Success through Integration

Integrated Care Management Conference September 21 and 22, 2016 Joe Mott, VP – Population Health

Next Generation ACO Model Comprehensive Primary Care Plus

MACRA - MIPS - APMS

CJR

Anyone who isn’t really confused doesn’t understand the situation.

- Edward R. Murrow

There who was a man with Graham Bell who was agent for a new invention called the telephone. He believed there was great fortune in store for it and wanted me to take some stock. I declined. I said I didn’t want anything more to do with wildcat speculation.

Mark Twain Autobiography, page 305

“Helping people live the healthiest lives possible”

Shared Accountability – strategies we own

Community Health – strategies on which we collaborate

FFS PHM Fee For Service Population Health Management

Discrete Engagement Across the Continuum

Managing Population Health The Imperative to Integrate

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© Intermountain Healthcare, 2016

Pt. Care Revenue

Pt. Care Expense

NOI

Intermountain Hospitals

Admin Expense

NOI

Medical Expense

SelectHealth Revenue

Pt. Care Revenue

Pt. Care Expense

NOI

Intermountain Medical Group

Pt. Care Revenue

Pt. Care Expense

NOI

Intermountain Home Care

Pt. Care Revenue

Pt. Care Expense

NOI

Affiliated Clinics

Fee-for-Service Model Intermountain Health Services

© Intermountain Healthcare, 2016

Population Health Model

Pt. Care Revenue

Pt. Care Expense

NOI

Intermountain Hospitals

Admin Expense

NOI

Medical Expense

SelectHealth Revenue

Pt. Care Revenue

Pt. Care Expense

NOI

Intermountain Medical Group

Pt. Care Revenue

Pt. Care Expense

NOI

Intermountain Home Care

Pt. Care Revenue

Pt. Care Expense

NOI

Affiliated Clinics

Medical Expense

Capitation Revenue

NOI

Population Budget

Intermountain Health Services

© Intermountain Healthcare, 2016

2016 Population Budgets – Health Services Accountability for SelectHealth Products

Member Months Budget $PMPM Medicaid 1,152,013 $285,743,461 248.04 Medicare 305,163 $172,517,004 565.33 Share 123,996 $33,291,968 268.49 LE / FEHP 2,193,015 $668,843,207 304.99 Total 3,774,187 $1,160,395,640 307.46

© Intermountain Healthcare, 2016

Managing Population Health

Intermountain Hospitals

Intermountain employed Physicians Contracted affiliated

Physicians

Intermountain Hospitals

Intermountain employed Physicians

Regional Population Health Operations Committee Geographic Committee

Engage Physicians Operationalize Population Health

© Intermountain Healthcare, 2016

Benefit Design

Integrated Care Management

New

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ectH

ealth

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Physician Pmt M

odel Pop Health Services

Pricing / Transparency

Regional Population Health Teams

Pers

onal

ized

PC -

MHI

Evidence Based

Medicine Defined

System Com

petencies

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Shared Dec

Capital Budgeting Patient Education

Evidence Based

Medicine Used

Shared Accountability Scope

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Contracting He

alth

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Fee for Service World

(Volume)

Population Health World (Value)

© Intermountain Healthcare, 2016

CPC+ CJR / SHFFT CCM MACRA – MIPS & APMs

The Over Abundance of Opportunities

Connected Health Strategy OPERATIONS COUNCIL

AUGUST 2016

It is one of the paradoxes of success that the things and the ways which got you where your are, are seldom those that keep you there.

- Charles Handy The Age of Paradox

Integrated Care Management in the Age of Population Health: What does that mean?!?

Integrated Care Management Conference September 21 and 22, 2016

Dot Verbrugge, MD Medical Director of Integrated Care Management

Perspective – Case-by-Case vs Big Picture

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What is this???

Perspective – Case-by-Case vs Big Picture

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Did ya’ get it?!?

Perspective – Case-by-Case vs Big Picture

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What is this???

