Building a Seamless Care System

Doug ThompsonChief Administrative Officer for ACO DevelopmentCambridge, MA

CAMBRIDGE HEALTH ALLIANCEAn Integrated, Academic, Public Health Care System in MA Transforming into an Accountable Care Organization

CHA’s Change AssetsDELIVERY SYSTEM• Network of primary and specialty health centers, hospital campuses, employed physicians,

cultural and linguistic expertise, academic programs, and public & community health programs serving 90,000 primary care patients – 80% public payer

• Two CHA PCMHs earned Level 3 NCQA accreditation in 2010; remaining are on track for 2012• Quality Core Measures are above National and MA benchmarks• IT program meets Stage 1 Meaningful Use Standards for eligible providers

HEALTH PLAN• State-wide Medicaid and Commonwealth Care managed care plan with 170,000 members• A successful Elder Service Plan (PACE model) for Frail Medicare-Medicaid Eligible Seniors

INTEGRATION• 12,500 members/patients shared between delivery system and health plan • Managed under a shared-risk global payment arrangement that includes a range of services

including behavioral health and services provided outside of CHA• Strategic relationships and partnerships (State EOHHS, community agencies, other systems)

PATIENT CENTERED CARE IN A PRACTICE WITHOUT WALLS

How do we address the gaps in the health care system?

TECHNOLOGY• Instant notifications to primary care team when patient “hits” the CHA delivery system

or a note is entered into the EMR

• Bi-directional EMR connections with other delivery systems

CLINICAL SYSTEMS• Pro-active Planned Care Teams moving toward Population Management

– Multi-disciplinary integrated care planning– Actionable, routine reporting delivered to appropriate care team member

• PCP to Specialist and Inter-Specialty Collaboration– Specialists initiated and agreed on service standards for their interaction with primary care teams

PATIENT ACCESS AND ACTIVATION PROGRAMS• Cultural and linguistic competency and outreach

• Patient Navigators

• Open access begun in primary and specialty care practices

CASE STUDY: Diabetic Patient, Mr. M • Mr. M is a 43 year old gentleman with insulin-dependent diabetes and bipolar

disorder.

• He is homeless, and can’t keep his insulin in a refrigerator. He has a hard time remembering to take his medicine on time. He also had multiple ER visits and hospitalizations for diabetic complications.

• Complex care management for Mr. M:

– A CHA Community Health Worker (CHW) was assigned to Mr. M and helped him obtain housing.

– A CHA Nurse Practitioner (NP) helps him manage his medications and educates him about what foods to eat.

– His CHW also helps him get to appointments with his PCP and mental health providers.

• Mr. M now has well-controlled diabetes and bipolar disorder, and is working at a grocery store.

5

• Patients identified as having asthma as soon as anyone (ED, pediatrician) puts asthma on the EMR problem list.

• Proactive outreach to patients by Planned Care Team to get them controlled on asthma medications (over 99%).

• Healthy Homes assessment through public health partnership.

• Result: Disappearance of inpatient and ED visits for pediatric asthma – led to closure of pediatric inpatient unit.

RESULTS: Comprehensive Care for Childhood Asthma

0%

2%

4%

6%

8%

10%

12%

J an-2002

(N-Pilot = 125)

(N-Rest = 18)

J an-2003

(N-Pilot =369)

(N-Rest = 30)

J an-2004

(N-Pilot = 479)

(N-Rest = 209)

J an-2005

(N-Pilot=596)

(N-Rest = 643)

J an-2006

(N-Pilot = 926)

(N-Rest = 880)

J an-2007

(N-Pilot = 1097)

(N-Rest = 889)

J an-08 J an-09

% P

atie

nt

Co

un

t

Pilot Sites (PEDO & SOPED) Rest of CHA

Goal <=0.5%

Childhood Asthma:% Patients with Asthma Admissions

Childhood Asthma:% Patients with Asthma ED Visits

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

J an-2002(N-Pilot = 125)(N-Rest = 18)

J an-2003(N-Pilot =369)(N-Rest = 30)

J an-2004(N-Pilot = 479)(N-Rest = 209)

J an-2005(N-Pilot=596)

(N-Rest = 643)

J an-2006(N-Pilot = 926)(N-Rest = 880)

J an-2007(N-Pilot = 1097)(N-Rest = 889)

J an-08 J an-09

% P

atie

nt

Co

un

t

Pilot Sites (PEDO & SOPED) Rest of CHA

Goal <= 2%

PARTNERING WITH PUBLIC HEALTHMet Definition of Physical Exercise City of Somerville: 2002 and 2008

23.6

34.6

41.7

64.0

48.0

26.8

0

10

20

30

40

50

60

70

80

Somerville 2002 Somerville 2008

Pe

rce

nt

Moderate Exercise

Vigorous Exercise

Moderate or Vigorous

*Moderate: Adults w/ 30+ minutes of moderate activity 5 or more days per week.

