11 Kansas Heart & Stroke Collaborative August 28, 2014

2 A Call To Action In 2011, there were 3,321 deaths attributed to heart disease and 1,333 deaths attributed to cerebrovascular disease in Kansas One in four Kansans die from heart or cerebrovascular disease Highest mortality rates in rural communities Higher incidence of chronic disease Higher than national average costs per beneficiary

3 Health Care Innovation Award Grants to applicants who will implement the most compelling new ideas to deliver better health, improved care and lower costs…, particularly to those with the highest health care needs. KUH awarded $12.5 million over 3 years to work with HaysMed, 10 CAHs, and their medical staffs to create a rural clinically integrated network September 1, 2014, start date

4 The Kansas Heart & Stroke Collaborative is a care delivery and payment model to improve rural Kansans’ heart health and heart attack and stroke outcomes to reduce total cost of care for that population.

5 Kansas Heart and Stroke Collaborative Participants

6 Target Population Residents of rural Northwest Kansas counties at risk of or have suffered heart attack or stroke Approximately 13,000 Medicare/Medicaid beneficiaries

7 Anticipated Outcomes Reduce total cost of care for target population by $13.8 million (1.9 percent savings) Reduce deaths from heart and cerebrovascular disease by 20 percent

8 Benefits First, lives saved and outcomes improved Resources and technology to allow easier applications of evidence-based protocols Resources and technology to facilitate communication surrounding patient care Data to drive meaningful interventions Reduce costs due to collaboration and sustainable models for access and treatment

9 Strengthening Competencies In Population Health Management Risk stratification Clinical integration Patient engagement

10 What the Collaborative Is Not Merger, acquisition, or consolidation Management agreement Replacement for fee-for-service/cost-based reimbursement New out-of-pocket expense KUH or HaysMed doctors dictating clinical practice KUH or HaysMed telling CAHs how to run their hospitals Requirement to refer patients to KUH or HaysMed

11 Three-Legged Stool Integration – Teamwork Interventions – Fieldwork Incentives – Rewards for teamwork and fieldwork

12 Integration Teamwork Form collaborative governance structure Strengthen care continuum for rural Kansans Pursue clinical integration among providers to provide accountability for population health

13

14 Intervention Field Work Collaboratively adapt guidelines and pathways to reflect the community and its resources Expand use of telehealth Leverage IT and data analytics Develop regional/local plans for care management and patient engagement

15 Interventions

16 Year One – STEMI Regional System No KS hospitals perform PCI within 90 minutes when patient transferred from non-PCI facility System solution – Standardized protocols and personalized training for CAHs and EMS – Supportive telehealth through KUH – Immediate access to patient data through HIE – Integrated transfer system with HaysMed

17 Year One – STEMI Regional System Rural hospitals, with protocol for rapid transfer of STEMI patients to regional center, achieve outcomes comparable to regional centers Regional systems experience improvements in long- term outcomes for STEMI patients – Henry, T.D., et al., A Regional System to Provide Timely Access to Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction, C IRCULATION, 2007; 116: – Ting, H.H., et al., Regional Systems of Care to Optimize Timeliness of Reperfusion Therapy for ST-Elevation Myocardial Infarction, C IRCULATION, 2007; 116:

18 Year One – Stroke Regional System Expansion of Kansas Initiative for Stroke Survival – Supported by KUH’s Advanced Comprehensive Stroke Center – Emergent Stroke Readiness System solutions – Standardized protocols and personalized training EMS transport and CAH receipt of potential stroke patients Use of tPA – Telehealth – Immediate access to patient data through HIE – Integrated transfer system with HaysMed

19 Year One – Stroke Regional System Rural hospitals with protocols that link to comprehensive stroke center achieve outcomes comparable to patients presenting at stroke center – Lamonte M.P, et al., A Regional System of Stroke Care Provides Thrombolytic Outcomes Comparable With the NINDS Stroke Trial, A NN. E MERG. M ED., 2009; 54: 319–327.

20 Year One Transitional Care Management (TCM) Post-discharge follow-up care for Medicare + Medicaid acute care admissions with discharge diagnosis of ischemic heart disease or cerebrovascular disease – Coordination with PCP – Provision of resources and personnel for patient engagement and community involvement

21 Year Two Expanded TCM + Health Coaches Expand TCM to include acute care admissions with discharge diagnosis of hypertensive disease, disorders of lipid metabolism, and tobacco use Deploy health coaches – Using physician referrals as well as data analytics (e.g., analysis of Medicare and Medicaid claims data), identify and engage high-risk patients in local communities – Collaborative employs and trains local staff to provide care management services with management and oversight by the PCP

22 Year Three Expanded TCM, Chronic Care Management, and Health Homes Expand TCM to include acute care admissions with discharge diagnosis of diseases of the circulatory system Collaborative staff to provide Medicare chronic care management services Collaborative staff to provide Medicaid health home services

23 Target Population

24 Incentives Rewards for Teamwork & Field Work Transitional payment model – Direct payment for care management services – Upward payment adjustments for participating rural physicians and mid-level providers – Disease-specific shared savings program Transformational payment model – Build shared analytic infrastructure to identify and evaluate alternatives to cost-based reimbursement to preserve local access to care

25 Payment Model - Year One All providers continue to bill and collect in same manner, in all three years Starting 3Q, Collaborative employs mid-level and health coaches to provide TCM for patients with acute care admissions with ICD (ischemic heart disease) or (cerebrovascular disease) Collaborative bills Medicare and collects for TCM (details to be negotiated with CMS) – Any Medicaid reimbursement? – Issue: What if patient’s PCP intends to provide TCM?

