Atrius Health as a Patient-Centered Medical Home: Successful Strategies to Reduce Readmissions

MassPro October 30, 2012 3:00p-3:30p Kate Koplan, MD, MPH Director of Medical Management Atrius Health 1

Atrius Health – Background

• • • • Non-profit alliance of six leading independent medical groups – Granite Medical – Dedham Medical Associates – Harvard Vanguard Medical Associates – Reliant Medical Group – Southboro Medical Group – South Shore Medical Center • Long history with global payments, currently managing 50% of our patients with global payments. • Strong infrastructure to manage risk • One of first to sign BCBSMA Alternative Quality Contract (AQC) and One of 32 Medicare Pioneer ACOs nationally Provide care for ~ 1,000,000 adult and pediatric patients in almost 50 ambulatory sites 1000 physicians, 1450 other healthcare professionals across 35 specialties NCQA-Level 3 Certified Patient Centered Medical Home at all Groups

Elements of Patient Centered Medical Home

• • • • • • • • Personal physician Physician-led care team Whole person orientation

Coordinated Care



HOSPITAL/SNF/HOME CARE

Enhanced access Quality Safety Patient and family centered

Comprehensive PCMH work must extend to the “Neighborhood”

• • 20% of Medicare beneficiaries hospitalized at least 1x/yr They require services at discharge: » 41.1% to SNF » 37.4% to Home Health » 10.3% to In-patient rehab facility » 9.1% to outpatient/ambulatory therapy » 2.0% to long term care hospital

Source: Gage et al (2009). Examining post acute care relationships in an integrated hospital system, ASPE.

Preferred hospitals

will have at least two of the following:

– Unique contracting relationship – High-volume or at least a regionally high-volume – Site or Group preference, with supportive communication strategy – Formal collaborative relationship between Atrius Health and Hospital, including steering, clinical collaboration, and IT committees – Standards and metrics agreed upon and regularly reviewed, including discharge coordination and use of Atrius’ preferred network – Mutual agreement that Atrius and Hospital will collaborate on IT interoperability, including Atrius patient identification at registration and notification to primary team of admission and discharge – Atrius Health and Hospital physician and administrative leads to guide relationship 5

Preferred SNF Facility Standards

• • • •

General:

– Staffing/HR requests, incl. credentialing – Facility agrees to use Atrius Health preferred providers (DME, VNA, specialists)

Pre-Admission:

– Patient screen and bed availability streamlined – Patients are identified as Atrius Health patients – Able to accept direct admits from home/ER/clinician office.

During stay:

– Facility comfort for pts and staff – INTERACT tool (or comparable quality tool) – Therapies are available seven days per week; Mental Health coverage – Team and care planning meetings; facility case manager responsibilities – Radiology, Lab, Pharmacy expectations

At Discharge and Post-Discharge:

– Patient experience survey – Atrius preferred vendors utilized for DME, Home Care, Home Infusion, Hospice, etc.

– D/c planning based on checklist, incl. med list, sharing ACP directives, teach back 6

Preferred SNF Provider Standards

• Discharge Planning – Templated summary; sent w/i 24h to Atrius Med Records – Ensure that f/u care is appropriate and that patient returned to Atrius Health PCP • 24/7 coverage by experienced and responsive clinicians • Timely communication to PCP if unexpected change in patient’s status • Newly admitted patients seen w/i 48h of admission by physician • Utilize Atrius Health preferred providers during stay • Participate in team and family meetings • Participate in quality and INTERACT or other related readmissions reviews • Comply with all payer minimum requirements 7

Standards and Metrics to Define our Hospital/SNF Strategy

• Relationship structure •

Care coordination

, including case management and transitions of care • On-site functions • IT interoperability 8

Improved Care Coordination & Work in the “Neighborhood”

• Differential process for discharge to ECF, home with services, and home without services, plus care coordination’s link with elder care services – Standards & Metrics, incl. IT interoperability • Post ED and hospitalization follow up within 7d, w focus on medication reconciliation • “Call First” campaign – encourage follow-up at our facilities if ambulatory-sensitive, or use of our preferred inpatient facilities, if that is level of care that is appropriate • Data: post-facility f/u, readmissions trending (3d, 7d, 30d), high risk patient reviews, etc… • Direct liaison with our hospital/SNF/homecare partners 9

Open Time

Questions & Discussion 10