Care Integration and Network Models: How to Become a Player
Care Integration and Network Models: How to Become a Player Chris Palmieri, BS, MHA, President, VNSNY Health Plans Samuel Heller, BA, MBA, Senior Vice President, CFO, VNSNY July 29, 2013 Table of Contents I. II II. III. IV. V. VI. VNSNY: Who We Are The Changing Healthcare Landscape VNSNY CHOICE: Our Heath Plan What We Have Learned: Our Model of Care Market Opportunities: Moving Forward Our Vision For The Future 1 I. VNSNY: Who We Are The Visiting Nurse Service of New York VNSNY: Who We Are Lillian Wald • Founded in 1893 by Lillian D. Wald, VNSNY is the largest non-profit non profit community community-based based healthcare agency in the U.S. • Serves 33 counties in New York with its core market in the five boroughs of NYC • Continues to expand statewide • Provides a range of services to customers enterprise-wide enterprise wide, from newborns to seniors • 18,900 employees comprise our interprofessional team • Serve a socio-economically diverse population (28% speak a foreign language) 2 VNSNY Offers a Wide Range of Services & Integrates Care Across Settings Charitable Care Traditional Home Health Care Hospice & Palliative Care Private Pay Services Children & Family Services Congregate Care Health Plan Community Mental Health • MLTC • MA • HIV - SNP VNSNY Stands Apart from the Competition Mission People Quality Finance Growth Critical Differentiators Opportunities Scale Practice Model Advancement Management of Vulnerable Populations From Community Anchor to the C Suite Care Coordination / Interprofessional Team Administrative and Operational Simplicity and Nimbleness Product Line Diversification Migration to a best in class IT architecture Research Center Geographic Expansion 3 II. The Changing Healthcare Landscape The Healthcare World is in Flux & Change is Imminent Value-Based Purchasing Consolidation Declining Reimbursement Shared Risk More Patients at Risk Increased Competition Greater Application of Technology Health Reform (ACA) Evolving Models of Care Integrate Care for Duals CrossContinuum Partnerships 4 Prevalence of Chronic Illness in U.S. Population will Continue to Increase Populations with multiple chronic diseases have greater risk of disability and greater need for care coordination The Need for Superior Care Management and Care Coordination is Growing U.S. population is aging and chronic illness increases with age High prevalence of comorbidities among the elderly make care management particularly important for this group 5 Controlling Spending is Vital Other Health Care Spending 16.2% National Healthcare Expenditures 2012: 18% GDP = $3 Trillion Other Personal Health Care 12.7% ACOs Hospital Care 31.1% Home Health Care 2.6% Nursing Home Care 5.9% Prescription Drugs 10.1% Physician/ Clinical Services 21.4% The Affordable Care Act & The Triple Aim • Designed to be a collaborative process that focuses on receiving feedback from various stakeholders including payers, providers, and patients –Multi-year strategy designed to make sure the healthcare needs of States’ populations are met ACCESS Improve Health 1 Member satisfaction & improved patient outcomes COST Spend Less Interdisciplinary team approach Triple p Aim 2 3 QUALITY Improve Care Experience Reduction in Readmissions Leveraging Care Management to Balance the Triple Aim 6 III: VNSNY CHOICE: Our Health Plan Our Health Plan at a Glance Historical & Projected Membership (2011 – 2015) Current Future Footprint Currentand & Future Footprint 70 000 70,000 60,000 CT (Membership) 50,000 40,000 30 000 30,000 20,000 • New York: 62 Counties(1) 10,000 • New Jersey: 13 Counties(2) 0 '11 (1) (2) By Year-End 2013 By April 2014 Long Term Care '12 '13 Medicare Advantage '14 '15 Medicaid SNP 7 Why Should a Provider Also Be a Health Plan? • We are focused on vulnerable populations, those with Medicare and/or Medicaid, and special needs populations • VNSNY seeks to serve our patients because we have an opportunity t it to: t – – – – – Repair the fragmented care system Remove unnecessary utilization of services Better serve the poorest and sickest patients Improve consumer and family experiences Move furthest upstream • Opportunity to fill consumer niche as a low cost, high quality managed d care plan, l ffocusing i on th the medically di ll frail f il and d people l with ith limited income What We Offer… Managed Long Term Care (MLTC) - VNSNY CHOICE Managed Long Term Care Medicare Advantage (MA) - VNSNY CHOICE Medicare Maximum - VNSNY CHOICE Medicare Preferred - VNSNY CHOICE Medicare Enhanced Dual Eligible - VNSNY CHOICE Total HIV – SNP - VNSNY CHOICE SelectHealth - Fully Integrated Duals Advantage (Demonstration