics/Gynecology

Plastic Surgery

Dermatology

Hand Surgery

Neurology/Neurosurgery

Perinatal

General Surgery

Gastroenterology

Endocrinology

Infectious Disease

Breast Surgery

Psychology

Rheumatology

Cardiology/Cardiovascular & Thoracic Surgery

20 Primary Care Clinics:PediatricsFamily PracticeInternal MedicineUrgent Care

CaroMont Health Footprint

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High Quality

‘A’ Grade 2012-2014PCMH Level 3

Longest Continuous Accreditation in CLT

Region

Continuum of Care

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Health Revolution

Step Up to Shape Up

Executive Wellness Program

LEAP – Weight Management Program

Couch to 5K

Healthy Through the Holidays

Wellness Lunch and Learns

QuitSmart – Tobacco Cessation Program

Jumpstart Weight Loss Program

Diabetes Management Program

Wellness Programs

Our Journey2011 2012 2013 2014

Began Deploying Robust Community Wellness Programs

Certified all Primary Care and Specialist Practices as PCMH Level 3

Embed Care Coordination in Primary Care Practices

Begin MSSP Year 1

Negotiated first  Commercial Shared Savings Agreement w/ CCF

Create Care Coordination Team

Accepted into MSSP upside only for PYs 14‐16

CCF= Care Coordination FeePCMH=Patient Centered Medical HomeMSSP=Medicare Shared Savings ProgramPY=Performance Year

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Our Journey2015 2016 2017

Begin 3 year PCMH Pilot with NC State Health Plan

Medical Group Live on EPIC.  Market Narrow Network Plan Direct to Self Insured Groups

Achieved over $5m in Shared Savings with MSSP

Launch Branded Employer Services Program

Begin CIN Integration

EPIC implementation within Hospital.

Implementation of EPIC in other areas of CaroMont to include:SNF, Occupational Med, and Hospice.

Begin MSSP Phase 2

Begin evaluation of CIN’s.  Value proposition analysis of CIN for the system.

CIN-Clinically Integrated NetworkPCMH-Patient Centered Medical HomeMSSP-Medicare Shared Savings Program

Value Based Growth

PAYORS CONTRACTSCOVERED LIVES TODAY

COVEREDLIVES JULY 2014

GROWTH

MEDICARE & MEDICARE ADVANTAGE

5 14,519 13,126+ 1,393 LIVES

11 %

COMMERCIAL & DIRECT EMPLOYER

4 13,731 11,955+ 1,776 LIVES

15 %

MEDICAID 1 5,551 5,551 0 0 %

TOTAL MEMBERSHIP =  33,801 (JULY 2015) vs. 30,632 (JULY 2014)

+ 3,169 NET GROWTH ( 10 % )

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Care Coordination in the Continuum of CarePathway to Care Coordination

STEP #1: 18 Month Pilot Program (Hospital Based)

• Offered in a small group of practices.(Team consisted of RN, dietician, pharmacist, and social worker)

• Readmission focused.• Outcomes were very good; however, no income generated to

support the above layout, and quality was not a focus in this step.• No integration with Medical Group.• No analytic approach or reportable outcomes.• Did not support vision of value based care to support Patient

Centered Medical Home model.

Care Coordination in the Continuum of CarePathway to Care Coordination

STEP #1: Medical Group

• Worked on getting all Primary Care offices Patient Centered Medical Home certified.

• Centrally Located.• Created admission/discharge/ED visit reports for all offices.• Pitfall: Clinic Education needs, hospital pilot not

communicating to Medical Group.• Not generating Revenue.

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Care Coordination in the Continuum of CarePathway to Care Coordination

STEP #2

• Embedded care coordination within Medical Group as part of Quality & Education Department due to pilot completion.

• Integrated clinic orientation, skills check offs, Computer Based Learning modules and staff education within the Quality department.

• Certified Medical Assistants (familiar with work flow and processes in clinics)-centrally located.

• Financial model for integrating care coordination was presented to financial committee.

• Task Driven; Gaps in Care; telephonic patient education.• Higher level of clinical skills and critical thinking required for Provider buy-in,

and management of increased quality contracts.

