Caring for Children with Disabilities: The View from ...Accountable Care Organizations (ACOs) are...

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Caring for Children with Disabilities:

The View from Inside

an Accountable Care Organization

American Academy for Cerebral Palsy and

Developmental Medicine, 2014, IC21

Garey Noritz, MD, FAAP, FACP

Nationwide Children’s Hospital

The Ohio State University

Columbus, Ohio

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Disclosures

I have no financial disclosures.

This presentation will not include discussion of pharmaceuticals

or devices that have not been approved by the FDA.

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What's an ACO?

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare/Medicaid patients.

The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare/Medicaid program.

-CMS.gov

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ACOs vs. HMOs1. ACOs are about creating value, not withholding service.

2. ACOs are local. Where HMOs created large bureaucracies that

layered in cost and complexity, ACOs are designed to directly

manage healthcare in small, manageable settings.

3. Incentives are aligned. HMOs invested in improving the health

of members without reaping the long-term benefit. For ACOs,

financial upside is more immediate.

4. Physicians are now more accepting of integration.

5. ACOs offer an array of payment models.

6. Information technology has transformed the capability for

population health management.

6. ACOs may not avoid high risk patients.Bob Edmondson, VP

Innovation, West Penn

Allegheny Health

System | May 10, 2011

• ACO Affiliated with Nationwide Children’s Hospital

• Full risk contracting for Central/Southeast

• Includes all children on Medicaid Managed Care aged 0-18

Partners For Kids

6

Flow of Funds

$

Ohio Department of

Medicaid

Plan B Plan C Plan D

ODM pays the Medicaid Managed

Care Plans an age-sex adjusted per

member amount each month for all

CFC members in their regions

Plan passes the capitation for members 18 and

under less a small amount for administration

(reporting, member service, claims processing)

Per Member Per Month

capitation payments with

risk

NCH employed physician

group paid per member

per month capitation

payments

Community member

physicians paid fee-for-

service @ % over

Medicaid

Other providers (non-

members) paid fee-for-

service @ % of Medicaid

PAA

$ $ $

PFK provides care coordination,

population health initiatives, credentialing,

network management

Plan EPlan A

For children covered under Aged,

Blind, Disabled (ABD), this

capitated amount is significantly

higher.

7

Financial Incentives

Primary Care Pay for Performance

Access

Practice Improvement—Medical Home recognition,

quality collaborative

Paying for

Quality

OutcomesSelected HEDIS measures

• Well Child Visits

• Appropriate treatment of URI

• Asthma medication

8

Partners for Kids StructurePhysician-Hospital Organization formed in 1994.

• Ohio taxable, not for profit private entity

• Joint venture between Nationwide Children’s Hospital, its

employed physicians and contracted community physicians

• Approximately 95 employed and 180 community PCPs, 480

employed and 50 contracted community specialists

(approximately 900 physicians in total)

Ohio Department of Insurance considers PFK to be an

“intermediary organization”---accepts financial risk but not a

health plan. Must maintain reserves and stop loss coverage.

9

Evolutionary Growth

0

50000

100000

150000

200000

250000

300000

350000

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

Patient Membership

Contracting Strategy

Managed Care Strategy

Accountable Care Org.

(Population Health)

10

Data Acquisition, Maintenance and Use

Partners for Kids

Data Warehouse

Financial

reporting

Quality

monitoringPhysician

Incentives

Program

Development

Population

Management

Plan B Plan C Plan D

Eligibility

Capitation

Claims

Eligibility

Capitation

Claims

Eligibility

Capitation

Claims

Plan E

Eligibility

Capitation

Claims

Plan A

Eligibility

Capitation

Claims

11

Tools

Accountable Care

Organization

Technology

Web Tools

Financial

Incentives

MOC Credit

Collaborative

Learning

Data Sharing

Partnerships with

Other Organizations

PCMH

Certification

NCQA

Increased

Access

Home Care

Outreach

Standardizing

Care

Distance

Medicine

PFK Care Coordination

12

Physician - Hospital Alignment

16 Board Members• 50% of the board are hospital appointees (2 of which are community

physicians)

