Managing ACO Populations Managing ACO Populations Across the Continuum

Fi i ll d Cli i llFinancially and ClinicallyDonna Medina MS, BSN,RN, CHA.

Objectivesj

Id tif th k t d t t f h t tiIdentify the key components and structure of each tactic

Identify the tactics feasible and appropriate for your organization

Identify barriers to success

Identify mitigation solutions for each barrier

Develop the framework for monitoring outcomes and success for each tactic

ACO Defined

Managing patients across continuum clinicallyManaging patients across continuum clinically

1. Beyond walls of facility

2. Engaging ambulatory and physicians

3. Engaging patientsg g g p

4. Maximizing reports through EMR

Managing patient costs across continuum

1. Physician offices

2. Home Health and Hospice

3. Nursing Homes

4 I th i h 4. In their own home

Needed Support Structurespp

Ministry Supportive Care Model

Must develop infrastructure first

1. Governing Board

2. Regional Committeesg

3. Operational Committees

4. Front line staff

Services within Supportive Care Services within Supportive Care

1. Care Decisions

2. Inpatient Palliative Care

3 Hospice3. Hospice

4. Outpatient Palliative Care

Care Decisions

B d L th G d Based program on Lutheran Gunderson program

More than 200 trained facilitators in all regions and facilities

Not about a signed document, it is all about the discussion

Have completed more than 22,000 since 2005

Target high risk, chronically ill, and over 60 years of age

Allocate resources/time

Computerized tracking/data entry

Access to documents in EMR

Approach for hospital, physician offices, and home care

Care Decision Impact Analysisp y

St ti ti ll d d i i i k h 49 th i bl t ll d Statistically reduces readmission risk when 49 other variables are controlled

Risk Total Enco nters

Readmits Expected Readmits

DifferenceEncounters Readmits

Low to medium low

899 33 33 0

Medium low to 895 37 59 22Medium low to Medium high

895 37 59 22

Medium high to high risk

320 21 37 16

Summary 2114 91 129 38

Inpatient Palliative Carep

St d di d b t i t h h it l i l ti d itStandardized, but unique to each hospital size, population, and community

Interdisciplinary approach

Achieving this outcome 80% of time

Improved clinical outcomes for pain, dyspnea, nausea and vomiting

Patients with Inpatient Palliative Care referral had decreased LOS by 2 days

Cost avoidance and opened beds for new admissions

Increased referrals to Hospice

These patients had longer hospice LOS

Better patient satisfaction

Ambulatory Palliative Carey

I iti l Pil t 2 • Initial Pilot 2 years ago

• Serious issues/challenges/failures

• New Pilot 2015 successful

• Implementation plan in development for 2016

• APN and interdisciplinary team driven

• Number was 128 patients from Inpatient Palliative Care

• 20% came into pilot

• Others went to hospice, lived outside geographic area, rehab, L tach, or died

• 56% of patients in pilot had multiple disciplines involved

OPC disciplinesp

APN 75 FTEAPN .75 FTE

MSW, Chaplain, RN, Aide, Care Manager combined to equal .4 FTE

Total cost for 3 months was $19,000

Time included 15 minute huddles 2-3 times per week (done with Lync), IDT, chart audits, scheduling/emails, coordination, travel time, telephone time, visits and charting

44% of these were medium risk and 56 % high risk patients44% of these were medium risk and 56 % high risk patients

33% had Care Decisions completed prior to their referral to Inpatient Palliative Care. 76% completed during their stay.

88% of them were Medicare or Medicaid

Out Patient Palliative Care

G l D h it l d i iGoals; Decrease hospital readmissions

Avoid ED visits

Pulled historical data for previous 12 months on these patients and compared it to their pilot data Avoided 13 ED visits during pilot and annualized would it to their pilot data. Avoided 13 ED visits during pilot and annualized would be 52 Ed visits.

Avoided 6 readmissions for pilot 3 months and annualized would be 24 readmissions.

Freed up 342 bed days for these readmissions avoided.

Avoided costs of $571,140.00 annually at a cost of $76,000 for OPC staff and freed these bed days for other paying patients.

One team can manage 267 patients per year.

Home Care Services

Home Health Initiatives:

1 Case Management Model1. Case Management Model

2. Nurse and buddy: case load of 25 and buddy 10

3. Continuity, care improvement.

Continuity increased from 3.5 or greater to 1.5y g

Nursing productivity improved, mileage increase of less than 1 mile per visit.

Satisfaction scores improved from less than 30 percentile ranking to above

80th percentile.

4. Physician relationship

5. Using data alerts to identify and transition patients form HH to hospice

Hospice Initiativesp

I f ti l i itInformational visits

EMR report identifying all potential HH patients with hospice diagnosis

Collaboration with HH

Identification with HH admission visit and transition

Successful transition of more than 450 patients from HH to hospice

96% of patients admitted day of referral

More than 250 community education events

SNF Practice for ACO patientsp

Ph i i d APN d iPhysician and APN driven

35% of discharges go to HH, Hospice or SNF

15.4% discharged to SNF

$13 million in claims of OSF ACO patients made to Preferred Network SNF

Preferred SNFs: 14 of current 18 used are preferred.

Criteria includes CMS Star rating, willingness to collaborate, accept patients 24/7 dit d d i i fi t d bilit ll di ti 24/7, expedited admission process, first dose capability, all medications within 3 hours of order, RN on site, offer therapy 6 days a week, all ACO OSF patients followed by OSF physician and services.

Why would they partner?

Preferred SNF Metrics

2013 2014 2015 2013 2014 2015

Average LOS 42 29 24

% ED visits 24% 23% 11%

% 30 day readmissions 33% 27% 19%

% flu shot 15.74% 53%

% HH/HO referral 62% 68%

% pneumonia vaccine 70% 81% 82%

Physician Practicey

E Ph i i Engage Physicians:

* Using ACO data

* Focused story telling

* Reducing their work load where possible

* Earning RVU for advance care planning and End of Life discussions

Medical Home

* Care Coordinators assigned to high risk patients

* Collaboration between entities, hand offs

Hospitalists

IMPACT of EMR

I f ti AInformation Access

Visibility across continuum

One medication record

OSF My Health Chart

Amazing reporting abilities and potential

Real time data

Ministry Wide Roundingy g

H it lHospitals

Ambulatory centers

Physician Offices

Home Health

Hospice

HME

HIP

Ministry wide, structure unique

Eating The Elephantg p

A lAnalyze

Identify Quick Wins

ROI

Prioritize

Long range Strategy

Barriers

O i ti l C ltOrganizational Culture

IC2IT

Beliefs:

1. Patient First

2. Be One

3. Align Priorities

4. Embrace Decisions

5. Be Accountable

6. Live It

CulturePyramid

Change experience to change belief to move to new actions and new outcomes outcomes.

Tools

Barriers ContinuedBarriers Continued

Ph i i E t Physician Engagement

Associated costs

ACO outmigration

Understanding and adoption of Cost avoidance benefit

Outcomes

C D i iCare Decisions

Cost avoidance

Reduction in re-admissions

Reduction in repeat ER visits

Reduction in inpatient mortality

Improved scores in CAPC and Press Ganey

Admitted to appropriate level of care

How Can I Help?p

D M M di MS BSN RN CHADonna M. Medina MS, BSN, RN, CHA.

donna.medina@osfhealthcare.org

(309) 683-7745