Atrius Health as an ACO/PCMH: Strategies to coordinate with our patients across the continuum (Hospitals, SNF’s, Home Care) MassPro February, :30p-3:30p Kate Koplan, MD, MPH Director of Medical Management Atrius Health 1

Atrius Health – Background Non-profit alliance of six leading independent medical groups –Granite Medical –Dedham Medical Associates –Harvard Vanguard Medical Associates –Reliant Medical Group –Southboro Medical Group –South Shore Medical Center Provide care for ~ 1,000,000 adult and pediatric patients in almost 50 ambulatory sites 1000 physicians, 1450 other healthcare professionals across 35 specialties NCQA-Level 3 Certified Patient- Centered Medical Home at all Groups Long history with global payments, currently managing 50% of our patients with global payments. Strong infrastructure to manage risk One of first to sign BCBSMA Alternative Quality Contract (AQC) and One of 32 Medicare Pioneer ACOs nationally

Elements of Patient Centered Medical Home Personal physician Physician-led care team Whole person orientation Coordinated Care Across Continuum  HOSPITAL/SNF/HOME CARE Enhanced access Quality Safety Patient and family centered

Comprehensive ACO/PCMH work must extend to the “continuum” ~20% of Medicare patients hospitalized at least 1x/yr (Medicare Preferred and ACO) They require services at discharge: »20-45% hospital discharges lead to SNF or Rehab stay »1/3 receive Home Health »1/10 receive outpatient/ambulatory therapy

Preferred hospitals will have at least two of the following: –Unique contracting relationship –High-volume or at least a regionally high-volume –Site or Group preference, with supportive communication strategy –Formal collaborative relationship between Atrius Health and Hospital, including steering, clinical collaboration, and IT committees –Standards and metrics agreed upon and regularly reviewed, including discharge coordination and use of Atrius’ preferred network –Mutual agreement that Atrius and Hospital will collaborate on IT interoperability, including Atrius patient identification at registration and notification to primary team of admission and discharge –Atrius Health and Hospital physician and administrative leads to guide relationship 5

Preferred SNF Facility Standards General: –Staffing/HR requests, incl. credentialing –Facility agrees to use Atrius Health preferred providers (DME, VNA, specialists) Pre-Admission: –Patient screen and bed availability streamlined –Patients are identified as Atrius Health patients –Able to accept direct admits from home/ER/clinician office. During stay: –Facility comfort for pts and staff –INTERACT tool (or comparable quality tool) –Therapies are available seven days per week; Mental Health coverage –Team and care planning meetings; facility case manager responsibilities –Radiology, Lab, Pharmacy expectations At Discharge and Post-Discharge: –Patient experience survey –Atrius preferred vendors utilized for DME, Home Care, Home Infusion, Hospice, etc. –D/c planning based on checklist, incl. med list, sharing ACP directives, teach back 6

Preferred SNF Provider Standards Discharge Planning –Templated summary; sent w/i 24h to Atrius Med Records –Ensure that f/u care is appropriate and that patient returned to Atrius Health PCP 24/7 coverage by experienced and responsive clinicians Timely communication to PCP if unexpected change in patient’s status Newly admitted patients seen w/i 48h of admission by physician Utilize Atrius Health preferred providers during stay Participate in team and family meetings Participate in quality and INTERACT or other related readmissions reviews Comply with all payer minimum requirements 7

Pioneer ACO SNF-based Collaboration Representatives from the five Eastern Massachusetts began regular meetings in November The group has recently expanded to include representatives from Leading Age and Mass. Senior Care Federation. The first initiative was to create expectations for both SNF Facilities as well as for SNF Providers. So that SNFs would have one set of common expectations and not five. Expect that they will be released in the next few weeks. The next effort will be develop a set of expectations for hospitals when transferring a patient to a SNF.

Standards and Metrics to Define our Hospital/SNF Strategy Relationship structure Care coordination, including case management and transitions of care On-site functions IT interoperability Unique contracting opportunities Preferred providers/vendors post-dischargee 9

Improved Care Coordination & Work across “Continuum” Differential process for discharge to SNF, home with services, and home without services, plus care coordination’s link with elder care services –Standards & Metrics, incl. IT interoperability Post ED and hospitalization follow up within 7d, w focus on medication reconciliation and care coordination “Call First” campaign – encourage follow-up at our facilities if ambulatory-sensitive, or use of our preferred inpatient facilities, if level of care is appropriate Data: post-facility f/u, readmissions trending (3d, 7d, 30d), high risk patient reviews, etc… Direct liaison with our hospital/SNF/homecare partners 10

Open Time Questions & Discussion 11