Realizing the Value of Annual Wellness Visits

Kyle Moore & Dan Hager

March 24, 2017

Speakers & Disclosure

The speakers have no actual or potential conflicts of interest in relation to this presentation.

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Dan Hager, MHA Program Manager, Physician & Ambulatory Services Bon Secours Health System, Inc. 1505 Marriottsville Road Marriottsville, MD 21104 Email: Daniel_Hager@bshsi.org LinkedIn: https://www.linkedin.com/in/daniel-hager-89300949/

Kyle P. Moore, CPA Vice President, Ambulatory & Home Care Bon Secours Health System, Inc. 1505 Marriottsville Road Marriottsville, MD 21104 Email: Kyle_Moore@bshsi.org LinkedIn: https://www.linkedin.com/in/kyle-moore-9b6b225/

Acknowledgments

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This presentation represents several years’ work led by a number of immensely talented leaders and their teams, including but not limited to: • Lani Alison, Director, Care Coordination & Outcomes (former)

• Dr. Tom Auer, CEO – BSMG in Richmond & Hampton Roads • Michelle Berkley-Brown, Director Ambulatory – Baltimore • Richard Green, Director, Revenue Cycle • Akbar Khan, VP Service Line Development • Dr. Andrea Mazzoccoli, SVP, CNO • Kyle Moore, VP Ambulatory & Home Care • Dr. Anselmo Nunez, CEO – BSMG in Greenville • Dr. Liana Orsolini, Care Delivery & Advanced Practice System Consultant • Ken Petronis, CEO, GoodHelp ACO • Dr. Martin Portillo, Director, Population Health • Dr. Marlon Priest, EVP, CMO • Dr. Patty Sengstack, CNIO • Deann Tate, Director, Coding Effectiveness • Tyler Walters, VP Physician Services – BSMG in Kentucky

Objectives

• Upon completion of this activity, participants should be able to:

– Understand how an integrated healthcare delivery system demonstrated the value of Annual Wellness Visits in improving preventive health screening and improve patient engagement and loyalty in the process

– Learn how a greater than 50% completion rate for Annual Wellness Visit was achieved

– Identify strategies and tactics for leveraging the AWV to achieve system goals and elite performance

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Bon Secours Health System, Inc.

5

NY

MD

VA

SC

FL

KY

Kentucky 1 Hospital, Home Health, 72 Provider Practice FTEs

Greenville 1 Hospital with 2 locations,

2 Outpatient Surgery Centers, Home Health,

294 Provider Practice FTEs

Baltimore 1 Hospital, 12 specialty and

outreach centers, 4 Provider Practice FTEs

New York Skilled Nursing, Assisted

Living, Home Health

St. Petersburg Skilled Nursing, Assisted Living, Home Health

Hospital or Skilled Nursing Practice Physician Practice Prior to 2010( =3 practices) Practices added since 2010 ( = 3 practices)

Roper St. Francis 3 Joint Ventured Hospitals,

150 physician partners

*Dots only represent current practices for Roper St. Francis Healthcare

Charity Minority partnership in 3 Hospitals,

2 Skilled Nursing Facilities, Home Health, Group Practice

Hampton Roads 3 Hospitals (+1 Joint Ventured),

Free-standing ED, 3 Surgery Centers, Home Health, Skilled

Nursing, Assisted Living, 162 Provider Practice FTEs

Richmond 5 Hospitals (+1 Joint Ventured),

Free-standing EDs, 2 Surgery Centers, Home Health,

312 Provider Practice FTEs

Bon Secours Health System, Inc.

Pursuing Clinical Transformation

7

Goals set on the Strategic Quality Plan (SQP).

Success monitored through our Board Summary Dashboard

AWVs completed (80% Medicare recipients, employees, and risk

contracted)

Board Summary

Dashboard Short-Term Board Approved Goals are basis of annual executive and

leadership incentive compensation program

9

LEGAL_BSHSI

Board Summary DashboardBon Secours Health System, Inc.

