Camden Eliminating Healthcare Industry Silos 2 1 12...1/31/2012 2 THE CAMDEN GROUP 2/01/2012 ι 3...

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1/31/2012 1 HASC Blurring the Lines: Eliminating Healthcare Industry Silos Hospital Association of Southern California Los Angeles, California February 1, 2012 2/01/2012 ι 1 THE CAMDEN GROUP The Time is Now “The greatest threat to America’s fiscal health is not Social Security; it’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nations' balance sheet is the skyrocketing costs of health care” President Barack Obama, March 2009 2/01/2012 ι 2 THE CAMDEN GROUP Institute for Healthcare Improvement: The Triple Aim The Triple Aim TM set forth by the Institute for Healthcare Improvement: Optimal care delivery within and across the continuum Focused on improving the health of the population and cost of care Right care, Right place, Right time Triple Aim Experience of Care Per Capita Costs Population Health Source: http://www.ihi.org/IHI/Programs/StrategicInitiatives/TripleAim.htm

Transcript of Camden Eliminating Healthcare Industry Silos 2 1 12...1/31/2012 2 THE CAMDEN GROUP 2/01/2012 ι 3...

Page 1: Camden Eliminating Healthcare Industry Silos 2 1 12...1/31/2012 2 THE CAMDEN GROUP 2/01/2012 ι 3 Health Plan Activities: 2012 Use their huge cash reserves Buy health plans (prefer

1/31/2012

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HASC Blurring the Lines: Eliminating Healthcare Industry Silos

Hospital Association of Southern CaliforniaLos Angeles, California

February 1, 2012

2/01/2012 ι 1THE CAMDEN GROUP

The Time is Now

“The greatest threat to America’s fiscal health is not Social Security; it’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nations' balance sheet is the skyrocketing costs of health care”

President Barack Obama, March 2009

2/01/2012 ι 2THE CAMDEN GROUP

Institute for Healthcare Improvement: The Triple Aim

The Triple AimTM set forth by the Institute for Healthcare Improvement:

Optimal care delivery within and across the continuum

Focused on improving the health of the population and cost of care

Right care, Right place, Right time

Triple Aim

Experienceof Care

Per CapitaCosts

PopulationHealth

Source: http://www.ihi.org/IHI/Programs/StrategicInitiatives/TripleAim.htm

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2/01/2012 ι 3THE CAMDEN GROUP

Health Plan Activities: 2012

Use their huge cash reserves

Buy health plans (prefer Medicare)

Acquire medical groups and hospitals

Health plans are diversifying: 85 percent medical loss ratio (“MLR”) will impact profit margins

Market individuals in anticipation of the exchanges

Build BRAND

Partner with hospitals/medical groups

ACO (joint risk sharing)

Narrow network delivery systems

Be the data supplier/infrastructure

Who is going to manage the population’s healthcare?

2/01/2012 ι 4THE CAMDEN GROUP

Destination: Start with the End in Mind

Destination:Better Health. Better Care. Lower Cost.

Patient Safety and Throughput

Hospitalist and Hospital-based

Physicians

Reduce Re-admissions

Bundled Payment

Patient-centered

Medical Home

Transactions/ Network

Development

ACDs/ACOs

Physician Relationships/

Leadership Development

Hospital Case Management Improvement

Clinical Co-management

Physician Enterprise

Restructure

System Wide Care

Management Restructuring

Clinical Integration

2/01/2012 ι 5THE CAMDEN GROUP

ACO Structure

HospitalSNF

Outpatient Clinics/Centers

Physicians

Home HealthRehab

Behavioral MedicinePharmacy

ACO

Accountable care organization (“ACO”) responsible for:

Clinical care management (clinical integration)

Capture data for continuum of care

Measure and monitor costs and quality

Infrastructure(Provided or Contracted

ACO Operations)

Information Technology EMR, CPOE, PACSData warehouseReportingHIE

Care ManagementHospitalists and

IntensivistsCMODisease managementClinical protocols Advanced analytics and

modelingCall centerUtilization management Knowledge management

Health NetworkDelivery network

Financial/Payment Systems

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2/01/2012 ι 6THE CAMDEN GROUP

ACO: How Do You Generate Savings

50%Care Management

15-20% Lower Cost Site

15-20% Throughput

(Volume)

15-20%

Post acute, outpatient, ER use

Extended hours, higher occupancy, narrower network

Generic use, GPO, standardization

Population management

Well care Chronic disease

management Effective use of

appropriate clinicians

Medical home Bundled payment

Appropriate Economic Indicators

2/01/2012 ι 7THE CAMDEN GROUP

Where Sacramento Area

Who CalPERS (41,000 members)

