Department of Medicine Faculty Meeting November 21, 2017 ACO Update- Alastair Bell Announcements DOM Administrative Initiatives LCME Visit Self-study Inpatient Clinical Care Update

Preparing for MassHealth Reform Fall 2017

Agenda Basics of MassHealth reform BMC Health System preparations What to expect in the coming months

MassHealth is undertaking reform of the Medicaid program to curb the growth in spending MassHealth as a proportion of all State spending $ Billions Other State spending MassHealth-covered services $39.3 $37.4 $34.7 $32.5 $31.3 $28.9 $29.6 $30.3 $28.9 $27.8 State Fiscal Year MassHealth % spending 27% 28% 30% 31% 34% 33% 33% 34% 37% 38%

There are 5 core elements of MassHealth reform ACOs Providers coming together to form ACOs to take responsibility for cost and quality of care for patients ACOs partner with MCOs or the State to assume risk 1 Incentive funding 2 $1.8B in Delivery System Reform Incentive Payments (DSRIP) to ACOs, social service providers, CPs, and Statewide investments Social determinants 3 Updated risk coding to reflect the impact of social determinants of health on the cost of care Community partners 5 ACOs will collaborate with certified Behavioral Health (BH) and Long Term Services and Supports (LTSS) Community Partners Accountability & quality 4 Quality and performance on total cost of care modifies DSRIP funding and surplus/deficit sharing with the State

Agenda Basics of MassHealth reform BMC Health System preparations What to expect in the coming months

Through BMC Health Plan, we have 4 ACO partners across Massachusetts ACO partner organizations by region Boston ACO Boston Medical Center 10 Community Health Centers 3 Community Hospitals Mercy/Riverbend Signature Brockton Southcoast

While BMC is part of Boston Accountable Care Organization, our patients will be enrolled into the BMCHP Community Alliance health plan product BMC Health Plan (BMCHP) BMC is part of Boston ACO Boston ACO (BACO) BMCHP Community Alliance BMCHP Signature Alliance BMCHP Mercy Alliance BMCHP Southcoast Alliance Patients select the BMCHP Community Alliance health plan product

BACO is the largest of the 4 BMC Health System MassHealth ACOs with ~110,000 members Boston Area Community Health Centers Boston Health Care for the Homeless Program Codman Square Health Center DotHouse Health Greater Roslindale Medical & Dental Center Manet Community Health Center Mattapan Community Health Center South Boston Community Health Center South End Community Health Center # Lives 2500 10756 9534 3402 9023 4105 4672 5009 BMC Faculty Practices BU Affiliated Practices (BUAP) BU Child Health General Internal Medicine BU Family Medicine # Lives 3315 8172 11376 4225 Fall River/New Bedford Health Centers Greater New Bedford Community Health Center Health First Care Center Stanley Street Treatment and Resources (SSTAR) # Lives 13649 5452 3600 Community Hospital Systems Holyoke/Valley Health Partners South Shore Health System & PHO Sturdy Memorial Hospital # Lives 5600 5300 10172

We have made progress on a number of areas that emerged as recommendations. . . Recommended focus Select progress updates Care management for top 1-5% Complex care management Transitions of care ED avoidance Disease management Detail to follow Cross-system care redesign Department value based approaches Radiology decision support Clinically-driven UM Palliative care BMCHP levers Progress on ESRD, Sickle Cell, COPD Radiology decision support live on inpatient, pending on outpatient Expansion of palliative care service Managing leakage and service capacity Pediatrics Obstetrics Others (e.g., cardiology, GI, hematology) Substance use disorders Integrated & sub-specialty BH Estimation of leakage confirms – OB, Pediatrics, and Orthopedics as opportunities Engagement of partners on SUD and tele-psychiatry service models Continuity of care SNF / Rehab Substance use disorder Behavioral health Expansion of current SNF / Rehab program for uninsured patients Community partner engagement Enablers Central analytic function Provider compensation model Talent pipeline Educational programming Selection and build underway for Arcadia analytics platform Established research and evaluation position (Mike Silverstein, MD)

…and created the Population Health Services division of the system to provide a mechanism for integration of health plan and hospital expertise BMC Health System BMC Health Plan BMC Health Plan Population Health Services BMC / Faculty Practice Foundation BMC / Faculty Practice Foundation Boston ACO Care Management Services, e.g. Complex patients Transitions in care Disease specific programs Supporting functions: ACO partner support Performance analytics Research / innovation Quality

