HealthLeaders Media LIVE From Memorial Hermann
Memorial Hermann:
A Care Management ACO
Care Coordination and Physician Alignment Drive Nation’s Greatest ACO Savings
2 Case Study
2 Lesson 1: Engage, Align, and
Empower Independent Physicians to
Drive Accountable Care
5 Lesson 2: Accountable Care
Coordination: A Care Management,
Case Management, and CommunityBased Plan
11Resource Guide
Additional Resources From
HealthLeaders Media
Featuring a live event on November 11, 2015
11 a.m.–1 p.m. ET | Memorial Hermann
Houston
Case Study // LESSON 1
Engage, Align, and Empower
Independent Physicians to Drive
Accountable Care
BY JIM
MOLPUS
Memorial Hermann
Health System
B
ack around 2007, Houston-
right things to care for patients,
based Memorial Hermann
be measured in quality and cost,
Health System had only a
and prove to the community and
distant promise when it began to
themselves that they were the highest
» 12 hospitals
talk with area physicians about the
quality and most cost-efficient.
» More than 20,000 employees
concept of clinical integration. Terms
» A top-performing ACO
like accountable care organization
were still mostly left to theory. As
Keith Fernandez, MD, recalls, the
selling point that he and other leaders
of the MHMD Memorial Hermann
Physician Network had to offer was a
more manageable life for physicians.
Recalls Michael Shabot, MD,
executive vice president and chief
clinical officer of Memorial Hermann
Health System, and founding
chairman (now past chairman) of the
Memorial Hermann ACO: “In a way,
our secret was starting early before
we knew what the actual goal or
“We had a great advantage over many
plan was going to be. We had a more
other groups,” recalls Fernandez,
generic goal of taking better care and
now also chief medical officer of the
more efficient care of our patients.”
Memorial Hermann Accountable
Care Organization. “We had a group
of doctors in very small practices
(averaging 1.8 per practice) that had
no collective vision of how they might
move successfully into an uncertain
future. The doctors were ready to do
things differently and were intrigued
by models of clinical integration.”
That promise of the future rang
true, and success has followed. In
the first full year of the Medicare
Shared Savings Program in 2013, the
Memorial Hermann ACO led all MSSP
ACOs with savings of nearly $58
million, almost $20 million more than
the next highest ACO. From a ground
of zero at-risk lives in July 2012,
The concept that attracted the
Memorial Hermann now has almost
doctors was simple—do the
240,000 in risk arrangements.
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO
2
Panelists
»Keith Fernandez, MD,
president, MHMD Memorial
Hermann Physician
Network, and chief
medical officer, Memorial
Hermann Accountable Care
Organization
»Mary Folladori, RN,
system director of care
management, Memorial
Hermann Health System
»Paula Lenhart, associate
vice president of care
management, Memorial
Hermann Health System
»Christopher Lloyd,
CEO, Memorial Hermann
Accountable Care
Organization
»Pat Metzger, senior vice
president and chief of care
management, Memorial
Hermann Health System
»Carol Paret, senior vice
president and chief
community benefits officer,
Memorial Hermann Health
System
» Michael Shabot, MD,
executive vice president and
chief clinical officer, Memorial
Hermann Health System, and
founding chairman, Memorial
Hermann Accountable Care
Organization
But building the physician alignment strategy for successful clinical integration
took some learning.
“We sold doctors on the concept of being able to manage their future practice
by defining what quality is, improving it, and measuring performance,”
Fernandez says. “In other words, not relying on other people to decide what
good quality is, relying on them to report it accurately, and then using that to
determine what defines a good doctor. I was really hoping for 500 physicians on
the first pass, but we had 1,200 physicians sign up, which was a surprise to me.”
The number of physicians in the network swelled to almost 3,000 after the
success of the shared savings program, and this created a problem. “When
we looked at our quality metrics at that time, we saw a deterioration in
performance. And so we implemented more stringent criteria to both enter and
stay in the clinical integration program that would protect the quality and costefficiency of the network.”
