The SCCIPA Story 24 jan12

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The SCCIPA Story 24 jan12

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Presentation delivered at Opal ACOs Summit: A Transitional Model to Full Risk Care Management, Austin, TX 24JAN12

Presentation delivered at Opal ACOs Summit: A Transitional Model to Full Risk Care Management, Austin, TX 24JAN12

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  • 1. theSCCIPAstorywaynepanmdmbachief medical officer SCCIPA A Pacific Partners Medical Group
  • 2. Early ACO learnings from the “Left Coast”
  • 3. Who is ?
  • 4. Individual Practice Association Medical Group of Santa Clara County
  • 5. SCCIPA
  • 6. largest IPA in Santa Clara County
  • 7. Santa Clara Countysize 1,304.01 sqmiles pop 1,781,642 (2010)medianincome $74,335
  • 8. 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) Anthem Commercial ACO pilot (2011)
  • 9. urban/ suburban ruralSCCIPA 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) Anthem Commercial ACO pilot (2011)
  • 10. 130,000patients
  • 11. 76,000commercialACO
  • 12. 50,000commercialHMO
  • 13. 5,000MedicareHMO
  • 14. nooriginal Medicare, Medi-Cal, CHIP, uninsured
  • 15. = managementservicesorganization medicalmanagement casemanagement networkmanagement providercontracting qualityimprovement credentialing memberservices claims&encounterprocessing clinicaldataanalytics&reporting marketingoutreach grievance&appeals compliance&auditing ITservices finance&riskmanagement
  • 16. partialrisk
  • 17. managingDOFR
  • 18. DivisionOfF inancialResponsibility
  • 19. outpatientservices
  • 20. inpatientservices
  • 21. capitatepcps
  • 22. specialistspaidffs
  • 23. performancebonus
  • 24. IHAP4P&HCC
  • 25. IPAcitizenship
  • 26. = softwareservicescompany ExAccess Express TM Utilization Management Case Management Quality Management
  • 27. = softwareservicescompanyAccess Express TM Excelicare TM
  • 28. = softwareservicescompanyCoordinated Care Platform
  • 29. Utilization Access Express TM Management Case Access Express TM Management Quality Access Express TM Management ClinicalExcelicare TM Integration Engine
  • 30. 130,000patients
  • 31. 130,000patients
  • 32. 130,000patients “Living Laboratory”
  • 33. peopleprocessesplatform
  • 34. peopleprocessesplatform
  • 35. 4 groupsofpeople
  • 36. physiciansphysicianofficestaffmedicalmanagementstaffhealthplanstaff
  • 37. teamsport
  • 38. howdoteamsworkbest?
  • 39. communicate
  • 40. communicate collaborate
  • 41. communicate collaborate coordinate
  • 42. skatetowherethepuckwillbe Walter Gretzky (Wayne Gretzky’s father)
  • 43. communicate collaborate coordinate anticipate
  • 44. playbook
  • 45. careplan
  • 46. coach?
  • 47. managedcare:PCP
  • 48. unmanagedcare:?
  • 49. people:IPA/MSOhospitalistsSNFistsonsite case managerscomplex case managersutilization review staff
  • 50. patientcenteredness
  • 51. MIND THE GAP
  • 52. carecoordination andtransitions
  • 53. peopleprocesseshospitalistsavailable 24/7evaluation of patients for possible redirection to SNFaggressive use of observation statusannual coding/documentation training for risk adjustmentnotification of PCP of admission/dischargedischarge summary faxed to PCP
  • 54. peopleprocessesSNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP
  • 55. peopleprocessesonsite case managersdaily review of patients based on Milliman guidelinesactively involved with discharge planningall discharge needs authorized/arranged prior to dischargepost-discharge follow-up on all patients with DME/HHC needs
  • 56. peopleprocessescomplex case managerswarm hand-off between onsite and ccmuse of clinical and non-clinical staff to assist patient and family caregivers with care coordinationinsure follow-up with PCP/specialist within 2 weeks
  • 57. peopleprocessesutilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with PCPs/specialists/ccm to facilitate care coordinationcompliance with regulatory guidelinesgenerate member/provider letters regarding medical necessity decisionsphysician performance and quality reportingidentification of potential quality issuescontinuous process improvement
  • 58. people:physicians/staffprimary care physiciansspecialistsancillary providers
  • 59. people:physicians/staffprimary care physiciansspecialistsancillary providersfront office staff
  • 60. people:plan staffcase managersdisease managersmember outreachbenefit design
  • 61. peopleprocessesplatform communicate collaborate coordinate anticipate
  • 62. peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedback
  • 63. peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own data
  • 64. peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own dataallow patients to provide feedback/enter their own data
  • 65. more than an EHR more than an HIEclinicalintegrationengine
  • 66. virtually integrated healthcare delivery system
  • 67. designphilosophy
  • 68. “put hottriggers inthe path ofmotivatedpeople”BJ Fogg, PhDDirector, Persuasive Technology LabStanford University
  • 69. TRIGGERS: Are people being triggered at themost appropriate time and in their workflow (path)?ABILITY: Have I made it easy for people to act?How can I make it even simpler?MOTIVATION: Are incentives alignedproperly? How can I increase their motivation?
