1. Super Panel: Lessons, Predictions and Pearls: 2016 and Beyond Moderator: Steven Landers, MD, MPH Panelists: C. Gresham Bayne, MD Peter Boling, MD Thomas Edes, MD MS Bruce Leff, MD Connie Row, LFACHE Robert Sowislo, MBA Barbara Sutton, MSN, APRN, ACHPN George Taler, MD

2. Faculty Disclosures Bayne – no relevant disclosures Boling – no relevant disclosures Edes – no relevant disclosures Landers – no relevant disclosures Leff – no relevant disclosures Row – no relevant disclosures Sowislo – no relevant disclosures Sutton – no relevant disclosures Taler – Merck, Inc. – Speakers Bureau

3. Objectives Plan for some of the changes that are anticipated for home-centered care. Recall the lessons learned.

4. C. Gresham Bayne, MD Emeritas Director, AAHCM Lesson: I entered the field with passionate principals. I learned it is, first, a business proposition. Prediction: The payors will continue corrupting our models, missing the intrinsic value of housecall medicine: it has the potential to restore doctor/patient trust. Pearl: When patient satisfaction controls behaviors more than quality of care, the risk of “therapeutic nihilism” can be a real danger.

5. Boling Resource-intensive IAH team & extra payments are essential…. for the more complex patients Stay true in targeting focus, provide & demonstrate real value Workforce development will be critical for responsible scaling of IAH – this is not easy work Develop robust educational opportunities tied to new funding mechanisms Linking mission and margin is essential Learn to make the business case, persevere Prediction: “if we build it, they will come” - before we retire, anyone who needs home-centered medical care will be able to get it (personal goal)

6. VA Experience in Home Based Primary Care – Can We Impact Beyond VA? Comprehensive Interdisciplinary Teams : Physician, Nurse, Social Worker, Rehabilitation Therapist, Dietitian, Mental Health Provider, Pharmacist. High cost or high value? Those with greatest need for most frequent care face steepest challenges with access to care. HBPC provides the solution. Future: HBPC at every academic training program Focus on Outcomes - clinical and economic. Caregiver support; Mental Health – 40% depression, 21% PTSD, 19% Schizophrenia. If we do not adequately manage mental health conditions, we will not adequately manage medical conditions. Reduce avoidable hospitalizations - Gold standard medication reconciliation happens at the kitchen table. Future: HBPC recognized as Integral to solution to unsustainable rise in health care costs Palliative Care – Moving palliative care upstream. Veteran decedent use of hospice. 2000-5%; 2014 – 41%. Among VA inpatient decedents, more die in hospice beds than in ICU plus hospital combined. Person centered. Future: HBPC as model for innovation: Palliative care, hospital in home, transitions, Medical Foster Home Growth: 1996 to 2000 – in half of VA Medical Centers, declining, misperception that “we cannot afford HBPC.” 2000 to 2016: From half to 100% of VAMCs, plus 250 Clinics,12 Reservations; Rural. Expanded from 7000 to over 36,000 Veterans daily. VA and IAH. Future: HBPC increases access, improves quality and lowers total cost of care – by adding services, not restricting services.

7. Bruce Leff – Importance of Quality Measurement in Home-Based Medical Care Lesson: MACRA / MIPS changes everything Prediction: robust quality improvement processes will need to be integrated into home-based medical care Pearl: we are creating mechanisms for home-based medical care providers to engage in value-based care via 2 mechanisms: 1) a CMS Qualified Clinical Data Registry (QCDR) in association with professional society; 2) NQF measure endorsement process for setting and patient-appropriate quality indicators

8. Row – The “Villages” Movement and House Calls Lessons: The lack of social service supports defeats aging in place for many, including those who have medical supports. Predictions: “Villages” volunteers are providing social service supports across the country; the movement has taken off and is growing from hundreds to thousands. Villages need medical care connections. Pearls: Wise house call programs are already connected to Villages. Consider making yours one of them!

9. Sowislo – Scalability Steps to SCALE in a delivery environment moving to value Lesson: Scale Requires Capital Scale must be accomplished that supports care coordination functions of current and future models Comprehensive Primary Care + Functions: Access and Continuity Care Management, Comprehensiveness and Coordination, Patient and Caregiver Engagement, and Planned Care Operational breakeven, Shared Savings provides returns and sustainability Prediction: Consolidation MCO interest will grow (Duals/Medicaid) Multiple Shared Savings Programs for ALL HBPC patients Practice certifications Pearl: Innovate Around Care Delivery Team based care with a non face-to-face component

10. Sutton Mission and margin: learn the business side Define your practice: we want to be everything to everyone Know your community partners and build relationships Build strong interdisciplinary teams Administrative support

11. Taler Legislative initiatives IAH has been perceived as a success in both Congress and CMS by all measures, so far. Telehealth Infusion services Conversion of IAH to a national program requires both a legislative and regulatory strategy This is harder than we ever imagined: Responsible scaling Culture change Rapid-Cycle Improvement, both clinically and regulatory Right-sizing expectations

12. Panel Discussion Go to: 2Shoesapp.com/AAHCM20162Shoesapp.com/AAHCM2016 1.Click on the session you are in 2.Ask and vote on questions

13. References The national Villages network: www.vtvNETWORK.org. See national map, meeting, research results, concerns about medical care needs of residents. www.vtvNETWORK.org Washington (DC) Area Villages Exchange: an example of regional networks: www.wavevillages.org/index.php/about-us/our- villages www.wavevillages.org/index.php/about-us/our- villages