Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. 1 Rich Bringewatt Chair, The SNP Alliance, and President, National Health Policy Group October 27, 2011 Critical Dimensions of Integrating Primary, Acute and Long-term Care: Learning from the Past

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. 2 Joint venture: The Wilder Foundation and General Mills (January 1991 through December 2003.) Leadership organization: Leading acute and long- term care systems and health plans…by invitation. Health system collaborative: Care systems with full service array, working together to integrate primary, acute and long-term care within their own care network as a means to improving total quality and cost performance in chronic illness care. Financed: Through a combination of member dues, fees, and foundation support. Joint venture: The Wilder Foundation and General Mills (January 1991 through December 2003.) Leadership organization: Leading acute and long- term care systems and health plans…by invitation. Health system collaborative: Care systems with full service array, working together to integrate primary, acute and long-term care within their own care network as a means to improving total quality and cost performance in chronic illness care. Financed: Through a combination of member dues, fees, and foundation support. 2 Background Information The National Chronic Care Consortium was—

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. 1.Nature of chronic conditions: Multi-dimensional, interdependent, disabling, personal and ongoing. 2.Nature of most care: Single-dimensional, fragmented, illness focused, impersonal, and event or episode driven. 3.Fundamental disconnect: Leads to significant and unnecessary confusion, medical complications, and costs. 4.Work with industry leaders: If leading acute and long-term care programs established new integrated methods under real-world conditions, and demonstrated success, others would follow. 1.Nature of chronic conditions: Multi-dimensional, interdependent, disabling, personal and ongoing. 2.Nature of most care: Single-dimensional, fragmented, illness focused, impersonal, and event or episode driven. 3.Fundamental disconnect: Leads to significant and unnecessary confusion, medical complications, and costs. 4.Work with industry leaders: If leading acute and long-term care programs established new integrated methods under real-world conditions, and demonstrated success, others would follow. 3 Strategic Assumptions

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. A person ‐ centered, system ‐ oriented alliance of primary, acute and long ‐ term care providers, serving a common group of people, working together to improve total quality and cost performance for persons with chronic conditions as their care needs evolve across time, place and profession. 4 Geriatric Care Networks The Focus of System Transformation

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. Key Issues 1.Pervasive presence of co-morbid illness. 2.Use of multiple medications. 3.Interdependence of mental, behavioral and physical health. 4.Volatile, complex, and ongoing conditions. 5.Managing illness within the context of disability. 6.Safe and effective care transitions. 7.Continuity of care among providers. 1.Pervasive presence of co-morbid illness. 2.Use of multiple medications. 3.Interdependence of mental, behavioral and physical health. 4.Volatile, complex, and ongoing conditions. 5.Managing illness within the context of disability. 6.Safe and effective care transitions. 7.Continuity of care among providers. 5

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. Building Blocks for Integration 6 Continuum Full array of primary, acute and LTC. Information Aligned medical records & communication. Financing Aligned incentives for quality and cost. Care Care management across settings & time. System Total quality and cost management. Policy Aligned health policy and oversight.

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. Performance Capabilities (SASI) 7 1.Empowerment of person and family. 2.High-risk assessment/screening/triage. 3.Full array of primary, acute and long-term care. 4.Seamless care across settings and over time. 5.Population-based care management with disability prevention orientation. 6.Meaningful information shared among related providers across the continuum. 7.Management supports interdisciplinary behavior. 8.Network governance supports integration effort. 1.Empowerment of person and family. 2.High-risk assessment/screening/triage. 3.Full array of primary, acute and long-term care. 4.Seamless care across settings and over time. 5.Population-based care management with disability prevention orientation. 6.Meaningful information shared among related providers across the continuum. 7.Management supports interdisciplinary behavior. 8.Network governance supports integration effort.

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. Keys to Advancing Integration Findings From SASI Project 8 1.Forward thinking executive leadership with one or two champions of integration in key roles. 2.Partners willing to put in significant time & effort. 3.Team approach; shared learning culture. 4.Visible physician leadership in integration effort. 5.Clearly defined project with tangible results. 6.Spectrum of disciplines and programs involved. 7.Sufficient presence throughout organizations to effect standard operating procedures. 1.Forward thinking executive leadership with one or two champions of integration in key roles. 2.Partners willing to put in significant time & effort. 3.Team approach; shared learning culture. 4.Visible physician leadership in integration effort. 5.Clearly defined project with tangible results. 6.Spectrum of disciplines and programs involved. 7.Sufficient presence throughout organizations to effect standard operating procedures.

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. Selected NCCC Integration Tools Barriers to Integration CareLink Resource Guide Chronic Care Network in Rural Areas Chronic Care Networks for Alzheimer’s Disease M/SHO Resource Material Self Assessment for Systems Integration (SASI) Risk Identification Tool Serving the Dually Eligible Risk-sharing Arrangements Across the Continuum Barriers to Integration CareLink Resource Guide Chronic Care Network in Rural Areas Chronic Care Networks for Alzheimer’s Disease M/SHO Resource Material Self Assessment for Systems Integration (SASI) Risk Identification Tool Serving the Dually Eligible Risk-sharing Arrangements Across the Continuum The Elements of Integrated Care Management Extended Care Pathways Integrating Pharmaceutical Care Perspectives in Disability Prevention Population-based Planning: Emerging Approaches in Chronic Care The Primary Care Team: Cornerstone of a CCN State of the Art in Network Performance Measurement The Elements of Integrated Care Management Extended Care Pathways Integrating Pharmaceutical Care Perspectives in Disability Prevention Population-based Planning: Emerging Approaches in Chronic Care The Primary Care Team: Cornerstone of a CCN State of the Art in Network Performance Measurement 9

