PHYSICIAN ALIGNMENT AND CARE MANAGEMENT LEADS TO VALUE BASED CARE Scott Hines, MD Betty Jessup, RN, BSN March 7, 2012

OUTLINE Introduction to Crystal Run Healthcare The Evolution of our Care Manager Program Keys to aligning physicians Next Steps

Crystal Run Healthcare Highlights Physician owned MSGP in New York State Originated 1996 250 provider, 11 locations, 1300 FTE Joint Venture Ambulatory Surgery Center, Urgent Care, Diagnostic Imaging, Sleep Center, High Complexity Lab Early adopter EHR (NextGen®) 1999 Accredited by Joint Commission 2006 NCQA-designated Level III Patient Centered Medical Home 2009 Crystal Run-CDPHP Focused EPO 2010 Any way to dress this up a bit

Crystal Run Healthcare Locations

Advanced Care Management Building Blocks Advanced Care Management Program Patient-Centered Medical Home Care Manager Role and Function

Overview: High-Risk Patient Management High-risk patient characteristics Frequent fliers (2+ hospitalizations in last 6 months) 30-day hospital readmission pattern Noncompliance with prescribed treatment options and medications Complex comorbidities, heart failure, COPD) Advanced care management Patient and system impact Better care coordination Increases communication between internal and external providers Enhances collaboration between PCPs and specialists Improves interaction among team members Facilitates seamless transitions in care management Improves outcomes Hospital based Transitions Coordinator Increases satisfaction and patient experience Practice guidelines Supported by Best Practice Council Improves care effectiveness Reduces unwanted variation Establishes goals and determines effectiveness Patient-centered medical home – level 3 Population management Prioritizes chronic conditions Identifies comorbidities Uses disease registries Integrates population management with care managers Utilizes population data to conduct profiling and predictive modeling Embeds care managers on site Conducts remote monitoring and pharm management Conducts pharm management and remote monitoring

Patient Care Cost Reduction Strategic initiatives for 2012 Avoidance of complications, hospitalizations and readmissions New York State certification of utilization management program Implement next phase of value-based physician compensation program (one-third to one-half of compensation)

Performance Improvement Priorities Risks associated with the disease, process or technique Frequency of occurrence Likelihood for error or complications Likelihood that intervention will improve outcomes or enhance value Probability of improving patient satisfaction and access Decision criteria and measures Relative cost, value, and outcomes related to alternative interventions

Organizational Engagement In Performance Improvement Active committee involvement Executive Management Committee Quality and Patient Safety Committee Infection Control Committee Medication Management Committee Environment of Care Committee Best Practice Council Clinical Transformation Committee

Care Management Initiatives 1 Structured documentation of targeted high-risk patients and populations 2 Standardized assessments, treatment plans, goals and outcomes 3 Real-time patient tracking and provider communication 4 Embedded care managers at medical homes sites, Ortho and transition coordinator at hospital Care manager-to-patient ratio: 1:100-125

Performance Improvement Monitoring Rate of complications Hospital admissions Reduction in 30-day readmissions Current tracking measures Patient satisfaction Frequency of preventive services Cost of care

Advanced Clinical Analytics And Predictive Modeling Identify gaps in in care and assessment Assess burden of disease in patients and population Develop outcome-based physician compensation program Implement predictive modeling platform

Care Manager Program Specialized registered nurse role and function Coordinators of care Transitions in care Access to EHR (appointment scheduling, electronic prescribing) Initiate transition care process within 24 hours of admission Meet with patients, families and caregivers Assess need for post discharge services, support and supplies Betty will add in these

Care Management Effectiveness Program assessment criteria Length of stay Post discharge complications 30-day readmissions Patient and caregiver satisfaction Goal: Patient quality of life Goal: Cost per episode of care (admission through 90 day post discharge)

Evolution Of Population Management 2004 2006 2008 2009 2010 2011 2012 2013 Health maintenance Health maintenance and disease management Disease management High-risk complex patients Pediatric vaccine management (children under 2) Joint replacements Hospital discharges 30-day readmissions CHF COPD Pediatric asthma Hospital discharges to SNF SNF 30 day readmission Add in: 2004 Health maintenance; 2006: Health maintenance and disease management