• 50% are member physicians elected by their peers

Extensive involvement of both community and employed

physicians in setting up programs and engaging in quality

initiatives---alignment with Hospital’s strategic plan

Committees include:• Internal: Executive, Credentialing, Physician Incentive, Clinical Oversight

• Wellness: Asthma, Better Birth Outcomes, Diabetes, HNHF

• Ad hoc and other hospital-based committees

13

Population Management Tools

AsthmaHealth

SupervisionObesity

Preterm

BirthPharm.

Provider Focus

Collaborative Learning

Standard care

Technology

MOC Credit

Certification

Partnerships

Incentives

Patient Activation

Care Coordination

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Expand the PFK Model

New Geography: Akron region (8 more counties)

New Population: Aged/Blind/Disabled (SSI + <60% FPL)

Shared Savings agreement with state

Focus on certain clinical groups

Behavioral Health

Complex Care

BUT

Many of the most complicated patients are excluded from or may opt out of PFK

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HCIA Grant – PFK Expansion

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Exclusions from PFK

Children who are:

• On Medicaid Waivers

• In Foster Care (some)

• In Long-Term Care Facilities

• In the Juvenile Justice System

Patients who receive Title V Funds (in Ohio, Bureau for Children

with Medical Handicaps) may opt out

Opportunities: New Geographies

Adams

Allen

Ashland

Ashtabula

Athens

Auglaize

Belmont

Brown

Butler

Carroll

Champaign

Clark

Clermont

Clinton

Columbiana

Coshocton

Crawford

Cuyahoga

Darke

Defiance

Delaware

Erie

Fairfield

Fayette

Franklin

Fulton

Gallia

Geauga

Greene

Guernsey

Hamilton

Hancock

Hardin

Harrison

Henry

Highland

Hocking

Holmes

Huron

Jackson

Jefferson

Knox

Lake

Lawrence

Licking

Logan

Lorain

Lucas

Madison

Mahoning

Marion

Medina

Meigs

Mercer

Miami

Monroe

Montgomery Morgan

Morrow

Muskingum

Noble

Ottawa

Paulding

Perry

Pickaway

Pike

Portage

Preble

Putnam

Richland

Ross

Sandusky

Scioto

Seneca

Shelby

Stark

Summit

Trumbull

Tuscarawas

Union

Van Wert

Vinton

Warren Washington

Wayne

Williams

Wood

Wyandot

Opportunities: New Kinds of Patients

RN/SW Case Managers

Telehealth

Unlicensed Staff

Complex Care Clinic

Nationwide Childrens Akron

Focus Area Existing CMMI Existing CMMI

Prematurity X X

DM X

Asthma X X

Health Supervision X

Obesity X

Complex Care NEW X X

Behavioral Health NEW X X

Infrastructure X X X

Centers for Medicaid & Medicare Innovation

(CMMI) Award

19

Grant Awarded 7/2012 to improve quality/reduce cost

$13.1M awarded over 3 years

Funding key initiatives:

• Expanding the PFK model to Akron Children’s

• Focusing on children with complex needs• care coordination

• weight management

• standardization

• Focusing on children with behavioral health needs• reducing readmissions—transition care/care coordination

• appropriate drug management

• support through Parent Partners

Health Care Innovations Award

Major Challenges

• Feeling comfortable with the risk when you don’t have a lot of control!

• Regulatory issues---changing Medicaid landscape with little ability to influence, no seat at the table

• Maintaining managed care plan relationships and ongoing collaboration

• Competing priorities

• Data management

• Many children excluded whom we want to impact

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Although informal in the past, now officially

delegated to do care coordination for:

• Molina

• Buckeye

• Paramount

Working on United---may be delegated by mid year.

