Care Coordination in the ACO EraPresented by:

Anne Meara, RN, MBA

July 9, 2015

The Bronx

• 1.4 million residents in the poorest

urban county in the nation

• Median household income $34,000

• 54% Hispanic, 37% African-

American

• High burden of chronic disease

• Per capita health expenditures 22%

higher than national average

• 80% of health care costs paid by

government payers

Who We Are• Children’s Hospital at Montefiore

• Montefiore Einstein Center for Cancer Care

• Montefiore Einstein Center for Heart and

Vascular Care

• Montefiore Einstein Center for Transplantation

• Clinical

• Translational

• Health

Services

• ~1,323 Residents & Fellows

• ~420 Allied Health Students

• ~1,552 Graduate &

Undergraduate Nursing

• ~200 Home Health Aides

• ~100 Social Workers

ResearchTeaching

• Home Health

Programs

• Primary Care

• House Call

Program

• 8 Campuses

• 7 Hospitals

• 2,200 Beds

• 150 Skilled

Nursing Beds

• 1 Freestanding

ED

HomeCare

Hospitals

• Clinical

support

• Network

applications

• Finance

• Legal

• Planning

• Purchasing

• Compliance

• Marketing

• Human

Resources

• Care

Management(>300K Covered Lives)

• Disease

Management

• Care Coordination

• Telemedicine

• Pharmacy

Education

Information Technology

CorporateFunctions

CMO

• Health Education

• Community Advocacy

• Wellness

• Disease Mgmt.

• Nutrition

• Obesity Prevention

• Physical Activity

• Reduce Teen Pregnancy

• Lead Poisoning Prevention

Population Health

• ~23,000 Employees

• ~3,450 Integrated Provider

Association Physicians

• ~1,800 Employed MDs

• ~4,270 RN/LPN

• ~3,300 NYSNA RNs

• ~10,280 SEIU/1199

Workforce

Community

AcademicHealthSystem

Notable Centers of Excellence

Primary & Specialty

Care

• Advanced Primary

Care

• Sub-specialty Care

• Dental

• School Based

Health Centers

• Mobile Health

• Neuroscience

• Orthopedic

• Ophthalmology

• OB/GYN

Population Health Infrastructure

• Formed in 1995• MD/Hospital Partnership• Supplies network of par

providers committed to cooperation in care improvements

• Accepts some full risk capitation from health plans

• Established in 1996

• Wholly-owned subsidiary of Montefiore Medical Center

• Performs care management delegated by health plans

• CMO performs most functions for MIPA

• 1000 staff

CMOMontefiore Care

ManagementMontefiore IPA (MIPA)

3

Overview of Value-Based Payment Arrangements at Montefiore

Goal: To reach 1,000,000 covered lives

Source 2015 Population

Risk Contracts 221,000

Shared Risk 170,000

Medicaid Health Home

(Care Coordination)10,000

Totals 401,000

1996 Established the

Montefiore IPA and

CMO to facilitate risk

contracts

2000Major expansion of

risk membership

2011Montefiore

selected

as

Pioneer ACO

2012Formation of

Montefiore-led

Medicaid

Health Home

Program

2013Creation of

Montefiore

HMO (MLTC)

and

expansion of

Pioneer ACO

2009Montefiore

leads creation

of

Bronx RHIO Development of

care management

infrastructure;

extension of care

management core

competencies

into network

2014 -2015DSRIP

planning and

implementation;

development of

commercial

ACOs

Montefiore’s Journey to Accountable Care

Sunset of NYS all-payer hospital

reimbursement

Affordable Care Act

Performance-Based Culture

Managed Care Expansion

Identify & Prioritize

Enroll

Assess Needs

(Baseline and Ongoing)

Develop Personalized Care Plans

Stratify into Programs

Monitor &

Update Care

Plans until

Discharge

Patient

Primary CareProvider,

PCMH

Care Management Process Lifecycle

7

Care Planning

Develop Personalized Care Plans

• Accountable

care manager

assigned

• Stratification of

service levels

• Care plan

developed

(based on

problem list)

Initial engagement

Enroll

• No contact • Opt out

• Make contact

• Opt-in to care

management

• Self-

management

• Customized

assessments

• Access to

information as

needed (e.g.,

PHR, general

health info)

b

Care Management Process Lifecycle: High-Level Workflow

Preliminary identification of cohorts

High utilizers/ High risk

Functionally ill

Healthy/worried well

Identify & Prioritize

• Conduct

analytics to

segment

attributed

populations

• Segment

based on

utilization,

cost, and

available

clinical

information

Comprehensive needs assessment

Assess

Needs

• “Problem list” developed

• Telephonic

interview to

determine

medical and

psycho- social

needs

Care Guidance

Ongoing component

Monitor &

Update Care

Plans

• Inter-disciplinary

team assigned

Care team• Accountable Care Mgr

(RN, LPN, SW)

• Behavioral Care Mgr

Support resources• Clinical SMEs

o MD

o Pharmacist

o Disease-specific

SMEs

• Programs

o SNF

o Palliative Care /

Hospice

o House Calls

Community Services

Specialists

8

• Analyst,

utilizing the

following

enablers:

– Patient list

from State

– Claims,

administrative,

clinical data

– Risk

stratification

software/

applications

Preliminary identification of cohorts

Identify & Prioritize

• Coordinator

• Non-clinical staff

with minimum

high school

education

• Knowledge of

community

members,

sensitive to local

needs

• Bilingual

preferred

Initial engagement

Enroll

• Interviewer

• Trained and

experienced in

motivational

interviewing

• Clinical

background

(RN, LPN, SW)

Comprehensive needs assessment

Assess

Needs

• Accountable

Care Manager

• Clinical

understanding

and knowledge

of local

community

resources

• Clinical

background (RN,

SW)

Care Planning

Develop Personalized Care Plans

Care Management Process Lifecycle: Resources requiring varying skill sets

Care Guidance

Monitor &

Update Care

Plans

Care Team• Accountable Care

Mgr (RN, LPN, SW)

• Behavioral Care Mgr

Support resources• Clinical SMEs

o MD

o Pharmacist

o Disease-specific

SMEs

• Programs

o SNF

o Palliative Care /

Hospice

o House Calls

Community Services

Specialists

Analytics alone will not be able to

identify underlying drivers of medical

expense

• Unstable Housing

• Substance Abuse

• Mental Health

• Financial Distress

“Big Data” Is Not Enough

8% Generate 55% of Medical Expense

10

Social Determinants of Healthcare Costs

Based on results of over 4,000 assessments of high-risk

patients conducted at Montefiore CMO

Montefiore: An Introduction – Revised 5/2012

Medical/Behavioral ConditionsFood · Housing Finances

Education Transportation

FoodHousingFinancesEducation

Transportation

Medical/

Behavioral

Conditions

Care Coordination

Community Based Services • Care Transitions • Intensive Care Mgmt • Chronic

Care Mgmt • Palliative and Hospice Care • Behavioral Health Mgmt • Telemonitoring

The Provider View The Patient View

Aligned Priorities and Goals

Care Management Bridges the Gap

Montefiore: An Introduction – Revised 5/2012

Lessons Learned

• Skill set to manage complex psychosocial issues does not reside in traditional health care setting

• Data is a means to an end, not the end

• No one discipline/organization has all the requisite expertise/resources to manage a complex population

• Care coordination is a dynamic process requiring constant review and improvement

• Collaboration is key to success