medicaid accelerated exchange series and medicaid ... · assessment and preparation es s phase 2:...

© 2017 New York State, Department Of Health, Office of Health Insurance Programs. All rights reserved.

Medicaid Accelerated eXchange Series andMedicaid Accelerated eXchange New York (MAXny) Series

Program OverviewJune 12, 2018

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MAX and MAXny


The MAX Series Program is offered by the New York State Department of Health(NYS DOH) and facilitated by NYS DOH contracted facilitators as part of theDelivery System Reform Incentive Payment (DSRIP) program.

• As part of the Delivery System Reform Incentive Payment (DSRIP) program, the

NYS DOH launched the Medicaid Accelerated eXchange (MAX) Series Program, to

redesign the way care is delivered for New York State’s most vulnerable patients.

• The DSRIP program is designed to stabilize New York’s healthcare safety-net

system, and realign its delivery system by shifting the focus from service volume to

quality for its Medicaid population. Ultimately, the statewide goal is to reduce

avoidable hospital use by 25% over five years.

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MAX and MAXny


• The MAX Series is a rapid cycle continuous improvement (RCCI) program, which

aims to bridge the gap between “how-we’ve-always-done-it” traditional healthcare

and the provision of interdisciplinary services at the community level, by bringing

together frontline care providers from across the care continuum.

• Through highly structured and dynamic workshops and action periods, change is

implemented and results are driven at the local level.

• The MAX Series was launched in the summer of 2015

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MAX and MAXny


• The MAX Series was complemented by the Train-the-Trainer (TTT) program,

which was designed to scale and sustain process improvement work by training

participants in the same RCCI methodology used in the MAX Series.

• These TTT participants will continue to implement the RCCI methodology

throughout their respective PPS’s through the MAXny Series: MAX New York!

• The MAXny Series is offered by the PPS, and facilitated by qualified MAXny

facilitators as part of the DSRIP program.

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Train The Trainer Participant Role• To become experts in RCCI Methodology

• To enhance facilitation skills and techniques

• To develop a Sustainability Plan outlining the next RCCI Workshop Series (to be independently lead upon completion of the program)

See One Do One Lead One

MAX Series Roles and Responsibilities

• MAXny Series Executive Sponsor: Provides overall sponsorship and championing of the MAXny Series, including the development of new Sustainability Plans and ongoing reporting to the NYS DOH.

• Site Executive Sponsor: Provides leadership, sponsorship, and championing of the MAXny Series at the site enrolled into the program.

• Action Team Members: Frontline care providers directly involved in meeting the needs of the target population

• Action Team Lead: Provides leadership on the Action Team and serves as the MAXny Series Lead’s primary point of contact

HU Readmission Rate = 40%

Non-HU Readmission Rate = 8%Jiang et al. HCUP Statistical Brief #184 Nov 2014

Medicaid Members with 4 or more hospitalizations in 1 year

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The MAX & MAXny Series are rapid cycle continuous improvement (RCCI) program that brings together frontline providers to redesignthe way care is delivered to those who need it

MAXny Series Methodology Programs

Objectives6.2018▪ Leveraging a highly structured methodology,

approach and coaching

▪ Utilizing data to measure and drive

performance

▪ Facilitating system integration by breaking

down silos and bringing together multi-

disciplinary providers

▪ Focusing on sustainability

1) Decrease High Utilizer’s of ED and inpatient hospitalization


2) Improve provider quality of life

3) Increase integration across the care

delivery system

4) Develop and build rapid cycle continuous

improvement capability

June 2017© 2017 New York State, Department Of Health, Office of Health Insurance Programs. All rights reserved.

MAXny Series Medicaid Accelerated eXchange New York (MAXny) Series

Phase 1:

Assessment and Preparation

MA

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eri

es

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Phase 2:

Workshops and Action Periods

Phase 3:

Reporting

MAXny

Workshop 1

Site and Participant

Enrollment

MAXny

Workshop 2

MAXny

Workshop 3Final Report

Note: Action Periods are rapid Plan Do Study Act continuous improvement cycles

30 day Action Period 60 day Action Period60 day Action Period

Data collection, analysis, evaluation, and reporting will be critical throughout the duration of the MAXny Series Workshops

Action Team

Members

Aug 1, 2017 – Sept 28, 2017 Sept 28, 2017 Oct 27, 2017 Jan 1, 2018 Mar 9, 2018

Phase 3:

Reporting

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February 26, 2016

June 2017


Theory: PLAN-DO-STUDY-ACT

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Small, focused, measured changes can have significant positive impact on your daily processes.