Patient Engagement Features 1 Establish resource center for shared decision-making (2013) 2 Provide evidence-based decision-making tools and support (patients and families) 3 Offer interactive internet-based education 4 Provide comprehensive services to patient support groups in community (including resources listed on Internet page) 5 Maintain web-based survey tools for patient feedback

Advanced Care Management Going Forward Documentation Data sources Advanced medical management Patient Centered Medical Home Chronic care Disease management programs Self-management tools Plan design financial incentives Care coordination Primary care Specialty care Post discharge transition management Telehealth Patients Biometric screening Health Risk Assessment Patients Health Risk Assessment Predictive modeling Risk stratification Asthma CAD CHF COPD Dementia Depression Diabetes Hypertension Low back pain High-risk populations Care manager Clinical Medical claims Pharm claims Laboratory Imaging EMR Encounters Physicians Resource use Practice pattern variation Patient satisfaction Patient engagement Motivational interviewing Interactive education Personal treatment plan Behavioral coaching Shared decision making Family support Complex patients Health promotion Preventative services Health screenings Lifestyle decision support Ancillary services Office visits High-impact preventable events Admissions Readmissions Emergency visits Outpatient visits Prescriptions Quarterly Committee Monitoring Executive Management Committee Best Practice Council Clinical Transformation Quality and Patient Safety Medication Management Infection Control Environment of Care

KEYS TO PHYSICIAN ALIGNMENT Prove that it works Improve quality Reduce cost Improve patient experience Translates to increased compensation personally (physician matrix) and globally (risk based contracts) Prove that it makes their lives easier

IMPROVING POPULATION HEALTH Diabetes Registry Meetings Included an endocrinologist, group of primary care physicians, nutritionist and care manager Identify patients with poorly controlled DM2 or lost to follow-up Care Manager Involvement at Point of Care Identify gaps in screening, treatment Encouraged compliance with regimen

IMPROVING POPULATION HEALTH Results Initial reduction in percentage of patients with poor DM control (A1c >9) from 23%  11%, mainly through registry meetings Further reduction in poor DM control and improvement in excellent DM control with embedded care managers

Poor DM Control (A1c >9)

Excellent DM Control (A1c <7)

COST REDUCTION Reduced outpatient cost Diabetes Reduced inpatient cost Admission data for CHF

COST REDUCTION

COST REDUCTION Cost increase for providers caring for patients encouraged by care managers to follow-up Overall cost decreased Cost increase offset by Standardization of care through variation reduction Improvement in A1c resulting in decreased need for office visits, labs

COST REDUCTION Admissions for CHF (Medicare) Practice has 1412 patients with CHF Care managers actively following highest risk CHF patients 517 admissions from 10/1/09-9/30/10 451 admissions from 10/1/10-9/30/11

IMPROVING PATIENT EXPERIENCE “…Sherry Rogers has gone above and beyond…She realizes the difficult situation my various health conditions put me in, and that my recent move to take care of my father means careful coordination of my medical visits to CRHC. Without Sherry's reminders, I may have put off (my mammogram) despite having symptoms such as a lump in my breast. I have been fortunate to have been taken care of by her…”

PHYSICIAN ENGAGEMENT - PROVE THAT IT WORKS Individual success: The Physician Matrix Hgb A1c <9 BP <140/90 LDL <100 for CAD patients Mammography Cervical cancer screening Colorectal cancer screening Influenza, pneumococcal vaccination Readmissions Global success: Shared Savings (MSSP, Private Payors)

PHYSICIAN ENGAGEMENT – PROVE IT MAKES LIFE EASIER

PHYSICIAN ENGAGEMENT – PROVE IT MAKES LIFE EASIER Improved transitions of care with inpatient care manager Appreciate assistance in coordinating follow-up visits with primary care providers and specialists Invaluable asset in ensuring patient is following the care plan Cases, near misses, saves

NEXT STEPS Embedded Care Managers in specialty departments CARETEAM program Reduce LOS Prevent readmissions Prevent initial admissions

THANK YOU QUESTIONS??? Scott Hines, MD: shines@cyrstalrunhealthcare.com Betty Jessup, RN, BSN: bjessup@crystalrunhealthcare.com