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

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 Presentation Transcript

  • 1. Facilitating Care Coordinationand Transitions in an ACOWayne Pan, MD, MBASanta 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
  • 3. Whycarecoordination andtransitions?
  • 4. because of these
  • 5. too many of these
  • 6. MIND THE GAP
  • 7. source: SF Jencks et al., Rehospitalizations among Patients in the Medicare Fee-for-Service Program, New England Journal of Medicine, 2009;360:1418-28.
  • 8. $17Bsource: SF Jencks et al., Rehospitalizations among Patients in the Medicare Fee-for-Service Program, New England Journal of Medicine, 2009;360:1418-28.
  • 9. 4processes
  • 10. communication
  • 11. collaboration
  • 12. Case ManagersPatients PCPs Specialists coordination
  • 13. anticipation
  • 14. 4dimensionaldata
  • 15. financial
  • 16. administrative
  • 17. clinical
  • 18. retrospective
  • 19. reactivecare
  • 20. + behavioral
  • 21. predictive
  • 22. proactivecare
  • 23. provideclinicaldata
  • 24. @pointofcare
  • 25. @home
  • 26. thecareteam
  • 27. thecarecontinuum
  • 28. Santa Clara County 1,304.01 sq. miles 1,781,642 (2010) $74,335
  • 29. 5 PCP 80 Specialists 173 PCP 343 Specialists 57 PCP 104 Specialists 11 PCP 30 SpecialistsSCCIPA 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)
  • 30. outpatientcapitation
  • 31. professional services outpatient services DME/injectables
  • 32. people, processes, platform
  • 33. hospitalists SNFists onsite case managerscomplex case managers utilization review staff
  • 34. hospitalists available 24/7evaluation of patients for possible redirection to SNF aggressive use of observation statusannual coding/documentation training for risk adjustment notification of PCP of admission/discharge discharge summary faxed to PCP
  • 35. SNFistsevaluation of patients to reduce rehospitalization notification of PCP of admission/discharge discharge summary faxed to PCP
  • 36. onsite case managersdaily review of patients based on Milliman guidelines actively involved with discharge planningall discharge needs authorized/arranged prior to dischargepost-discharge follow-up on all patients with DME/HHC needs
  • 37. complex case managers warm hand-off between onsite and ccm use of clinical and non-clinical staff to assistpatient and family caregivers with care coordinationinsure follow-up with PCP/specialist within 2 weeks
  • 38. utilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with PCPs/specialists/ccm to facilitate care coordination compliance with regulatory guidelinesgenerate official documentation regarding medical necessity decisions physician performance and quality reporting identification of potential quality issues continuous process improvement
  • 39. platform
  • 40. common web-based communication platform facilitates administrative functions rules-based management of processes intuitive user-interfaceembed quality reminders into office/provider workflow provider feedback provide clinical data at point of care allow patients to access their own dataallow patients to provide feedback and enter their own data
  • 41. more than an EHR more than an HIEclinical integration engine
  • 42. virtually integrated healthcare delivery system
  • 43. ourresults
  • 44. Medicare Admits)%(&)!%&)((&!"%& !"#$%& &!%%$!&&!%(&!!%&!((&"%& *+,& ./0& 123& 4/5& 627& 897& 62:& 1;3& 1;<& 8;=& >/9& ?0@& *+,& ./0& 123& 4/5& 627& !((-& !((-& !((& !((& !((& !((& !((& !((& !((& !((& !((& !((& !((& !((& !(& !(& !(&
  • 45. Medicare Bed Days!*))&!#))&!+))& !"#"$%&!"))& &!!((&&!)))& *))& #))& ,-.& 012& 345& 617& 849& :;9& 84<& 3=5& 3=>& :=?& @1;& A2B& ,-.& 012& 345& 617& 849& "))/& "))/& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!!& ")!!& ")!!&
  • 46. 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#
  • 47. improve the patient experience,population health,reduce cost per capita
  • 48. engage the patient,use evidence-based guidelines,efficient processes
  • 49. discussion
  • 50. thankyou
  • 51. SCCIPA A Pacific Partners Medical Groupwpan@ppmsi.com