Improving Quality Through the Accountable Care Organization (ACO) Cheryl Jansen RN BSN Clinical Application Analyst II University Hospitals Elizabeth R. Hammack Associate General Counsel University Hospitals Health System, Inc.

Candace L. McGovern RN Manager, IT Clinical Applications Susan Semrau RN, CPHQ Senior Quality Improvement Nurse Institute for Healthcare Quality & Innovation William W. Steiner II, MD PhD Interim President, University Hospitals ACO Nathan Hunt Director, University Hospitals Accountable Care Organization Corinne Hurley Director Clinical Management UHPS Michele Lemonovich RN Clinical Liaison, UHCare University Hospital Geauga Medical Center Eric M. Yasinow, M.D.

Medical Director, UHACO

Objectives

• Provide introduction to ACO • Present ACO quality measures • Understand how using the AEMR can improve quality • Be aware of shared Savings and Financial Incentives for Physicians

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UH Accountable Care Organization Strategy & Initiatives

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$5,000 $4,500 $4,000 $3,500 $3,000

Total Expenditures and % Gross Domestic Product (GDP)

National Health Expenditures % of GDP 17.2% 2.8T

25% 20% 15% $2,500 $2,000 $1,500 $1,000 $500 10% 5% $0 1960 1970 1980 1990 1993 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2020

Projected

4/26/2020 University Hospitals 0% 4

Volume 348(26) 26 June 2003 pp 2635-2645

The Quality of Health Care Delivered To Adults In the United States

McGlynn, Elizabeth A.: Asch, Steven M.: Adams, John: Jeesey, Joan: Hicks, Jennifer: DeCristofaro, Alison: Kerr, Eve A.

BACKGROUND

We have little systematic information about the extent to which standard processes involved in healthcare —a key element of quality —are delivered in the United States.

METHODS

We telephoned a random sample of adults living in 12 metropolitan areas in the United States and …received written consent to copy their medical records …to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventative care …

RESULTS

Participants received 54.9 percent of recommended care.

CONCLUSIONS

The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits are warranted.

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UHACO Strategy

• Achieve improved outcomes for patients of all ages: – Quality of care, – Patient experience, and – Cost of care • Maximize value of high quality patient-centered care • Remain ahead of the ‘health reform curve’ • Pilot new models of care delivery and reimbursement • Leverage expanded system to coordinate care: – Large primary care network – Outpatient facilities – Technology

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UH ACO Objectives & Strategies

Objective Improve Population Health Enhance Patient Experience of Care Reduce And Control Cost of Care Strategies • Increase preventive care and wellness activities • Expand clinical care protocols built around UH Centers of Excellence • Coordinate care across health system • Increase role of Primary Care Physician (PCP) • Engage patients and families • Deliver care in appropriate settings by appropriate providers • Minimize waste & duplication

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UHACO Initiatives

University Hospitals Rainbow Care Connection University Hospitals Accountable Care Organization University Hospitals Coordinated Care Organization

Medicare ACO ACO: Pediatric ACO Employee/ Commercial ACO

Center for Medicare & Medicaid Innovation (CMMI) Centers For Medicare & Medicaid Services (CMS)

Attributed Membership: Payer:

70,000 Ohio Medicaid 80,000 Self-Insured Plans/ Commercial Payers 50,000 Medicare Traditional

Attributed lives account for over $1 Billion in annual medical expenditures 4/26/2020 University Hospitals 8

UH Accountable Care Organization Quality

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Medicare ACO Quality Reporting

• Quality reporting of 33 measures in 4 domains required for shared savings – Patient/Caregiver Experience – Care Coordination/Patient Safety – Preventative Health – At-Risk Populations • Replaced PQRS Reporting for Physician Incentive – Achieved for all UH Physicians 2012 & 2013 • 2014 Reporting begins January 26, 2015 • Select results published on Physician Compare

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2012 & 2013 Quality Results: 2014 Percentiles

50 40 30 20 10 0 90 80 70 60

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2012 2013

**Confidential**

2012 & 2013 Quality Results: 2014 Percentiles

Patient/Caregiver Experience

Measure

ACO #1 ACO #2 ACO #3

Description

Getting Timely Care, Appointments, and Information How Well Your Doctors Communicate Patients’ Rating of Doctor ACO #4 Access to Specialists ACO #5 Health Promotion and Education ACO #6 Shared Decision Making ACO #7 Health Status/Functional Status

4/26/2020 University Hospitals **Confidential**

2012 & 2013 Quality Results: 2014 Percentiles

Care Coordination/Patient Safety

Measure

ACO #8 ACO #9 ACO #10 ACO #11 ACO #12

Description

Risk Standardized, All Condition Readmissions ASC Admissions: COPD or Asthma in Older Adults ASC Admission: Heart Failure % of PCPs Qualified for EHR Incentive Payment Medication Reconciliation ACO #13 Falls: Screening for Fall Risk

4/26/2020 University Hospitals **Confidential**

2012 & 2013 Quality Results: 2014 Percentiles

Preventive Health

4/26/2020 University Hospitals Measure Description

ACO #14 Influenza Immunization ACO #15 Pneumococcal Immunization ACO #16 ACO #17 ACO #18 Adult Weight Screening and Follow Up Tobacco Use Assessment and Cessation Intervention Depression Screening ACO #19 Colorectal Cancer Screening ACO #20 ACO #21 Mammography Screening Proportion of Adults who had blood pressure screening in last 2 years