Perspective – Case-by-Case vs Big Picture

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Did ya’ get it?!?

Managing the Population The BIG Picture

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© Intermountain Healthcare, 2016

Population Health Financial Model

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SelectHealth “Shared Accountability” since 2013

Intermountain is “At Risk” for all Medical costs What does that mean?!?

o Payer • Manage Revenue (Premiums) • Pay Claims • Sales / Marketing • Compliance

o Intermountain (Delivery System) • Medical Management

• ALL MEDICAL EXPENSES!

Payer

Intermountain

Right Care at the

Right Time in the

Right Place

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But what does this mean for me as a Care Manager?!?

What is different now?

1. No More Silos! • Think beyond YOUR setting ... And the next one! • Transitions (not “Discharges”)

2. Identify and Address Risk Early • Longitudinal Care Management initiative

3. Understand Payments and Penalties • Payments / Costs

• Inpatient • Clinic • Medications

• Penalties from CMS for poor quality and value

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Six Ideas:

4. Influence Utilization in all settings • Appropriate Use Criteria

5. Documentation Precision • Demonstrate Measurable Value of Care

Management • Patient risk factors and comorbidities

6. Communicate, Communicate, Communicate

• PCP informed across the Spectrum • Patient Education • Share Care Plans

1) No more silos!

TOTAL Care matters, not just what happens in your setting • TRANSITION Care (Don’t just “discharge!”) • “What could have been done previously to avoid this problem?” • “Where will this patient be in

• 30 days? 60 days? 120 Days?” • Does this patient have what s/he needs to successfully transition?

• Medical Needs Assessments and plan • Psychosocial Needs Assessments and plan

• Intermountain “Transition in Care Model” under development • COMMUNICATION with patient, caregivers, and providers

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Think beyond your setting … and the next one!

2) Identify and Address Risk Early

Intermountain Risk Screening and Assessment Process • Highest Risk patients identified based on

• Utilization • Quality (Gaps in Care) • Cost

• Top 1% of patients with LONGITUDINAL Care Plans by • Medical Group Care Managers (if Medical Group PCP) • SelectHealth Care Managers (if SelectHealth and affiliated PCP)

• TRANSITION care between settings • COMMUNICATION with patient and providers

• Medical Group NCQA Certification dependent on success of this program!

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Risk Stratification Process and Patient Lists

3) Understand Payments and Penalties

Management Strategies: • Post-Acute Care Screening Tool • Palliative / Hospice referrals • Post Discharge Follow-Up Calls (Call

Center) • TRANSITION care between settings • COMMUNICATION with patient and

providers

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Inpatient Payments / Costs

Medicare Example:

Cost Per Day How It Pays Home Care $190 60-Day Bundle SNF $300 - $516 Per Day RUG Rate Rehab $1098 - $1122 DRG Bundle LTAC $1746 30-Day DRG Bundle Medical Hospital $2105 - $2948 DRG Bundle

3) Understand Payments and Penalties

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Outpatient Payments / Costs

Medicare Example:

Cost Per Visit

PCP $101

Specialist $97 - 229

Urgent Care $107

Emergency Care $586 - $825

• PCP cost per visit • Specialist cost per visit • Urgent Care cost per visit • ER cost per visit

Management Strategies: • Access to PCP Care • Patient Education on cost-effective care • Preventive Care • TRANSITION care between settings • COMMUNICATION with patient and

providers

3) Understand Payments and Penalties

Management Strategies: • Generic Preferred • Formulary Preferred • TRANSITION with medications • COMMUNICATION with patient and

providers

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Medication Payments / Costs

Medicare Example:

Cost per Script

Generic $34

Formulary Brand $122 Non-Formulary Brand $646

Specialty $436

3) Understand CMS Payments and Penalties

Initiatives: • Readmission Risk Score and

automated tasks in iCentra • Patient follow-up calls (Call Center) • Protocols and Standards (CPM’s) built

into work flows • Compliance measurement and

feedback • TRANSITION care between settings • COMMUNICATION with patient and

providers

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“As goes Medicare, so goes Health Care”

Examples of Penalties: • Readmissions

• 3% withheld from ALL Admissions • Hospital Acquired Conditions

• “Never Events” • 1% withheld from ALL Admissions

• Value Based Purchasing Program • Patient Safety Indicators (PSI) • Clinical Process and Outcomes • Patient Experience • 1-2% withheld from ALL Admissions

Measurements are Adjusted for Case Mix Index based on Physician Documentation & Coding!