When January - December 2010

Savings

$20 million ($15 million to BS and $5 million to Hill and CHW)

Reduced 30-day re-admissions (by 15 percent)

Reduced length-of-stay

No premium increase for some of employers

Reduced out-of-network treatment at hospitals

Reduced elective surgeries by 13 percent

12 percent of population uses 70 percent of the healthcare services

Pilot Program Results: CalPERS in 2010 (California)

2/01/2012 ι 8THE CAMDEN GROUP

ACO Potential Market Segments

ACO(IDN)

Medicare Medi-Cal Commercial Self Funded

FFS MA FFS HMO HMO PPO(tiered)Benefit

YourEmployees

CommunityEmployers

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2/01/2012 ι 9THE CAMDEN GROUP

Accountable Care Building Blocks

ClinicalIntegration

PopulationAnalytics

SupportInfrastructure

MedicalManagement

Tools

ClinicalProtocols

Continuumof Care andTransitions

CareModels

InformationTechnology

PaymentModels

Incentives/Metrics

DeliveryNetwork

Development

ACOAssessment

ProviderEducation

Governance andManagement

Structure

EmployeesDefined Population

Self-funded EmployersMedicare Health Plans

Improved Qualityand Access

Reduce Costsand Waste

2/01/2012 ι 10THE CAMDEN GROUP

Destination: Bump in the Road – The Payment System

Destination:Better Health. Better Care. Lower Cost.

Patient Safety and Throughput

Hospitalist and Hospital-based

Physicians

Reduce Re-admissions

Bundled Payment

Patient-centered

Medical Home

Transactions/ Network

Development

ACDs/ACOs

Physician Relationships/

Leadership Development

Hospital Case Management Improvement

Clinical Co-management

Physician Enterprise

Restructure

System Wide Care

Management Restructuring

Clinical Integration

CAUTION

2/01/2012 ι 11THE CAMDEN GROUP

Critical Success Factor: Payment Method

Align the payment BEFORE you start making care improvement:

Set, maintain, and reward individual provider performance metrics tied to overall goals

Severity – adjust – HCC and RAF scores

Re-insurance

Keep it simple

ProviderExample:

Payment Method Pools

PCP FFS plus “coordination fee” Participate in Pools (IP, OP, Diagnostic)

Specialists Captation/Case Rate Participate in Pools (IP, OP, Diagnostic)

Hospital Per Diem – if payer Case Rate/DRG – if hospital

Participate in hospital Pools (IP, OP)

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2/01/2012 ι 12THE CAMDEN GROUP

ACO(set medical targets and pools)

ACO Financial Model: General Flow of Funds - Pools

Pools are established using actuarial data tied to CMS filing

Actual claims expenditures are charged against the pool based on claims paid throughout the year

Surpluses available for distribution/deficits absorbed by health plan

Hospital,SNF, and

Rehabilitation Budgeted

Pool

Outpatient Ancillary Budgeted

Pool

Outpatient ServicesBudgeted

Pool

Outpatient Diagnostics Budgeted

Pool

POOLS

2/01/2012 ι 13THE CAMDEN GROUP

ACO Financial Model: How Does it Work? – Example

There will be pre-determined quality measures established by the ACO Quality and Service Committee to monitor and ensure appropriate care provision.

Continuum of Care Component Proposed Payment Type Incentivized Behaviors

PCPs FFS + Surplus distribution from Budgeted Pools

Treat patients in office (which also maximizes PCP’s income) instead of referring care that is appropriately done in PCP’s office to specialists

Specialists FFS + Surplus distribution from Budgeted Pools

Treat patients appropriately and will return patients to PCP if care is more appropriately done there

Will look for the provider of best value for services

Hospitals Per diems + Surplus distribution from Budgeted Pools

Physicians (including Hospitalists and Intensivists) will work to keep patients out of the hospital and, if they are admitted, work to maximize care with appropriate resources

Hospitals will work to keep costs low

2/01/2012 ι 14THE CAMDEN GROUP

2011 Medical Expenditures

Physician Services

31%

Other(non-RX)

7%

Hospitals and Skilled

Nursing Facilities

62%

Distribution of Expenditures(Current - $88.2 million)

Distribution of Expenditures(Target - $74.4 million)

* Target based on Moderately Managed Midwest Utilization Targets - Milliman

Physician Services

35%

Other(non-RX)

6%

Hospitals and Skilled

Nursing Facilities

59%

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2/01/2012 ι 15THE CAMDEN GROUP

Destination: Redesign Care Management and Become More Patient-centered

Destination:Better Health. Better Care. Lower Cost.