For The Five Months Ending January 31, 2017 Indicator Description Timing Comments

Short Term Board Approved

1 Hospital Acquired Infections - SIR ML Standardized Infection Ratio used by CMS for VBP

2 Mortality Index - Medicare VBP M3L Medicare Only, Diagnoses - AMI, HF, PNU, COPD

3 Patient Engagement - HCAHPS Overall % Top Box ML % of Top Box (9 or 10) on 0-10 ranking

4 Patient Engagement - HCAHPS Overall Percentile Ranking ML Percentile ranking associated with % Top Box

5 Pct Medicare Patients w Annual Wellness Screening M Based on ConnectCare practices only

6 Continuity of Care - % of MSSP Claims within BSHSI M3L % of MSSP Part A Claims Occurring at BSHSI Facilities

7 Readmission Index- Reform Subset, Medicare M3L Medicare population only

8 Depression Screening Rate M % of patients receiving PHQ-2 Screening and Follow-up

9 Total Cost per Case (without Physician Practices) M Targeting Budget; Stretch 0.5% < Budget

10 Adjusted Operating EBIDA M

Long Term Board Approved

11 CMS Star Ratings - % 4 or 5 M Currently includes Acute, HH, SNF

12 Operating Margin M

13 Total Operating Revenue M

14 Gallup Employee Engagement A Surveying Spring 2017

15 Gallup Employee Engagement - Inclusion Index A Surveying Spring 2017

16 Physician Engagement - Percentile Ranking A Surveying Summer 2017

17 Direct Dollars Community Benefits M

18 Mortality Index M3L All Payer, Excludes Hospice

19 Patient Engagement - IP HCAHPS Overall - ED ML % 9s or 10s in HCAHPS; IP admitted thru ED

20 Patient Engagement - Nursing Communication ML % Top Box responses for Nursing Communication

21 Patient Engagement - Doctor Communication ML % Top Box responses, Doctor Communication domain

22 Patient Engagement - Addressed Spiritual Needs ML

23 Patient Engagement - CG-CAHPS Overall Rating ML % 9 or 10 on overall provider rating

24 Patient Engagement - CG-CAHPS: Access ML % Top Box, Access Domain

25 Serious Safety Event Rate (SSER) ML

26 Days to Third Next Available Appointment M

27 MyChart Activation Rate M Enterprise Rate, % the same for all Markets

28 Primary Care Provider Growth M Results reflect MTD FTEs within Lawson

29 Unique Patients within BSMG Prior 18 Months M

30 ACO Quality Metrics - % of Points Available ML Points Earned based on ConnectCare (13 measures)

31 MSSP - Post Discharge Office Visits (7 Days, PCP) ML Patient must be seen in a BSHSI CC Hospital/Practice

32 MSSP SNF LOS M3L

33 MSSP SNF Preferred Network Utilization M3L

34 Home Health Acute Care Referral Capture Rate M % MSSP home health discharges to BSHSI HH

35 Advance Care Planning Notes Created for Target Population M

Board Approved Goals

Co-Create Healthy Communities

Be Person Centric

Building a High-Functioning Medical Group

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• Creating Common Culture

• Fostering the Partnership

• Formalizing Physician control

An Integrated Identity

• Extending Performance-Enhancing Tools

Infrastructure for Shared Success

• Leveraging Transparency

• Designing Strategy-Aligned Compensation

Individual Behavior Aligned

with Strategy

Source: Advisory Board

Medical Groups function differently than the old hierarchical approach to quality many hospitals took,

requiring a biologic approach to engage providers for self-directed change.

The core care capabilities required for successfully managing the health of populations are dramatically different than the historically inpatient-focused paradigm under which

many health system group practices were organized.

Care

•High quality, safe and reliable- all settings and Markets

•Proactive and preventative, targeted outreach on most at risk

Access

•Points of access to meet diverse needs and desires of population

•Clinical information transferred seamlessly between providers

Cost

•Care in the most appropriate setting

•Length of stay, level of care, and cost per case reduction strategies

•Reductions in unwanted variation

Managing the “white spaces” for triple aim success across the continuum requires a very different set of

expectations for many providers.

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Small-Group Interaction

• What is your organization’s strategy for quality improvement and the provision of preventive services specifically?

• What is the group practice’s role in setting and executing your quality strategy?

