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The ABCs of ACOs for MCH May 30, 2013
For assistance: Please contact [email protected]
or for web support 888-447-1119 option 2
Brief Notes about Technology
A u d i o • Audio is available through your computer
speakers or earphones. • For assistance, contact [email protected]
or for web support 888-447-1119 option 2
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Brief Notes about Technology Continued Q u e st i o n s • To submit questions at any time throughout
the webinar, type your question in the chat box at the lower left-hand side of your screen. – Send questions to the Chairperson (AMCHP) – Be sure to include to which
presenter/s you are addressing your question.
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Technology Notes Continued
Re c o rd i n g • Today’s webinar will be recorded
• The recording will be available in a week on the AMCHP
National Center for Health Reform Implementation
website at www.amchp.org • A PDF version of the presenters' slides will also be
available on the AMCHP website
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Objectives
Webinar attendees will: 1) Increase their knowledge of ACOs and ACOs that include MCH populations
2) Increase their understanding of how public health can play a role in ACOs
3) Will be able to identify strategies and resources to collaborate with, ACOs in their state
Evaluation Attendees will receive a link to a survey evaluation upon
completion of this webinar. Please take a few minutes to share your feedback.
Featuring: Colleen A. Kraft, M.D., FAAP, Carilion Clinic, VA Cate Wilcox, MPH, Maternal & Child Health Section
Manager, Public Health Division, Oregon Health Authority Don Ross, Policy & Planning Section Manager, Division of
Medical Assistance Programs, Oregon Health Authority Marilyn Hartzell, M.Ed., Director, Oregon Center for Children
and Youth with Special Needs
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The ABCs of ACOs: Making
Them Work for Maternal-Child Health
Colleen A. Kraft, M.D., FAAP
Family-Centered Medical Home
Child and Family
Developmental Services
Home-visiting network
Early Intervention
Child Care Resource & Referral Agency
Early HeadStart & HeadStart
Early Child Mental Health Services
Prevention, Building Health
Acute Care
Chronic Care
Developmental Services
Parenting Support
Lactation Support
Vulnerable children and
families
Medically Complex Children
Accountable Care Organizations
ACO
Hosp
PCP
Spec
Coordinates care for shared patients
Medicare, Medicaid Or private insurer
Financial bonus from savings
ACO Attributes • Coordinates care for shared population of patients with the goal of
meeting and improving on quality and cost benchmarks • Hires an administrator and establish a formal legal structure to work with
payers, monitor performance, and collect any shared savings • Receives a financial bonus that is divided among its participants
according to their agreement.
Traditional Medical Care and Financing “Un-accountable” care
Low Cost Care • Primary Care • Preventive Care—Screenings, Immunizations, Anticipatory Guidance • “Gatekeeper” • Health/Lifestyle counseling • Home-based care • Home visiting • Primary Care access for evenings and weekends
No Coordination of Care
• No incentive for communication and collaboration • No care coordinators • No measurement of outcomes • No comparative effectiveness Research • No focus on population health • No co-location of services • No self management services • No transportation
High Cost Care • Hospitalizations • Procedures • Duplication of labs, studies, procedures • Transportation = Ambulance • Complications of Chronic Disease • End of life care in an ICU
Low Cost Care Payment poor = No incentive
Transparency of Finances? Outcome Measures? Quality Reporting? Aligned incentives?
High Payment = Plenty of Incentive
Accountable Care Reduce Cost
of Care • Develop robust primary care access •.Streamline administrative tasks • Co-management between primary care and subspecialty to avoid hospitalization • Greater use of palliative care • Greater use of home care and home visiting • Patient/Family portals • Avoid duplication of care/HIT
Improve Coordination of Care--Investments
• HIT that promotes communication and interaction • Office Care Coordinators • Home Visiting/Home Care • Primary Care-Ancillary Health co-location, including therapists, dieticians, psychology • Electronic portal for patient communication/collaboration • Support for advanced primary care and Q/I initiatives • Data management infrastructure to evaluate processes and outcomes
Improve Quality of Care • Improving Scientific Basis of Healthcare Decisions • Based on Comparative Pediatric Effectiveness Research • Measurement of Outcomes • Longitudinal data collection and evaluation
• Payment Tied to Patient Outcomes • Based on Quality Measures
Fair Payment for Low Cost Care
Transparency of ACO Finances Patient/Family-Centered Investment in Infrastructure
Shared System Savings Aligned Incentives
Improved Outcomes
Accountable Care “Three-Part Aim”
Better Care
Better Health
Lower Cost
Pediatric Accountable Care
Prevention of Adult Disease
Optimize Health and Development
Reduce High Cost Care
Factors Affecting Child Health
SOURCE: Healthy People 2010, US Department of Health and Human Services, 2000.
Medical Services
10%
Environ-ment20%
Genetics20%
Health Behaviors
50%
Health Innovation can be funded through an ACO
• Extension of the Medical Home • In-home care management
– Early Childhood – Oral Health – Prenatal – Asthma – Development/Behavioral Health
Carilion Clinic-Aetna Partnership
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Carilion Clinic
ACO
Carilion Clinic
Physicians
Private Practice
Physicians
Update: 12/08/2011
Virginia Medicaid Regions
ACO System Savings
• Co-management between primary care and specialty
• Less duplication of services • Tracking of “high utilizers” with care
coordination to provide proactive care • Access to primary care, less use of ED and
hospitalization
CORE Predictive Modeling from Aetna
Mbrs who are Top 1%
Mbrs who are High Risk ED
Mbrs who are Medium/High
Risk IP
A Venn diagram, combining top 1% general risk with ED and IP risk, is used to help illustrate what risk groups a member falls into, and are they falling into multiple groups…
Members who are Top 1% AND high risk for an ED visit next 12 mos.
Members who are Top 1% , high risk for an ED visit, AND medium/high risk for IP admit next 12 mos.
Members who are top 1% general risk AND medium/high risk for IP admit next 12 mos.
Members who are high risk for an ED visit AND medium/high risk for IP admit next 12 mos.
Personalize the Profile for Medical Homes Increasing Medical and Behavioral Complexity
Group 3: •Ave age 33
•72% female
•PMPM $962
•5 ED visits, 0.2 admits
•32% asthma prevalence; 25% med adherence (asthma)
•85% MH prevalence
•58% co-occurring mental health and substance abuse
•52% with 5+ Rx classes
•5 Specialist visits
•10 PCP visits
Group 4: •Ave age 49
•PMPM $3908
•2.6 admits
•12 IP bed days
•7 ED visits
•51% diabetes prevalence
•73% MH prevalence
•87% with 5+ Rx classes
•20 Specialist visits
•10 PCP visits
Group 6: •Ave age 43
•PMPM $2425
•1.6 admits
•7 IP bed days
•6 ED visits
•Low medical disease prevalence
•85% MH prevalence
•62% co-occurring MH and SA
•12 Specialist visits
•9 PCP visits
3 6
4 Group 5: •Ave age 53
•PMPM $3202
•2 ED visits
•2 admits
•10 IP bed days
•56% diabetes prevalence
•41% MH prevalence
•84% with 5+ Rx classes
•19 Specialist Visits
•7 PCP visits
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ED Risk Only
ED Risk/IP Risk Only Top 1%/
ED Risk/IP Risk Top 1%/ IP Risk Only
Home Visiting Partner
• Child Health Investment Partnership of the Roanoke Valley
• Home Visiting with a Health Focus – Parents As Teachers – Oral Health – Asthma Management – Pregnant Moms – Behavioral Health
Home Visiting
• Pediatric Asth
Care Management Design
• Home Visiting Contract – Paid per member/per month
• “High Touch”, in-person, in-home • Data Collected in home
– HEDIS metrics – Health Outcomes – Reduced costs
Medical Home
Oral Health and Fluoride Varnish
• Begin with a Grin!
Asthma Case Management
• Assess environment, modifications
• Smoking cessation • Observe inhaler use • Asthma control
assessment • Asthma action plan and
education • Transportation to visit
Behavioral Health
• Prenatal to age 7 • Perinatal/postpartum
depression screening • Connection to services
for parents and children at-risk and diagnosed
• Transportation to visits
Results
In-Home Screening
Ready for School?
Pediatric Asthma
Home Visiting Intervention Pilot
Home Visiting = In-Home Prenatal Care Management
IDEA • Poverty is a risk factor for
poor maternal and newborn outcomes.
• What if every mother with Medicaid had a Home Visitor to provide support, education, transportation?
• How would this impact health of the next generation?
AIM STATEMENT • Reduce the number of
infants born at <37 weeks gestation and low birth weight (<2500 grams) by 30% by December 2012 utilizing home visitors as in-home case managers.
National Benchmark=March of Dimes
Virginia • “C” grade for premature
birth • Total prematurity = 11.3% • Late preterm (34-36 wk) =
8% • Uninsured = 17.2% • Maternal smoking = 15.2%
Roanoke/Allegheny • Metrics worse for this
region • Prematurity = 12.2% • Late preterm (34-36 wk) =
10.1% • Uninsured =15.6% • Maternal smoking = 24.4%
Measures Measure Health Care Cost
Percent of infants born at < 37 weeks gestation O
Percent of infants born between 34 and 36 weeks gestation (late preterm) O
Birth weight term infants <2500 grams O
Percent of Pregnant Moms participants who smoke that stopped smoking O
Percent of Pregnant Moms participants who start prenatal care in the first trimester P
Percent of Pregnant Moms participants who attend all the recommended prenatal visits P
Percent of Pregnant Moms participants who are uninsured P
Percent of Pregnant Moms participants identified with depression P
Percent of Pregnant Moms participants connected to treatment for depression P
Cost of Care C
1st Trimester—Goal =90%
Percent Goal = 90%
All Visits-Goal = 60%
Percent Goal = 60%
Reduce Maternal Smoking by 1/3
Percent Goal = 16%
Perinatal Depression
Reduce Percentage of Infants born <37 weeks by 30%
<37wk 34-36 wk
Goal
Reduce Percentage of Term Infants born < 2500g by 30%
Cost of Care
Note: One premature infant March 19-May 10
Next Steps • Continue current project, data analysis • Continue Home Visiting Contract after birth • Expand Asthma and Behavioral Health HV models • Assess
– HEDIS measures – Compliance with Asthma guidelines, ER and hospital
admissions, missed school and work days – Co-locate HV teams in OB and Pediatric practices – Feasibility of project replication as ACO expands – Development and school readiness of birth cohort
Other Outcomes
• 92% of children with asthma are well controlled with minimal inhaler use
• 90% of all pregnant mothers attended all their prenatal visits, starting in first trimester
• 57% of pregnant moms who smoked were able to stop smoking
• 100% of children with behavioral health problems improved on PECFAS
Care Connection for Children
Special Families
Special Families
• 42 families with successful IEP meetings • 10 families connected with waiver services • 10 hospitalizations avoided due to connection
to home health services • 8 support group meetings • Special Families facebook page • Respite program
Accountable Care
• Health of a population – Pregnancy outcomes? – Decrease in hospitalizations and ED visits? – School attendance, grades? – Parental education and employment – Function and performance of the Medical Home
CONCLUSION:
It is easier to build strong children than to repair broken men.
Frederick Douglass
Don Ross Oregon Division of Medical Assistance Programs
Cate Wilcox Oregon Public Health Division
Marilyn Hartzell Oregon Child Development and Rehabilitation Center, OHSU
Coordinated Care Organizations
Health System Transformation and Opportunities for Preconception Health
What we’ll talk about today
Basics of Coordinated Care Organizations Public Health Role in CCOs (ACOs) MCH Metrics Preconception Health (One Key Question)
Opportunities for Children and Youth with Special Health Care Needs to work with CCOs (ACOs)
www.health.oregon.gov
Oregon Health Plan
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www.health.oregon.gov
Triple Aim: A new vision for Oregon
www.health.oregon.gov
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Changing health care delivery
www.health.oregon.gov
Benefits & services are integrated and coordinated
Physical health, behavioral health, dental health Get better outcomes: Health equity Prevention Social determinants of health: education, employment
MH: Supported Employment Community health workers/non-traditional health
workers Collaborate and Integrate with other health and
human services (e.g. long term care; public health; schools)
www.health.oregon.gov
Global budget
Current system MCO/MHO/DCO/FFS Payments based on actions No incentives for health outcomes
CCO global budget One budget Accountable to health outcomes/metrics Local vision, shared accountability, shared savings Flexibility to pay for the things that keep people healthy
www.health.oregon.gov
CCOs: governed locally
State law says governance must include: Major components of health care delivery system Entities or organizations that share in financial risk At least two health care providers in active practice Primary care physician or nurse practitioner Mental health or chemical dependency treatment
provider
At least two community members At least one member of Community Advisory Council
www.health.oregon.gov
ACOs vs CCOs-What’s Different?
ACOs have distinct features: ACOs developing around health systems, not payers ACOs in the ACA are aimed primarily at Medicare savings Providers in ACOs share in Medicare savings in:
Medicare Shared Savings Model Advance Payment ACO Model Pioneer ACO Model
CCOs are accountable to the state, and local community Medicaid enrollment in CCOs is required
www.health.oregon.gov
Community Advisory Council
Majority of members must be consumers. Must include representative from each county government in
service area. Duties include Community Health Improvement Plan and
reporting on progress.
CCOs and public health Variety of requirements in statute:
o State shall require and approve agreements between CCOs and publicly funded providers for payment for certain services (immunizations, STIs and other communicable diseases)
o State shall allow CCO enrollees to receive family planning and HIV and AIDS-related services from fee-for-service providers, as well as maternity case management if CCO cannot do it
o State shall encourage and approve agreements between the two entities for authorization and payment of other services including maternity case management, prenatal care, school-based clinics, services provided through schools and Head Start programs, screening services for early detection of health problems in vulnerable populations
www.health.oregon.gov
CCOs and public health (2) Variety of requirements in contract:
o Collaborate with local public health authority, local mental health authority, community based organizations and hospital systems for community health assessment and development of community health improvement plan
o Actively promote screenings with A or B grades from USPSTF, or recommended in Bright Futures guidelines
o Contribute to implementation of state’s plans for physical activity, healthy nutrition, tobacco prevention, suicide prevention, and local public health and health promotion planning efforts
o Partner with local public health and culturally, linguistically and demographically diverse community partners to address the causes of health disparities. www.health.oregon.gov
Accountability Metrics for CCO’s Reduction of disparities - report all other metrics by race and
ethnicity
Member/patient Experience of care
Health and Functional Status among CCO enrollees
Rate of tobacco use
Obesity rate
Outpatient and ED utilization
Potentially avoidable ED visits
Ambulatory care sensitive hospital admissions
Medication reconciliation post discharge
All-cause readmissions
Alcohol misuse – SBIRT
Initiation & engagement in alcohol and drug treatment
www.health.oregon.gov
Accountability Metrics for CCO’s
Mental health assessment for children in DHS custody
Follow-up after hospitalization for mental illness
Effective contraceptive use among women who do not desire pregnancy
Low birth weight
Developmental Screening by 36 months
Planning for end of life care
Screening for clinical depression and follow-up
Timely transmission of transition record
Care plan for members with Medicaid-funded long-term care benefits
www.health.oregon.gov Metrics in bold can be applied to Preconception Health
Initial Metrics Designed to achieve quick return on investment to
meet the federal requirements Maternal and Child Health is imbedded in many, but
not necessarily called out
www.health.oregon.gov
Second Phase of Metrics
Important to be at the table—we have a lot to offer! MCH brings the sustainability factor MCH brings the lifelong wellness factor
www.health.oregon.gov
Possible MCH metrics
Look at a broad range of standards of care/practice HP2020, Bright Futures, USPSTF, Title V priorities
Include Adolescent measures Look for means of coding/tracking the measure
www.health.oregon.gov
Possible MCH metrics
Targeted measures for MCAH populations Oral Health Positive Parenting Sleep hygiene Positive Youth Development Family violence prevention Safety/Injury prevention Pregnancy intendedness
www.health.oregon.gov
Example: One Key Question
Do you plan on getting pregnant in the next 12 months?
If yes, preconception health care If no, contraceptive health care
www.health.oregon.gov
ACA, Public Health, & Data
Pay attention to Electronic Health Record requirements in the ACA The concept of “Meaningful Use” introduces more complex
reporting to public health by Electronic Health Record users.
Public health needs to be ready to be able to receive data from providers.
Public health needs to be ready to be able to provide data to providers.
www.health.oregon.gov
Opportunities for Children and Youth with Special Health Care Needs to work
with CCOs (ACOs) Join the conversation – get to know the ACOs/CCOs Educate ACOs about the population of children with
special health care needs Who are CYSHN?
Complex Broad and inclusive definition Commonalities of needs across the population of indivduals
Educate ACOs about how to identify CYSHN within a system of care
Screeners Complexity Scales
www.health.oregon.gov
Opportunities for Children and Youth with Special Health Care Needs to work with
CCOs (ACOs) …and their families
Family-Professional Partnerships
Patient Engagement is not Family-Professional Partnership Family Professional Partnerships involve: Shared knowledge and expertise Mutual respect Collaborative problem solving
www.health.oregon.gov
Opportunities for Children and Youth with Special Health Care Needs to work
with CCOs (ACOs) Advocacy and Education
Encourage family leaders, F2F HICs, community leaders to join the Advisory Committees
Support family leaders in their work with ACOs The Family Voice
#1: Nothing about us without us! #2: Decisions made under Parent/professional
partnership involves compromise for both! #3: Please listen to our concerns.
www.health.oregon.gov
Opportunities for Children and Youth with Special Health Care Needs to work
with CCOs (ACOs)
Effective Systems of Care for CYSHN Family Centered Care Early and continuous screening Medical home with care coordination Ease of Use of Community-based services Youth Transition to adult health care (think specialty
care too!) Health care finance
Be a resource to ACOs
www.health.oregon.gov
Opportunities for Children and Youth with Special Health Care Needs to work
with CCOs (ACOs)
Public health programs support ACO aims & metrics Immunizations Flu vaccination Annual well-child visits Annual dental visits Reduced ER usage
Build partnership with ACO to help achieve the 3 aims Remember – there are 3 aims!
www.health.oregon.gov
Opportunities for CYSHN to work with CCOs (ACOs) - An expanded model for statewide care coordination
Tertiary-based Care Coordination Team
CYSHN are assigned to when they are identified through the hospital or clinics CC Team serves as single point of contact for families in the targeted group
of children CC Team nursing, social work, family navigator, psychology – according
to the needs of the child and family Regional Unit of Care Coordination (Senior Nurse Coordinator)
Regionally based senior nurse coordinator (expert nurse with CYSHN) Child/family referred to/through back into community-based care Links family with PCP and community-based care coordination as needed Senior Nurse Coordinator provides connections between the tertiary care
coordinators, PCPs and the community public health services Community-based Care Coordination
Child identified within the community through public health nursing or primary care settings; goals identified by PHN and/or PCP
Linked to Senior Nurse Consultant for input, and behavioral specialist when needed
For More Information: Don Ross, Manager Policy and Program Unit Division of Medical Assistance Programs Oregon Health Authority [email protected] 503-945-6084
www.health.oregon.gov
Marilyn Hartzell Director, OCCYSHN OCCYSHN / Oregon Center for Children and Youth with Special Health Needs Institute on Development and Disability (IDD) at OHSU [email protected] 503-494-6961
Cate Wilcox, Manager Maternal and Child Health Section Public Health Division Oregon Health Authority [email protected] 971-673-0299
Question & Answer
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•Please submit questions through the chat feature and direct them to the chairperson
Thank you for attending “The ABCs of ACOs for MCH”
Colleen A. Kraft, M.D., FAAP, Carilion Clinic, VA Cate Wilcox, MPH, Maternal & Child Health Section Manager, Public Health Division, Oregon Health Authority Don Ross, Policy & Planning Section Manager, Division of Medical Assistance Programs, Oregon Health Authority Marilyn Hartzell, M.Ed., Director, Oregon Center for Children and Youth with Special Needs
The recording will be posted on www.amchp.org