Transcript MA - Many Partnering Initiatives Underway

MA - Many Partnering Initiatives Underway
Selected Partners
Activities
Hospitals:
Physicians:
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Services:
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Baystate Health System
Berkshire Medical Center
BIDMC
Brockton
Cambridge
Cooley Dickinson
Emerson Hospital
Health Alliance
Gardner
Lahey Clinic
Milford Regional
Partners Healthcare
Northeast Health System
Steward Norwood
Hospital
Tufts Medical Center
UMass Medical Center
Vanguard Health Systems
Winchester
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Acton Medical
Atrius Health
Family Practice Group
HCA (BIDMC)
Lahey Medical Group
Meeting House Family
Practice
The Medical Group
Somerville Primary
Care
Dedicated Link
CTI/Enhanced Coleman
Community Liaison
On-site Options Counseling
Meetings:
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Inpatient interdisciplinary
team
STAAR Teams
PCMH Multi Payer Initiative
Continuum of Care Quality
Assurance Initiative
Emergency Dept.
CMS CMP
Community Connections
Group
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Hospital/ASAP Collaboration
“Emerson Hospital
and Minuteman
Senior Services have
banded together with
the goal of preventing
unnecessary repeat
hospital stays.”
Atrius Health/ASAPs Practice-Based Pilots
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Chelmsford & Elder Services
of Merrimack Valley
2. Peabody & North Shore
Elder Services
3. Southboro & Baypath
4. West Roxbury & Ethos
5. Concord & Minuteman
Senior Services
6. Watertown & Springwell
Currently expanding to new sites
Community Care Linkages SM
A Division of Mass Home Care
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Atrius Health
 100% on an electronic medical record
combined with corporate data warehouse,
used for managing quality and cost.
 Long history with global payments: greater
than 50% of patients under global risk across
Commercial, Medicare and Medicaid
 Widespread use of rosters in population
management
 Track record of quality measurement and
reporting
 Over 30 NCQA certified Level 3 PatientCentered Medical Homes
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Why Pioneer? “Reason for Action”
Participating in the Pioneer ACO will help Atrius Health achieve highquality, high-value care for all Medicare-eligible patients across the care
continuum.
Successful implementation for Medicare-eligibles will improve
performance for commercial risk patients with similar clinical needs.
Access to full claims data set for Pioneer population offers true
opportunity to be accountable for quality and cost across the
continuum.
Contracting for Medicare Fee for Service patients under a global budget
through Pioneer ACO maintains our position as a market leader in
payment reform, moving towards 100% global payment.
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Atrius Health – ASAP Collaboration
 Expansion of the “Care Team” to include the patient’s home and
community-based networks
 Requires: effective communication for timely and efficient referrals, hand
offs, and “closing the loop”
 Results in: patient centered care plans with realistic goals and resources
for implementation
 Collaboration through:
 Practice-based Pilots
 Population-based Interventions
Community Care Linkages SM
A Division of Mass Home Care
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Atrius Health – ASAP Practice-based Pilot
 Practice referral to ASAP with brief description of
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patient/needs
Referral form completed and faxed along with the problem
list, medication list and the latest office visit
ASAP contacts the patient and arrange an intake interview,
updating practice on barriers and services recommended
ASAP provides services, closes the loop with practice via
phone call
Practice documents care coordination note and routes to
PCP pool. Epic flag notes patient receiving care from ASAP.
Community Care Linkages SM
A Division of Mass Home Care
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Population-Based Intervention:
Falls Risk Assessment
 Identify population appropriate for homebased FRA
 Develop standard work for non-medical ASAP
intervention (population based, rather than
practice or ASAP dependent)
 Develop data capture in Epic to meet Pioneer
quality measure
Community Care Linkages SM
A Division of Mass Home Care
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Current ASAP/ACO Contracts
Atrius Health/Southboro Medical Group (SMG) &
BayPath for “Community Social Services”
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Social Worker from BayPath to support SMG 24 hours per week
Access to SMG EpicCare (EHR)
Provide general community social services
Participate in case management, quality assurance and quality improvement,
utilization review and peer review activities
– Metrics:
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Number of patients referred
Number of ED admissions
Number of hospital readmissions
Pre- and post-intervention costs
Number of cases on-going
Number of resistant patients referred – must define non-compliant
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Current ASAP/ACO Contracts
“one woman
I&R
department”
Beth Israel Deaconess Physician Organization (BIDPO)/
Springwell for “Community Care Linkages”
– a Springwell-employed Community Resource Coordinator (CRC) to work on
site at BIDPO’s office located in Westwood, MA, 3 days per week
– identify the most affordable community resource options available to meet
the identified needs of any referred Patient regardless of age or ASAP
eligibility
– educate the BIDPO’s CNCMs and other staff as to range of community
resources available, including the abilities of ASAPs, so that CNCMs are fully
aware of potential supports available to Patients
– identify ASAP clients receiving services by any of the 27 ASAPs in MA and
work with BIDPO staff to identify additional services that may be helpful to
Patients who are receiving services from a Massachusetts ASAP
– establish a community resources catalogue or reference library
– participate with BIDPO staff in case conferences
– Options Counseling visits
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