**Confidential**

2012 & 2013 Quality Results: 2014 Percentiles

Diabetes Composite

Measure Description

ACO #22 Hemoglobin A1c Control (<8%) ACO #23 Low Density Lipoprotein (<100mg/dL) ACO #24 Blood Pressure <140/90 ACO #25 Tobacco Non Use ACO #26 Aspirin Use

4/26/2020 University Hospitals **Confidential**

2012 & 2013 Quality Results: 2014 Percentiles

At-Risk Populations

Measure

ACO #27 ACO #28 ACO #29 ACO #30 ACO #31

Description

% of beneficiaries with diabetes whose HbA1c in poor control (>9%) % of beneficiaries with hypertension whose BP <140/90 % of beneficiaries with IVD with complete lipid profile and LDL control <100mg/dl % of beneficiaries with IVD who use Aspirin or other antithrombotic Beta-Blocker Therapy for LVSD

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2012 & 2013 Quality Results: 2014 Percentiles

Coronary Artery Disease (CAD) Composite

Measure Description

ACO #32 Drug Therapy for Lowering LDL Cholesterol (Removed From Program) ACO #33 ACE Inhibitor or ARB therapy for patients with CAD and Diabetes and/or LVSD

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2015 Medicare ACO Quality Measures

Measure Description Status

ACO #34 CAHPS Stewardship of Patient Resources ACO #35 Skilled Nursing Facility 30-Day All Cause Readmission Measure ACO #36 All-Cause Unplanned Admissions for Patients with Diabetes ACO #37 All-Cause Unplanned Admissions for Patients with Heart Failure ACO #38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions ACO #39 Documentation of Current Medications in Medical Record

NEW NEW NEW NEW NEW NEW

ACO #40 Depression Remission at Twelve Months

NEW 4/26/2020 University Hospitals 18

2015 Medicare ACO Quality Measures

Measure Description Status

ACO #22 Diabetes Composite: Hemoglobin A1c Control (<8%)

REMOVED

ACO #23 Diabetes Composite: LDL (<100mg/dL)

REMOVED

ACO #24 Diabetes Composite: Blood Pressure <140/90 ACO #25 Diabetes Composite: Tobacco Non Use

REMOVED REMOVED

ACO #26 Diabetes Composite: Aspirin Use

REMOVED

ACO #27 % of beneficiaries with diabetes whose HbA1c in poor control (>9%) ACO #41

4/26/2020

Diabetes: Eye Exam % of patients 18-75 with Type 1 & 2 Diabetes with retinal/dilated eye exam in measurement period or negative in the year prior

University Hospitals RESCORED NEW 19

UHACO Commercial Programs

• Shared savings targets based on lower cost of care and quality targets met – Quality measured for preventative, disease-specific, & hospital care – Quality alignment across programs where possible • UHACO to provide population health services to improve quality and help manage cost • Provider network includes University Hospitals employed providers – Fee for service reimbursement to providers with potential for shared savings

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UHACO Commercial Programs

Quality Measures

Colorectal Cancer Screening Breast Cancer Screening Cervical Cancer Screening Chlamydia Screening Pediatric Measures Diabetic preventive screenings Diabetic HbA1c controlled Heart Failure/CAD Hospital Re-Admissions Hospital Length of Stay Pregnancy Management

Medicare ACO

     

Commercial ACO Programs

                       

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UH Accountable Care Organization Infrastructure & Support

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UHACO Population Health Management

Centralized and practice-based team focused on coordinating care for ACO populations: – Patient Navigators (Central & Embedded) – Nurse Care Coordinator – Health Educators & Dietitians – Social Worker – Pharmacist – Network Administrator – Data Analyst

Analyze Population Connect Identify 4/26/2020 University Hospitals University Hospitals Engage 23 23

UHACO Population Health Management

Health Education & Wellness Programs for broad population needs Preventative Care Adherence Align primary care physicians & protocols All Members Screening Campaigns Resolve gaps in care Disease Management Address chronic illnesses Targeted Outreach Case Management Individualized care Highest Risk © 2013 University Hospitals Health System, Inc. All rights reserved.

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UHACO Population Health Management

•

Health Education & Wellness:

Programs for broad population needs •

Preventative Care Adherence:

Align primary care physicians & protocols

UHACO Physician & Provider Update 4/26/2020 University Hospitals 25

Leveraging Resources & Technology

• Utilizing Electronic Medical Record (EMR) for ACO specific functions – Tasking – Health maintenance log – Quality documentation • Expanding ability to schedule directly

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Colonoscopy Campaign: Initial Telephonic Outreach

• 1,040 commercial ACO members • 1,632 call attempts

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Colonoscopy Campaign: Fecal Immunochemical Testing (FIT)

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UHACO Mammogram Campaign

Compile ACO member/beneficiary data emmi scheduling outreach & warm transfers to 216-844-BRST UHACO Patient Navigator in-office outreach UHACO Network Administrator to organize physician orders for mammograms Outreach to ACO members/beneficiaries to schedule UHACO follow up with ordering physicians on documentation Coordinate with UH #WomanUp Marketing Campaign

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UHACO Master Patient Index

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UHACO Transitions of Care

•

During Hospitalization:

– Visit selected beneficiaries •

Post-Hospitalization:

– Contact beneficiary within 72 hours of discharge • Confirm Primary Care Provider (PCP) appointment • Review medications & discharge notes • Document needs assessment – Conduct follow up coordination as indicated

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UHACO Transitions of Care

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Discussion

• • •

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