  • 70. patient front desk staff
  • 71. patient analog to digital front desk staff converter
  • 72. 112 MARY SMITH 1/1/2011 1234567890 $5.00 $10.00 $25.00analog to digital analog to digital eligibility check converter converter
  • 73. QualityAccess Express TM Management Click here to register for a password or request more informationPowered by Access ExpressQ-v5.0.#.0.1 Build 2011.04.04.00
  • 74. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 75. ACCESSEXPRESS Q New Eligibility Response New Message (3) ANTHEM BLUE CROSS
  • 76. ACCESSEXPRESS Q New Eligibility Response New Message (3) TH PA ANTHEM BLUE CROSS E TH IN
  • 77. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 POP-UP 1234567890 MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
  • 78. digital to analog converter module
  • 79. x x x x x x x xdigital to analog converter module
  • 80. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 1234567890 MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD CLICK HERE
  • 81. ANTHEM BLUE CROSS
  • 82. ANTHEM BLUE CROSS
  • 83. ANTHEM BLUE CROSS
  • 84. ACCESSEXPRESS Q New Eligibility Response New Message (3) ER SMITH, MARY 8/15/1945 G 1234567890 IG MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, TR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD T O H
  • 85. ACCESSEXPRESS Q New Eligibility Response New Message (3) ENABLING SMITH, MARY 8/15/1945 1234567890 FRONT OFFICE MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, STAFF GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
  • 86. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 SIMPLE 1234567890 CARE PLAN MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
  • 87. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 1234567890 MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
  • 88. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 89. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 90. ACCESSEXPRESS Q New Eligibility Response New Message (3) N O TI VA TI O M
  • 91. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 92. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 93. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 94. Description ofmeasure
  • 95. Capability forphysician officeentry
  • 96. Capability forphysician officeentry Y IT IL AB
  • 97. our healthcare journey we are herefrom: missclaudiawong.blogspot.com (January 30, 2011)
  • 98. 4x4 healthcare
  • 99. 4processes x4dimensionaldata
  • 100. communicationanticipation collaboration Case Managers Patients PCPs Specialists coordination
  • 101. financial administrativebehavioral clinical
  • 102. reactivecare
  • 103. $$$$$$
  • 104. predictive
  • 105. proactivecare
  • 106. From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
  • 107. SCCIPAresults