4) Influence Utilization in all settings

Procedures at Intermountain that significantly exceed national benchmarks: • Hip Replacement • Knee Replacement • Spinal Fusion • Hysterectomies • Tonsilectomy

Appropriate use criteria implementation in all Health Care settings

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Appropriate Use Criteria

5) Documentation Precision

Accurate Documentation and reporting: • Demonstrates Measureable Value of

Care Management • Patient registries for disease

management • Comorbidity adjustments for CMS

penalties • Impacts decisions about best practices • COMMUNICATION between Care

Managers and providers • Address all TRANSITION needs

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Standardized documentation for accurate reporting

Example areas of concern: • Completion of screening and assessments

• Comorbidities • Completion of psychosocial assessments

• Social Determinants of Health • Completion of Care Plan • Advance Directives • Transition Plan and completion of tasks • Post-Acute Care disposition screening and

decision

6) Do what you do best

Care Plan Development with the patient • What is the patient’s goals? • Involve caregiver when possible TRANSITION Planning • Follow-Up plan with PCP • Referral completion • Medication Reconciliation and Information *Top area of concern on follow-up calls* • Community links to resources

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Communicate, Communicate, Communicate!!!

Additional Education Available on • Motivational interviewing • Talk back • Behavioral Change Model

Case Example

66-year-old female at inpatient at Intermountain Facility Chief Complaint • Explosive diarrhea and increasing joint pain Medical History • Bilateral Total Knee Replacements • Polymyalgia rheumatica Pertinent Findings • BP 102/50, HR 87, RR 31., RA Sats 86%, afebrile • Gen: Cognitively intact • Resp: Rales and ronchi, infiltrates on CXR • MS: Red swollen knee Diagnosis • Septic knee with MRSA • Pneumonia

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Care Management transformation in the age of population health

Plan: • IV Abx • To OR for cleanout of infected prosthetic Post Op course: • Sepsis controlled on Abx • Increasing confusion and not coherent after OR

• MRI showed evolving bilateral infarct involving cerebrum and cerebellum.

• Evolved to no spontaneous movement • Tone decreased. External rotation LE • Absent deep tendon reflexes

• Unable to extubate New Diagnoses: • Stroke with encephalopathy, prognosis unknown • Vent dependent, Trach placed

Case Example – “Discharge” Plan

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Before Population Health

Plan: Discharge to LTAC • Vent weaning (expecting 2 weeks) • Transport by Life Flight • “Discharge” to SNF when vent weaned

Advantages to “Discharging” to LTAC: • Patient needs can be met at LTAC • Transport costs will be covered by Medicare

(+$5000*) • LTAC costs will be covered by Medicare under

30-day DRG (+$52,380*)

• Hospital avoids cost of caring for patient that will not be paid under Inpatient DRG payment from CMS

($18,000 =[$300/day x 14 days])

*But patient cost share applies!

Post-Acute Care Cost: $57,380

Case Example – Transition Plan

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The Age of Population Health

Plan: Maintain patient at Intermountain Facility • Vent weaning (expecting 2 weeks) • “Transition” to SNF when vent weaned

Advantages to Continuity at Dixie: • Patient needs will be met without transport • Continuity of Care for within facility • Patient remains in home town by family

• Patient avoids costs of additional admission (LTAC) (Inpatient co-pay)

• Intermountain avoids costs of additional medical services

• LTAC 30-day DRG cost avoided ($52,380)

• Transport cost avoided ($5000)

• Intermountain incurs cost of 14 days IP stay

(+$18,000)

Post-Acute Care Cost: $18,000 AND Better Care!

