Community Care Linkages SM

A Division of Mass Home Care

September 11, 2012

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Mass Home Care’s2012 Network Conference

Topics

Implementation of ACA – New Models of Care and Payment Reform

Community Care Linkages Year 2 The COMMUNITY LIVING Program Next Steps

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Acute Health Care System 1.0

Acute Health Care System 1.0

Health Care Delivery System Transformation

Community Integrated Health Care System 3.0

Community Integrated Health Care System 3.0

Coordinated Seamless Health Care System 2.0

Coordinated Seamless Health Care System 2.0

• High quality acute care

• Accountable care systems

• Shared financial risk

• Case management and preventive care systems

• Population-based quality and cost performance

Population-based health outcomes

Care system integration with community health resources

Innovation Center Portfolio

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Health Care’s BLIND SIDEThe Overlooked Connection between

Social Needs and Good Health 85% physicians surveyed say unmet social needs are directly 

leading to worse health. 85% physicians surveyed say patients’ needs are as important 

to address as their medical conditions. – Especially true (more than 9 in 10, or 95%) for patients in low-income, 

urban communities. 

76% would like the health care system to cover the costs associated with connecting patients to services that meet their social needs; and

80% are not confident in their capacity to address their patients' social needs.

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Robert Wood Johnson Foundation summary reviews key findings from an online survey of 1,000 American physicians in the American Medical Masterfile who agreed to be invited to participate in the survey. The participation rate was 5 percent (1,000 physicians completed the survey out of 20,000 invited to participate); 690 were primary care physicians and 310 were pediatricians.

Health Care’s BLIND SIDE Con’t• Top social needs they would write a prescription for include:– Fitness program 75%– Nutritional food 64%– Transportation assistance 47%

• For patients in mostly urban and low-income communities– Employment assistance 52%– Adult education 49%– Housing assistance 43%

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http://community.rwjf.org/community/healthcaresblindside

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Bridging medical care and long term services and supports (LTSS) is a critical component tomeeting the needs of individuals with chronic conditions and functional limitations, and improving system outcomes. Riskbearing entities present a unique avenue to pursue this integrated vision.

Aging Network – An Infrastructure that Supports 11 Million Older Adults and Caregivers

AoA56 State Units on Aging629 Area Agencies

246 Tribal organization

242 million meals 

20,000 Service Providers  & 500,000 Volunteers

28              million rides

29 million  hours of 

personal  care

69,000    caregivers trained 855,000 assisted

4 million hours of case 

management

0ver  22,000 individuals transitioned

81,759 individuals completing  CDSMP

Provides Services & Supports to 1 in 5 Seniors 

Getting to: 

High quality acute careAccountable care systemsShared financial riskCase management and preventive care systems

Population-based quality and cost performance

Population-based health outcomesCare system integration with community health resources

ASAP Strategy: Link Primary Care to Community Home Care Services

Achieve triple aim objectives by linking primary care practices to community care management services – Reduce costs through prevention 

and/or reduction of unnecessary utilization of health care services

– Improve health outcomes through better care coordination and patient education

– Improve patient experience and satisfaction by aligning with goal of remaining functionally active at home 

Community Care Linkages SM

A Division of Mass Home Care 9

Community Integrated Health Care System 3.0

Community Integrated Health Care System 3.0

Pioneer ACOsCMMI selected 32 in US, 5 in MA:1. Atrius Health2. Beth Israel Deaconess 

Physician Organization3. Mount Auburn 

Cambridge Independent Practice Association (MACIPA)

4. Partners Healthcare5. Steward Health Care 

System

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Experienced in coordinating care across all care settings

Allow rapid movement from a shared savings payment model to a population-based model

Separate track from Medicare Shared Savings Program

Coordinated with private payers to align provider incentive to achieve triple aim

Medicare Shared Savings/ Advanced Payment ACOs

Jordan Community ACO, Plymouth• 100+ physicians from Plymouth Bay 

Medical Associates, Jordan Physician Associates, and a number of specialty physicians from Jordan Hospital to coordinate the healthcare of 6,000 Medicare beneficiaries in Plymouth and Barnstable Counties.

Physicians of Cape Cod ACO• Physicians of Cape Cod ACO to serve 

approximately 5,000 beneficiaries living in Cape Cod, Massachusetts.

Harbor Medical Associates PC, South Weymouth

• ACO group practices, with 116 physicians, to serve Medicare beneficiaries in Massachusetts.