What is a Medicare Annual Wellness Visit?

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Only 42% of U.S. seniors report very good or excellent health.

Despite 94% having a dedicated provider, gaps still exist in key

preventive services and measures of wellness.

Source: America’s Health Rankings by United Health Foundation http://www.americashealthrankings.org/measures

The Health of U.S. Seniors

Medicare Annual Wellness Visits

• Beginning in 2011, Medicare covered an Annual Wellness Visit to develop or update a personalized prevention plan at no-cost to the beneficiary.

• The intent of this service is to remove barriers to Medicare beneficiaries receiving recommended preventive services to support a healthier life through disease prevention, early detection, and lifestyle modification.

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Medicare Wellness Visit Types

• Welcome to Medicare Visit – Previously known as an “IPPE” – Initial

Preventive Physical Exam; a misleading name, as it includes only vital signs and visual acuity

– Must be offered within 12 months of Medicare eligibility

• Annual Wellness Visits (AWV) – Initial Annual Wellness Visit

• 2nd year of Medicare eligibility (13-24 months)

– Subsequent Annual Wellness Visit

• 3rd year of Medicare eligibility and each additional year 25+ months)

Important Points • Not a “routine physical”

• Acute E/M service may be separately reported

• Patient may request a complete physical exam but are responsible for the full cost

Little Utilized Service

16

14.50%

17.70% 19.80%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Medicare Part B, Annual Wellness Visit Utilization 2014 - 2016

National Average (Medicare Part B)

“Be Person Centric” through Annual Wellness Visits

Desired Future Annual wellness visits completed (80% Medicare

recipients, employees and risk contracted)

Top decile achieved for ACO metrics, value-based reimbursement, mortality, and hospital-acquired

conditions

The AWV is a critical component of being

“Good Help”, delivering on our commitment to

Medicare, improving our quality, and

delivering on our SQP.

ACO Quality Metric

Falls Screening Influenza Immunization Pneumococcal Vaccination

BMI Screening/Follow-Up Tobacco Use/Cessation

Depression Screen

Colorectal Cancer Screen

Mammography Screen Blood Pressure Screen Hypertension, BP Control

IVD- Aspirin Use HF- Beta Blocker for LVSD

ACE/ARB for CAD and Diabetes and/or LVSD

With its impact on care coordination, safety and reliability, and engagement and loyalty, the Annual

Wellness Visit (AWV) is well situated to help facilitate BSHSI’s Clinical Transformation strategy.

Facilitating Clinical Transformation

Improving Annual Wellness Visit Rates

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Improving Medicare Annual Wellness Visit Rates

20

People • Measured Medicare

Annual Wellness Visit rate for Board reporting

• Included goal of 80% by 2018 in SQP

• Set goal for Short-Term Executive Incentive program and local provider compensation programs • FY16: 50% • FY17: 65%

• Heavily emphasized in annual coding effectiveness training

• Include in staff annual performance goals

Process • Designed and

implemented extensive communication activities • Employee

communications • Practice staff scripting

for in office and outreach

• Marketing materials

• Utilized system-wide forums to identify and disseminate local best practices

• Established practice “daily huddles”

• Included in PCMH and ACO activities

Technology • Created “SmartSet” in

ConnectCare (Epic EMR) addressing all statutory requirements of AWV and included in training

• AWV flags within EMR

Reporting Medicare Annual Wellness Visit Rates

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Medicare IPPE/AWS Analysis

YTD Report: September 2015 - January 2017

Local Market / Metric Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16

Baltimore: Number of Pts with IPPE/AWS (12 Months) 52 63 69 89 97 96 113 128 141 152 164 164

Baltimore: Number of Medicare Pts Seen by PCP 133 207 262 303 333 371 199 221 230 236 244 252

Baltimore: Pts with IPPE/AWS / Medicare Pts Seen 39.10% 30.43% 26.34% 29.37% 29.13% 25.88% 56.78% 57.92% 61.30% 64.41% 67.21% 65.08%

Charity: Number of Pts with IPPE/AWS (12 Months) 1,086 2,189 3,016 3,646 4,048 4,378 4,580 4,794 5,125 5,375 5,608 5,863

