Facilitating Care Coordination and Transitions in an ACO
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Presentation at the World Congress 2nd Annual Leadership Summit on Accountable Care Organizations, May 22-24, 2010, Vienna, Virginia
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Facilitating Care Coordination and Transitions in an ACO
- 1. Facilitating Care Coordination and Transitions in an ACO Wayne Pan, MD, MBA Santa Clara County IPA SCCIPA A Pacific Partners Medical Group
- 2. take-aways • focus on the patient • fix processes first • empower providers and the care team • clinical must lead technology initiatives • focus on the patient
- 5. too many of these
- 7. MIND THE GAP
- 9. source: SF Jencks et al., Rehospitalizations among Patients in the Medicare Fee-for-Service Program, New England Journal of Medicine, 2009;360:1418-28.
- 10. $17B source: SF Jencks et al., Rehospitalizations among Patients in the Medicare Fee-for-Service Program, New England Journal of Medicine, 2009;360:1418-28.
- 12. 4processes
- 13. communication
- 14. collaboration
- 15. Case Managers Patients PCPs Specialists coordination
- 16. anticipation
- 18. financial
- 19. administrative
- 20. clinical
- 21. retrospective
- 22. reactivecare
- 23. + behavioral
- 24. predictive
- 25. proactivecare
- 27. @pointofcare
- 28. @home
- 29. thecareteam
- 30. thecarecontinuum
- 31. Santa Clara County 1,304.01 sq. miles 1,781,642 (2010) $74,335
- 32. 5 PCP 80 Specialists 173 PCP 343 Specialists 57 PCP 104 Specialists 11 PCP 30 Specialists SCCIPA founded in 1986 physician-owned, physician-governed 800+ physicians - 240+ PCPs, 550+ specialists all 9 hospitals - including a tertiary care center 9 health plans (Commercial and Medicare Advantage)
- 34. professional services outpatient services DME/injectables
- 36. hospitalists SNFists onsite case managers complex case managers utilization review staff
- 37. hospitalists available 24/7 evaluation of patients for possible redirection to SNF aggressive use of observation status annual coding/documentation training for risk adjustment notification of PCP of admission/discharge discharge summary faxed to PCP
- 38. SNFists evaluation of patients to reduce rehospitalization notification of PCP of admission/discharge discharge summary faxed to PCP
- 39. onsite case managers daily review of patients based on Milliman guidelines actively involved with discharge planning all discharge needs authorized/arranged prior to discharge post-discharge follow-up on all patients with DME/HHC needs
- 40. complex case managers warm hand-off between onsite and ccm use of clinical and non-clinical staff to assist patient and family caregivers with care coordination insure follow-up with PCP/specialist within 2 weeks
- 41. utilization review staff all authorizations/referrals reviewed using Milliman guidelines working closely with PCPs/specialists/ccm to facilitate care coordination compliance with regulatory guidelines generate official documentation regarding medical necessity decisions physician performance and quality reporting identification of potential quality issues continuous process improvement
- 42. platform
- 43. common web-based communication platform facilitates administrative functions rules-based management of processes intuitive user-interface embed quality reminders into office/provider workflow provider feedback provide clinical data at point of care allow patients to access their own data allow patients to provide feedback and enter their own data
- 44. more than an EHR more than an HIE clinical integration engine
- 45. virtually integrated healthcare delivery system
- 46. ourresults
- 47. Medicare Admits )%(& )!%& )((& !"%& !"#$%& &!%%$!&& !%(& !!%& !((& '"%& *+,& ./0& 123& 4/5& 627& 897& 62:& 1;3& 1;<& 8;=& >/9& ?0@& *+,& ./0& 123& 4/5& 627& !((-& !((-& !('(& !('(& !('(& !('(& !('(& !('(& !('(& !('(& !('(& !('(& !('(& !('(& !(''& !(''& !(''&
- 48. Medicare Bed Days !'*))& !'#))& !'+))& !"#"$%& !'"))& &!'!((&& !')))& *))& #))& ,-.& 012& 345& 617& 849& :;9& 84<& 3=5& 3=>& :=?& @1;& A2B& ,-.& 012& 345& 617& 849& "))/& "))/& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!!& ")!!& ")!!&
- 49. Medicare ALOS )"!# )"(# )"'# !"&# !"%# !"!# #!"!## !"!# !"(# !"'# $"&# $"%# $"!# *+,# ./0# 123# 5/6# 728# 9:8# 72;# 1<3# 1<=#('4'# 9<># ?/:# @0A# *+,# ./0# 123# 5/6# 728# (''-# (''-# ('4'# ('4'# ('4'# ('4'# ('4'# ('4'# ('4'# ('4'# ('4'# ('4'# ('4'# ('44# ('44# ('44#
- 50. improve the patient experience, population health, reduce cost per capita
- 51. engage the patient, use evidence-based guidelines, efficient processes
- 52. discussion
- 53. thankyou
- 54. SCCIPA A Pacific Partners Medical Group wpan@ppmsi.com