The result was a more specific business agreement that the physicians now sign
to join the ACO. It requires physicians to supply EMR data for 90 days, be on a
preferred EMR, and agree with and abide by the MHMD compact, Fernandez
says. Other requirements include appropriate policies and procedures that
govern patient safety.
Aligning hundreds of independent physicians meant addressing some initial
cultural and governance barriers. Many held true to a spirit of physician
autonomy in the state, where historically physician groups had been relatively
small and deeply competitive.
To create a physician-driven structure that could propel clinical improvement,
the physician organization created clinical program committees in each
specialty, Shabot says, which focus on evidence-based best practices. While
there were just a handful of core committees in the program’s first year, that
number has since increased to 50.
“Years and years and years of effort went into this to create quality protocols,
safety protocols, and efficiency protocols developed by the physician
committees,” Shabot says. “And then to make them active in the hospitals, we
had developed a mechanism for getting them through each of our currently
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO
3
“WE SOLD DOCTORS ON THE CONCEPT OF BEING
ABLE TO MANAGE THEIR FUTURE PRACTICE BY
DEFINING WHAT QUALITY IS, IMPROVING IT, AND
MEASURING PERFORMANCE.”
—Keith Fernandez, MD, president of MHMD Memorial Hermann Physician Network
and chief medical officer of Memorial Hermann Accountable Care Organization
11 medical executive committees. Getting 11 MECs to agree on the same
thing—that wasn’t easy either. And we put literally scores of quality and safety
measures through the MECs in that way over the past seven or eight years.”
Each of those more than 500 measures sent through the clinical program
committees and then to the hospitals started with some basic agreements,
says Christopher Lloyd, CEO of the Memorial Hermann Accountable Care
Organization.
“There has to be some focus,” Lloyd says. “There has to be some reason why
certain things are done, and usually that’s guided by clinical data and input from
a whole bunch of other different team members. Even beyond what clinical
condition you identify, you have to ask, what’s the point in doing it? What driver
are we looking to drive? Do we all have agreement on that before we even step
into it? Do we all agree that we’re managing a cost metric or we’re managing a
clinical metric? It just depends from measure to measure, but I think that there’s
a lot of discussion around making sure that our goals and our roles are in the
same direction.”
Early success and shared incentives have also helped usher in “a gigantic cultural
change,” Fernandez says. “I rarely have any trouble with engaging physicians
now. In fact, I have to sometimes restrain them. We have 50 clinical practice
committees—not because I’m looking for more committees, but because the
doctors are demanding them. I have doctors coming to me now saying, ‘I’ve got
to get this problem fixed.’ ”
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO
4
Case Study // LESSON 2
Accountable Care Coordination:
A Care Management,
Case Management, and
Community-Based Plan
A
ny health system that is
care managers who have been
taking on risk for the care of
attached to Memorial Hermann’s
a population faces the same
MHMD physician network practices;
hole in its skill set: care coordination.
there were a relative handful when
No inpatient enterprise built for fee-
the journey to accountable care
for-service healthcare has enough
began, but now there are more
hospital-based case managers,
than 40. The care managers work
ambulatory-based care managers,
to identify and guide chronically ill,
social workers, pharmacists, health
high-cost patients through a more
coaches, and community health
efficient system.
liaisons to form an ACO efficient
enough to create value.
Mary Folladori, RN, system director
of care management for Memorial
Even if they did have the FTE
Hermann Health System, says the
numbers, provider health systems
care managers work extensively
have little experience or existing
with people who have chronic health
models for how the pieces of the
conditions, most of whom have one
care coordination team should
or more of the conditions usually
work together. Memorial Hermann’s
associated with high cost and high
approach has been a multipronged
utilization: chronic obstructive
growth strategy for key areas of care
pulmonary disorder, congestive
coordination, with the goal that all
heart failure, and diabetes. The
will eventually meet in the middle to
care management team uses risk
close gaps around patient care.
stratification tools to identify which
The most growth in terms of overall
FTEs has been in the ambulatory
of the 240,000 patients in Memorial
Hermann risk contracts would benefit
from enhanced care coordination. The
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO
5
“WHAT WE DO IS BASED ON RELATIONSHIPS
AND NETWORKING, KNOWING HOW TO BE THE
CATALYST TO MAKE THINGS HAPPEN ON BEHALF OF
OUR PHYSICIANS AND THEIR PATIENTS.”
