1. health and fitness

5/28/2014
The Current Environment Requires
Progress On All Four Simultaneously!
2014 TransforMED
Bruce Bagley, MD
President and CEO
TransforMED
 Brief
environmental scan
 Triple
AIM?...key
T i l AIM?
k elements
l
t
 Why the “Plus One?”
 How do we get there?
 What will be the advantage for us?
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“The Problem”
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People/Organizations/Integration/Work
gy and Connectedness
Technology
Patient Engagement and Self-management Support
Payment Reform and Incentives
Community Involvement in design and execution of new
models of care
Patient Centered Medical Home
Medical Neighborhood
Accountable Care Organizations
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1. The current path of medical cost growth and societal
expenditure is not sustainable
2. How providers are paid makes a difference
3. Fee for service payment is one of the root causes of the
problem and most now realize it must go
4. Clinical, financial and information technology integration
is essential for efficiency
5. Value based purchasing requires performance data on
metrics for service, cost and clinical quality
6. Distribution of resources will mirror value contribution
2014 TransforMED
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More emphasis on wellness and prevention
p
y of care
The importance
of the community
Access redefined as addressing patient’s needs when
and where they have the need rather than a
conversation about appointment availability
Strategic distribution of the work (team care)
Consolidation, integration and market forces for greater
efficiency and effectiveness
Many practices and systems are already successful in
making transformational change
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Health care providers will work together with a true team
approach and a focus on the best results for patients
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They will work in organizations that provide the required
infrastructure support for optimal outcomes for patients
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Integration, coordinated care and seamless transitions
from one point of care to another will be the norm
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There needs to be a strategic distribution of the work
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We must apply the great technology we already enjoy in our
everyday lives to health care delivery
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Knowledge management, communication and information
exchange
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Electronic health records
Patient portals
Community wide Health Information Exchange (HIE)
Email with patients and e-visits
Video visits
Systems for tracking, care management
and care coordination
 Registries (chronic illness care, high risk
patients, preventive services etc.)
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Gretchen Hoyle, MD, Twin City Pediatrics, Winston‐Salem, NC
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Eliminate “non-compliant patient” from our vocabulary
y
g
g g
Patient/Family/Caregiver
engagement
Patient Self-management Support
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Patient activation
Motivational interviewing
Health coaching
Shared goal setting
Informed Medical Decision Making
g
Home monitoring and between visit contact
Care coordination across the medical neighborhood
Home care as needed
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Better individual care
 Quality of care-clinical performance measures
 Satisfaction with the experience of care
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Better population health
 Defined population within the practice
 Ability to aggregate individuals for quality assessment
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Lower per capita cost of care
 Total cost of care on a PMPM basis
 Proxies such as ER utilization, bed days/1000, ALOS
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“The Happy Triple Aim”
 Providers need support and systems to help them provide
excellent care to individuals and populations
 They must feel that their work is helping patients and they
are not doing things that matter less.
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Staff satisfaction
 Rewarding and meaningful work that is valued
 Sense of team and contribution by all
 Positive work environment
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Quality of care delivered as measured by the available
clinical performance measures (starting place)
Systems, protocols, reminders, registries, home
monitoring and between visit follow up are necessary to
do this well (required processes and infrastructure)
Care management and care coordination, ideally risk
stratified by need and complexity (pro-active approach)
Patient self-management
support
to assist them in
g
pp
managing chronic conditions in their daily lives
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Service orientation to build patient trust and loyalty
Patient/familyy and care g
giver engagement
in helping
g g
p g to
manage chronic conditions
Access, broadly defined as the ability for patients to get
what they need, when they need it without barriers, waits
and delays
Input from patients to help define and redesign what
g
yp
great service looks like (p
(patient advisory
panels))
Patient satisfaction surveys to identify opportunities for
improvement
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“Population management” of a sub-group of patients in
the practice vs. the health of the community
Required
the quality
thatt
R
i d tto assess th
lit off care delivered
d li
d tto th
sub-group of patients (“N of 1” vs. valid assessment of
systems and approach)
Allows evaluation of systems for performance and
outcomes for patients
Provides useful information for comparison data and
identification of optimal performance (best practices)
Requires processes and systems such as registries,
out-reach, between visit follow up and active care
management
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Reduce waste by eliminating tests and treatments that
add no benefit to patients or have no chance of
improving the outcomes of their care
Pro-active care management and care coordination in
the medical neighborhood
Conversations and service agreements among
providers to build a shared sense of responsibility for
service, cost and quality
Alignment, simplification and integration of finances,
clinical quality and information technology
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Better individual health
 Clinical performance measures based on EBM (IHA)
 Satisfaction surveys, retention, loyalty
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Better population health
 Aggregate of clinical performance measures for the subgroup that defines the population
 Must have levels, trends and comparison data
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Lower per capita cost of care
 Total cost of care calculated on a PMPM basis
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Better individual health
 Registries, protocols, reminders and pro-active outreach
 People and training to do patient engagement, selfmanagement support, care coordination etc.