Patient Safety and Throughput

Hospitalist and Hospital-based

Physicians

Reduce Re-admissions

Bundled Payment

Patient-centered

Medical Home

Transactions/ Network

Development

ACDs/ACOs

Physician Relationships/

Leadership Development

Hospital Case Management Improvement

Clinical Co-management

Physician Enterprise

Restructure

System Wide Care

Management Restructuring

Clinical Integration

2/01/2012 ι 16THE CAMDEN GROUP

Example of Fragmentation in the Continuum of Care

Community ED Hospital Post-acute Community

Complex CM:CHFCOPDNephrologyNeuroCV

CM1 CM2

Health Plan

Medical Group

CM3 CM4 CM5 CM2 CM1

A patient experience in an episode of care could result in many different Care Models (“CM”) with a perspective of their specific care setting (model) serving the patient.

Hospital

Fragmented Patient Care Can Lead To: Poor patient quality outcomes Inefficiencies in transition of care High-cost Poor patient satisfaction

Physician Office

2/01/2012 ι 17THE CAMDEN GROUP

Patient Accessand

Communication

Facilitiesand Technology

Principles of Patient-Centered Medical Home

“When and how” based on patient preference and needs

Metrics used to define performance: quality, access, efficiency

Culture of continuous improvement

Clear lines of authority/ responsibility and process for

decision-making

Team orientation

Work to top of license

Share resources to maximize efficiency

Orientation and training

Standardized roles and work flows

Facilities support teamwork, and efficient work flow

Technology facilitates aims of care model

Aligned providers

Facilitate physician-physician communication

Proactive in identifying patient needs

Patient-Centered Quality and

Efficient Care

Ensure patients have goals for their care and responsibility for health related behaviors

Processes assure smooth transition of care and communication between providers (across continuum)

Source: The Camden Group

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2/01/2012 ι 18THE CAMDEN GROUP

Delegated“Carveout Expertise”

Specialists

The Care Team

Care Management

Behavioral HealthComprehensive Care Clinics

Social ServicesHealth Education

PrimaryCare

Physician

2/01/2012 ι 19THE CAMDEN GROUP

Conceptual Model for Patient-centered Coordination

Patient-centered Coordination

Hospital PHOHealth Plan Medical Group

RolesAdminMedical StaffClinicalIT

OutcomesQualityDiseaseFinancialSatisfaction

Populations Hospital Health Plan PHO Med Group

Complex CaseManagement

Coordination, UM and DCP

when admitted

Intensive outpatient management for high-risk patients provided by RN, MSW, Pharmacist, APN

Disease Management NoneIndividualized patient management provided by a dedicated healthcare team member (e.g., Clinical Nurse Specialist)

Population Wellness NonePatient monitoring and education specific to individuals’ chronic illnesses

Preventative NonePatient screening and education from healthcare team

2/01/2012 ι 20THE CAMDEN GROUP

Stratify Patients into a Level of Care Based on Care Needs

Level 4Home Care Management

Level 2Complex Care and Disease

Management

Level 1Self-management and Health Education

Programs

Home Care Management – End StageProvides in-home medical and palliative care management by Specialized Physicians, Nurse Care Managers, and Social Workers for chronically frail seniors that have physical, mental, social, and financial limitations that limits access to outpatient care, forcing unnecessary utilization of hospitals.

Complex Care and Disease ManagementProvides long-term whole person care enhancement for the population using a multidisciplinary team approach.Diabetes, COPD, CHF, CKD, Depression, Dementia.

Self-management, PCPProvides self-management for people with chronic disease.

Level 3 High-risk Clinics

High-risk Clinics and Care ManagementIntensive one-on-one physician/nurse patient care and case management for the highest risk, most complex of the population. As the risk for hospitalization is reduced, patient is transferred to Level 2. Physicians and Care Managers are highly trained and closely integrated into community resources, physician offices or clinics.

High Cost Patient

Low Cost Patient

Hospice/Palliative Care

BaselinePreventive Care/Wellness programs

Population MonitoringPreventive care, education and monitoring for the community.

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2/01/2012 ι 21THE CAMDEN GROUP

Destination: Obstacles on the Road

Destination:Better Health. Better Care. Lower Cost.