It is important to:

1. Plan – Develop a plan

2. Do – Try it! Identify a specific action a specific person(s) will

take and how many time/how long to test.

3. Study – How did this change work and what did we learn

from it?

4. Act – Should we adapt, adopt or abandon the change?

What’s our next step?

Breakthrough

Results

Theories, hunches,

& best practices

A P

S D

A P

S D

A P

S D

A P

S D

PDSA Ramps

NYS DOH MAX Series: Five Lessons Learned

About Improving Care for High Utilizers

• know who to focus on.

• view frequent utilization as a symptom of an unaddressed or unmet need.

• “do something different.” • successfully engage with and intensively serve patients after they leave

the hospital setting.

• actively collaborate with community providers and agencies.

Improving care for high utilizers requires we …

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February 26, 2016

https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/pps_workshops/docs/2017-jan-

jul_imp_care_for_high_utilizers.pdf

Change Management

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MAX Series: E3 A-Team

• Mary Whalen, COO, Samaritan Medical Center

• Aaron Campbell, DO, Director of Hospitalist Program, Samaritan Medical Center

• Sarah Delaney-Rowland, MD, Emergency Department Physician, North Country Emergency Medical Consultants

• Jilayne Salisbury, RN, Clinical Director of Physician Practices, Samaritan Medical Center

• Kathy Hunter, RN, Manager of Case Management & Discharge Planning, Samaritan Medical Center

• Kim Thibert, RN, CNO, Samaritan Medical Center

• Tim Ruetten, Executive Director, Jefferson County Office for the Aging

• Jeri Fuller, LCSW, Medical Social Worker, Jefferson County Public Health Services

“E3 A Team”

• Our Goal Statement: To improve the quality of

life of high utilizers by collaboration across the

spectrums of the individual’s life including psychosocial, economic, and clinical factors.

Who are high utilizers?

• Four (4) or more inpatient admissions within the last year (131)

• Combination of medical, behavioral health, and social needs – Social isolation

– Lack of family support

– Lack of engagement with preventative care

– Behavioral health

– Social determinants

– Lack of advanced care planning

SMC Super-Utilizers in the last 12 Months

Baseline Data 11/15/2015 – 11/14/2016

PATIENTS 131

ADMISSIONS 641

Average ADMISSIONS/PATIENT 4.9

0

2

4

6

8

10

12

14

16

0 20 40 60 80 100 120 140

Count of Admissions

Number of

Admissions

Number of Patients

Samaritan Medical Center 11/15/2015 – 11/14/2016

PAYERS

AGE

Mean

25th Percentile

Median

75th Percentile

SMC Super-Utilizers 11/01/2015 – 10/31/2016

Average

Cost/AdmissionTOTAL COST

$14,989 $9,113,502

Admission Location

• 96% admitted from Home

• 2% admitted from a Nursing Home

Discharge Location

• 80% discharged to Home

• 10% discharged to a Nursing Home

What can be done?

• Identify the “drivers of utilization” – do not

over medicalize.

• What is the root cause?

– Ask “why”– Assess for clinical – behavioral – social needs

Getting Started

• Electronic notification of all members of the

action team

• Provider engagement plan

• Expanding care coordination meeting

• Interview patients with consistent tool to

identify the drivers of utilization

Collaborate Across the Care Continuum….

• Case conferencing

• Definitive linkage to outpatient services

• Develop “Intensive Care Transition Team”• Increase the number of HU interviews

• Identify the HU in multidisciplinary rounds and discuss the

drivers of utilization

3030

E3 A-Team | NCI, Samaritan Medical Center

* Denotes workshop action plan

Inpatient High Utilizer Care Pathway

Identify

• Send dynamic twice daily high utilizer report to Samaritan Medical Center, Jefferson County Public Health, Jefferson County Office for the Aging (automatic via Meditech)

Assess

• Identify Drivers of Utilization through discharge planning assessment Monday through Friday; conducted by discharge planners

• Share identified DOUs with care team

• Identify HUs in interdisciplinary rounds and discuss DOUs*

• Identify advanced directives

Link

• Hold monthly advanced care coordination meeting with CBOs, Primary Care Practices and the hospital

