Comprehensive Primary Care Transforming Care - Centura Health

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10/18/2016

Comprehensive Primary Care Transforming Care Delivery that Demonstrated Improved Patient Outcome and Lowered Cost 9th Annual Centura Health EBP, Research and Innovation Conference October 28th, 2016 Tamra Lavengood RN, BSN, MSN, CPNP, CNS Mercy Family Medicine Centura Health Physician Group Mercy Regional Medical Center Durango, Colorado

Outline •

Beginning October 2012, The Comprehensive Primary Care Initiative



9 Milestones and the key elements: – Empanelment – Risk stratification • Mercy Adult Risk Stratification Tool (MARST) development • Mercy Pediatric Risk Stratification Tool (MPRST) development – Care Management of High Risk Population – Integrated Behavioral Health Care Management – Care Coordination for ED and Hospital Discharges – Clinical Quality Measures



Clinic Model and Outcomes

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What is the Comprehensive Primary Care Initiative? Four-year multi-payer initiative designed to strengthen primary care Population-based care management fees and shared savings opportunities to participating primary care practices to support the provision of a core set of five “Comprehensive” primary care functions. – Risk stratified care management – Access and continuity – Planned care for chronic conditions and preventive care – Patient and caregiver engagement – Coordination of care across the medical neighborhood

http://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative

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CPCi Now called CPC Classic Demographics – 474 practice sites – 2,200 practitioners – 2.7 million active patients – 38 public and private payers – 335,000 Medicare beneficiaries Purpose – Improved care – Better health for populations – Lower costs – Inform future Medicare and Medicaid policy http://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative

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Comprehensive Primary Care: 9 Milestones 1. Budget 2. Care management for high-risk patients – Behavioral Health Integration 3. Access and continuity 4. Patient experience 5. Quality improvement: Report on 9 CQMs 6. Care coordination across the medical neighborhood 7. Shared decision making 8. Participation in learning collaboratives 9. Health Information Technology

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Comprehensive Primary Care Initiative: Our Story CMS selected key elements that aligned with Patient Centered Medical Home elements The two that required the most practice transformation: Milestone 2: Empanelment; Risk Stratification; Care Management; Behavioral Health Integration Milestone 6: Care coordination across the medical neighborhood

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Comprehensive Primary Care Milestone 2 Care Management for High Risk Patients Empanelment Risk Stratification • All 500 clinics asked to develop their own risk stratification methodology • Mercy Family Medicine reviewed tools from: – California Quality Collaborative – AAFP Risk Stratification Tool – Telluride Medical Center in Colorado (another CPC practice)

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Risk Stratification in CPC Practices Comprehensive Primary Care practices risk stratify their patients by: • Clinical intuition: 71% • Practice developed clinical algorithm: 61% • Published clinical algorithm: 40% • Claims: 24% • EHR methodology: 19% Practices were able to select more than one method

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Comprehensive Primary Care Initiative Our Story

Developed our own Mercy Adult Risk Stratification Tool (MARST) and the Mercy Pediatric Risk Stratification Tool (MPRST) Critical to have not only Objective elements but Subjective elements as well and the ability to risk stratify in real time.

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HIT Needed for Risk Stratification •

Using the system we had our risk stratification elements flow exactly like our EHR

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Care Management for High Risk Patients – Care Management (person/disease centered) of patients in the highest risk quartile: For the Mercy Risk Tool Level 6 – Care Management (person/disease centered) of patients with rapidly rising risk and likely to benefit from active, ongoing, intensive care management For the Mercy Risk Tool Level 5’s and Level 4’s – Integration of behavioral health care management strategies for patients in higher risk cohorts

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Risk Stratification and Care Management

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Risk Stratified Care Management Adapted from the AAFP risk stratification model

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Behavioral Health Integration



Behavioral Health care is needed for the majority of level 6 patients



Fully Integrated Licensed Clinical Social Worker – Warm handoffs and Scheduled patients – PHQ9 Tracking

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Care Coordination

Care Coordination across the Medical Neighborhood (System Focused) – Emergency Department discharges – Hospital discharges

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Mercy Family Medicine’s Care Model

Care Management Behavioral Health Care Coordination Clinical Quality Measures

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Medicare Expenses Per Patient Per Month All Attributed Patients

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Hospital admissions, ED Visits, 30 day Re-Admissions for all attributed Medicare Patients

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CPC Great Idea! Three elements lead to outstanding outcomes – Care Management for high-risk patients identified through risk stratification in real time using objective and subjective-intuitive elements, able to isolate the top 1% of our patient population – Integrated Behavioral Health Care Management for high-risk patients – Care Coordination in the clinic setting providing communication between the inpatient and outpatient settings for ED and hospital discharges enabling follow up at 97.5% within 1.8 day for ED visits and 96.7% within 8hrs for hospital discharges

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Positive Outcomes…

(Q12)



Decreased Per Member Per Month (PMPM) Expenses for Medicare population of $604, 8th lowest in Colorado region of 75 practices of which $676 is the median and high $1,195. Decreased for Highest-Risk Quartile PMPM expense of $1019, 13th lowest and median of $1,208 and high $2,774 for Colorado region. Mercy Family Medicine (MFM) has around 3000 attributed Medicare patients. MFM reduced Medicare expenditures by $216,000 annually compared to the Colorado region average.



Decreased ED Utilization from $683 to $674 (not risk adjusted) per 1000 Medicare patients. Average in Colorado region is $712. MFM reduced Medicare expenditures by $74,100 annually compared to the Colorado region average. *

*based on Mercy Regional Medical Center average of $650/ED visit) 23

Continued Positive Outcomes…

(Q12)



Decreased Hospital Admissions for Any Cause from 175 patients to 170 patients per 1000 Medicare patients. Average for Colorado region is 259 patients. Mercy Family Medicine reduced Medicare expenditures by $6,942,000 annually compared to the Colorado region average. *



Decreased Hospital Admissions for Ambulatory Care Sensitive Conditions (ACSC) from 33 to 25 per 1000 Medicare patients. Average for Colorado region is 54. Mercy Family Medicine reduced Medicare expenditures by $2,262,000 annually compared to the Colorado region average. *



Decreased 30 Day Re-Admit from 101 to 89 per 1000 Medicare patients. Average for state of Colorado is 134. Mercy Family Medicine reduced Medicare expenditures by $3,510,000 annually compared to the Colorado region average. *

*based on Mercy Regional Medical Center average of $26,000/hospital visit) 24

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Variables  This is a picture looking at where MFM was in Q1 and where MFM was in Q12 (3 years). There were some quarters that we were lower and some quarters that we were higher. This reflects the beginning of MFMs CPC journey though the end of the third year.  MFM also grew from 1117 Medicare patients to 2799, an 80% increase. The Colorado region clinic average grew from 446 to 664 Medicare patients, a 60% increase.  There are differences in demographics across the 75 Colorado Primary Care clinics: age; race/ethnicity (MFM has more Native American, less African American); HCC scores (MFM has more high risk patients); dual eligible (MFM has more patients also on Medicaid).

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Leave you with a story….. How care management and care coordination saved a life

Questions

Feel free to contact [email protected]

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Comprehensive Primary Care Transforming Care - Centura Health

10/18/2016 Comprehensive Primary Care Transforming Care Delivery that Demonstrated Improved Patient Outcome and Lowered Cost 9th Annual Centura Healt...

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