Patient Safety and Throughput

Hospitalist and Hospital-based

Physicians

Reduce Re-admissions

Bundled Payment

Patient-centered

Medical Home

Transactions/ Network

Development

ACDs/ACOs

Physician Relationships/

Leadership Development

Hospital Case Management Improvement

Clinical Co-management

Physician Enterprise

Restructure

System Wide Care

Management Restructuring

Clinical Integration

CAUTION

2/01/2012 ι 22THE CAMDEN GROUP

Potential Obstacles and Critical Success Factors: Care Management

Potential Obstacles

Breakdown in information/communication

Provider-centric information/communication

Reporting relationships = Control and emphasis (e.g., CFO maximize revenue)

Payment method: FFS

Lack continuum

Lack of coordinate transition

Turf wars

Critical Success Factors

Integrated IT backbone and coordinated communication

Patient-centric education, communication, patient accountability

Reporting relationship that matches patient-centric goals (e.g., capitated medical group quality at lowest cost)

Payment method = cap or case rate

Partner/Align/Acquire continuumComprehensive discharge communicate plan for patients

Comprehensive discharge communicate plan for patients

Align incentives (e.g., incentive pools, co-management)

2/01/2012 ι 23THE CAMDEN GROUP

Destination

Destination:Better Health. Better Care. Lower Cost.

Patient Safety and Throughput

Hospitalist and Hospital-based

Physicians

Reduce Re-admissions

Bundled Payment

Patient-centered

Medical Home

Transactions/ Network

Development

ACDs/ACOs

Physician Relationships/

Leadership Development

Hospital Case Management Improvement

Clinical Co-management

Physician Enterprise

Restructure

System Wide Care

Management Restructuring

Clinical Integration

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2/01/2012 ι 24THE CAMDEN GROUP

Bundled Hospital Payments Will Increase Care Collaboration

Source: Medicare Payment Advisory Commission (MedPAC)

Me

dic

are

sp

en

din

g fo

r th

e h

osp

italiz

atio

n e

pis

od

e

$6,500

Episode A (higher utilization)

Episode B (lower utilization)

X X X X X X X X

X X X X X

HospitalizationRehabilitation Hospitalization Readmission

HospitalizationHome Health

Services

Episodes A and B Have Same Bundled Payment

Acute Care Episodes

2/01/2012 ι 25THE CAMDEN GROUP

PhysicianGroup/Venture

Hospital

ExecutivePhysicianDirector

Service Line/Department

DirectorClinical

Co-management Committee

HospitalCEO/COO/VP

Cath LabMedical

CardiologyCardiac Surgery

Interventional Cardiology

Electro-physiology

Benchmark and

Performance

Cost EffectivenessProcess ImprovementLeadershipQuality assuranceClinical standardsResearch

Non-physician staffing BudgetingPurchasing/InventoryLicensingDatabase tracking

Phy

sici

an A

dvis

ors

Clinical and cost goalsBusiness development

Which Clinical Areas Will Be Included?

Management Service Agreement

2/01/2012 ι 26THE CAMDEN GROUP

Physicians Are Involved In Each Aspect of Operations

Co-management company governance structure includes various committees for managing all aspects of planning and care delivery (i.e., Quality Care Committee, Technology Committee,

Operations Committee, Finance Committee, Research Committee)

Possible Co-management Responsibilities

Financial and Operations

• Management oversight of staffing• Negotiation of service arrangements• Operating and capital budgets• LOS management and patient throughput

Planning and Business Development

• Strategic plan development• Technology planning• Marketing strategies• Clinical research plan

Quality of Care

• Development of care protocols• Quality management and improvement policies• Quality outcomes• Patient experience

Hospital

Physicians

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2/01/2012 ι 27THE CAMDEN GROUP

Destination: Obstacles on the Road to Bundled Payment

Destination:Better Health. Better Care. Lower Cost.

Patient Safety and Throughput

Hospitalist and Hospital-based

Physicians

Reduce Re-admissions

Bundled Payment

Patient-centered

Medical Home

Transactions/ Network

Development

ACDs/ACOs

Physician Relationships/

Leadership Development

Hospital Case Management Improvement

Clinical Co-management

Physician Enterprise

Restructure

System Wide Care

Management Restructuring

Clinical Integration

CAUTION

2/01/2012 ι 28THE CAMDEN GROUP

Bumps in the Road: Bundled Payment

Obstacles Critical Success Factors

Politics Vision and perseverance Transparency Participation Communication

Lack of Physician Participation Physician leadership and co-management and gainsharing/financial incentives

Current Performance Not Optimal – Need90th + Percentile Clinical Quality/Patient Satisfaction

Robust report card and incentives Cost accounting system/infrastructure Gainsharing models Best Practices

Volume/Market share Target marketing and education to distribution channels

How it fits with the population management?