Coordinate the Right Care

at the Right Time

in the Right Place

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What Care Managers Do Best:

CMS Quality Measures MASOOD SAFAEE, M.D. MEDICAL DIRECTOR | MCKAY-DEE HOSPITAL INTERMOUNTAIN HEALTHCARE SEPTEMBER, 2016

Goal 1: Make care safer by reducing harm caused in the delivery of care.

Goal 2: Strengthen person and family engagement as partners in their care.

Goal 3: Promote effective communication and coordination of care.

Goal 4: Promote effective prevention and treatment of chronic disease.

Goal 5: Work with communities to promote best practices of healthy living.

Goal 6: Make care affordable.

The CMS Quality Strategy Goals

Hospital Readmission

Penalty Up to 3% of

Medicare Payment for

Inpatient Care

AMI CHF Pneumonia COPD TKA / THA CABG

FY-2017:

CMS estimates that 2,603 hospitals will pay penalties

save approximately $532 million in FY 2017 An increase of approximately $100 million over the

estimated FY 2016 savings

HOSPITAL VALUE-BASED PURCHASING (VBP) PROGRAM

Up to 2% of Medicare

Payment for Inpatient Care

FY-2016:

1,235 hospitals had a negative payment adjustment from VBP

1,806 hospitals had a positive payment adjustment from VBP

CMS estimates that the total amount available for value-based incentive payments for FY 2017 is approximately $1.7 billion

HOSPITAL ACQUIRED CONDITION REDUCTION PROGRAM

Up to 1% of Medicare Payment for Inpatient Care

Patient Safety Indicators PSI 90

composite measure Central Line Associated Bloodstream

Infections (CLABSI) measure Catheter Associated Urinary Tract

Infections (CAUTI) measure SSI - Colon Surgeries and Abdominal

Hysterectomies

FY 2017 Additions MRSA CDI

FY-2016:

758 hospitals had a negative payment adjustment from HAC

Mortality

(7) Safety of Care

(8)

Readmission (8)

Patient Experien

ce (11)

Effectiveness of Care

(18)

Timeliness of Care (7)

Efficient Use of Medical

Imaging (5)

Factors Impact Quality Measures:

Pre-Index Admission Index Admission

Discharge

Process @ Index Admissio

n

Post Discharge -Index

Admission

Readmission

ER / OBS

Readmission

Inpatient

Quality Improvement Projects: Measure Specific

DIXIE FY – 2017

20 Readmissions

Respiratory Conditions (CHF, PNA, SOB, Pleural effusion)

9 Cases (45%)

Cardiac Conditions (NSTEMI; AFIB; Cardiac Arrest)

5 Cases (25%)

Infection (Lower Ext Cellulitis)

2 Cases (10%)

Other (GI Bleed; Syncope; Hypotension;

Thrombocytopenia) 4 Cases (20%)

Readmission Dx :

CABG Readmissions (FY2017: July 1, 2012 to June 30, 2015)

Risk Adjustment of Measures:

Documentation of Comorbid Conditions

Risk Adjustment • Documentation of Chronic Conditions • Has to be documented within 12 month before or during

the index admissions • Impact many of quality measures and penalties

– Mortality Rate – Hospital Readmission Reduction Program (HRRP) – Value Based Purchasing (VBP) – Inpatient Quality Reporting (IRQ)

• Applies to Traditional Medicare accounts

Discharge Planning: -Hospital Process

-Post Hospital Process

Survey of patients' experiences

Pneumonia

CHF

COPD

AMI

THA / TKA

National Average

Best

Worst

Best

Worst

Best

Worst

Best

Worst

Best

Worst

Patient survey summary star rating (More stars are better)

