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

Health & Medicine

Facilitating Care Coordination
and Transitions in an ACO
Wayne Pan, MD, MBA
Santa Clara County IPA

SCCIPA
A Paciﬁc Partners Medical Group

take-aways
• focus on the patient
• ﬁx processes ﬁrst
• empower providers and
the care team
• clinical must lead
technology initiatives
• focus on the patient

source: SF Jencks et al., Rehospitalizations among Patients in the Medicare Fee-for-Service Program, New England
Journal of Medicine, 2009;360:1418-28.

$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.

Case
Managers

Patients PCPs

Specialists

coordination

Santa Clara County
1,304.01 sq. miles
1,781,642 (2010)
$74,335

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)

professional services
outpatient services
DME/injectables

hospitalists
SNFists
onsite case managers
complex case managers
utilization review staff

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

SNFists
evaluation of patients to reduce rehospitalization
notiﬁcation of PCP of admission/discharge
discharge summary faxed to PCP

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

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

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

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

more than an EHR
more than an HIE

clinical integration engine

virtually integrated healthcare delivery system

Medicare Admits

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improve the patient experience,
population health,
reduce cost per capita

engage the patient,
use evidence-based guidelines,
efﬁcient processes

SCCIPA
A Paciﬁc Partners Medical Group

wpan@ppmsi.com

Microvascular environment plays a fundamental role in the adaptive response to increases in activity, involving an increase in energy demand. To puntual increases in demand, the response is effected by changes in local flow, but if demand remains high, angiogenic process is triggered through the formation of new capillaries from preexisting vessels. The trigger factor of angiogenesis is local neuronal hypoxia as result of increased activity, mediated by angioglioneurins whose main exponent is VEGF. There are situations in which hypoxia is not from an increased activity, but a decrease in available oxygen, as occurs in the altitude exposure. Our goal is to study the changes underlying microvascular acute adaptation to moderate altitude and the possible effects of physical exercise. Wistar rats bred to 400 m (P47) and transported to a height of 2800m on a journey of 35 minutes. We used the following cohorts of 7 rats each: a group was housed indoors in standard laboratory conditions, another group had free access to an exercise wheel. As controls, we used animals born at 400m. After 48 h, animals were sacrificed and after neuropathological examination by conventional histology, capillary density was quantified using computer assisted stereology on thick sections processed using Butyryl Cholinesterase Histochemistry (Argandoña, Brain Res, 1996). Three cortical areas were quantified, motor, somatosensory and visual cortices. Rats with free access to exercise wheel showed higher vascular density in response to hypoxia, while the rest showed similar values. Differences were significant in all three areas, being highest in the motor cortex. The acute adaptation to moderate altitude is an increasingly relevant issue given the increase in displacements at moderate or high altitudes, with serious consequences such as Acute Mountain Sickness, which in its most severe degree leads to Brain edema. Our results show that exercise can play a protective role through adaptive angiogenesis.

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