Determine where the risk is and where the care management resources need to be

2/01/2012 ι 29THE CAMDEN GROUP

Destination: Initiatives to Start the Journey

Destination:Better Health. Better Care. Lower Cost.

Patient Safety and Throughput

Hospitalist and Hospital-based

Physicians

Reduce Re-admissions

Bundled Payment

Patient-centered

Medical Home

Transactions/ Network

Development

ACDs/ACOs

Physician Relationships/

Leadership Development

Hospital Case Management Improvement

Clinical Co-management

Physician Enterprise

Restructure

System Wide Care

Management Restructuring

Clinical Integration

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2/01/2012 ι 30THE CAMDEN GROUP

Example Initiatives to Start the Journey Reduce readmissions CMS estimates that readmissions cost $26 billion in a decade Congestive heart failure, heart attack, and pneumonia Additional disease added in 2014

Hospitalists/Hospital-based physicians Expanded roles (SNFist, laborists) Compensation methods that measure LOS, readmissions, satisfaction Share performance data Coordination with case managers

Patient throughput Patient placement in the right level of care Coordinated care through the acute care stay Design the internal processes for the professional staff, case managers, and

hospital based physicians Coordination with other levels of care Transfers out of ED Partnerships with TCUs Integration of hospice and palliative care in acute setting Health plan benefit coordination with disease management

Case Study Example

2/01/2012 ι 32THE CAMDEN GROUP

Centralized Care Management Model – Organizational Chart

Disease Management

Case Managers

RN Case Managers (“CM”)

Medical Social Workers (“MSW”)

Behavioral Specialists

Pharmacists

Embedded into PCMH

Advanced Practice Nurse (“APN”)

CM

Medical Office Assistants (“MOA”)

Hospital

Hospitalist

Inpatient Case Management

Patient Centered Medical Home

(“PCMH” or the “Medical Home”)

PCMH Primary Care Providers

(“PCP”)

Hospitalists

PhysicianAdministrator

Support Functions

Finance

Information Technology (“IT”)

Contracting/Network

Performance Improvement

Post-acute Services

Regulatory Compliance Director

Advisory BoardBaystate Hospitals

Baycare Health Partners

Health New EnglandCommunity Physicians

BH Management

Post-acute

Clinic Providers

Home Health CM

Phase 1 Prototype Phase 2 Post-prototype

Baystate Health System

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2/01/2012 ι 33THE CAMDEN GROUP

Framework to Categorize Interactions Between Medical Staff

PCMHProvider—each patient has an ongoing relationship with a personal provider trained to provide first contact and continuous and comprehensive carePhysician-directed medical practice—the personal physician leads a team of individuals at the practice level that collectively takes responsibility for the ongoing care of patientsWhole-person orientation—the personal physician is responsible for providing all the patient’s healthcare needs or taking responsibility for appropriately arranging care with other qualified professionalsCare is coordinated and/or integrated—across all elements of the healthcare system. Care is facilitated by registries, information technology, health information exchange, and other means

Medical Staff

Hospitalist

Provision of inpatient care 24/7 for a designated patient population based on evidence-based protocols

Physician assignments may be physician, specialty, or PCMH aligned

Engages the healthcare team in the Care Progression of the patient

Consistent communication and hand-offs with the Primary Care Team throughout the hospitalization

Specialist

The principle care provider for the disease will be negotiated by the PCMH and the specialist active in the treatment. Examples of patient management are:

The PCMH maintains responsibility for patient care and is the first contact for the patient

Shared management: the specialty practice would provide expert advice, but not manage the disease on an ongoing basis

Specialty practice assumes the role of the PCMH after consultation with the PCMH and approval by the patient i.e., end-stage renal disease

2/01/2012 ι 34THE CAMDEN GROUP

Care Transition Strategies to Acute Care and Post-acute Services

Post-acute Care

Services

HH, SNF, LTACH, ClinicsRehab

Acute CareServices

Inpatient

Transition Transition

Care Transitions Management Strategies (cont’d.)

