1. Partners in Accountable Care: Atrius Health and Aging Services Access Points (ASAPs) May 29, 2013 Community Care Linkages SM Mass Home Care

2. Today’s Discussion Atrius Health: Who We Are Atrius Health’s Pioneer ACO Strategy Community Care Linkages/Mass Home Care, Aging Service Access Points (ASAPs) Atrius Health - ASAP Partnership Lessons Learned and Next Steps 2 Community Care Linkages SM Mass Home Care

3. Atrius Health. 3

4. Atrius Health Core Competencies Corporate Data Warehouse integrates single platform, electronic health record data with multi-payer claims data to manage quality and cost Long history with and majority of revenue under Global Payment across commercial and public payers Widespread Population Management tools including disease-based and risk-based rosters Sophisticated development and reporting of Quality and Performance Measures Patient-Centered Medical Home foundation, achieving level 3 NCQA Newest Addition to Atrius Health: home health care, private duty nursing and hospice care through VNA Care Network & Hospice 4

5. Why Participate in Pioneer ACO? “Reason for Action” 5

6. 6 Key Features of Pioneer & Performance Measures

7. Quality Measures: Key Features 7

8. Outcome Primary Drivers Secondary Drivers High Value Care for Medicare Patients Stratified, population- based, geriatric model of care Coordination of post- acute care and care transitions Aligned hospital relationships Integration of home-based care and community supports Longitudinal management of chronic conditions Population-based outreach and preventative care Effective network of facilities and providers Consistent and appropriate documentation and information exchange Shared SNF coverage with other Boston Pioneers Discharge process that includes standard Atrius Health elements Bi-directional access to medical records Atrius Approach to Pioneer Tight coordination of 5% highest risk patients Concurrent reporting of admissions, discharges, ER visits Collaborative care improvement and performance incentives 8

9. Addressing the Gaps in Home-Based Care Accountable for managing care, cost and quality of Medicare services in the home setting. Costs are substantial across dozens of post-acute providers. Patients have choice and are geographically distributed. Poor transitions result in unnecessary readmissions and other wasteful costs, harm, and errors. No standard model of home- based care across Atrius Health, no standard measurement 9 ASAPs, while not currently Medicare providers, can be an important resource in closing these gaps.

10. ASAP Strategy: Link Primary Care to Community Home Care Services Achieve triple aim objectives by linking primary care practices to community resources –Reduce costs through prevention and/or reduction of unnecessary utilization of health care services –Improve health outcomes through better care coordination and patient education –Improve patient experience and satisfaction by aligning with goal of remaining functionally active at home 10 Community Care Linkages SM A Division of Mass Home Care

11. ASAPs (AAAs) are a valued partner in moving health reform efforts forward: o CCTP/Section 3026 (care transitions) o Self Management Supports/CDSMP – Healthy Living Center of Excellence, http://www.healthyliving4me.orghttp://www.healthyliving4me.org o The Community Living Program - Partnering with SCOs, ACOs, PCMHs and Integrated Care Organizations (ICOs) to serve dual eligibles 11 Community Care Linkages SM Mass Home Care Community Care Linkages is a strategic initiative that effectively integrate services of the Massachusetts Aging Services Access Points (ASAPs) with the evolving healthcare delivery system.

12. Atrius Health – ASAP Collaboration  Expansion of the “Care Team” to include the patient’s home and community-based networks  Requires: effective communication for timely and efficient referrals, hand offs, and “closing the loop”  Results in: patient centered care plans with realistic goals and resources for implementation  Collaboration through: Practice-based Pilots Population-based Interventions Community Care Linkages SM A Division of Mass Home Care 12

13. Atrius Health/ASAPs Practice-Based Pilots 1.HVMA Chelmsford & Elder Services of Merrimack Valley 2.Southboro & BayPath 3.HVMA West Roxbury & Ethos 4.HVMA Wellesley/Watertown & Springwell Currently expanding to new sites Community Care Linkages SM Mass Home Care 13

14.  Practice-based pilots and population-based interventions of varied intensity  Creation of patient centered care plans with resources for implementation  Development of standard work processes for optimal care coordination OUR PARTNERSHIPS Harvard Vanguard Medical Associates- Chelmsford with Southboro Medical Group with Harvard Vanguard Medical Associates- Wellesley and Watertown with PROGRESSION OF SERVICE DELIVERY Direct communication between practices and ASAPs with secure e-mail Enhanced care coordination to “close the loop” on services provided On-site ASAP Social Worker integrated into the practices Community Care Linkages SM Mass Home Care