Charity: Number of Medicare Pts Seen by PCP 2,232 4,275 5,775 6,977 7,759 8,359 9,067 9,761 10,308 10,775 11,144 11,522

Charity: Pts with IPPE/AWS / Medicare Pts Seen 48.66% 51.20% 52.23% 52.26% 52.17% 52.37% 50.51% 49.11% 49.72% 49.88% 50.32% 50.89%

Hampton Roads: Number of Pts with IPPE/AWS (12 Months) 2,004 3,697 5,007 6,006 6,921 7,713 8,207 8,612 9,027 9,397 9,517 9,676

Hampton Roads: Number of Medicare Pts Seen by PCP 4,213 7,399 9,513 10,922 12,035 12,929 13,538 14,012 14,436 14,836 15,206 15,552

Hampton Roads: Pts with IPPE/AWS / Medicare Pts Seen 47.57% 49.97% 52.63% 54.99% 57.51% 59.66% 60.62% 61.46% 62.53% 63.34% 62.59% 62.22%

Richmond: Number of Pts with IPPE/AWS (12 Months) 3,598 6,752 9,314 11,463 12,974 14,523 15,728 16,913 18,191 19,413 20,410 22,067

Richmond: Number of Medicare Pts Seen by PCP 9,367 16,733 23,681 27,824 30,685 33,417 32,734 34,138 35,361 36,402 37,578 39,470

Richmond: Pts with IPPE/AWS / Medicare Pts Seen 38.41% 40.35% 39.33% 41.20% 42.28% 43.46% 48.05% 49.54% 51.44% 53.33% 54.31% 55.91%

BSV Rollup: Number of Pts with IPPE/AWS (12 Months) 5,602 10,449 14,321 17,469 19,895 22,236 23,935 25,525 27,218 28,810 29,927 31,743

BSV Rollup: Number of Medicare Pts Seen by PCP 13,580 24,132 33,194 38,746 42,720 46,346 46,272 48,150 49,797 51,238 52,784 55,022

BSV Rollup: Pts with IPPE/AWS / Medicare Pts Seen 41.25% 43.30% 43.14% 45.09% 46.57% 47.98% 51.73% 53.01% 54.66% 56.23% 56.70% 57.69%

Kentucky: Number of Pts with IPPE/AWS (12 Months) 1,046 1,748 2,363 2,779 3,132 3,532 3,836 4,009 4,191 4,259 4,274 4,268

Kentucky: Number of Medicare Pts Seen by PCP 2,338 4,102 5,403 6,287 6,851 7,330 7,716 7,968 8,186 8,389 8,550 8,693

Kentucky: Pts with IPPE/AWS / Medicare Pts Seen 44.74% 42.61% 43.73% 44.20% 45.72% 48.19% 49.71% 50.31% 51.20% 50.77% 49.99% 49.10%

South Carolina: Number of Pts with IPPE/AWS (12 Months) 1,835 3,475 4,819 5,970 7,015 8,261 9,605 11,433 13,332 14,864 16,161 17,550

South Carolina: Number of Medicare Pts Seen by PCP 8,801 15,476 19,972 23,271 26,196 28,178 29,460 30,475 31,276 32,012 32,669 33,379

South Carolina: Pts with IPPE/AWS / Medicare Pts Seen 20.85% 22.45% 24.13% 25.65% 26.78% 29.32% 32.60% 37.52% 42.63% 46.43% 49.47% 52.58%

BSHSI: Number of Pts with IPPE/AWS (12 Months) 8,535 15,735 21,572 26,307 30,139 34,125 37,489 41,095 44,882 48,085 50,526 53,725

BSHSI: Number of Medicare Pts Seen by PCP 24,852 43,917 58,831 68,607 76,100 82,225 83,647 86,814 89,489 91,875 94,247 97,346

BSHSI: Pts with IPPE/AWS / Medicare Pts Seen 34.34% 35.83% 36.67% 38.34% 39.60% 41.50% 44.82% 47.34% 50.15% 52.34% 53.61% 55.19%

Source: COCOA (ConnectCare)

Excluding Charity E

Established reporting at the system and local market level…

Local Market VISIT_LOCATION

# of Unique

Medicare Pts Seen

in PCP Office (Sept

1, 2016-Jan 31,

2017)

# of Patients

From PCP OV List

With AWV (Feb.

