1. Join the conversation! Our Twitter hashtag is #CPI2011. Training Tomorrow’s Family Physicians in an ACO Mary Elizabeth Roth, M.D. Program Director Kistler Family Medicine Residency at Geisinger, Wilkes Barre Pa

2. Competencies of Family Physicians of the future Clinical knowledge, attitude and skills in family medicine across the six clinical competencies Proficiency with EMR Documented quality performance in core family medicine and work with performance improvement systems Efficiency to generate productivity for incentive programs Continuous professional learning Team care in the patient centered medical home Appreciation for their role as part of the systems of care

3. Accountable Care Organization Attributes Integrated system with own health plan Led by physician executives Large dedicated primary care network Electronic monitoring of care and outcomes Efficiency through teamwork Patient centered medical home gives personal care in large system

4. Geisinger Health System as ACO Physician led-CEO Glenn Steele M.D. PhD for $3 billion health system 850 physicians over large service area and three main hospitals /adding three more hospitals 200 employed FP’s in 40 separate practices over 32 counties EPIC electronic charts for all facilities with 2 million enrolled patients; 1 million primary care patients Geisinger Health Plan in 47 /67 Pennsylvania counties provides incentive for best practices, quality and paitent satisfaction

5. GHS-ACO Community Practice Service Line pays incentives for productivity and practice improvements and sharing of CMS cost reduction plans All offices and physicians have electronically monitored outcomes and initiatives for chronic disease GHP pays for case managers for at risk patients in patient centered medical home All physicians rated for outcomes on HEDIS, CMS, ADA, NCQA, etc

6. The Key Quality Issues in US HealthCare Unjustified variation Fragmentation of care-giving Perverse payment incentives – Units of work – Outcome irrelevant Patient as passive recipient of care

7. Join the conversation! Our Twitter hashtag is #CPI2011. Geisinger Health System Seeks to minimize variability while improving outcomes and lowering costs

8. Promising ACO Models of Payment and Care Delivery Risk- adjusted global fees Medical home fees + Bundled acute case rates Blended FFS and medical home fees Continuum of Payment Bundling Continuum of Organization Advanced primary care networks Multi-specialty physician group practices with hospital affiliation Integrated systems with ambulatory, inpatient, and post-acute care Continuum of Quality Bonuses and Shared Savings Quality bonuses for outcomes; large % of savings, some shared risk Quality bonus for prevention, chronic conditions; small % of shared savings Quality bonuses for coordination + intermediate outcome measures; moderate % of shared savings Less Desirable More Desirable Source: The Commonwealth Fund

9. How shared savings plans work A spending benchmark is established If quality targets are met within that spending target, shared savings from payers are then distributed to participating providers The ACO does not take insurance risk: –If costs go up instead of down, there is no penalty other than the amount invested to improve the performance Sg2 special report ACP Oct 2010

10. The functional components of an ACO Value Driven Acute Care: Proven Care Acute Value Driven Specialty Care: PHN Integration Value Driven Actuarial and Operational Informatics Value Driven Population Care ProvenHealth Navigator, Clinical Redesign Value Driven Post- Acute Care: TOC, SNFist 10 Cultural Transformation Data Driven Care and Leadership Evolutions

11. Geisinger’s Innovation Initiatives ProvenCare ® for Acute Episodic Care (the “Warranty”) ProvenCare ® Chronic Disease ProvenHealth Navigator SM (Advanced Medical Home) Transitions of Care

12. Proven Care ® Contracted Programs ProvenCare ® Coronary Artery Bypass (CAB) ProvenCare ® Coronary Artery Bypass (CAB) ProvenCare ® HIP Surgery ProvenCare ® HIP Surgery ProvenCare ® Cataract Surgery ProvenCare ® Cataract Surgery ProvenCare ® Percutanious Coronary Intervention (PCI) ProvenCare ® Percutanious Coronary Intervention (PCI) ProvenCare ® Low Back Pain ProvenCare ® Low Back Pain ProvenCare ® Perinatal ProvenCare ® Perinatal ProvenCare ® Bariatric Surgery ProvenCare ® Bariatric Surgery ProvenCare ® Cardiac Imaging ProvenCare ® Cardiac Imaging ProvenCare ® Thoracic Lung ProvenCare ® Thoracic Lung

13. ProvenCare ® Acute Programs CABG Perinatal Bariatric Surgery Low Back Hip Replacement Cataract Others: Erythropoietin (EPO) PCI Lung Cancer 13

14. ProvenCare ® Key Objectives Support the reengineering of care to deliver more value Support the reengineering of care to deliver more value –Episode Care – driven by proven clinical criteria Align reimbursement incentives with new approach Align reimbursement incentives with new approach –Global episode payment Build a business case to ensure sustainability Build a business case to ensure sustainability

