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. 1. Facilitating Care Coordinationand Transitions in an ACOWayne Pan, MD, MBASanta Clara County IPA SCCIPA A Pacific Partners Medical Group
  2. 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. 3. Whycarecoordination andtransitions?
  4. 4. because of these
  5. 5. too many of these
  6. 6. MIND THE GAP
  7. 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. 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. 9. 4processes
  10. 10. communication
  11. 11. collaboration
  12. 12. Case ManagersPatients PCPs Specialists coordination
  13. 13. anticipation
  14. 14. 4dimensionaldata
  15. 15. financial
  16. 16. administrative
  17. 17. clinical
  18. 18. retrospective
  19. 19. reactivecare
  20. 20. + behavioral
  21. 21. predictive
  22. 22. proactivecare
  23. 23. provideclinicaldata
  24. 24. @pointofcare
  25. 25. @home
  26. 26. thecareteam
  27. 27. thecarecontinuum
  28. 28. Santa Clara County 1,304.01 sq. miles 1,781,642 (2010) $74,335
  29. 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. 30. outpatientcapitation
  31. 31. professional services outpatient services DME/injectables
  32. 32. people, processes, platform
  33. 33. hospitalists SNFists onsite case managerscomplex case managers utilization review staff
  34. 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. 35. SNFistsevaluation of patients to reduce rehospitalization notification of PCP of admission/discharge discharge summary faxed to PCP
  36. 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. 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. 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. 39. platform
  40. 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. 41. more than an EHR more than an HIEclinical integration engine
  42. 42. virtually integrated healthcare delivery system
  43. 43. ourresults
  44. 44. Medicare Admits)%(&)!%&)((&!"%& !"#$%& &!%%$!&&!%(&!!%&!((&"%& *+,& ./0& 123& 4/5& 627& 897& 62:& 1;3& 1;<& 8;=& >/9& ?0@& *+,& ./0& 123& 4/5& 627& !((-& !((-& !((& !((& !((& !((& !((& !((& !((& !((& !((& !((& !((& !((& !(& !(& !(&
  45. 45. Medicare Bed Days!*))&!#))&!+))& !"#"$%&!"))& &!!((&&!)))& *))& #))& ,-.& 012& 345& 617& 849& :;9& 84<& 3=5& 3=>& :=?& @1;& A2B& ,-.& 012& 345& 617& 849& "))/& "))/& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!)& ")!!& ")!!& ")!!&
  46. 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. 47. improve the patient experience,population health,reduce cost per capita
  48. 48. engage the patient,use evidence-based guidelines,efficient processes
  49. 49. discussion
  50. 50. thankyou
  51. 51. SCCIPA A Pacific Partners Medical Groupwpan@ppmsi.com

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