Care management has been a major area of focus and we are both building new programs and scaling up existing programs Disease specific care mgmt. Integrated Behavioral Health Addiction Services Pharmacy ED Care Management Care transitions End of life care Social determinants of health Patient in care management

Increasing control over medical expense management We have negotiated with partners to directly deliver care management services for the majority of the ACO population Increasing control over medical expense management Partner delivered care management BMCHS Data and Care Management IT BMCHS delivers Care Management at partner sites CM protocols Performance data on CMs Prioritization of patients IT platform CM protocols Prioritization of patients Hires and manages staff at partner sites ~17K lives ~20K lives ~150K lives

Housing Stabilization and Support Services Addressing Social Determinants of Health is another critical component of our approach Nutritional Needs Educational Opportunities BMC Food pantry & demonstration kitchen: providing food for more than 80K people per year Thrive screener: assessing patients’ desire for additional education and connecting them with resources Financial Stability Social & Cultural Needs StreetCred: helping families obtain the Earning Income Tax Credit – the program returned $400K to ~200 families in 2016 Violence Intervention Advocacy Program: working to break the cycle of violence for those presenting to the ED with gunshot or stab wounds Patient/Member Health Housing Stabilization and Support Services Housing Prescriptions: helping 50 families with young children find and maintain affordable housing Investment in REIT focused on sustainable housing

Agenda Basics of MassHealth reform BMCHS preparations What to expect in the coming months

Timeline of key ACO milestones including patient/member enrollment 2017 2018 Jul Aug Sep Oct Nov Dec Jan Feb Mar 1/1 ACO soft launch and patient assignments 7/28 Updated rates released 8/16 ACO signed contracts 11/1 Advertising Campaign launch 11/13 – 12/22 Special assignment letters & enrollment guides mailed to members 3/1 ACO Launch and Enrollment effective Patients who already have PCPs will be auto-assigned to the ACO product their PCP is a part of If patients like their product assignment they do nothing Patients will have the option to select a new PCP in a designated time period After patients receive their enrollment information, we will be sending letters to our patients as well

Between now and program launch on March 1, we will focus on three major areas with BACO and other ACO partners Administrative Complete regulatory certifications Set up governance of combined BMCHP-ACO products 1 Medical management Core medical management program implementation IT platform implementation Approach to Quality Metric performance Preferred partnerships with BH and LTSS community partners DSRIP investment planning 2 Operational readiness Round out coding gap analysis and create action plan for improved coding Provider and staff training and education Member transition and communications 3

Announcements Jerry Ellner, M.D. is stepping down as Chief, Infectious Disease Section effective December 31, 2017 but will continue as a member of the faculty Tamar Barlam, M.D. has agreed to serve as Interim Chief of the Section of Infectious Diseases effective January 1, 2018 Search for the Chief, Infectious Disease Section ongoing Matt Kulke, M.D. has accepted the position of Chief of the Hematology-Oncology Section effective March 1, 2018. TB clinic being re-structured in partnership with the Boston Public Health Commission. Search for VC Research underway, Barbara Corkey to step down from the position December 31, 2017

Faculty Development Seminars CV Boot Camp Appointments & Promotions Committee Members December 5th from 12-1pm in Wilkins How to Conduct a Systematic Literature Review & Meta-Analysis David Flynn & Ludovic Trinquart December 11th from 12-1pm in Yawkey Basement Conference Room

DOM Networking Dinners Women’s Dinner (faculty, post docs, residents, fellows) November 28th from 6:30 to 8:30 Educators’ Dinner January 10th from 6:30 to 8:30 Enjoy good food and meaningful discussion with your DOM colleagues. Emelia Benjamin’s home in Brookline RSVP to Robina Bhasin at rbhasin@bu.edu

Upcoming Grant Deadlines Faculty Development & Diversity Grants Open to ALL DOM FACULTY at all levels seeking to further their professional development Next deadline is January 15th http://www.bumc.bu.edu/facdev-medicine/grants/

Writing from the Front Lines of Clinical Care, Education, and Research New DOM program launching 2018 Target—clinicians, educators, scientists Thursday 4-6 pm, monthly January-June Develop narrative skills through reflective writing, reading, listening, & peer mentoring Goal to submit piece June 2018 Applications open soon For information or interest please contact Christy Di Frances, PhD at christyd@bu.edu