*Vigorous: Adults w/ 20+ minutes of vigorous activity 3 or more days per week.

Differences between 2002 and 2008 are statistically significant.

Change in Obesity from 2002 to 2008:Cambridge, Somerville, and MA

36.3

11.7

30.6 30.9

16.4

21.5

29.7

18.3

15.2

27.3

10.4

36.6

0

5

10

15

20

25

30

35

40

Cambridge Somerville Massachusetts Cambridge Somerville Massachusetts

Percent

2002 2008

Overweight = BMI between 25.0 and 29.9; Obese = BMI greater than or equal to 30.0* About 24% of the 2008 survey respondents are missing the weight variable necessary to calculate BMI.

Overweight Obese

Work collaboratively with public and community health partners to improve the health of the public.

Mobilize effective partnerships to:

• improve physical activity and decrease obesity

• decrease substance abuse (including tobacco cessation)

• support public health infrastructure (content providers, extenders of service)

PARTNERING WITH PAYERS - ACO MODELS

How do we optimize resources and gain synergies?

• SHARED DATAMART

– claims, enrollment, referrals, authorizations, EMR

– Real-time reporting when appropriate

• COMPLEX CARE MANAGEMENT PROGRAM (Network Health Alliance)– Community health workers

– 80/20 of the first 80/20

– Community partners – Commonwealth Care Alliance, PACT

• GLOBAL PAYMENT ARRANGEMENT– Focuses budgeted resources on wellness, preventive care, care coordination along the full health

and mental health continuum, and primary care sensitive hospitalizations and emergency room care

– Makes it possible to provide typically poorly reimbursed and non-billable services, which is especially critical for safety net population needing significant social supports

CASE STUDY: Asthma Diagnosis, Nicholas• Nicholas is a 4 year old patient with an asthma diagnosis.

• In the past year, he had 5 ER visits for asthma and was treated with powerful steroid medications 5 times. He is sleepy during the day and considered “oppositional.” He has missed three recent psychiatric appointments.

• He is the youngest son of a single mother of three. She ensures Nicholas takes his medications and had her home inspected by the Healthy Homes Program to identify any asthma triggers in the house. She suffers from PTSD and anxiety, conditions that have been worsened by the sleepless nights caused by her son’s frequent coughing fits.

• Nicholas was identified as a candidate for the NHA complex care program. A NP and Portuguese-speaking CHW met with the family to learn more about Nicholas’ symptoms and their affect on the family. A diagnosis of reflux was suspected, as it commonly mimics asthma. Nicholas and his Mom agreed to try a medication to treat reflux.

• It has been 3 weeks and Nicholas has not had any asthma episodes, ER visits, or need for his rescue inhaler. Within 24 hours, his Mom had her first full night of sleep. Next, the team will assess how Nicholas’ lack of sleep may be playing a role in his behaviors. They also plan to continue coaching his Mom.

EARLY RESULTS: COMPLEX CARE PROGRAM

NHA eligible (age >=18, CDPS2+ or AIDS)

Cambridge Health Alliance Revere Family Health Center

Scorecard for January – July 2010 (paid through September 2010)

2009 2010 % change(January – July, 60-day lag) (January – July, 60-day lag) 2009 – 2010

Member Months 1,206 1,247 3%DxCG Risk Score 2.56 2.49 -3%Facility Inpatient admits per 10004 448 385 -14%Outpatient Clinic (facility only)

encounters per 1000 48,019 6,178 -23%

ED (facility only) encounters per 1000 4 1,761 1,405 -20%

Professional-PCP units per 1000 4 6,606 5,832 -12%

Professional-Specialist units per 10004 19,819 18,717 -6%

POLICY ISSUESInitial findings are directional and show great promise in achieving near-termgains in health and cost effectiveness for complex populations, especially thoserelying on Medicaid, Medicare and Other low-income public programs.

• Need Medicare and Medicaid to move to global payment models quickly and to collaborate on Dual Eligibles.

• Need Medicare and Medicaid to provide ACO and PCMH infrastructure funding.

• Need continuous enrollment (such as 1 year continuous enrollment in Medicaid and other low-income public programs) to make care management work and worth investment.

• Need a partnership to ensure adequate risk adjustment methods to reflect both the social acuity and behavioral health complexity, including socio-economic adjustments, for low-income and vulnerable patient populations.

• Need stronger Behavioral Health - Primary care integration, fostered through new global payment models that “carve-in” Behavioral Health (BH) to the benefits design. To promote required access and resource availability, payment reforms must address chronic inadequacy of BH reimbursement and case mix systems that fail to account for the resource intensity in providing BH care.

Health Affairs thanks these organizations for their support of today’s conference and the resulting case studies to be published in a forthcoming issue of the journal: