The Tahoe/Carson Valley Transitions in Care Collaborative

“A Solution for Improved Care Management in Rural Environments”

CM

S

GO

AL

: P

roacti

vely m

anag

e 10%

of

the 50%

(CM

S

2009

Hospita

l R

eferral

Region

Data

)

Cost Per Medicare Beneficiary

Our High Risk Populations

• Congestive Heart Failure *• Pneumonia *• Chronic Obstructive Pulmonary Disease• Diabetes• Elderly patients with co-morbidities

* (No Medicare Payment for 30 Day Readmission Effective October 2012)

The Transitions in Care Option

The Four Pillars

http://www.caretransitions.org/structure.aspR

ed F

lag

s

Ph

ysic

ian

F

ollo

w-u

p

Dyn

amic

Pat

ien

t-C

ente

red

Ap

pro

ach

Med

icat

ion

Sel

f-M

anag

emen

t

A

Regional Concept

Epic

Nurse Remote Care Center

Broadband

Nurse Remote Call Center

T.I.C. Provider

A

Regional Concept

Epic

T.I.C.

T.I.C. T.I.C.

HomeMonitoring

“Prevent the Financial Bleed”Ju

st “on

e” chro

nic d

isease p

reventab

le readm

ission

p

er mo

nth

can im

pact yo

ur

bo

ttom

line

Averag

ing

go

vernm

ent an

d

com

mercial p

ayors fro

m

actual B

arton

Health

cases sh

ow

s:

$11,859.50*/mo

nth

=

$142,314 ann

ual im

pact

(*no

t a fully lo

aded

cost)

We m

ust co

ntro

l the b

leed

to d

emo

nstrate efficien

cy w

hile im

pro

ving

qu

ality in

care

Integrated Delivery Through Rural ACO Model

ACOs…groups of doctors, hospitals, and other health care providers coordinating high quality care for patients.

Care coordination leading to service duplication prevention and error avoidance.

Success equals high-quality care and efficient spending of health care dollars.

Benefits for Rural Health Communities

• Lowering our cost of care, offsetting expected potential inpatient revenue losses due to reimbursement changes.

• Achieving savings from CMS, through providing Medicare beneficiaries quality and patient satisfaction.

• Gives all of us alternative options for survival other than becoming part of a larger established health system entity.

(http://www.cms.gov/affordable-care-act-in-action-at-cms.html)

Rural Provider Survival