  • 108. 45.0% 50.0% 55.0% 60.0% 65.0% 70.0% No v%2 0 De 09% c%2 0 Ja 09%JA n N%201 Fe 100% b% 20 M 10% ar %2 0 Ap 10%AP r % 0 M R21 1 ay 00% %2 0 Ju 10% n% 20 1 Ju 0% % JUl%2 0 Au L110% g%2 0 0 Se 10% p% 20 1OOct% 0% CT 0 2 No 110% v%2 0 0 De 10% c%2 01 JaJAn% 0% N211 0 Fe 1 % 1 b% 20 M 11% ar %2 0 Ap 11%APr %2 0 Commercial*ADM* M R11 ay 1 % 1 %2 0 Ju 11% n% 20 1 Ju JUl% 1% L211 0 Au 11% g%2 0 commercialadmits/1000 Se 11% Milliman ’11 Well-Managed p% 20 O Milliman ’11 Loosely-ManagedO ct 11% CT0 %2 Milliman ’11 Moderately-Managed 1 SCCIPA 111% 53.6%
  • 109. 150.0% 175.0% 200.0% 225.0% 250.0% 275.0% No v%2 0 De 09% c%2 0 JJAan 09% 2 1 N%10 Fe 00% b% 20 M 10 ar % %2 0 Ap 10%AP r R%201 M 1 0 ay 0 % %2 01 Ju 0 n% % 20 1 Ju 0% JU l%2 0 Au L110% g%2 0 0 Se 10% p% 20 1OOct% 0% CT20 No 110% v%2 0 0 De 10% c%2 0 Ja 10%JAn% 0 N2111 Fe b% 1 % 20 M 11 ar % %2 0 Ap 11%APr% M 0 Commercial*BDAYS** R2111 ay 1 % %2 0 Ju 11% n% 20 1 Ju 1% JU l%2 0 Au L1 11% g%2 1 0 Se 11% Milliman ’11 Well-Managed p% 20 1 Milliman ’11 Loosely-Managed commercialbeddays/1000OOct%2 1% CT 01 Milliman ’11 Moderately-Managed 1 1% SCCIPA 1 175.5%
  • 110. 3.0# 4.0# 2.5# 3.5# 4.5# No v#2 0 De 09# c#2 00 JJAan 9# N#20 Fe 100# 1 b# 20 10 # SCCIPA MAAp ar# PR2r# 01 100# M Ju ay# n# 20 1 Ju JUl# 0# 0 L211 Au 0 # 0 g#2 0 Se 10# p# 20 OO ct 10# C#20 T No 110# v#2 0 0 De 10# c#2 01 aJJAn 0# #2 commercialalos N 01 Fe 11 # 1 b# 20 11 # M ar # Commercial*ALOS* pAAP r#2 0 R11 1 1# M Ju ay# n# 20 JuJUl 11# # 0 L211Au 1 # 1 g#2 01 1 Milliman ’11 Well-ManagedSe p# # 20 Milliman ’11 Loosely-Managed OO c 11# Ct#2 Milliman ’11 Moderately-Managed T01 1 11# 3.3#
  • 111. !200.0!! !250.0!! !300.0!! !350.0!! No v!2 0 De 09! c!2 JJAa 009! n N!21 01 Fe 00! b! 20 M 10! ar !2AAp 010! PR r!2 01 M 100 ay ! !2 01 Ju 0 n! ! 20 Ju ! JUl 10! ! 0 L211 Au 0 ! 0 g!2 0 Se 10! p! 20OOc 10! CtT !2 0 No 110! 0 v!2 0 De 10! c!2 0JJA 10! an ! N21 0 Fe 11! b! 1 20 M 11! ar !2AAP 011! pr Medicare(ADM( !2 R1 01 M 1 ay 1! !2 01 Ju 1 n! ! medicareadmits/1000 20 Ju JU 11! !2 lL 0 11 Au 11! g!2 0 Milliman ’11 Well-Managed Se 11! p! 20 Milliman ’11 Loosely-ManagedO 11! OC ct !2 T0 Milliman ’11 Moderately-Managed 111 SCCIPA 1! !274.6
  • 112. 1,000! 1,200! 1,400! 1,600! 1,800! 800! No v!2 0 De 09! c!2 JJAa 009! n N!20 Fe 00! 11 b! 20 M 10! ar !2AAp 010! PR2 r! 01 M 100 ay ! !2 0 Ju 10! n! 20 1 Ju JUl 0! ! L2110 Au 0 ! 0 g!2 0 Se 10! p! 20OOct 10! CT0 !2 No 110! v!2 0 0 De 10! c!2 01 aJJAn 0! ! N211 0 Fe 1 ! 1 b! 20 M 11! ar !2 0 Ap 11!APr !2 Medicare(BDAYS*( 0 M R11 ay 1! 1 !2 0 Ju 11! n! 20 1 JuJUl! 1! 0 L2111 medicarebeddays/1000 Au 1 ! g!2 0 Se 11! Milliman ’11 Well-Managed p! 20 O Milliman ’11 Loosely-ManagedO ct 11! CT0 !2 SCCIPA Milliman ’11 Moderately-Managed 111! 1 !1192!!
  • 113. 4.0! 5.0! 6.0! 3.5! 4.5! 5.5! No v!2 0 De 09! c!2 00 JaJA n ! 9 ! N201 Fe 100! b! 20 10 ! MAApr ar! PR!20 1 100! M Ju ay! n! 20 1 Ju 0! JUl!2 L0 Au 110! g!2 0 0 Se 10! p! 20 1OOct 0! C !20 T No 110! medicarealos v!2 0 0 De 10! c!2 01 aJJAn 0! ! N201 Fe 11 ! 1 b! 20 11 ! M Medicare(ALOS( ar pAAP ! r!2 R110 11! M ay Ju n! ! 20 JuJU 11! l! 0 L211 Au 11! g!2 01 Milliman ’11 Well-Managed Se 1! p! 2 Milliman ’11 Loosely-ManagedOO 011! c Ct! Milliman ’11 Moderately-Managed 20 T1 SCCIPA 11 1! !4.3!!