• Create linkages to Jefferson County Public Health, Northern Regional Center for Independent Living, Health Home, PCP Care Managers

Manage

• Conduct interagency case conferencing

• Develop intensive care transitions process/team* to ensure long-term follow up in the community

-85

-78

-71

-59-57

-29

-21

8

-29 -33

-100

-80

-60

-40

-20

0

20

Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sept 17 Oct 17 Nov 17

Percent Change in HU IP Hospitalization

45% Decrease in HU IP Hospitalizations

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Lessons Learned# Topic Description

1 There is no single solution

• A majority of this population engage in behaviors that are difficult to change overnight. We recognize we must take an individualized approach and look at DOU differently than we have in the past, but also be mindful that ultimately the patient/family have to be willing to make a change.

2 Competing priorities and incentives

• There are competing priorities and incentives in the healthcare system that can impede process improvement.

3 This isn’t a project- it is a process change

• It is important to have caregivers understand this is a long-term and on-going process improvement.

CBOs have unrealistic expectations of the role of the hospital

• There is still a need to change CBOs expectation of care provided in the hospital vs. outside the hospital.4


Medicaid Accelerated eXchange New York (MAXny) Series

The Next MAX……..

2

MAXny Series: E3 A-Team

• Mario Victoria, MD, Chief Medical Officer, Samaritan Medical Center

• Sarah Delaney-Rowland, MD, Emergency Department Physician, North Country Emergency Medical Consultants

• Kathy Hunter, RN, Manager of Case

Management & Discharge Planning, Samaritan Medical Center

• Kim Thibert, RN, CNO, Samaritan Medical Center

• Aileen Martin, Executive Director, NRCIL

• Christen Norris, ED Nurse Manager, Samaritan Medical Center

• Michelle Treadwell, ED Clinical Discharge Planner, Samaritan Medical Center

• Linda Hayes, LPN, Family Practice Administrator, North Country Family Health Center

• Anne Hodkinson, Patient Relations Manager, Samaritan Medical Center

• Lisa Hedger, Community Outreach Specialist, Children’s Home of Jefferson County

SMC ED Data7/1/2016 - 6/30/2017

ED Stats 7/1/2016 - 6/30/2017

• 48,589 Visits

• 28,580 Patients

• 81% Discharged to Home

• 15.6% Admitted as Inpatients

• 3.8% LWBS/AMA

Mon Tues Weds Thu Fri Sat Sun

(51.3%)

(25.4%)

(10.1%)(13.2%)

Count of ED HU Patients

(25.7%)

(2.7%)(1.1%)

(9.4%)

(0.8%)(1.1%)

(55.7%)

Mon Tues Weds Thu Fri Sat Sun

(79.9%)

(10%)

High Utilizers

Patients with a PCP Visit N= 142

▪ Needs assessment to identify social and behavioral needs

▪ ED resources mobilized for initialpatient engagement

PATIENT IDENTIFICATION

PLANNING MANAGEMENT FOLLOW UP

Target population: Patients with 10+ ED visits in a 12 month period

Samaritan Medical Center: Overview

▪ Flag in EMR

▪ Real time alert to hospital and community care team

▪ Care managementengages with patients after discharge

▪ Community SocialWorker/Care Manager connects patient to services

▪ Definitively connectpatients to critical social services

▪ Bi-weeklyinterdisciplinary care plan meetings

Process improvements:

=189

Patients2741

ED Visits275

IP Admissions

Drivers of

Utilization

Final Thoughts

• Challenges with sustainability: it seems like more work, takes

resources, new things eventually become old

• The definition of insanity : making the same discharge plan for

the patient every time they come to the hospital even though

it clearly doesn’t work.

• This is a journey with lots of exits and detours

Final Thoughts (cont.)

• It’s about improving quality of life, helping our patients and families to be safer, reducing suffering while at the same time

being fiscally responsible

• It’s not a project, its about doing something different, rethinking, revamping, trying something new

• Focus on patients that are impactable

Any change, even a change for the better, is

always accompanied by drawbacks and

discomforts. – Arnold Bennett

• When you’re finished changing, you’re finished. - Benjamin

Franklin

The price of doing the same old thing is far higher

than the price of change. – Bill Clinton

• What are you going to do differently?

Questions

June 2017


Change Management

Thank you!

“The most important single condition for success in quality of healthcare is the determination to make it work”

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