Project) 8 Expanding Our Product Base… State Demonstrations to Integrate Care for Dual Eligible Individuals • Fifteen states across the country were selected to design new approaches to better coordinate care for dual eligible individuals: – California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington, and Wisconsin • The Fully Integrated Duals Advantage (FIDA) program is a demonstration project in collaboration with NYS and CMS • Integrates all Medicare and Medicaid physical health, behavioral health, LTSS, and transportation services • A comprehensive benefit package that includes all Medicare and Medicaid medical, pharmacy, behavioral health, long term services and d other h supplemental l lb benefits. fi • A model of care that incorporates both CMS and State requirements • A comprehensive provider network that ensures access to Medicare and Medicaid services VNSNY Geographic Footprint: Committed to Regional Expansion Presently Operating in NYS Anticipated Approval in NJ in 2013 Further Expansion throughout NY, NJ, & CT in 2013 and 2014 9 Over 18,700 Providers in Our Network… • NY Counties: 62 • NJ Counties: 13 • Primary Care Physicians: 4,100+ • Specialists: 10,000+ • Hospitals: 70 • Nursing Homes: 55 • Pharmacies: 4,200+ • Labs: 301 19 VNSNY Revenue Is Shifting to Managed Care 2013 Expected 2012 2012 Hospice, 5% Hospice, 4% Home Care, 23% Home Care, 41% VNSNY CHOICE, 71% VNSNY CHOICE, 52% Private Care Care, 1% Private Care, 1% Family Care Services, 1% Family Care Services, 1% 10 VNSNY Revenue Drivers 2013 Changes in Rates Home Care CHHA Medicaid – No Trend Home Care CHHA Managed Care excluding CHOICE as a Payor – 2% increase All Programs Medicare Medicare Sequestration – (2%) reduction VNSNY CHOICE MLTC PMPM rate – (3%) reduction VNSNY CHOICE Medicare Advantage PMPM rate – 4% increase, despite (2%) drop in underlying benchmark VNSNY CHOICE HIV SNP PMPM rate – 6% increase VNSNY CHOICE Revenue Drivers Revenue(millions) Total DollarsTotal Revenue PMPM Revenue $1,600 $1,400 $1 400 $1,200 $1,000 $800 $600 $400 $200 $0 2012 Projected 2012 MLTC MA 2013 Budget Budget 2013 HIV-SNP Total MLTC: MA: HIV-SNP: 2012 2013 Budget A decrease of 3% in 2013 vs. 2012 An increase of 4% in 2013 vs. 2012 An increase of 6% in 2013 vs. 2012 11 VNSNY CHOICE Guiding Principles VNSNY CHOICE Health Plans: • Offer benefits that improve access to appropriate care, including assistance with navigating an increasingly complex health care system • Shift the focus of care from the institution to the home and community • Believe care coordination is the cornerstone of all plan options and all members are provided with a care manager that facilitates integration across all care settings • Target and customize interventions IV: What We Have Learned: Our Model of Care 12 Four Cornerstones of VNSNY Care Coordination Four Cornerstones of VNSNY Care Coordination: Person Centered • Holistic, integrative • Physical, Physical Emotional Emotional, Social, Spiritual • Personal goal-setting • Address psycho-social complications • Self-management a key objective • Personalized plan of care • Culturally congruent 13 Four Cornerstones of VNSNY Care Coordination: Evidence Based • Data collection and data mining • Timely and ongoing assessment • Protocols and best practices • Expected outcomes defined for each component of model • Center for Home Care Policy & Research • Proprietary Risk Stratification algorithm • Nurse Researcher Four Cornerstones of VNSNY Care Coordination: Mission Driven • History and legacy • Commitment to community • Where locus of care is shifting • Dedication to most vulnerable • Expertise in high risk populations • Safety S f net • Public policy leadership 14 Four Cornerstones of VNSNY Care Coordination: Nurse Led • Clinical expertise • Compassion + savvy • Embedded in community • Advocate • Integrator • Navigator The VNSNY Model of Care 15 The VNSNY Model of Care was Recently the Subject of a Case Study by the Respected Commonwealth Fund • • • • • • Integration of care across settings Bridging gaps between hospital and home Outcomes-driven Transitional Care protocol 54% reduction d ti iin h hospital it l admissions d i i 24% reduction in 30-day readmits 27% reduction in emergency visits Examples of The VNSNY Model of Care 16 The VNSNY Heart Failure Transitional Care Program: The VNSNY Heart Failure Transitional Care Program: Reduced 30-day hospital readmissions 43% 17 VNSNY CHOICE Medicare Advantage: VNSNY CHOICE Medicare Advantage: Reduced 30-day readmissions by 24% 18 VNSNY Strong Foundations™ Falls Prevention: VNSNY Strong Foundations™ Falls Prevention: Reduces falls and falls-related complications, hospitalizations and d ER