15. ProvenCare ® Document appropriateness of careDocument appropriateness of care Establish evidence or consensus-based best practicesEstablish evidence or consensus-based best practices Reliably deliver these by redesign of complex clinical systems embedding them into everyday patient flowReliably deliver these by redesign of complex clinical systems embedding them into everyday patient flow Activate patients and families, engaging them in the care processesActivate patients and families, engaging them in the care processes Provide a packaged price for the episode of careProvide a packaged price for the episode of care The “Warranty” transfers risk for financial effects of preventable complications to GeisingerThe “Warranty” transfers risk for financial effects of preventable complications to Geisinger

16. Quality/Value - Clinical Outcomes Before ProvenCare® ProvenCare® % Improvement (n=132) (n=321) In-hospital mortality 1.5 %0.3 % 80 % Patients with any complication (STS) 38 % 33 % 13 % Patients with >1 complication 8.4 % 5.9 % 30 % Atrial fibrillation 24 % 21 % 13 % Neurologic complication 1.5 %0.9 % 40 % Any pulmonary complication 7 % 5 % 29 % Re-intubation 2.3 %0.9 % 61 % Blood products used 24 % 22 % 8 % Re-operation for bleeding 3.8 % 2.8 % 26 % Deep sternal wound infection 0.8 % 0.3 % 63 % Readmission within 30 days 6.9 % 5.6 % 20 %

17. ProvenHealth Navigator SM (Advanced Medical Home) Partnership between primary care physicians and GHP that provides 360-degree, 24/7 continuum of care “Embedded” nurses Assured easy phone access Follow-up calls post-discharge and post-ED visit Telephonic monitoring/case management Group visits/educational services Personalized tools (e.g., chronic disease report cards)

18. ProvenHealth Navigator SM (Advanced Medical Home) Currently serves 40,000 Medicare recipients and 25,000 commercial patients Results from best primary care sites: 25% patients’ admissions 23% days/1000 53% readmissions following discharge Significant benefit to patients and families, avoiding multiple hospital admissions

19. Clinical Process Redesign Components of a System of Care Established Techniques Guideline Development Education Measurement Timely Feedback of Data Patient Education New Techniques Delegated Team Responsibilities Strategies to Pull Patients into Care Non Office Visit Based Care EMR Reminders Pay for Performance

20. Workflow Principles 1.Automate work that can be done outside of an office encounter 2.Distribute work that is done at an office visit to trained non-physician staff when possible 3.Create reminders and EMR tools to enhance the reliability and efficiency of care provided at the office encounter

21. Practice Redesign Case Study Diabetes Systems of Care All or None “Bundle” measure for Diabetes Clinical process redesign – Eliminate, Automate, Delegate, Incorporate, Activate Clinical decision support – Health Maintenance and Best Practice Alerts Patient specific strategies using registry report data Care Gaps Patient centered strategies – Patient report cards Compensation

22. All or None Measures Measure the percentage of patients who receive all related services, not the scores of the individual measures Better reflects the patient’s interest and desires – to have all recommended care provided Encourages a systems approach to achieving all goals rather than work on one measure at a time Gives a more comprehensive scale for tracking systemic improvements

23. All or None Measure Even if individual criteria have great results, when calculated as an All or None metric – the need to work differently (systems of care) becomes evident

24. Diabetes Bundle

25. Diabetes Bundle Score Not all patients should achieve each measure – for instance not all diabetics should have a HgbA1c < 7 Individual component scores for GHS were very good – above the ADA recommended goals Yet initial GHS score was only 2.4% Easy to recognize that a dramatic restructuring of the care provided to diabetics was needed Practice Redesign Diabetes Systems of Care

26. Diabetes Process Redesign Computer/EHR Alerts and Reminders As Previsit Planning Reminder letters – CareGaps Outreach Clerical Scheduling of Flu/Pneumococcal, Follow Up Clinic Nurse Immunizations, Lab Testing, Foot Exam Case Manager High Intensity Coordination/Education Nurses Nurse Rooming Tool, Process Measure BPAs Providers Alerts and Reminders for Complex Decisions Patients and Families MyGeisinger, Patient Report Cards Automate Delegate Incorporate Activate

27. Timely Feedback of Data EPIC EMR allows collection of clinical data without manual chart reviews Data is collected on an individual physician basis, but summarized into site reports to encourage team based solutions and accountability Bundle percentage is the percentage of the site patients who are achieving all 9 of their diabetic goals

28. Improving Diabetes Care for 24,551 Patients 3/063/072/102/11 Diabetes Bundle Percentage2.4%7.2%10.8%11.5% % Influenza Vaccination57%73%76%77% % Pneumococcal Vaccination59%83%84%83% % Microalbumin Result58%87%79%78% % HgbA1c at Goal33%37%46%49% % LDL at Goal50%52%53%55% % BP < 130/8039%44%52% % Documented Non-Smokers74%84%85%

30. Diabetes Bundle Improvement Number of Bundle Elements Achieved % of all diabetic patient s 20 % 10 % 012345678All 3/31/06 6/30/06