—Mary Folladori, RN, system director of care management for Memorial Hermann Health System
care managers are based and work within the regions where the physicians and
their patients live. This affords team members an awareness of and access to
resources and healthcare services available in different parts of the city.
MHMD care managers are equipped to ease care transitions so that a change in
venue is no longer perceived as a disruption in care, but instead recognized as a
way to improve patient safety and satisfaction.
“We have built the care management team to follow the member throughout
their continuum of care,” Folladori says. In order to do that, a multidisciplinary
professional team was deliberately assembled and trained as a team
that supports members and families based on their unique and changing
healthcare needs.
The team uses RN care managers and care management assistants who are
LVNs, clinical pharmacists, masters of social work, registered health coaches,
and communication coordinators.
The goal is to engage the member in his or her own care, utilizing motivational
interviewing and shared decision-making, Folladori says, adding that because
the team represents the member’s physician, the engagement rates are higher
than those previously achieved by payers.
Each member has a primary care manager; however, to gain efficiency, other
team members can move in and out, so a patient who needs a pharmacist at one
visit and a social worker the next can be accommodated, she says. Workflows
and procedures have ensured handoffs between team members are seamless
and transparent to the patients.
“Engagement methodologies can be really simple. Many times we try to get too
complex,” Folladori says, “It can be as simple as an introductory phone call to
the member before they leave the hospital. Or for very complex patients, our
staff will go in and do a brief introduction at the bedside with the member and
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO
6
family. Or it could be one of our unlicensed support team members who goes
to the patient’s home to let them know that Dr. Smith’s care manager, Debbie,
is going to call them tomorrow just to see how they’re doing. They may leave
them a magnet or a bright-colored piece of paper to remind them, because these
patients get so overwhelmed when they go home. We try to keep some of those
things really simple.”
Oftentimes, the role of the care managers is to be an expediter or facilitator for
a member who is stuck in a tight spot in the system. “One example is that we had
a member who was understandably anxious and wanted to have a biopsy for
a potential cancer diagnosis as soon as possible, rather than in the three-week
time period it was originally scheduled for,” Folladori says.
“Obviously she was very frightened. Her surgeon’s office was having scheduling
challenges and initially couldn’t schedule her biopsy sooner, and that was very
distressing for her. We dug into it. Turned out it was an OR scheduling matter.
Someone on our team had the right contact in OR scheduling. She was able to
get the case scheduled for the next day. What we do is based on relationships
and networking, knowing how to be the catalyst to make things happen on
behalf of our physicians and their patients,” Folladori says.
Some members require a higher level of care, and for those people Memorial
Hermann has designed and expanded its supportive medicine program (also
known as palliative care). The supportive medicine team is a physician-led
interdisciplinary care team that is focused on improving quality of care delivery
for patients with serious and life-threatening illnesses by providing an extra
layer of support.
The supportive medicine team is led by Sandra Gomez, MD, a palliative care
specialist, and includes nurse practitioners, registered nurses, social workers,
chaplains, and counselors. Care is focused on providing patients with relief
from the symptoms, pain, and stress associated with their illness, whatever
the diagnosis. The goal of care is to improve quality of life for both patients
and families.
Supportive medicine programs are located at eight Memorial Hermann
hospitals and four outpatient clinics. The expansion of this service has
allowed for more than a 27% increase in the number of patients served from
2013 to 2014.
