1. #HASummit14 Session #13: Allina: How a Pioneer ACO Is Using Analytics to Improve the Management of Heart Failure Pre-Session Poll Question On a scale of 1-5, how effective is your organization’s ability to deliver coordinated care? 1)Not at all effective 2)Somewhat effective 3)Moderately effective 4)Very effective 5)Extremely effective 6)Unsure or not applicable Spencer Kubo, MD, HF Program Medical Director Allina Health

2. #HASummit14 11 hospitals, 3 cardiovascular offices, 55 PCP offices, 50,651 HF patients, 12,735 HF admissions (14% of all hospital admissions) About the organization 2 Not-for-profit integrated delivery system, Pioneer ACO Serving communities in Minnesota and western Wisconsin

3. #HASummit14 The Problem Individuals with chronic diseases must manage their care between highly intermittent interactions with care providers within a complex and fragmented health system. The elevated cost of care among patients with chronic diseases offers a significant opportunity to develop a coordinated care plan that meets patients’ needs more effectively, at a lower cost. Allina hospitals’ 30-day readmission rates for HF were generally running well above 20 percent. Allina recognized that they had limited access to high quality data. Fee-for-service world creates silos—not conducive to effective collaboration and coordination of care. Unintentional, yet profound lack of care coordination in the management of HF patients. 3

4. #HASummit14 The Problem at United 4

5. #HASummit14 30-Day HF Re-admits Are Epidemic 5 Google HF Readmissions= 2.5 million hits

6. #HASummit14 Analysis of 30-Day Readmissions 6 3Q 2011 – 15 cases 4Q 2011 – 13 cases 1Q 2012 – 15 cases 2Q 2012 - 9 cases 6 general categories: 1. Patients transferred from another hospital: n=6 2. Patients admitted for a scheduled procedure: n=5 3. High-risk patients (multiple co-morbidities) admitted with fluid overload: n=18 4. Patients with documented non-compliance: n=12 5. Rapid re-admits within 0-2 days of discharge: n=7 6. Patients admitted with a new unrelated diagnosis in addition to HF: n=10 Bottom line:- MANY different reasons for HF readmission. - No one size fits all - Need to have clinical judgment. 52 Total

7. #HASummit14 Secret Sauce: People and Process 7 Clinical expert in heart failure (HF RN Care Coordinator) Patients identified each day by the HF nurses using EHR See all hospitalized patients with primary HF regardless of which physician is following Ensures education completed and clinic appointments are made prior to discharge Followed until stable by phone and in clinic to coordinate care and for early identification of issues Connects all the OP providers Tandem visits with cardiology NP during hospital follow-up visit

8. #HASummit14 HF Readmissions at United 8 Yellow arrow denotes start of the Heart Failure Program at United

9. #HASummit14 The Allina HF Program The HF Program coordinates patient care activities among all participants to achieve safer and more effective care 9 Nursing Care Coordination Protocols and Guidelines Measurement and Reporting Education Heart Failure Program Committee

10. #HASummit14 The Need for Actionable Data 10 Implemented a late-binding enterprise data warehouse (EDW) platform to take advantage of available information and provide support for providers and managers. The EDW aggregates clinical, financial, operational, experience, and other data to create consistent views of the data to inform decisions. The HF dashboard is used to monitor and manage performance, to drive behavior change, and as “case finding tool.”

11. #HASummit14 The Heart Failure Dashboard The HF dashboard is used to monitor and manage performance, to drive behavior change, and as “case finding tool.” 11

12. #HASummit14 Poll Question #2 15 On a scale of 1-5, how effectively is your organization using data to drive behavior change and performance improvement? 1)Not at all effective 2)Somewhat effective 3)Moderately effective 4)Very effective 5)Extremely effective 6)Unsure or not applicable

13. #HASummit14 HF Readmission Rates Pre- and Post- Care Coordination Programs 13 Population: HF patients who are eligible for Readmission Flag; numerator patients with Readmission Flag - Yes, denominator patients with Readmission Flag Yes and No (N/A not counted); Significance analyzed with Chi-Squared tests, 1 degree of freedom Pre and Post Dates: ANW 01/2009-09/2013 (Pre), 10/2013-05/2015 (Post); MCY/UTY 01/2009-12/2009 (Pre), 01/2010-05/2015 (Post); UTD 01/2009-05/2012 (Pre), 06/2012-05/2015 (Post)

14. #HASummit14 5-Day Follow-Up Rates Pre- and Post- Care Coordination Programs 14 Population: HF patients who are eligible for Follow-up Flag; numerator patients with follow-up- Yes, denominator patients with Follow-up Flag Yes and No (N/A not counted); Significance analyzed with Chi-Squared tests, 1 degree of freedom Pre and Post Dates: ANW 01/2009-09/2013 (Pre), 10/2013-05/2015 (Post); MCY/UTY 01/2009-12/2009 (Pre), 01/2010-05/2015 (Post); UTD 01/2009-05/2012 (Pre), 06/2012-05/2015 (Post)

15. #HASummit14 Future Plans Continue to improve HF care coordination and performance Continue to expand and improve analytics capability In addition to 30-day readmissions, focus on readmissions at 6 and 12 months Continue to strengthen and improve partnerships with primary care, cardiologists, and other care providers Improve the rate at which newly diagnosed HF patients are entered into the HF program Improve compliance with best practice protocols and care plans with the goal of improving quality and length of life Measure the financial impact of the HF program 15

16. #HASummit14 Lessons Learned 1.Start small and work your way up 2.Reaching out to people reaps enormous benefits 3.A strong motivated physician champion/leader that has the time to spend on leading and driving things forward is essential 4.Care Coordinators and the NPs play a vital role in making the HF program work 5.Everyone on the care team needs to step up and look for care gaps (ways to improve care)

17. #HASummit14 Analytic Insights 17 A Questions & Answers

18. #HASummit14 Choose one thing… 18 Write down one thing will you do differently after hearing this presentation

19. #HASummit14 Thank You 19

20. #HASummit14 20 Session Feedback Survey 1.On a scale of 1-5, how satisfied were you overall with this session? 1)Not at all satisfied 2)Somewhat satisfied 3)Moderately satisfied 4)Very satisfied 5)Extremely satisfied 2.What feedback or suggestions do you have?

21. #HASummit14 Upcoming Speakers 3:45 PM – 4:35 PM 16)Delivering Excellence at Stanford Health Care Amir Dan Rubin, President and CEO, Stanford Health Care 4:35 PM – 5:00 PM 17)The Future World of Value-Based Healthcare (Documentary featuring Michael Porter) Caleb Stowell, MD, Vice President, Research and Development, International Consortium for Health Outcomes Measurement (ICHOM, Senior Researcher, Harvard Business School) 21 Location Grand Ballroom