1, 2016-Jan. 31,

2017) AWV Rate

Baltimore Bon Secours Family Health and Wellness 174 118 68%

Baltimore Family Health and Wellness at New Hope 5 3 60%

Hampton Roads AIRLINE MEDICAL ASSOCIATES 177 107 60%

Hampton Roads AMELIA MEDICAL ASSOCIATES 686 481 70%

Hampton Roads Bon Secours Grassfield Medical Associates 123 72 59%

Hampton Roads Bon Secours Greenbrier Medical Associates 161 95 59%

Hampton Roads BON SECOURS INTERNAL MEDICINE OF PORTSMOUTH 1241 787 63%

Hampton Roads BON SECOURS MEDICAL ASSOCIATES 1853 1377 74%

Hampton Roads Bon Secours Monarch Medical Associates 122 70 57%

Hampton Roads Bon Secours Suffolk Medical Associates 132 76 58%

Hampton Roads Bon Secours Town Center Medical Associates 422 199 47%

Hampton Roads DePaul Medical Associates MOB 957 726 76%

Hampton Roads EAGLE HARBOR MEDICAL ASSOCIATES 194 127 65%

Hampton Roads EAST BEACH MEDICAL ASSOCIATES 487 383 79%

…followed by the practice and provider

level.

Promoting Medicare Annual Wellness Visits

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Developed and deployed print and electronic

communication pieces across

BSHSI practices, websites, and patient portal

(MyChart)

Patient Brochure, 2014

Poster, 2014

MyChart Homepage, 2014

Promoting Medicare Annual Wellness Visits

Developed workflow and scripting for

outreach to patients in and out of the

office.

23

Medicare Annual Wellness Visits: BSHSI Performance

24

103 IP 14 Births

26.21%

32.42%

55.19%

50.00%

14.50%

17.70%

19.80%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Bon Secours Health System, Inc. Annual Wellness Visit Performance - FY2015 & FY2016

BSHSI: Pts with IPPE/AWS / Medicare Pts Seen BSHSI FY16 Target National Average (Medicare Part B)

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Small-Group Interaction

• Do your primary care providers regularly provide Annual Wellness Visits?

– If so, why did your group practice focus on them and how did you implement?

– If not, why not? What are the major barriers you have experienced?

Improving Engagement, Loyalty, & Quality through the Annual Wellness Visit

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Engagement & Loyalty: Widening “The Funnel” with AWVs

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3,200 Physician Office &

500 TeleHealth Visits

(43% ED visits used imaging)

320 Hospital

OPD visits

117 Ambulatory

surgeries

(67 Hospital

based)

(50 ASC

based)

420 Hospital ED visits

1,000 Population

103 IP 14 Births

AWVs present a unique opportunity to drive engagement and loyalty, as we build

relationships with our patients and communities.

Time Frame: Calendar Year 2015 Data Source: Meaningful Use Quality Measures - ConnectCare

Of the eligible patients for each measure in our Meaningful Use

Quality Measures, how many were seniors who also had an

AWV?

Title Total %

Breast Cancer Screening 57.95%

Colorectal Cancer Screening 33.81%

Pneumonia Vaccination Status for Older

Adults 54.89%

Preventive Care and Screening: Influenza

Immunization 57.86%

How have we impacted the preventive care of our patients through completion of AWVs?

AWVs & Quality Performance

AWVs & Quality Performance

While the causal relationship is unclear, there is a significant difference in quality measures

performance between those without and those with an AWV.

Total – 66 & Up

Total

Eligible % Met

Breast Cancer Screening 33035 67.2%

Colorectal Cancer

Screening 122793 40.5%

Pneumonia Vaccination 215999 60.3%

Influenza Immunization 97652 93.4%*

AWV – 66 & Up

Measure

Met

Measure

Not Met

AWV - %

Met

6876 877 88.7%

18327 8932 67.2%

39438 7234 84.5%

26685 854 96.9%*

No AWV – 66 & Up

Measure

Met

Measure

Not Met

No AWV

- % Met

15317 9965 60.6%

31376 64158 32.8%

90713 78614 53.6%

64492 5621 92.0%*

Time Frame: Calendar Year 2015 Data Source: Meaningful Use Quality Measures - ConnectCare *Influenza immunization rate includes patient declinations.