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO
7
Patient satisfaction surveys were distributed to gauge the effectiveness of
supportive medicine consultations. The results showed significant improvement
in pain control after supportive medicine became engaged in the patients’
care: 92% of patients/families rated their pain control as “Excellent” after
a supportive medicine consult vs. only 41% who rated their pain control as
“Excellent” before the consult.
Eighty percent of patients who received a supportive medicine consult identified
that they would have preferred to have been consulted earlier in their diagnosis
so they could have benefitted earlier from these services. Ninety-six percent of
patients indicated that they would recommend these services to another patient
with a serious or life-threatening illness.
Memorial Hermann’s hospital-based care management team is likewise looking
for ways to reach out from the inpatient stay, particularly in populations at high
risk for readmissions or unnecessary admissions, says Pat Metzger, senior vice
president and chief of care management at Memorial Hermann Health System.
The care management team has started to look for tools, partnerships, and
communication to close gaps, recognizing that no health system can hire enough
care managers to cover everything, Metzger says.
One recent example is Virtual Care Check, a remote patient monitoring system
for patients with chronic heart failure, diabetes, chronic respiratory issues, or
pneumonia. Patients are given a dedicated 4G tablet device, along with weight
scales, pulse oximeters, glucometers, and blood pressure monitors. Physicians
customize a plan that blends the wireless data with a patient daily survey. If certain
downward indicators are met, a member of the care management team will call to
assess the need to either get the patient back in or assign other resources.
“We have about 300 patients through the system currently,” Metzger says.
“We’ve begun to see decreases in the cost of care associated with their care.
We see fewer hospitalizations for them, and when they do come in they’re less
complicated or less complex than they might have been left to their own devices.”
Telehealth tools can only go so far, so Memorial Hermann is partnering with
its preferred ambulance provider to send paramedics with special training to
check on patients at their homes who fit into a troublesome gap: sick enough
to need some monitoring but not sick enough to need home health or skilled
nursing. “There are those patients that we look at and we have this kind of
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO
8
sixth sense that they’re not going to do well,” Metzger says.
The paramedics take vital signs, listen to lungs, listen to hearts, check
medications, and do a safety evaluation. If needed, the paramedics work with
the case management team to schedule a primary care visit, or intervene if a
trip back to the hospital or emergency room is necessary, Metzger says.
Memorial Hermann has also:
• Created a preferred provider network with 60 Houston-area postacute
providers, who agree to share data and outcomes on Memorial Hermann’s
information exchange. The quality data is then shared when patients are
selecting a skilled nursing facility, Metzger says, though patients are free to
choose their own provider.
• Put more emphasis on palliative and supportive care earlier in the care
management process. “We’ve worked with the physician group to suggest
that perhaps those patients need to be caught more in an ambulatory
setting in the physician’s offices where the whole topic of palliation and the
whole topic of managing advanced illness can be had when the patient’s not
lying in a critical care bed in the ICU,” Metzger says.
One of the underlying challenges is in accurately and quickly identifying
at-risk patients. Memorial Hermann currently uses a patchwork of disease
management and population health tools, and has put out a request for
information for a tool that will identify and close the information gaps through
the entirety of the patient’s needs.
“We’re probably no further ahead than anybody else in terms of our ability to
have one common tool,” says Paula Lenhart, associate vice president of care
management for Memorial Hermann Health System. “But we have recognized
and are moving forward with trying to secure a common platform that will help
us risk-stratify patients in a way that we all understand.”
Ultimately, volume is growing faster than capacity for Memorial Hermann
in Houston. Even with an ambitious accountable care and case management
program, the system is also investing heavily in community health and
prevention to bring down overall community health disparities, says Carol
Paret, senior vice president and chief community benefits officer for Memorial
Hermann Health System.
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO
9
Paret sums up the goal of the community health approach: “We are all for how
you treat a diabetic patient better, but our goal has got to be how you don’t have
the diabetic patient to begin with. There’s just not enough money to take out of
the system by tweaking the medical care.”