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Better population health
 Disease registries, ability to analyze data in “near real time”
 Quality improvement strategy
 Comparison data and awareness of optimal performance
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Lower per capita costs
 Must have reliable cost data from payers for all care in the
community (at least a valid sample)
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Increasing quality and cost transparency will allow
much better assessment of relative performance on the
Triple Aim
Even before you have “all the numbers” there are some
systems that are known to work better for patients and
should be installed
Payers must begin to recognize and reward all aspects
of the Triple Aim
Your entire team will realize that the redesigned practice
works better than “the old way” and that patients are
getting better care and better service
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Primary care infrastructure cannot be solely funded
from visit based fee for service revenue
Care management fees (transition strategy)
Community wide support for IT and care
coordination
Global payments, bundled payments and capitation
Resources must flow to the people and practices in
relation to the value added for patients and
measured by the progress on the Triple Aim
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NCQA is useful but not sufficient
Real organizational development required
 Leadership and decision making
 Systems thinking
 Metrics and improvement strategies built in
 Team approach to care
 Strategic distribution of the work
Cost data needed down to the NPI
Remove barriers to change
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PCMH-Nothing less than an extreme make-over
for primary care practices to make them:
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More Service Oriented for patients
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More Effective for better patient outcomes
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More Efficient for better profit
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More
Fun
M
F to
t go to
t workk for
f allll
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True team approach to care and change
Quality
improvement
Q alit measures
meas res and a culture
c lt re of impro
ement
Patient and family engagement with patient selfmanagement support
Care management and care coordination
IT enabled for the core business,
clinical education and
clinical,
communication functions
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Practice and Payment Redesign
in the CPC initiative
2014 TransforMED
Creating a Shared Sense
of Responsibility for
Service, Cost and Quality
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Home
Care
Specialist
Facilitated
Access
Clinical
Information
PCMH
Care Plan
Mental
Health
Patient
Hospital
Surgery
Center
Imaging
Center
Family and
Caregiver
Support
Pharmacy
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• Shared responsibility for service, cost and quality
• Willingness to discuss process and interactions
• Efficient transfer of clinical information
• Multi-level accessibility
• Commit to a high level of service
• The patient is always the central focus
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A three-year project funded by a
CMS, Center for Medicare and
Medicaid Innovation ((CMMI)) Health Care Innovation Award
(HCIA)
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Expands the Patient-Centered
Medical Home to a Medical
Neighborhood connecting Primary
Care to:
p
 acute-care hospitals
 specialists
 community health resources
 increasingly assists patients
manage their health proactively
2014 TransforMED
Avera Health, O'Neill, Neb.
Charleston Area Medical Center, Charleston, W.Va.
Columbus Regional, Columbus, Ind.
Greater Baltimore Medical Center, Baltimore, Md.
Huntsville Hospital, Huntsville, Ala.
INTEGRIS Health, Oklahoma City, Okla.
Marquette General Health, Marquette, Mich.
Northeast Georgia Health System, Gainesville, Ga.
North Mississippi Health Services, Tupelo, Miss.
North Shore Physicians Group, Salem, Mass.
Novant Health, Winston‐Salem, NC
O l d H l h, Orlando, Fla.
Orlando Health
Owensboro Medical Health System, Owensboro, Ky.
Via Christi Health, Wichita, Kan.
Western Connecticut Health Network, Danbury, Conn.
**90 total primary care practices
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2014 TransforMED
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Phytel offers Insight and Coordinate solutions for
automating population health management
delivering advanced care coordination, patient
engagement, and quality-based analytical tools
for PCMH-N.
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VHA Inc. is a network of not-for-profit hospitals
that work together to improve their clinical and
economic performance. VHA includes more than
1,400 not-for-profit hospitals and 25,500+ nonacute health care organizations. Provides
consultation
blueprints
PCMH-N
lt ti and
d 12 bl
i t around
d PCMH
N
“leading practices.”
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Cobalt Talon helps healthcare companies
transform data into a strategic asset by providing
high-performance analytic and data management
products and services designed to solve the
complex issues facing the industry.
Reduce the Total Cost of
Health Care for Medicare and
Medicaid Beneficiaries by
$49.5
Million
$49 5 Milli
Improve Health of Eligible
Population Demonstrated by
an Average of 15% with at
least 3% Improvement in Each
Selected Quality Measure
A 25% Improvement in
Patient Experience
Demonstrate Ability to Scale
to Additional Practices within
Each Community
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5/28/2014
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High needs/high cost patients require special attention
 Risk stratified care management and care coordination
 Care plan, registry, team approach, clinical integration
 Patient/family/care giver engagement and support
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The “community footprint” is real and requires leadership
and comparison data to change
 Quality data
 Cost of care data, down to the NPI level
 Shared sense of responsibility for service, cost and quality
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New tools required
 Population health management and RSCM support
 Collaborative agreements or service contracts
 Development of a supportive community of care
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2014 TransforMED
“If We Build It…They Will Come” –Field of Dreams

-Christine Bechtel
N ti
lP
t
hi ffor W
dF
ili
 National
Partnership
Women and
Families
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For more information:
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www.transformed.com
www.delta-exchange.net
[email protected]
@TransforMEDCEO
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