31. Diabetes Bundle Improvement Entire Population Shifts Toward Better Care Bundle Increases 3/06 7/10

32. Improving CAD Care for 15,326 Patients 9/063/072/102/11 CAD Bundle Percentage8%11%21%22% % LDL <100 or <70 if High Risk 38%37%48%52% % ACE/ARB in LVSD,DM, HTN 65%66%76% % BMI measured79%86%99% % BP < 140/9074% 78% % Antiplatelet Therapy89%91%92% % Beta Blocker use S/P MI97% % Documented Non-Smokers86% 87% % Pneumococcal Vaccination80% 87%86% % Influenza Vaccination60%74%79%

33. CAD Bundle Primary Care Average

34. Adult Prevention Bundle Based on US Preventive Services Task Force (USPSTF) Recommendations and 2007 ACIP Immunization Schedule Received input from a broad group of primary care physicians from CPSL and GIM and also selected specialists Roll Out 1/08

36. Adult Prevention Bundle 203,695 Patients 66% of recommended tests performed on these patients Initial Adult Prevention Bundle Percentage = 9.2%

37. Improving Preventive Care for 216,562 Patients 11/072/11 Adult Preventive Bundle9.2%30% Breast Cancer Screening (q 2 40-49, q 1 50- 74) 46%61% Cervical Cancer Screening (q 3 yr Age 21-64) 64%72% Colon Cancer Screening (Age 50-84) 44%65% Prostate Cancer Discussion (Age 50-74) 72%76% Lipid Screening (Every 5 yr M > 35, F > 45) 75%86% Diabetes Screening (Every 3 yr > 45) 85%90% Obesity Screening (BMI in Epic) 77%96% Documented Non-Smokers75%78% Tetanus Diphtheria Immunization (every 10 yr) 35%70% Pneumococcal Immunization (Once Age >65) 84%87% Influenza Immunization (Yearly Age >50) 47%60% Chlamydia Screening (Yearly Age 18-25) 22%34% Osteoporosis Screening (every 3 yr Age > 65) 52%73% Alcohol Intake Assessment84%90%

38. Join the conversation! Our Twitter hashtag is #CPI2011. Consider completing a Self Assessment Module for MOC? Diabetes Hypertension Adult prevention CHF CAD Continuing professional development

39. Join the conversation! Our Twitter hashtag is #CPI2011. Training Family Physicians for tomorrow Let’s now talk about how residents get immersed in system redesign and expectations for performance in an ACO

40. Training family medicine residents Install residents in header as PCP Residents attend all practice group meetings FM residents attend PCMH team meetings FM resident receive monthly reports of productivity and personal and group’s performance on bundle measures

41. Residents as PCP Negotiate with health plans to recognize PGY1 as PCP Insist on scheduling continuity, based on header and patient choice Incorporate resident in all aspects of the practice’s care in office, home, hospital and SNF Send all forms to the residents

42. Monthly review for FM resident Bundle updates for the practice PCMH meetings Press Ganey reports about the resident as provider Residents appointed to quality initiatives and take the quality short course; reporting out at meetings

43. How many management meetings for a Geisinger FM Resident ? Monthly County CPSL meetings Monthly practice management at FMC– four FMC’s Every six month regional breakfast for all PCP’s Coding workshops in core lectures Coding updates in practice Each PGY3 resident joins CPSL leadership group once a year Each PGY3 resident sits with the Hospital clinical leadership group ( GWV-CLG) once a year PCMH meetings monthly for PGY3 and once a quarter for PGy1 and pGy2 Yearly CEO Vision meeting

44. Residents and Incentive Plans Effective July 2011 each FM resident may generate personal and team incentive similar to attendings –Charts must be closed each month for quarterly incentive –All GOALs courses must be up to date e.g. HIPPA, Influenza policies, elder abuse monthly as part of Continuing professional development –Team goal that monthly the residents as group must have representation at PCMH meetings – all or none quarterly incentive payment like attendings

45. Training Family Physicians for tomorrow Incorporate residents in quality improvement program as part of orientation Require all resident care in continuity meets system performance improvement goals and system tasks Residents have same professional training in GOALS as employed PCP’s

46. Performance improvement issues: Inpatient Hospitalist skills: –Rapid response teams –Morbidity-mortality reductions and monitoring –LOS, admissions and readmission –Ventilator care and reduction of infections –Central line care –PCMH –Case managers for aftercare –CHF, AMI and other Medicare Core measures

47. Join the conversation! Our Twitter hashtag is #CPI2011. Family medicine residents in performance improvement All care by residents monitored on same guidelines for excellence as employed attendings. Today’s FM resident may be tomorrow’s attending for GHS!

48. The six Clinical Competencies for medical staff credentialing Medical Knowledge Patient Care Practice Based Learning and Improvement Systems Based Practice Professionalism Interpersonal and Communication Skills

49. Join the conversation! Our Twitter hashtag is #CPI2011. All six clinical competencies are monitored By the family medicine residency and the health system

50. Join the conversation! Our Twitter hashtag is #CPI2011. Training residents within an ACO Assures the clinical competencies of system based practice and practice based learning and improvement which are hard to document

51. Join the conversation! Our Twitter hashtag is #CPI2011. Questions? Discussion Mary Elizabeth Roth,M.D. FACPE Training Tomorrow’s Family Physicians in an ACO