One of the system’s community programs has been school-based health
programs in 10 clinics serving 70 schools. The program provides 12-month, free
medical, dental, mental health, nutrition, and navigation to kids.
“We can show from a medical perspective that our kids don’t have asthma
exacerbations, for example, they don’t use ERs,” Paret says. “We can show from
a dental space that we’re meeting the [federal government’s] Healthy People
2020 goals already. We can show from a mental health space that the kids
that we’re serving have decreased suspensions and detentions, increased GPAs,
decreased absences.”
But to truly make a significant impact on community health requires a new, and
in many ways counterintuitive, way of thinking for providers used to looking
through the health system prism, Paret says.
“If I am an hourly worker, do I really want to go to a health clinic where I may
need an x-ray, and I have to make a second appointment and take a second day
off work. Then I may need a specialist, so there is a third appointment. If I go
to the ER and starting at, let’s say, 11 at night and I’m seen at 3 in the morning,
I might give up a night’s sleep, but I get everything I need in one stop. What’s
better for my life? That’s where health systems and their smart minds and their
analytics get all out of whack,” Paret says. “You’ve got to understand the lives of
the people whose actions you are trying to change.”
Jim Molpus is leadership programs director for HealthLeaders Media.
He may be contacted at jmolpus@healthleadersmedia.com.
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO 10
RESOURCE
GUIDE
For Further Study
Leadership at Memorial Hermann has developed a care management ACO that focuses on
care coordination and physician alignment to drive outcomes and savings. For further study,
consider the following resources:
Resource 1:
The Need to Revisit Care Coordination,
Clinically and Financially
This piece is adapted from an
What are the top three challenges your organization faces in developing and
analysis by Michael Zeis, senior
extending care continuum collaboration?
research analyst, in the July 2015
HealthLeaders Media Intelligence
Report, Care Coordination: Closing
Dealing with payers’
protocols or regulations
Lack of commitment from
care partners
Care coordination in the form
Lack of financial incentive
mature activity, at least in the
acute care environment, but new
attention to value-based care and
at-risk reimbursements means
50%
Lack of standardized EHR
the Gaps Along the Continuum.
of patient transfer is a relatively
57%
42%
41%
28%
Lack of technology solutions
Lack of details on others’
services, capabilities
Lack of details on family
support options
Skilled nursing facilities
25%
19%
18%
that care coordination is poised for
Multi-response; among hospital and health system respondents.
development and growth.
SOURCE: HealthLeaders Media Intelligence Report, Care Coordination: Closing the Gaps Along the Continuum, July 2015; hlm.tc/1KwLHwk.
Just over two-thirds (68%) of
healthcare leaders say their
organization has a care transition
function that supports patient
percentage of supported
transfers to or from hospitals,
transfers. Other settings cited
which is the setting with the highest
ranges between 40% (for clinics
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO 11
or federally qualified health centers)
result has been a direct benefit for
and 55% (for home health agencies),
pay-for-performance indicators.
which gives hospitals a clear, but not
instructions.
“I’ve seen a huge transition in my
Do the worst first. That’s advice my
nursing career from high-acuity
preceptor gave me when I was a new
hospital-focused care to, now, a focus
Despite the growing expectation
nurse. It was her quick-and-dirty
on wellness across the care settings,”
that primary care physicians
tip on how to prioritize patient care.
says Hill, who has been a nurse for 37
should occupy pivotal spots in care
Her point was that I should focus my
years. “As we’ve done that, one of the
coordination activity, primary care
attention on the patients with the
things that I’ve tried to do is to help
practices are in the middle of the
highest acuity levels or who were the
develop a different way to look at
group, with 53% of respondents
most unstable. Postop patients or
hospital care.”
saying their organization has a care
those with drains, tubes, deep-brain
transition function that supports
electrodes, or changes in neuro status
patient transfers to and from
should have dibs on my time and care
primary care. “That means that
intensity.
commanding lead.