Circle Health Alliance, LLC , Lowell• Comprised of partnerships between 

hospitals and ACO professionals, with 353 physicians.  It will serve Medicare beneficiaries in Massachusetts and New Hampshire.

Coastal Medical, Inc. (Providence, RI) 

• ACO group practices, with 100 physicians to serve Medicare beneficiaries in Massachusetts and Rhode Island

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Integrated Care Entities (ICOs)for Dual Eligibles

Primary Care

Primary care and behavioral health will be integrated

All members will choose a provider Primary care providers may be at 

varying levels of capability to perform as person-centered medical homes (PCMHs); ICOs are ultimately accountable for all care, and must support primary care providers to become medical homes and/or Health Homes 

Independent LTSS Coordinator

ICO will be required to contract with community-based organizations to provide independent LTSS Coordinators

LTSS Coordinator must have no financial interest in the determination of an enrollee’s type or amount of services

LTSS Coordinator is a member of the care team, at the enrollee’s discretion

After initial assessment, if enrollee has specific needs outside the designated LTSS Coordinator’s expertise, ICO will arrange for assignment of a more appropriate LTSS Coordinator

LTSS Coordinator will work with enrollee to incorporate community-based services as appropriate into care plan 12

Community Care Linkages

Who are the MA ASAPs?– 27 Not-for-Profit Organizations – A 35 year old statewide network linking community resources to individuals and their families

– Managing 70,000 covered lives annually in home care programs (~$340m of services across MA)

– Bring value to evolving community based health care systems. 

13www.Communitycarelinkages.orgwww.masshomecare.org www.Communitycarelinkages.orgwww.masshomecare.org 

Community Care Linkages is a strategic initiative to effectively integrate  services of the Massachusetts Aging Services Access Points (ASAPs) into the evolving healthcare delivery system. 

Community Care Linkages SM

A Division of Mass Home Care

MEMBER-CENTERED LONG TERM SERVICES & SUPPORTS FOR DUAL ELIGIBLES

The COMMUNITY LIVING Program

– Statewide network– Successful partnering with community agencies and medical providers

• ILCs, ADRCs, SCOs, ACOs

– Key Services• Initial Assessment• Basic Coordination• Complex Care Coordination• RN Assessments• Network Management• Evidenced-Based Healthy Living Programs

A Mass Home Care Initiative for Integrated Care Organizations

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Community-based Care Transitions Program (CCTP)

1. Elder Services of Berkshire County– Berkshire Medical Center and 

the Berkshire Visiting Nurse Association

2. Elder Services of Worcester & BayPath Elder Services– MetroWest Medical Center; St. 

Vincent Hospital; UMass Memorial Medical Center; Wing Memorial Hospital; Marlborough Hospital; Clinton Hospital, and HealthAlliance Hospital

3. Somerville-Cambridge Elder Services & Mystic Valley Elder Services– Cambridge Health Alliance and 

Hallmark Health System

4. Merrimack Valley of Massachusetts and Southern New Hampshire Elder Services– Anna Jacques Hospital, Saints 

Medical Center, Holy Family Hospital, Lawrence General Hospital, and Merrimack Valley Hospital

15http://innovation.cms.gov/initiatives/Partnership-for-Patients/CCTP/partners.html

47 partners announced in three rounds, 4 in Massachusetts

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FY11 ASAP Spending ~$340m

On Behalf of MA Executive Office of Elder Affairs

2011 People Served Statewide

55,800 Clinical Assessment & Evaluation

66,200 Home Care/Respite Care, Enhanced Community Options & CM, Community Choices & CM

18,282 Protective Services reports

Many Partnering Initiatives UnderwaySelected Partners

Hospitals:• Baystate Health System • Berkshire Medical Center• BIDMC• Brockton• Cambridge• Cooley Dickinson• Emerson Hospital• Health Alliance• Gardner• Lahey Clinic• Milford Regional • Partners Healthcare• Northeast Health System• Steward Norwood 

Hospital• Tufts Medical Center• UMass Medical Center• Vanguard Health Systems• Winchester 

ActivitiesServices:• Dedicated Link• CTI/Enhanced Coleman • Community Liaison• On-site Options Counseling

Meetings:• Inpatient interdisciplinary 

team• STAAR Teams• PCMH Multi Payer Initiative• Continuum of Care Quality 

Assurance Initiative• Emergency Dept.• CMS CMP• Community Connections 

Group

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Physicians:• Acton Medical• Atrius Health• Family Practice Group• HCA  (BIDMC)• Lahey Medical Group• Meeting House Family 

Practice• The Medical Group• Somerville Primary 

Care

Hospital/ASAP Collaboration

“Emerson Hospital and Minuteman Senior Services have banded together with the goal of preventing unnecessary repeat hospital stays.”