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. Risk Identification: Key Findings 10 1.Purpose: Prevent, delay and/or minimize disease and disability progression for at-risk subgroups. 2.Key risk factors: At-risk of death, hospitalization, nursing home admission, functional decline and significant cumulative costs. 3.Process: Appraisal, screening and evaluation integral to a person’s primary care and follow-up. Advance triage according to special care requirements. 4.Initiation: Upon enrollment or in accessing primary, acute or long-term care services. 5.Data Source: Self-report provided reliable and valid information; risk levels need updating over time. 1.Purpose: Prevent, delay and/or minimize disease and disability progression for at-risk subgroups. 2.Key risk factors: At-risk of death, hospitalization, nursing home admission, functional decline and significant cumulative costs. 3.Process: Appraisal, screening and evaluation integral to a person’s primary care and follow-up. Advance triage according to special care requirements. 4.Initiation: Upon enrollment or in accessing primary, acute or long-term care services. 5.Data Source: Self-report provided reliable and valid information; risk levels need updating over time.

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. Extended Care Pathways 11 Standard set of policies and procedures to manage, monitor and evaluate care for a specific condition over time and across the continuum. Pathways are condition specific. Protocols are for common use across care settings and for empowering patients. Defines and standardizes the content and approach for assessment and care planning, for care interventions, roles and responsibilities of providers, transfer of information, and patient/care outcomes. Their primary focus is to prevent, delay or minimize disease and disability progression. Standard set of policies and procedures to manage, monitor and evaluate care for a specific condition over time and across the continuum. Pathways are condition specific. Protocols are for common use across care settings and for empowering patients. Defines and standardizes the content and approach for assessment and care planning, for care interventions, roles and responsibilities of providers, transfer of information, and patient/care outcomes. Their primary focus is to prevent, delay or minimize disease and disability progression.

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. Provider-based Risk Sharing Options for Aligning Economic Incentives 12 1.Risk plan; no provider capitation; use withholds. 2.All entities are cost centers (PACE and staff model HMO). 3.Partial capitation for pop. segment…rest FFS. 4.Single provider (physician group) capitated for all services. Others under sub-cap to provider. 5.All continuum entities at risk and receive sub- capitation. Common risk pool and re-insurance. 6.An integrated care system receives capitation for all services. Risk/rewards shared within network. 1.Risk plan; no provider capitation; use withholds. 2.All entities are cost centers (PACE and staff model HMO). 3.Partial capitation for pop. segment…rest FFS. 4.Single provider (physician group) capitated for all services. Others under sub-cap to provider. 5.All continuum entities at risk and receive sub- capitation. Common risk pool and re-insurance. 6.An integrated care system receives capitation for all services. Risk/rewards shared within network.

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. Aligned Policy Efforts ( ) 13 1.Supported MSHO and RWJF Integration Program. 2.Organized coalition of national associations to advocate for legislation on chronic care policy. 3.National conference on regulatory reform w/CMS. 4.Organized Medicare Payment Coalition to advance risk-adjustment (now SNP Alliance). 5.Advanced Chronic Care Act and other integration legislation (including with President Clinton, Senators Moynihan, Rockefeller, Hatch, Graham, Baucus, Durenberger, Cohen, Grassley, and Feingold, and Representatives Stark, Ramstad, Cardin and Thomas, etc.). 1.Supported MSHO and RWJF Integration Program. 2.Organized coalition of national associations to advocate for legislation on chronic care policy. 3.National conference on regulatory reform w/CMS. 4.Organized Medicare Payment Coalition to advance risk-adjustment (now SNP Alliance). 5.Advanced Chronic Care Act and other integration legislation (including with President Clinton, Senators Moynihan, Rockefeller, Hatch, Graham, Baucus, Durenberger, Cohen, Grassley, and Feingold, and Representatives Stark, Ramstad, Cardin and Thomas, etc.).

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. Legislative Proposals ( ) Dual integration demonstration and network prototypes. MedPAC and GAO studies on payment and duals. CMS Office on Duals. Tools and TA support for advancing integration. Process for developing national data base on duals. State access to Medicare data. Improved risk adjustment methodology for frail elderly. Performance-based financial incentives. Quality assurance guidelines for chronic illness care. Single funding stream, capitated payment, uniform risk factors, and payment method. Negotiated Rule Making Committee with stakeholders defining M/M authority, administration, and guidance. Dual integration demonstration and network prototypes. MedPAC and GAO studies on payment and duals. CMS Office on Duals. Tools and TA support for advancing integration. Process for developing national data base on duals. State access to Medicare data. Improved risk adjustment methodology for frail elderly. Performance-based financial incentives. Quality assurance guidelines for chronic illness care. Single funding stream, capitated payment, uniform risk factors, and payment method. Negotiated Rule Making Committee with stakeholders defining M/M authority, administration, and guidance. 14

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. Potential Applications for Today Development of Pioneer Accountable Care Organizations. Advancing Medical Homes for high-risk persons. Support for State Integration Demonstrations. Financial Alignment Demonstrations. SNP development of care networks. Advancing dual integration legislation. Development of Pioneer Accountable Care Organizations. Advancing Medical Homes for high-risk persons. Support for State Integration Demonstrations. Financial Alignment Demonstrations. SNP development of care networks. Advancing dual integration legislation. 15

Working to establish SNPs as a vehicle of choice in high-risk care. The SNP Alliance The nation’s leaders in specialty care. For Further Information Go to: National Health Policy Group Or contact: Rich Bringewatt, President, NHPG and Chair, SNP Alliance Phone: or National Health Policy Group th Street, NW Suite 600 Washington DC Go to: National Health Policy Group Or contact: Rich Bringewatt, President, NHPG and Chair, SNP Alliance Phone: or National Health Policy Group th Street, NW Suite 600 Washington DC