Will likely not be delegated by CareSource

Delegated Care Coordination

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KEY DRIVERS

A. Cost = By 6/2015:

• Reduce per member per month by 1.1%

for TANF and 2.0% for Disabled

• Reduce 60 day PFK behavioral health

readmissions by 30% from 9.8 to 6.9%

• Decrease hospital days of tube fed

children by 10%

• Reduce Summit County neonatal days by

10%

Payment Reform

Health Information

Technology

Patient, Family,

Community

Engagement

Patient Centered

Medical HomeCare

Coordination/Case

Management

Expand PFK model to reduce costs,

improve care and enhance outcomes for

Medicaid children in Ohio

Data Capture,

Analysis &

Reporting

Home Care

Technologies

Risk Model &

Contracting

Specialty Network

Performance &

ExtendersImprovement Science

and Implementation

SECONDARY DRIVERS

SPECIFIC AIMS:

B. Quality = By 6/2015:

• Increase completed 30 day outpatient

PFK medical follow up after behavioral

health hospitalization from 29% to

65% by 6/2015

• Proactive care plan implemented for

children with feeding impairment and

neurodevelopment disorders from 0%

to 85%

• Increase delivery of progesterone to

pregnant women with prior preterm

birth in Summit

County by 20%

C. Health = By 6/2015:

• Decrease Columbia Impairment Scores

from discharge to 60 days post

discharge by 15% for >75% of PFK

patients admitted for treatment of

psychiatric diagnoses

• Increase by 10% proportion of tube fed

kids between 5%ile & 95%ile for

weight on growth chart each year

• Decrease preterm birth rate to 11.6%

from 13.3% in Summit County.

Pay 4 Performance Contracts

Resource Consultation Line

Telemedicine

• Clinic

• Home

Care Coordination and Plans

Managed Care Orgs/PFK

Contracts

Quality Collaboratives

INTERVENTIONS

Progesterone Promotion

Cervical Screening

Parent Training, Advocates

GLOBAL AIMS:

HCIA Grant – PFK Expansion

https://www.akronchildrens.org/


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KEY DRIVERS

Cost: By 6/2015

• Reduce 60 day PFK

behavioral health

readmissions by 30% from

9.8 to 6.9%

Payment Reform

Health Information

Technology

Patient, Family,

Community

Engagement

Care

Coordination/Case

Management

Prevent Psychiatric Youth

Crises

Improvement Science

and Implementation

SPECIFIC AIMS

Quality: By 6/2015

• Increase 30 outpatient

follow up after behavioral

health hospitalization from

29 to 65%

Health: By 6/2015

• Decrease Columbia

Impairment Scores from

discharge to 60 days post

discharge by 15% for >75%

of PFK patients admitted

for treatment of psychiatric

diagnoses

Pay 4 Performance Contracts

Consultation Line

• Pediatric Psychiatry

Network

Telehealth

• Telepsychiatry

• Teletherapy, e-therapy

• Healthspot

Care Coordination

Managed Care Orgs/PFK

Contracts

PCP Collaboratives

• ADHD Collaborative

• Building Mental Wellness

INTERVENTIONS

Parent Partner Initiative

GLOBAL AIM:

Mental Health and

Primary Care Access

Public awareness and

education

• Triple P Program

Second opinion program for

medication use

HCIA

PFK

NCHKEY

Behavioral Health

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Parent Partners Intervention

Primary goal

Provide support to parents and families coping with children with behavioral problems

Secondary goals

Assist parents in identifying their own needs and concerns

Education and teach skills focused on coping, self-care, crisis management, problem solving, and personal skill development

Provide emotional support and facilitate sharing of experiences and social connections to other parents

Facilitate the empowerment of parents in decision-making

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Behavioral Health



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ADHD Medications

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Complex Patients

A child with

• One of about 60 neurologic conditions* AND

• A feeding tube

*These neurologic codes were selected by our team from ICD-9 as

those diseases most likely to result in functional dependency

(For a list of these codes, please email me at

[email protected])