26 Payment Model – Year One Collaborative develops model for disease-specific shared savings program (DSSSP) – Like MSSP, except attribution based on geographic location and diagnosis rather than primary care provider – Variation on proposed Better Care Plan model Collaborative compiles claims and other data for two purposes – Identification of high-risk patients – Development of transformational payment model MSSP-like waivers available to Collaborative members (to be negotiated with CMS)

27 Payment Model – Year Two Collaborative continues to provide and bill for TCM – Expand eligible patients to include those with acute care admissions with ICD (hypertensive disease); 272 (disorders of lipid metabolism); (tobacco use) Collaborative continues to compile and begins analyzing claims and other data to identify high-risk patients and to develop transformational payment model

28 Payment Model – Year Three Physicians receive value-based purchasing incentive payments based on RCIN participation (details to be negotiated with CMS) Collaborative continues to provide and bill for TCM – Expand eligible patients to include those with acute care admissions with ICD-9 390–459 (diseases of the circulatory system)

29 Payment Model – Year Three Collaborative begins to provide and bill for Medicare chronic care management services and Medicaid health home services (details to be negotiated with CMS) – Same patient population as TCM, except no acute care admission requirement – Patients identified and prioritized through data analytics – Same billing issues as with TCM Collaborative implements CMS-approved DSSSP Collaborative develops and submits to CMS proposed transformational payment model based on data analysis

30 Deliverables 1.Collaboratively form regional systems for response to heart attack and stroke – Commence operations of a STEMI & Stroke Regional Systems by 01/01/15 – All Collaborative hospitals “Emergent Stroke Ready” by 03/01/15 2.Establish efficient rural-to-quaternary patient continuums and leverage telehealth to deliver specialized care in rural communities – Commence implementation of governing board-approved operational plans by 01/01/15

31 Deliverables 3.Improve health literacy through patient engagement – Implement a Shared Analytic Infrastructure to identify at- risk patients by 09/01/15 – Commence outreach to at-risk populations via local providers and health coaches by 09/01/15 – Utilize Kansas Heart & Stroke Collaborative-developed patient engagement strategies by 09/01/15

32 Deliverables 4.Make care management services available – By 01/01/15, transitional care management for patients who have suffered heart attack or stroke – By 09/01/15, transitional care management for at-risk patients – By 09/01/16, chronic care management/health home services for at-risk population 5.Build foundation for regionalization – By 08/31/17, identify at least two additional clinical programs for regionalization

33 Immediate Timeline 1.Establish processes for grant management 2.Engage CAHs and FQHC 3.Engage physicians at all levels 4.Develop and implement governance structure 5.Identify and secure necessary IT infrastructure 6.Implement stroke and STEMI regional systems 7.Develop operational plans for care continuum and telehealth 8.Develop and implement staffing plan

34 Staffing Matrix Per Grant Role DescriptionFTEHire DateLocation Executive DirectorExecutive Manager of entire Collaborative(interim placement until Year 1; Quarter 2)1.09/1/2014Collaborative ControllerManage all financial aspects of the grant funding/distribution.59/1/2014Collaborative Medical DirectorExecutive clinical leader of the entire Collaborative0.59/1/2014Collaborative ClerksPerform office administration duties0.759/1/2014Regional Hub Mid-Level Provide local resource for transitional care management, clinical protocol implementation, and health coach education 0.33 per spoke 12/1/2014Collaborative Scheduler Coordinate non-episodic care appointments for target population for health coach visits or other follow-up care required by specialists /1/2014Regional Hub Analytics ProfessionalPerforms data analytics on applicable data repositories, all other data analysis needs0.512/1/2014Collaborative Claims AnalystAnalyzes Medicare and Medicaid claims for purposes of achieving grant savings goals0.512/1/2014Collaborative IT DirectorOversees all HIT hardware, software, and staffing1.012/1/2014Collaborative IT Staff Dedicated to telemedicine, data repository for population health, health information exchange 4.512/1/2014 Collaborative; Regional Hub; AMC Program ManagerManages specific care programs for heart disease and stroke each2.012/1/2014Collaborative Training Coordinator Responsible for training materials and education sessions with health coaches, care coordinators, and managers 1.012/1/2014Regional Hub Health Coach Individuals with associate degree or higher who provide basic screening and patient education/engagement for the target population 0.75 per spoke 12/1/2015Spoke Communities Pharmacist Oversees pharmacy and prescription drug-related concerns and protocols for the Collaborative 0.56/1/2015Collaborative Pharmacy TechProgram manager for medication reconciliation protocols0.56/1/2015Collaborative Nurse Triage 24/7 staffing to evaluate AMI and stroke episodes or suspected episodes and coordinate transfers 4.29/1/2015Regional Hub Care Coordinators/ Managers Manage episodic and post-episodic care coordination for the target population3.09/1/2016Regional Hub

35 What’s Next Complete and return Facility Survey by September 5 Introduce Collaborative to Governing Board, Medical Staff, and Hospital Staff Receive and review regular project updates Participate in “deep dive” webinar in late September Promote and participate in Collaborative Summit – Tentative Date is October 14 and 15 Ask questions, identify obstacles, share ideas

36 WE HAVE THE OPPORTUNITY TO CHANGE HEALTH AND HEALTHCARE – KANSAS CAN LEAD THE NATION

37 The project described was supported by Funding Opportunity Number CMS- 1C from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.