  • 114. readmissions%byquarter 12#Mo#Rolling#Readmits#%#by#Quarter# Commercial$Acute$ Medicare$Acute$20.0%$18.0%$16.0%$14.0%$12.0%$10.0%$ 8.0%$ 6.0%$ 4.0%$ 2.0%$ 0.0%$ 12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$ 2009Q4$ 2010Q1$ 2010Q2$ 2010Q3$ 2010Q4$ 2011Q1$ 2011Q2$ 2011Q3$
  • 115. * * * * *increase/same scores in 21 of 26 measures
  • 116. no
  • 117. When you improve a little biteach day, eventually big thingsoccur. Don’t look for big, quickimprovement. Instead, seeksmall improvement one day at atime. That’s the only way ithappens - and when it happens,it lasts. John Wooden
  • 118. iteration
  • 119. Virtually nothing comesout right the first time.Failures, repeated failures,are finger posts on theroad to achievement. Theonly time you don’t wantto fail is the last time youtry something. One failsforward toward success.Charles F. Kettering
  • 120. don’t be afraid to FAIL....
  • 121. failfast
  • 122. what’snext?
  • 123. shareddecision-making
  • 124. unmanagedcare?
  • 125. aco?
  • 126. createdynamiccareplancareplantoeverytouchpoint incentivizecareteam measurecompliance includepatient
  • 127. distributedpcmh
  • 128. patientaspcp
  • 129. patientself-coaching
  • 130. pch care
  • 131. CLINICAL DATA care plan data integration/analysis providers ADMIN DATA care teamBEHAVIOR DATA patient caregivers PATIENTCOLLECTED DATA care plan adapted from Mary Cain’s diagram (HT3.com)
  • 132. Patient flow Location Who Technologyadapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)
  • 133. Patient flow Location Who Technology Assessment PCP’s office PCP paper/EHRMeasurement PCP’s office PCP paper/EHRClinical Data Care Plan PCP’s office PCP paper/EHR Development Care Plan patient PCP & patient paper/EHRImplementationRe-assessment PCP’s office PCP paper/EHR adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)
  • 134. Patient flow Location Who Technology Assessment PCP’s office PCP paper/EHRMeasurement PCP’s office PCP AE/ paper/EHRClinical Data EC Care Plan PCP’s office PCP AE/ EC paper/EHR Development Care Plan patient PCP & patient paper/EHRImplementationRe-assessment PCP’s office PCP paper/EHR adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)
  • 135. Patient flow Location Who Technology Assessment PCP’s office PCP paper/EHRMeasurement PCP’s office PCP AE/ paper/EHRClinical Data EC Care Plan PCP’s office PCP AE/ EC paper/EHR Development Care Plan patient PCP & patient paper/EHRImplementationRe-assessment PCP’s office PCP paper/EHR adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)
  • 136. Patient flow Location Who Technology PCP’s/careteam PCP’s/careteam Assessment patient patient paper/EHRMeasurement PCP’s/careteam PCP’s/careteam AE/ paper/EHRClinical Data patient patient EC Care Plan PCP’s/careteam PCP’s/careteam AE/ EC paper/EHR Development patient patient Care Plan PCP’s/careteam PCP’s/careteam paper/EHRImplementation patient patient PCP’s/careteamRe-assessment patient patient paper/EHR adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)
  • 137. Patient flow Location Who Technology Assessment PCP’s/careteam PCP’s/careteam AE/ paper/EHR patient patient EC Continuous Measurement PCP’s/careteam PCP’s/careteamClinical/Personal Data patient patient AE/ EC paper/EHR Care Plan PCP’s/careteam PCP’s/careteamDevelopment w/SDM patient patient AE/ EC paper/EHR Care Plan paper/EHR AE/ EC PCP’s/careteam PCP’s/careteamImplementation promotoras patient patient Continuous PCP’s/careteam Re-assessment patient patient AE/ EC paper/EHR adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)
  • 138. FUTURE PATIENT ENGAGEMENT STRATEGY clinical adherence med data dataCHF Patient Technologytrack symptoms mobile app AE/ PCP mobile EC track diet app data dynamic & CareTeam integra tion care track weight mobile wireless & analysis plan mobile patient app scale app caregiver track other mobile behavior app adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)
  • 139. DYNAMIC CARE PLAN STRATEGY AE/ AE/ EC EC combine clinical patient clinical evidence adjust clinical ID & -based care match patient algorithm plan datamobile mobile app app patient patientcollected
  • 140. a patient-centered,evidence-based,high-quality,cost-effective,sustainable,healthcare delivery model
  • 141. ?From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
  • 142. get out of the rut
  • 143. keep doing the same thing?
  • 144. insanity: doing the samething over and over andexpecting different results
  • 145. think about...
  • 146. transformedhealthcare
  • 147. 2questions
  • 148. how will the patient benefit from this?does this make it easier for the patient?
  • 149. welcome tohealthcare2.0
  • 150. Thank you! wpan@ppmsi.comWWW.SNOOPY.COM