Grand Rounds December 1: “World AIDS Day Update” Dr. Jon Fuller December 8: “Clinical Case Discussion” Dr. Rob Lowe December 15: Clinical-Basic Discussion Series, Drs. Hemant Roy and Gustavo Mostoslavsky January 5: “Immunotherapy in Cancer and Toxicity Management” Dr. Kerry Lynn Reynolds, Mass General Hospital

2018 DOM Finance and Administration Strategic Initiatives 11/16/2017 1 Increase (Preserve) Revenue 2 Decrease Expenses Copay collection (Jen F) Epic RCM go-live (Sue) BACO MassHealth ACO (Eva) Fundraising (Laurie & Eva) New grant awards (Rachelle) Food expenses (Vidushi) Research expenses (Vidushi & Rachelle) True Grant deficit (Rachelle) Shared fellowship resources (Laurie) 3 Improve Efficiency 4 Celebrate Engagement Administrator Guide (Raquel & Casaundra) Faculty annual salary process (Rhea) Centralized website support (Erin) Marketing Plan (Erin) Admin Grand Round (Karman) Book Clubs (Donna) Social events (Nellie and Jen V) DOM Admin Awards (Erin)

LCME Accreditation Visit Visit Scheduled for February 2019 Self-study period underway Areas of Concern Amount of Mistreatment cited by Medical Students- only modest change since last survey Mental health resources for students Physical (Relaxation) space availability

Inpatient Clinical Initiatives Patient Flow and Discharge Time Readmission Risk Assessment LOS (O/E >1) Early Morning Discharge->Discharges before Noon Pre-Discharge Order (PDO) Morning Rounds: Discharges first where appropriate, target finish 10:30am Multidisciplinary Rounds Call Center Follow-up Appointments UBER Transport Meal Vouchers

Inpatient Clinical Initiatives Managing messaging: Operations and Quality Every 2 weeks face-to-face at attending orientation and every 3 weeks at resident orientation Email sent with responsibilities and initiatives eve of orientation to attendings on-service and to new rotation residents In person every Monday AM with each team during rounds: each team receives their data for prior week and teams on MP and ENC with best metrics receive gift certificate to DD Inpatient Service Directors also communicate messages and data to Section Faculty

Inpatient Clinical Operations Updates for FY17 FY17 YTD1 Last 3 months (Jul – Sep) 2 FY17 goal YTD Status Mortality O/E 1 ≤0.93 0.87 0.85 Preventable Harm Index 2 ≤0.90 1.27 0.82 Readmissions rate 3 ≤10.96% 10.79% 11.03% ED length of stay (admitted) 4 ≤320 mins 396 mins 389 mins Discharge time 5 1:37 PM 2:44 PM 2:45 PM Length of Stay O/E 6 ≤0.933 0.924 0.941 Patient Experience 7 ≥73.0% 70.9% 71.8% 1 For Mortality, LOS O/E = Oct – Aug, for readmissions = Oct-Jul, for PHI = Oct - Jun; For all other metrics Oct - Sep; 2 for Mortality, LOS O/E last three months = Jun - Aug , For readmissions May - Jul, For PHI Apr - Jun SOURCE: UHC, Data Analytics & Reporting

BMC Inpatient & Observation1 Average Discharge Time Time of day 1 Excluding OBS unit Source: SDK

Average Inpatient & Observation Discharge Time by Team – FY17 YTD (Oct - Sept) Note: Only teams with >20 discharges in the time period shown Source: SDK

Average Discharge Time by Service Last three months (Jun - Aug) FY17 YTD (Oct - Aug) Goal YTD Status 2:38 PM 2:56 PM 2:00 PM Cardiology N/A 3:12 PM 2:00 PM CHF 3:27 PM 3:31 PM 3:00 PM Geriatrics 2:55 PM 3:06 PM 1:45 PM Gen. Med 2:46 PM 2:34 PM 1:30 PM Infectious Disease 3:00 PM 3:41 PM 2:00 PM Hem Onc 3:09 PM 3:01 PM 1:15 PM ENC Hospitalists 2:38 PM 2:33 PM 1:15 PM MP Hospitalists 3:44 PM 3:53 PM 3:30 PM Renal Source: UHC, SDK, Data Analytics & Reporting team