**** ** **** ** *** *** *** ** **** *

Patients who reported that their doctors "Always" communicated well 83% 74% 81% 78% 82% 90% 77% 77% 86% 77% 82%

Patients who reported that staff "Always" explained about medicines before giving it to

them 66% 59% 64% 59% 64% 67% 59% 54% 74% 55% 65%

Patients who reported that YES, they were given information about what to do during

their recovery at home 91% 75% 90% 80% 88% 82% 88% 87% 93% 79% 86%

Patients who "Strongly Agree" they understood their care when they left the

hospital 55% 42% 58% 45% 50% 48% 49% 49% 64% 36% 52%

Worst / Best Hospitals for THA/TKA Readmission Rate in 2016 (National Rank)

Worst-Best

DIXIE FY – 2017

20 Readmissions

≤ 7 Days 12 cases (60%)

> 7 Days 8 Cases (40%)

Interval between Index admission & Readmission:

CABG Readmissions (FY2017: July 1, 2012 to June 30, 2015)

Goal: Not to Avoid Penalties But

Be among the Best

Measure Name

Number of

Hospitals Worse

Number of

Hospitals Same

Number of

Hospitals Better

National Rate

Rate of unplanned readmission for CABG 12 1040 6 14.9%

% of All Hospitals 1.1% > 98% 0.6%

Death rate for CABG 16 1037 14 3.2%

% of All Hospitals 1.5% > 97% 1.3%

Facility

CHF

AMI

PNA

COPD

TKA/THA

IMC

97

101

167

627

315

Dixie

353

795

53

979

McKay-Dee

422

158

94

256

Utah Valley

294

233

152

835

241

# of Hospitals 2753 1715 2719 2675 1322

1

6

2016 Readmission- National Rank

Longitudinal Care Management

September 2016

Longitudinal CM

Integrated Care Management Model, 2016

ALL

PATI

ENTS

& M

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RS

Risk

Sco

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Assig

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Long

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Clin

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Prog

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Prevention Services: PPC, Health Answers, LiVe

Well

SelectHealth CM

Episodic CM

MEDIUM SCORE OR

RISK

LOW SCORE OR RISK

HIGH NEED

MEDIUM NEED

IMG or SelectHealth CM

Community Partners & Resources

Patient Handover

LOW NEED

HIGH SCORE OR

RISK

Episodic Intermountain & Community-

based Interventions

Longitudinal Intermountain & Community-

based Interventions

Medical Group CM

Scre

enin

g:

Nee

d CM

?

Acute Event

Other C M

Referral

sources

* Patients will move between episodic and longitudinal as needed

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• All Intermountain patients stratified by risk:

• Screening of Top 1% for Longitudinal Care Management • Medical Group PCP by Medical Group Care Manager • SelectHealth insurance by SelectHealth Care Manager • (Affiliated PCP without SelectHealth receive Episodic Care

Management) • Assessment of patients that “Screen In” • Care Plan for those that accept Care Management

Risk Stratification, Screening, Assessment for Longitudinal Care Management

Quality Utilization Cost # Charlson Chronic Conditions # Ambulatory Sensitive

Encounters Hospital and Clinic Allowed

Amounts % Adherence to Evidence-Based

Quality Measures # Inpatient and Outpatient

Hospital Encounters Total Allowed Amounts for Non-

Hospital/Clinic SelectHealth Claims Indigo Expected Benefit Score # Emergency Department

Encounters Optum Pharmacy Risk Grouper

(PRG) Score

IMG PCP Affiliated PCP No PCP Total

SelectHealth** 100,000 100,000 230,000 430,000

Other Payers 150,000 140,000 190,000 480,000

Total 250,000 240,000 420,000 910,000

Care Manager Screening, Assessment, Plan of Care

*Model specific to post-NCQA certification by Medical Group, for purposes of SelectHealth accreditation **SelectHealth attribution calculation is based on adult members (>18) on for members on Utah plans, calculated on 1/15/2015

Longitudinal – Medical Group CM’s – 27%

Longitudinal – SelectHealth CM’s –

36%

Episodic - based on site of care or need – 36%

Integrated Care Management Structure Episodic Care Management Services Provided to patients who have a need for Care Management

for a particular “episode” of care that has a foreseeable “endpoint”.

