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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

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The SCCIPA Story 24 jan12

  1. 1. theSCCIPAstorywaynepanmdmbachief medical officer SCCIPA A Pacific Partners Medical Group
  2. 2. Early ACO learnings from the “Left Coast”
  3. 3. Who is ?
  4. 4. Individual Practice Association Medical Group of Santa Clara County
  5. 5. SCCIPA
  6. 6. largest IPA in Santa Clara County
  7. 7. Santa Clara Countysize 1,304.01 sqmiles pop 1,781,642 (2010)medianincome $74,335
  8. 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. 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. 10. 130,000patients
  11. 11. 76,000commercialACO
  12. 12. 50,000commercialHMO
  13. 13. 5,000MedicareHMO
  14. 14. nooriginal Medicare, Medi-Cal, CHIP, uninsured
  15. 15. = managementservicesorganization medicalmanagement casemanagement networkmanagement providercontracting qualityimprovement credentialing memberservices claims&encounterprocessing clinicaldataanalytics&reporting marketingoutreach grievance&appeals compliance&auditing ITservices finance&riskmanagement
  16. 16. partialrisk
  17. 17. managingDOFR
  18. 18. DivisionOfF inancialResponsibility
  19. 19. outpatientservices
  20. 20. inpatientservices
  21. 21. capitatepcps
  22. 22. specialistspaidffs
  23. 23. performancebonus
  24. 24. IHAP4P&HCC
  25. 25. IPAcitizenship
  26. 26. = softwareservicescompany ExAccess Express TM Utilization Management Case Management Quality Management
  27. 27. = softwareservicescompanyAccess Express TM Excelicare TM
  28. 28. = softwareservicescompanyCoordinated Care Platform
  29. 29. Utilization Access Express TM Management Case Access Express TM Management Quality Access Express TM Management ClinicalExcelicare TM Integration Engine
  30. 30. 130,000patients
  31. 31. 130,000patients
  32. 32. 130,000patients “Living Laboratory”
  33. 33. peopleprocessesplatform
  34. 34. peopleprocessesplatform
  35. 35. 4 groupsofpeople
  36. 36. physiciansphysicianofficestaffmedicalmanagementstaffhealthplanstaff
  37. 37. teamsport
  38. 38. howdoteamsworkbest?
  39. 39. communicate
  40. 40. communicate collaborate
  41. 41. communicate collaborate coordinate
  42. 42. skatetowherethepuckwillbe Walter Gretzky (Wayne Gretzky’s father)
  43. 43. communicate collaborate coordinate anticipate
  44. 44. playbook
  45. 45. careplan
  46. 46. coach?
  47. 47. managedcare:PCP
  48. 48. unmanagedcare:?
  49. 49. people:IPA/MSOhospitalistsSNFistsonsite case managerscomplex case managersutilization review staff
  50. 50. patientcenteredness
  51. 51. MIND THE GAP
  52. 52. carecoordination andtransitions
  53. 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. 54. peopleprocessesSNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP
  55. 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. 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. 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. 58. people:physicians/staffprimary care physiciansspecialistsancillary providers
  59. 59. people:physicians/staffprimary care physiciansspecialistsancillary providersfront office staff
  60. 60. people:plan staffcase managersdisease managersmember outreachbenefit design
  61. 61. peopleprocessesplatform communicate collaborate coordinate anticipate
  62. 62. peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedback
  63. 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. 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. 65. more than an EHR more than an HIEclinicalintegrationengine
  66. 66. virtually integrated healthcare delivery system
  67. 67. designphilosophy
  68. 68. “put hottriggers inthe path ofmotivatedpeople”BJ Fogg, PhDDirector, Persuasive Technology LabStanford University
  69. 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. 70. patient front desk staff
  71. 71. patient analog to digital front desk staff converter
  72. 72. 112 MARY SMITH 1/1/2011 1234567890 $5.00 $10.00 $25.00analog to digital analog to digital eligibility check converter converter
  73. 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. 74. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  75. 75. ACCESSEXPRESS Q New Eligibility Response New Message (3) ANTHEM BLUE CROSS
  76. 76. ACCESSEXPRESS Q New Eligibility Response New Message (3) TH PA ANTHEM BLUE CROSS E TH IN
  77. 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. 78. digital to analog converter module
  79. 79. x x x x x x x xdigital to analog converter module
  80. 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. 81. ANTHEM BLUE CROSS
  82. 82. ANTHEM BLUE CROSS
  83. 83. ANTHEM BLUE CROSS
  84. 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. 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. 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. 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. 88. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  89. 89. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  90. 90. ACCESSEXPRESS Q New Eligibility Response New Message (3) N O TI VA TI O M
  91. 91. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  92. 92. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  93. 93. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  94. 94. Description ofmeasure
  95. 95. Capability forphysician officeentry
  96. 96. Capability forphysician officeentry Y IT IL AB
  97. 97. our healthcare journey we are herefrom: missclaudiawong.blogspot.com (January 30, 2011)
  98. 98. 4x4 healthcare
  99. 99. 4processes x4dimensionaldata
  100. 100. communicationanticipation collaboration Case Managers Patients PCPs Specialists coordination
  101. 101. financial administrativebehavioral clinical
  102. 102. reactivecare
  103. 103. $$$$$$
  104. 104. predictive
  105. 105. proactivecare
  106. 106. From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
  107. 107. SCCIPAresults
  108. 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. 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. 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. 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. 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. 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. 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. 115. * * * * *increase/same scores in 21 of 26 measures
  116. 116. no
  117. 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. 118. iteration
  119. 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. 120. don’t be afraid to FAIL....
  121. 121. failfast
  122. 122. what’snext?
  123. 123. shareddecision-making
  124. 124. unmanagedcare?
  125. 125. aco?
  126. 126. createdynamiccareplancareplantoeverytouchpoint incentivizecareteam measurecompliance includepatient
  127. 127. distributedpcmh
  128. 128. patientaspcp
  129. 129. patientself-coaching
  130. 130. pch care
  131. 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. 132. Patient flow Location Who Technologyadapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)
  133. 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. 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. 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. 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. 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. 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. 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. 140. a patient-centered,evidence-based,high-quality,cost-effective,sustainable,healthcare delivery model
  141. 141. ?From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
  142. 142. get out of the rut
  143. 143. keep doing the same thing?
  144. 144. insanity: doing the samething over and over andexpecting different results
  145. 145. think about...
  146. 146. transformedhealthcare
  147. 147. 2questions
  148. 148. how will the patient benefit from this?does this make it easier for the patient?
  149. 149. welcome tohealthcare2.0
  150. 150. Thank you! wpan@ppmsi.comWWW.SNOOPY.COM

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