15. Atrius Health and ASAPs: Progression of Integration Atrius/AAA Level of Integration Points of Contact Secure Email Coleman/C ommunity Living Coaches Case Review Contract for ASAP Staff CDSMPs on site SMG/BayPath HVMA Chelmsford/ESMV HVMA W.Roxbury/Ethos HVMA Wellesley & Watertown/Springwell HVMA/Kenmore GMG & SSMG/SSES HVMA Medford/MVES HVMA Peabody/NSES HVMA Concord/Minuteman Future Sites TBD 15

16. A New Paradigm The Patient-Centered Medical Home  Southboro & Framingham Pilot –Goals: Reduce hospital and ED utilization Improve quality scores above rest of department Bring in new patients –Compare performance of both practices with ASAP Social Worker as “authentic member of care team”  Methods: –5 hours/week/FTE of Physician management time (Southboro only) –Care manager for ACO/TMP patients; monthly physician meetings –Team-based Diabetic and High Risk Roster reviews –Monthly all-staff meeting and patient discussions –Use of NPs in a collaborative care model (Southboro only) –Financial incentives for exceptional performance 16

17. Results of Pilot Hospitalizations and ED use were significantly reduced in 2012 for all of adult medicine. In terms of utilization, the Framingham pilot performed better than non-PCMH physicians, and Southboro performed better than Framingham. When the physicians were asked for the single aspect of the program that made a difference they stated the Care Management team. Spread model pending the full analysis (including patient experience, quality scores, provider satisfaction, net financial impact, etc.). 17

18. Value Proposition for MD Practice ASAP as Authentic Member of Care Team Quicker and "more economically feasible" to buy Better access to ASAP services through embedded staff in practice (vs. standard I&R) Improved care management that reduced duplication of handoffs More patients access ASAP network services through relationship Opportunity to focus on prevention, develop innovative model for best practice Align with ACO measures Reduces burden on MD practices 18 Community Care Linkages SM Mass Home Care “wish she was here 5 days per week” “Our staff can focus more on care management and less on the details or making arrangements”

19. Opportunities Build sustainable relationships beyond individuals Continuous learning together = innovation Demonstrate Value = Clinical and Financial Commitment Introduce new services and technologies Opportunities Build sustainable relationships beyond individuals Continuous learning together = innovation Demonstrate Value = Clinical and Financial Commitment Introduce new services and technologies Challenges Not fast enough –Pilot to Scale –Too many changes Data timing –Utilization & Costs –Quality measures Integration into primary care protocols –Work flow changes –Education Challenges Not fast enough –Pilot to Scale –Too many changes Data timing –Utilization & Costs –Quality measures Integration into primary care protocols –Work flow changes –Education

20. Lessons Learned External/CMS More unknowns than expected, more risk Pioneer is more than Medicare - federal agencies have a stake Potential conflicts AND/OR opportunities with other initiatives –CCTP, MSSP ACOs, Bundled Payment Pilot External/CMS More unknowns than expected, more risk Pioneer is more than Medicare - federal agencies have a stake Potential conflicts AND/OR opportunities with other initiatives –CCTP, MSSP ACOs, Bundled Payment Pilot 20 Internal Atrius Health MD engagement drives change Care Managers are key to everything Atrius Health level contract creates a burning platform Internal Atrius Health MD engagement drives change Care Managers are key to everything Atrius Health level contract creates a burning platform ASAP Collaboration Build relationship with one point of contact and spread Allow time for MD practice staff to “experience” value of ASAP, one patient at a time Participation in case “roster” review is powerful ASAP Collaboration Build relationship with one point of contact and spread Allow time for MD practice staff to “experience” value of ASAP, one patient at a time Participation in case “roster” review is powerful

21. What’s Next? Spread the good work Track the results For Pioneer and ASAP work 21 Community Care Linkages SM Mass Home Care SCO ICO For Atrius, More “O”s….

22. Questions? Emily Brower Executive Director, Accountable Care Programs Atrius Health Emily_Brower@AtriusHealth.org Amy S. MacNulty Project Director Community Care Linkages amy@macnultyconsulting.com Community Care Linkages SM Mass Home Care