visits i it 19 VNSNY CHOICE Managed Long Term Care: VNSNY CHOICE Managed Long Term Care: Keeps members living safely at home for over 5 years on average 20 VNSNY SPARK Palliative Care Program: VNSNY SPARK Palliative Care Program: Reduced inpatient admissions 39% among high-risk patients 21 VNSNY Behavioral Health Program: VNSNY Behavioral Health Program: Reduced depression 33% Improved functional ability 50% 22 These results are no accident. They are the outgrowth of a unique and comprehensive model of care. 23 An outcomes-driven approach to care coordination for vulnerable populations to enhance quality of care and reduce avoidable costs. An approach that is the product of our unique perspective as both a provider and a payer. 24 V: Market Opportunities: Moving Forward Care Coordination Population-based management RN HHA MD OT P ti t P Patient Population l ti PT Pharmacist SW 25 Innovative Models Health Homes Cost Quality Community Health Teams Hospital to Home 26 Payment Innovation Source: Remedy Partners Transitions of Care Patients C B O H Hospitals and S bA t Sub-Acute Facilities Home Care 27 Transitions of Care (Continued) TOC Team Health Information Technology Nurse Practitioner Insurance Case Managers g Patient Hospital Medical Staff Behavioral Health Plan a Notice of Admission 30 Day Transitional Care 7 Day Home Visit by LCSW Outreach to Hospital D/C Planner Inpatient Visit 28 Health Risk Assessments Appropriately tailored care plan, lower rates of disenrollment High risk (plan uses this to stratify membership, utilizes RN to coordinate care) Post-discharge transitional care Accountable Care Organizations High Cost Limited Access ACOs Patient Centered Care Coordination IT Accountability Primary Care Incentives Alignment Variable Quality Quality Outcomes Population Health Medical Home 29 Accountable Care Organizations (Continued) “Menu” of Opportunities Through Which to Interface With ACOs: Governance Community Health Outreach and Education Investor Primary Care Care Coordination p Hospice Nurse Practitioner Access Transitions of Care Homecare Health Promotion Health Information Exchange Menu of opportunities for HIE interface Care Coordination Screening Back Office MSO Chronic Disease Management Health Promotion Alternative Therapies Di Disease Prevention P i Mother h and d Child h ld Wellness Intervention Community Relationships 30 VI: Our Vision For the Future The Industry Needs to Align Health Plan, Provider, and Beneficiary Incentives… HEALTH PLAN • Accountabilityy • Reduced fragmentation • Coordination of care • Improve network access BENEFICIARY • Expense management • Value • Superior quality • Simplicity • Return on investment • Improved health outcomes – Positive patient experience PROVIDER – Navigation in increasingly complex system – Advocacy • Autonomy as a practitioner • Enhanced choice • Revenue maximization • Improve patient experience 31 Collaboration is Crucial • Partnering / Coordinating with other healthcare entities and systems is and will continue to be essential as changes are absorbed from the ACA and the industry transitions further to Managed Care Medicare Medicaid MLTC Managed C Care SNP FIDA Partnerships Are Key VNSNY Is Teaming Up With Other Providers and Payers to Improve Outcomes, Costs and Readmissions NYU Faculty Practice Home Visits Empire BlueCross Blue Shield / White Plains Hospital Transitional Care Mount Sinai Sternal Wounds Program NYU Langone Medical Center Bundled Payments 32 At VNSNY, We Will Continue to Convert Our Core Competencies into New Opportunities • Down the road… 9 Further integration of care systems for dual-eligible population 9 Well W ll positioned iti d ffor geographic hi expansion i 9 Leverages innovative practice design relationships with providers 9 Prepared for ACOs • Creation of a best-in-class care management organization… 9 Embrace a culture of collaboration and shared governance 9 Pioneer Pi new practice i models d l 9 Embed passion for improved quality and member satisfaction 9 Drive efficiency at all levels of care delivery and coordination 9 Ensure appropriate of care at all levels VNSNY Is Positioning Itself For The Future Vision Statement “Excelsior” Ever Upward VNSNY will become the most significant, best-in-class, nonprofit, community-based integrated delivery y p providing g superior p care system coordination and care management services to vulnerable populations across a broad regional footprint 33 Our Contact Information Chris Palmieri, BS, MHA, President, VNSNY Health Plans Phone: 212-609-5631 E-Mail: [email protected] Samuel Heller, BA, MBA, Senior Vice President, CFO,VNSNY Phone: 212-609-5701 E-Mail: [email protected] 34
© Copyright 2024