The hospitalist confirms the post acute services with the PCP The inpatient CM engages the patient and family to evaluate the post acute

services and make a decision regarding discharge/transfer The UR nurse confirms eligibility and obtains authorization as necessary and

documents in the medical record The inpatient CM facilitates communication with the patient and facility

regarding transfer data Provider communicates all relevant information to the PCP post-acute care

services and documents in the medical record The MH-CM arranges for a post discharge office visit with the PCP within two

to four days The MH-CM completes all required patient education and documents a follow-

up plan to facilitate compliance

Escalation due to: Interventions Failed outpatient

care Acute event

PCP with Care Management

Support

5

4

3

2

1

Baseline

5

4

3

2

1

Baseline

2/01/2012 ι 35THE CAMDEN GROUP

Continuum of Care Provider Transitions

Pre-Admit Admit Concurrent Discharge Post-discharge

PCP to Hospitalist/Attending DM-CM or MH-CM to Inpatient CM Medical Home CM to Inpatient CM

Hospitalist/Attending to PCP Inpatient CM to DM–CM/Medical Home CM Inpatient CM to nurse in Post-acute Care

Services CM transitional home visit Outpatient DC follow-up to PCMH

PCP to Hospitalist/Attending Hospitalist/Attending to Specialist Multi-disciplinary Care Progression Rounds

with patient and family involvement MH–CM to Inpatient CM

PCP to Hospitalist/Attending Hospitalist to Specialist Inpatient CM to DM-CM or DM -CM Staff Nurse to staff nurse Patient and family education Inpatient CM to aftercare providers

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2/01/2012 ι 36THE CAMDEN GROUP

Continuum of Care Communication Hand-offs

Pre-admit Admit Concurrent Discharge Post-discharge

Verbal and e-mail communication

Verbal and e-mail communication Discharge plan and treatment plan Post-acute services communication Medication reconciliation Home visit

Verbal and e-mail communication Treatment and Discharge plan Medication reconciliation Multi-disciplinary Care Progression Rounds Patient and family education Bedside hand-offs Readmission meetings

Bedside hand-offs Readmission meetings Patient/family discharge rounds Care transition strategies Medication reconciliation Discharge planning with aftercare services

Integrated IT: EMR, CPOE, pathway, and discharge plan

2/01/2012 ι 37THE CAMDEN GROUP

Guiding Principles for Care Coordination Between Medical Staff

Type of referral consultation and co-management available

Accountability for processes and outcomes Content of the patient record – directional Process to initiate secondary referrals Patient-centered approach: patient choice,

clarification of referrals, diagnosis, and treatment plan

Inpatient process: notification of admission, secondary referrals, data exchange, transitions into and out of hospital

Emergent circumstances: if PCMH not available role of the specialist to secure appropriate medical care

Incentive structure

Agreement BetweenPCMH and PCMH-N

Principles may be used to distinguish the roles between the PCMH Provider and PCMH (Neighbor) Specialist

2/01/2012 ι 38THE CAMDEN GROUP

Framework to Categorize Interactions Between PCMH and PCMH-N

Pre-consultation Exchange

Answers a clinical question Prepares the patient for a

specialty assistant

Establishes referral guidelines Provides guidance on what is

an “urgent” consult

PCMHand

PCMH-N

Formal Consultation

Process to deal with a discrete

question/procedure

A detailed report and discussion

would be provided to the PCMH

Sub-specialty practice would not manage the case on ongoing

basis

Co-management

Shared management: the specialty practice would provide expert advice, but not manage the disease on an ongoing basis

Principle care for the diseased: PCMH and specialty are active in the treatment, the PCMH maintain responsibility for patient care and is the first contact for the patient

Principle care for the patient for a limited period and subspecialty becomes the first contact of care for the patient

Transfer of the Patient for the Entirety of Care

Specialty practice assumes the role of the PCMH after consultation with the PCMH and approval by the patient i.e., end-stage renal disease

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2/01/2012 ι 39THE CAMDEN GROUP

Follow the Money: He Who Has the Risk Will Need to Blur the Lines with Care Management Resources

Who Has Risk? Level of Risk Concern/FocusCare Management

Focus

Health Plan Pays providers FFS

Low rates Decreased utilization

Wants to keep utilization review/approvals

Caps Providers

Grow membership/revenue

Case management at provider level

Medical Group/PHO Full capitation Shared

Savings on whole population

Professional cap with hospital risk pool

Decreased utilization Patient focus Whole continuum

Hospital Case rate/bundled for episode

Decrease resource consumption for episode

Eliminate readmits

Care management pre-/during/post episode

2/01/2012 ι 40THE CAMDEN GROUP

Single Biggest Challenge:

When Will My Market Change?

ProceduresDriven

PopulationHealth Management

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