Examples: Inpatient stay Post-acute care High risk pregnancy New cancer diagnosis Unstable episode for highly complex patients or patients with

unusually high utilization of healthcare services Need for navigation assistance to access healthcare

Episodic Care Management Programs Inpatient Care Management Health Answers Community Care Management (CCM) Complex Care Clinic (CCC) Integrated Community Care Management (ICC) Specialty Programs – Maternal Fetal Medicine, Neuro-

Oncology, Transplant Services, Endocrinology Services, Congestive Heart Failure Programs

Community Partnerships – Nurse Family Partnership, Community Health Workers, United Way 211, Community Paramedic Program

Integrated Care Management Structure Longitudinal Care Management Services Provided to patients who are determined to be high risk or

high complexity using a variety of scoring, screening and assessment tools and for whom an “endpoint” isn’t clear.

Examples of Factors contributing to high risk or high complexity: • Multiple Chronic Illnesses • High healthcare costs • High utilization of healthcare services • Behavioral Health and/or Substance Abuse diagnoses • Lack of social and other necessary support • Catastrophic event or diagnosis

Longitudinal Care Management Programs

Personalized Primary Care Clinic Care Management SelectHealth Care Management

Longitudinal Care Management - PPC Locations 79

Staff 62.5 RN 63.3 Heath Advocate/Car Guide

Patients Served Anticipate at least 4500 in 2017

Risk Screening Methods

Proprietary Risk Scoring Tool Care Management Screening Tool List of ED visits and IP stays Provider referrals Lists of Chronic Disease Patients

Services Provided • Telephone and In-person clinic visits to provide: • Risk Screening and Assessment • Individualized Care Plan • Identification of Barriers and Resources • Care Coordination and Facilitation • Health Education for Self Management • Referral to Community Resources

Measures of success • Team Based Care (TBC) (including Care Management) reduced delivery system payments by $115pmpy

• TBC reduce ED visits by 30% • TBC reduced IP admits by 14% • TBC improved Depression Screen Score, Adherence to DM bundle,

and HTN control • Note – PMPY investment $22.19 w/o overhead

Longitudinal Care Management - SelectHealth Locations 1

Staff Approximately 46 CM/DM RN’s Approximately 130 total including UR, Benefits Mgmt., admin.

Patients Served UM provided to all members using services Approx. 26,000 Screened/Evaluated Approx. 3700 enrolled in CM/DM

Risk Screening Methods Proprietary Risk Scoring Tool Care Management Screening Tool Trigger List (90+ items) Referrals from Providers Utilization and Cost Reports Specific Chronic Disease Diagnoses Health Risk Assessments High Risk Managed Medicaid and Dual Eligible populations

Services Provided • Telephone visits to provide: • Risk Screening and Assessment • Individualized Care Plan • Identification of Barriers and Resources • Care Coordination and Facilitation • Health Education for Self Management • Referral to Community Resources • Utilization Management • Disease Management

Measures of success Studies of Sample Care Managed Populations show: • ED visits decreased for Asthma patients • IP admits decreased for Heart Failure patients • Hgb A1C decreased for Diabetic patients • ED visits decreased for High Risk Managed Medicaid Patients

What’s Next? 1. Create Dashboard for Longitudinal Care Management to

demonstrate “Did it make a difference?” 2. Standardize and Optimize Care Management documentation

in EMR to support Shared Plan of Care and all regulatory and quality auditing requirements.

3. Expand target populations to include more high risk patients: • SelectHealth Medicare Advantage • SelectHealth Medicaid • New Risk Contract populations • SelectHealth individual plans sold through the exchange

4. Continuously evaluate the effectiveness of our Risk Scoring Tool and our work processes to improve our impact