Closing the Gap No AWV - % Met AWV - % Met

CMS ACO

Benchmark

Breast Cancer

Screening 60.6% 88.7% 90%

Colorectal Cancer

Screening 32.8% 67.2% 90%

Pneumonia Vaccination

Status for Older Adults 53.6% 84.5% 90%

Influenza Immunization 92.0%* 96.9%* 90%

Two-Fold Opportunity:

Improve rates of AWVs completed

Achieve elite performance through post-AWV LPOC

Increase AWVs Longitudinal Plan of Care

Time Frame: Calendar Year 2015 Data Source: Meaningful Use Quality Measures - ConnectCare *Influenza immunization rate includes patient declinations.

Longitudinal Plan of Care (LPOC)

LPOC Criteria • Health Risk assessment

• List of current providers and prescriptions

• Advanced Care Planning

• Review of medical/family history

• Height, weight, blood pressure, etc.

• Cognitive impairment

• Personalized health advice

• Risk factors and treatment options

• Preventive services schedule

• Goal setting, tracking, and mediation

• Self management/personal prevention plan

• Referral initiation, communication, and tracking

• Discharge summary

• Laboratory/test tracking

• Care coordination documentation

Pulls patient care management

information across care settings into

Snapshot and Summary report

activities in the EMR to support improved care coordination. Extends the “prevention plan

of care” from the AWV across the continuum.

Longitudinal Plan of Care Launched 2016

Clinical Excellence as One Bon Secours

Medical Group

AWV

Safety & Reliability

Care Coordination

Obtain appropriate reimbursement for

tobacco cessation and depression screening

Obtain appropriate reimbursement for

TCM and ACP

The AWV is core to our strategies for achieving clinical excellence in the BSMG.

Improve ACO Quality Measures

Performance

Improve transitional care management and advance care

planning

Achieving Clinical Excellence

33

Small-Group Interaction

• What focus, if any, does your organization have on delivery of preventive services?

– What approaches have you found successful?

– What barriers have you encountered?

– What has been the benefit to your patients and to your organization?

• What other strategies and tactics have you utilized to improve engagement, loyalty, and quality in your group practice?

Next Steps & Tying It All Together

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Next Steps: Outreach & Access

• How can we leverage technological and other solutions to drive protocol-based outreach to patients for completing their Annual Wellness Visits (e.g. text message, patient portal)?

• As we increase our goals for Medicare Annual Wellness Visits rates, how do we manage overall access to our primary care network?

• How can we align the infrastructure driving this initiative to reach other populations as clinically appropriate ?

35

Next Steps: Comprehensively Engaging Our Providers & Patients

Launch of Provider Dashboard, including performance rate

and 2-click drilldown to list of patients missing an Annual

Wellness Visit

36

The Ambulatory Four Quadrant Dashboard brings together a provider’s Clinical Quality, Patient Access, Patient Experience, and Population Health Cost performance on a single actionable tool

within the ConnectCare (Epic) EMR.

Holistically asking ourselves, “How are we…

• Growing primary care

• Driving preventive services for all populations

• Using MyChart

• Promoting Continuity of Care

…to drive patient engagement and earn patient loyalty?”

Tying It All Together

37

Bon Secours’ strategic focus on Annual Wellness Visits has resulted in

numerous benefits.

For our patients & communities • Improved quality of care • Access to full range of

offerings to manage health (e.g. MyChart, ACO resources)

• Full value of preventive services available to them

For our payor (CMS) • Improved preventive services

delivery and associated benefits

• Higher utilization of a strategically prioritized service

For our providers • Improved quality of care • Personal satisfaction • Performance enhancing tools • Financial benefit

For our health system • Improved quality of care • Patient and revenue growth • Acceleration to culturally

operating as “One Bon Secours”

38

Full Group Interaction

• What is one thing you will take back to your organization after today’s session?