Care Coordination in the Continuum of Care Cont.Pathway to Care Coordination

STEP #3 Centrally Located Care Coordination

• RN’s (covering 2-4 clinics) with certified Medical Assistants support.• Staff to patient ratio was not supportive for contract expectations.• Too much time spent traveling.• Too broad of a scope of practice-needed a narrow scope of

conditions.• Education material did not align from inpatient to outpatient.• Alignment with organization and programs working with patients

across the continuum.• Part D cost was hurting us in our Medicare Advantage shared

savings programs.

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Pathway To Care Coordination

STEP #4 Embedded Care Navigators in Clinics

• Each RN has 1 to 2 clinics based on patient panel.• RN’s able to do more face to face education, care plans, and

follow-up care with patients.• Certified Medical Assistants work centrally and are focused on

quality and contract specifics.• Manager of Care Coordination added to Managed Care

Operation Meetings & Joint Operating Committees.• Centrally located Pharmacist.

Care Coordination in the Continuum of Care Cont.

Department Focus of Education

• For our Staff• All office staff, whether clinic focus or not, were required

to attend yearly competency education classes.

• Centralized Orientation to CaroMont Medical Group (CMG) Quality Department.

• Classes provided were for diabetes, heart failure, chronic obstructive pulmonary disease, quality improvement updates and Spirometry training with a respiratory therapist.

• All material, from inpatient to outpatient, are standardized.

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Department Focus of Education

• For our Patients• Classes in Primary Care Clinics

– Diabetes (Class 1 of a 3 part series)

– Chronic Obstructive Pulmonary Disease

– Heart Failure

– Obesity (Healthy You)

– Quit Smart (Tobacco Cessation)

• Addition of Chronic Disease Educator

Pharmacist

• CaroMont Medical Group Pharmacist reviews all available patient records, outreaches to Primary Care Providers, and member as appropriate for:

- Medication alerts

- Quality medication metrics

- High Utilizers (HU)

- Transition of Care Members

- Complex Care Review

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Transparency within the organization• How do you define your department?

• Do you vary how you discuss quality with a Vice President versus with a Medical Provider? Should you?

• How much is this going to cost me? Organization? Providers?

• What is the value of a Quality Department?

• What is the value of an Outpatient Care Coordination Department?

• What synergies do the two departments share?

• How are these departments going to help my day to day practice?

• How confused will my patients be with all of these extra people working on their care?

Conversations with Physicians

• Leadership committees “Physician Lead”

– Quality Committee

– Disease Management Committee

– Care Transitions Committee

• Quarterly Provider Meetings-each physician lead

committee gives updates on meetings at each

quarterly meeting

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Conversations with Physicians

• Physician incentive models

• Unblinded scorecards for quality and

readmission rates

– Accountable

– Competition within the organization

– Ownership

Revenue Generating Department

• How does this happen?• Care Coordination Fees with Patient Centered Medical

Home (PCMH) contracts.

• Shared Savings Opportunities in contracts.

• Healthcare Effectiveness Data and Information Set (HEDIS)

/Medicare Risk Audits (MRA) are now centralized within

Care Coordination Department.

– Did you know? Under national legislation you can charge a

fee for each chart requested.

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Pitfalls

Pitfalls

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Current Contractual Pitfalls

• Current hybrid model (Care Coordination/Quality) does not align with all contracts.

• Contractual Alignment/Attribution models vary amongst contracts.

• Reporting capabilities vary amongst contracts.

• Ninety day run out delays reporting and timely patient follow-up.

• Required Care Coordination and Quality efforts vary.

Current Contractual Pitfalls (Cont.)

• Inability of all contracts to provide claims data.

• Inability of some contracts to close gaps in quality through means other than claims.

• Multiple platforms used amongst contracts for data analyst and entry.

• Meetings not aligning with Physician schedules.

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Our Future Strategic Objectives• Addition of Third Party Analytic Tool.

• Raw Claim Feeds

• Addition of Navigators in Specialty Clinics

• Addition of Education Classes in the Community

• Alignment of Contract Language

• Progressive Work on Physician Compensation

• Transparency and Timeliness of Data from Payers

• Physician Dashboards

• Organizational Alignment on One Electronic Medical Record

• Organization Education on Volume to Value Journey

Questions

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References

• http://www.northcarolinahistory.org/encyclopedia/590/entry

• http://www.textilehistory.org/LorayMills.html

• http://www.census.gov/

• http://www.countyhealthrankings.org/app/north-carolina/2015/overview

• http://www.homefacts.com/unemployment/North-Carolina/Gaston-County.html

• http://www.census.gov/hhes/socdemo/education/