half the people out there are being
coordinated without [a primary care]
physician’s direct involvement,” says
Gaurov Dayal, MD, former president
of healthcare delivery for St. Louis–
based SSM Healthcare, which
operates 19 hospitals, an insurance
A few years ago, Karen S. Hill, DNP,
FAAN, chief operating officer and
chief nursing officer at Baptist Health
Lexington in Kentucky, noticed nurses
at her facility were also engaging in
this type of prioritization.
company, nursing homes, homecare,
“If they had an assignment and a
hospice, telehealth, and a technology
patient was going to go to the OR or
company.
the cath lab, that patient rose in the
Resource 2:
How Patient Flow Nurses Help
Cut Readmissions
This piece is adapted from an August
4, 2015, online column by Jennifer
Thew, RN, senior nursing editor.
When she noticed RNs weren’t always
able to make patient discharge a top
priority, Baptist Health Lexington’s
CNO created a new nursing position
to improve the discharge process. The
level of priority,” Hill told me, “and
sometimes the patient who was more
stable or going to be discharged was
not the most important thing they
were doing.”
But, as she points out, healthcare
has evolved, and a greater emphasis
is now placed on issues such as
preventive care, quality outcomes,
and continuity of care, which
can all be affected by how well
patients understand their discharge
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO 12
About the Host
About Us
An integrated health system, Memorial
HealthLeaders Media is a leading
Hermann is known for world-class clinical
multi-platform media company dedicated
expertise, patient-centered care, leading-
to meeting the business information needs
edge technology, and innovation. The system,
of healthcare executives and professionals.
with more than 20,000 employees, serves to
To keep up with the latest on trends in
advance health in Southeast Texas and the
physician alignment and other critical
greater Houston community.
issues facing healthcare senior leaders,
Memorial Hermann’s 12 hospitals include
go to www.healthleadersmedia.com.
three hospitals in the Texas Medical Center
(the Texas Trauma Institute, a level I
trauma center that houses the Life Flight
air ambulance, a hospital for children, and
a rehabilitation hospital), eight suburban
hospitals, and a second rehabilitation hospital
in Katy. The system also operates three
Heart & Vascular Institutes, the Mischer
Neuroscience Institute, three Ironman Sports
Medicine Institute locations, cancer centers,
imaging and surgery centers, sports medicine
and rehabilitation centers, outpatient
Sponsorship
For information regarding underwriting opportunities for HealthLeaders Media
LIVE, contact Sales@healthleadersmedia.com or 800-753-0131.
laboratories, a chemical dependency
treatment center, a home health agency, a
retirement community, and a nursing home.
As an accountable care organization, the
system also offers employers health solutions
and health benefit plans through Memorial
Hermann Health Insurance Company.
When Memorial Hermann was chosen to
join the Medicare Shared Savings Program,
Executive Vice President and Publisher
ELIZABETH PETERSEN
epetersen@hcpro.com
Managing Editor
BOB WERTZ
bwertz@healthleadersmedia.com
Leadership Programs Director
JIM MOLPUS
jmolpus@healthleadersmedia.com
Media Sales Operations Manager
ALEX MULLEN
amullen@healthleadersmedia.com
Editorial Director
EDWARD PREWITT
eprewitt@healthleadersmedia.com
Medicare attributed 24,000 of its covered
beneficiaries to the system; that has grown
to 30,000. Memorial Hermann rapidly
processed the underlying metrics to identify
opportunities to reduce cost in this population
and achieved 100% compliance with year
Copyright ©2015 HealthLeaders Media, 100 Winners Circle, Suite 300, Brentwood, TN 37027 • Opinions expressed are not necessarily those of HealthLeaders
Media. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal,
ethical, or clinical questions.
1 quality requirements. For the first 18
months, MHACO earned the distinction of
being one of the top-performing ACOs in
the country, saving Medicare more than
$58 million as part of its Shared Savings
Program. Continued success in the MSSP will
require the system to conform to even higher
standards of quality and efficiency.
November 11, 2015 I HealthLeaders Media LIVE I A Care Management ACO 13