KEY DRIVERS

SPECIFIC AIMCost

Decrease hospital days

per 10,000 member

months for tube fed

patients from 24.8 to 22.3

days for 12-month period

ending 6/30/2015*

Care

Proactive Care

Coordination will be

provided for 85% of

children with feeding

impairment and

Neurodevelopment

Disorders from a baseline

of 0% by 6/30/2015

Health

Increase by 10% annually

the proportion of

NCH/ACH tube fed kids

between the 5th percentile

& 95th percentile for

weight on standard CDC

growth charts

INTERVENTIONS

Virtual Care

Management Support

infrastructure

Home Management

Support

Improve Health of

children at risk with tube

feedings or other

technologies

GLOBAL AIM

• Home visits for tube mechanics and

training

• G tube insertion/removal protocol

• Telemedicine Tube Advice

• PCP Training on Complex Care

• Resources provided to PCPs for

Complex Care Patients

• Self Management resources (e.g.

Home medication list) for Care Plan

• Centralized Medical Care

Coordination as needed in

cooperation with PCP

Tertiary Care

(Hospital-based care)

• Scheduled formula evaluations

• Family-Centered Care Planning

Complex Care

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HCIA Self-Monitoring DashboardComplex Care: May 2014

AIM #1: Decrease by 10% NCH Inpatient Hospital Days/ 10,000 PFK Member Months over 12-Month Period for Tube-Fed Children

Initiatives:

Modify ‘Feeding Tube Placement’ orders in EPIC to establish provider responsible for nutrition management

Construct ‘Complex Feeding Smart Form’ in EPIC to organize feeding tube related information for providers and families

Parent Education: journey board, workbook, videos, webpage, app, Family Resource Center kiosk

9/6/2014 28


9/6/2014 29

Secondary Program Aim for June 30, 2015 Baseline Results this Month Goal

Decrease the average length of stay for tube-fed children at

NCH by 10% from a baseline average of 6.7 days for Jul2011-

Jun2012 to average of 6.0 days for the 12 months ending June

30th, 2015.

6.7

days

12 month average through May 2014: 4.8 days

(28% ↓ from baseline)

6.0

(↓ 10% from

baseline)

Group Avg: Discharge or to-date LOS for all admissions in the month; admission months containing patients still in the hospital as of June 15, 2014

are color-coded red and are subject to change in upcoming months until patients are discharged

Group Size: Admission month for those with a tube-fed related visit (any patient class) in the prior 12 months.

Month with patient(s) yet to be discharged

Desired Direction of

Change

Care Coordination

Expanded

Med. Dir. of Comprehensive Health

Care Service (CCHCS) Starts

HCIA Grant Awarded/Feeding Tube Task Force

Formed

Dietician & RN Join CC

Team


9/6/2014 30

Secondary Program Aim for June 30, 2015 Baseline Results this Month Goal

Decrease the # of tube-fed children admitted to NCH by

10% from a baseline average of 15.5 admissions/100 cohort

patients for Jul2011-Jun2012 to an average of 13.9

admissions/100 cohort patients for the 12 months ending

June 30th, 2015.

15.5

admissions/

100 cohort pts

12 month average through May 2014:

13.4 admissions/100 cohort patients

(13% ↓ from baseline)

13.9

admissions/100

cohort patient

(↓ 10% from

baseline)

Desired Direction of

Change

Care Coordination

Expanded

Med. Dir. of Comprehensive Health Care Service (CCHCS)

Starts


Formed


Team


9/6/2014 31

Process Measures

Meets Expectations Mitigation in Progress Requires Attention Not started

Program Aim for

June 30, 2015

Monthly Process

MeasureResults Goal Notes Status

Decrease by

10% NCH

inpatient

hospital days

per 10,000 PFK

member months

over a 12-month

period for tube-

fed children.