Atrius Health/ASAPs Practice-Based Pilots

1. Chelmsford & Elder Services of Merrimack Valley

2. Peabody & North Shore Elder Services

3. Southboro & Baypath4. West Roxbury & Ethos5. Concord & Minuteman 

Senior Services6. Watertown & SpringwellCurrently expanding to new sites

Community Care Linkages SM

A Division of Mass Home Care

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Atrius Health 100% on an electronic medical record 

combined with corporate data warehouse, used for managing quality and cost. 

Long history with global payments: greater than 50% of patients under global risk across Commercial, Medicare and Medicaid

Widespread use of rosters in population management

Track record of quality measurement and reporting

Over 30 NCQA certified Level 3 Patient-Centered Medical Homes

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Why Pioneer? “Reason for Action”

Participating in the Pioneer ACO will help Atrius Health achieve high-quality, high-value care for all Medicare-eligible patients across the care continuum.  

Successful implementation for Medicare-eligibles will improve performance for commercial risk patients with similar clinical needs.

Access to full claims data set for Pioneer population offers true opportunity to be accountable for quality and cost across the continuum. 

Contracting for Medicare Fee for Service patients under a global budget through Pioneer ACO maintains our position as a market leader in payment reform, moving towards 100% global payment.

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Atrius Health – ASAP Collaboration Expansion of the “Care Team” to include the patient’s home and 

community-based networks

Requires: effective communication for timely and efficient referrals, hand offs, and “closing the loop”

Results in: patient centered care plans with realistic goals and resources for implementation

Collaboration through: Practice-based Pilots Population-based Interventions

Community Care Linkages SM

A Division of Mass Home Care22

Atrius Health – ASAP Practice-based Pilot

Practice referral to ASAP with brief description of patient/needs

Referral form completed and faxed along with the problem list, medication list and the latest office visit

ASAP contacts the patient and arrange an intake interview, updating practice on barriers and services recommended 

ASAP provides services, closes the loop with practice via phone call

Practice documents care coordination note and routes to PCP pool.  Epic flag notes patient receiving care from ASAP.

23Community Care Linkages SM

A Division of Mass Home Care

Population-Based Intervention:Falls Risk Assessment

Identify population appropriate for home-based FRA

Develop standard work for non-medical ASAP intervention (population based, rather than practice or ASAP dependent)

Develop data capture in Epic to meet Pioneer quality measure

24Community Care Linkages SM

A Division of Mass Home Care

Current ASAP/ACO Contracts

Atrius Health/Southboro Medical Group (SMG) & BayPath for “Community Social Services”

– Social Worker from BayPath to support SMG 24 hours per week– Access to SMG EpicCare (EHR)– Provide general community social services– Participate in case management, quality assurance and quality improvement, 

utilization review and peer review activities– Metrics:

• Number of patients referred• Number of ED admissions• Number of hospital readmissions• Pre- and post-intervention costs • Number of cases on-going• Number of resistant patients referred – must define non-compliant

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Current ASAP/ACO Contracts

Beth Israel Deaconess Physician Organization (BIDPO)/ Springwell for “Community Care Linkages”

– a Springwell-employed Community Resource Coordinator (CRC) to work on site at BIDPO’s office located in Westwood, MA, 3 days per week

– identify the most affordable community resource options available to meet the identified needs of any referred Patient regardless of age or ASAP eligibility

– educate the BIDPO’s CNCMs and other staff as to range of  community resources available, including the abilities of ASAPs, so that CNCMs are fully aware of potential supports available to Patients

– identify ASAP clients receiving services by any of the 27 ASAPs in MA and work with BIDPO staff to identify additional services that may be helpful to Patients who are receiving services from a Massachusetts ASAP

– establish a community resources catalogue or reference library– participate with BIDPO staff in case conferences – Options Counseling visits

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“one woman I&R

department”

“one woman I&R

department”

Next Steps

• Expand partnering opportunities• Share learnings from 4 Care Transitions (CCTP) projects• Prepare for ICO LTSS coordination opportunity• Develop “The COMMUNITY LIVING Program” for all providers/payers 

• Successfully contract with healthcare providers and payers under new health reform models 

• Continue to share best practices and support ASAP collaborative efforts

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