Cumulative

percent of

feeding-tube

patients in

the cohort

with

information

in the

Complex

Feeding

Smart Form

in EPIC

EPIC Complex

Feeding Form

Rollout

milestones:

• 10/1:

Available to

providers in

CP Clinic,

Complex Care

and IDF

• 11/1:

Available to

all providers

# of families

assessed for

tube feeding

competence

in the Family

Resource

Center

5 families

Complex Feeding Smart Form Usage in EPIC

0%

5%

10%

15%

20%

25%

30%

35%

40%

Oct

-13

No

v-1

3

De

c-1

3

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Cu

mu

lati

ve

% o

f P

atie

nts

in

th

e F

ee

din

g-T

ub

e C

oh

ort

wit

h In

fo

In S

mar

t Fo

rm S

ect

ion

/Fie

ld

Procedure Detail Section Care Team Section

Last Nutrition Assessment Field Weight at Goal Field


AIM #2: Provide Proactive Care Coordination for 85% of Tube-Fed Children with A Neurodevelopment Disorder

Initiatives:

Global Care Coordination with Complex Care Flag

Health Care Assessment Every 6 Months

Care Plan

Post Inpatient and ED Discharge Follow-Up

9/6/2014 32


9/6/2014 33

Program Aim for June 30, 2015 Baseline Results this Month Goal

Proactive Care Coordination will be provided for 85% of

children with a feeding tube and neurodevelopment

disorder(s).

0% May 2014: 55% 85%

Patients with A Feeding-Tube Dx/Px in Prior 12 Months and A Neuro Code As early as Jan 2010, Ages 0-18

Feb-14 Apr-14 May-14

Cohort N* 594 571 557

# Offered Care Coodination 263 273 306

# Discharged from Care Coordination 49

# Actively Enrolled 185

# Outreach but No Care Coordination 72

# No Care Coordination Activity 251

* Excludes deceased patients


AIM #3: Increase by 10% Annually, the Proportion of NCH Tube-Fed Children between 5th and 95th Percentile for Weight on Standard Growth Charts from Baseline

Initiatives:

Construction of the ‘Complex Feeding Smart Form’ in EPIC

Standardizing RD involvement for patients with a feeding tube

Complex Care App with Feeding Journal targeting patients with low weights

9/6/2014 34


9/6/2014 35

Program Aim for June 30, 2015 Baseline Results this Month Goal

Increase by 10% annually the proportion of NCH tube-fed

children between the 5th percentile and 95th percentile for

weight on standard growth charts.

59.5%

12 month average through May 2014: 63.4%

(0.2% chg from last month; 6.4% ↑ from baseline)

Month of May14: 63.5%/72.5% with Accept Wt Pts

79.2%

(↑ 33% from

baseline)

Care Coordination

Expanded

Med. Dir. of Comprehensive Health Care Service (CCHCS)

Starts


Formed


Team

Note: Beginning June 2012, the baseline shifted upward from 59.5% to 62%

*Number of patients who were in weight range PLUS patients out of weight range but with acceptable weights per dietician notes in Apex patient registry

or in EPIC Nutrition Smart Form

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Transition- Challenges

Ensuring Continuous health

coverage after age 19 (or 26).

Continue care management

Transfer to adult systems as

appropriate.

Staying on Medicaid (Ohio)

• On Waiver OR

• On SSI OR

• Income based

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Conclusions

An ACO is a workable model for organizing the care of children

with disabilities.

An ACO can improve care while reducing costs.

The Successful ACO requires:

• Close collaborations between physicians and organizations

• A family-centered approach to health care

• A vision that values outcomes over throughput

• A willingness to take financial risk

• A significant investment in data management

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Thank You!

[email protected]

Caring for Children with Disabilities: The View from ...Accountable Care Organizations (ACOs) are...

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