Atrius Health as a Patient-Centered Medical Home:
Successful Strategies to Reduce Readmissions
MassPro
October 30, 2012
3:00p-3:30p
Kate Koplan, MD, MPH
Director of Medical Management
Atrius Health
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Atrius Health – Background
•
Non-profit alliance of six leading
independent medical groups
– Granite Medical
– Dedham Medical Associates
– Harvard Vanguard Medical
Associates
– Reliant Medical Group
– Southboro Medical Group
– South Shore Medical Center
•
Provide care for ~ 1,000,000
adult and pediatric patients in
almost 50 ambulatory sites
•
1000 physicians, 1450 other
healthcare professionals across
35 specialties
NCQA-Level 3 Certified PatientCentered Medical Home at all
Groups
•
• Long history with global payments,
currently managing 50% of our patients
with global payments.
• Strong infrastructure to manage risk
• One of first to sign BCBSMA Alternative
Quality Contract (AQC) and One of 32
Medicare Pioneer ACOs nationally
Elements of Patient Centered Medical Home
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Personal physician
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Physician-led care team
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Whole person orientation
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Coordinated Care  HOSPITAL/SNF/HOME CARE
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Enhanced access
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Quality
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Safety
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Patient and family centered
Comprehensive PCMH work must extend to the “Neighborhood”
•
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20% of Medicare beneficiaries hospitalized at
least 1x/yr
They require services at discharge:
» 41.1% to SNF
» 37.4% to Home Health
» 10.3% to In-patient rehab
facility
» 9.1% to outpatient/ambulatory
therapy
» 2.0% to long term care
hospital
Source: Gage et al (2009). Examining postacute care relationships in an integrated
hospital system, ASPE.
Preferred hospitals will have at least two of the following:
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–
–
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Unique contracting relationship
High-volume or at least a regionally high-volume
Site or Group preference, with supportive communication strategy
Formal collaborative relationship between Atrius Health and
Hospital, including steering, clinical collaboration, and IT
committees
– Standards and metrics agreed upon and regularly reviewed,
including discharge coordination and use of Atrius’ preferred
network
– Mutual agreement that Atrius and Hospital will collaborate on IT
interoperability, including Atrius patient identification at registration
and notification to primary team of admission and discharge
– Atrius Health and Hospital physician and administrative leads to
guide relationship
5
Preferred SNF Facility Standards
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•
•
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General:
– Staffing/HR requests, incl. credentialing
– Facility agrees to use Atrius Health preferred providers (DME, VNA, specialists)
Pre-Admission:
– Patient screen and bed availability streamlined
– Patients are identified as Atrius Health patients
– Able to accept direct admits from home/ER/clinician office.
During stay:
– Facility comfort for pts and staff
– INTERACT tool (or comparable quality tool)
– Therapies are available seven days per week; Mental Health coverage
– Team and care planning meetings; facility case manager responsibilities
– Radiology, Lab, Pharmacy expectations
At Discharge and Post-Discharge:
– Patient experience survey
– Atrius preferred vendors utilized for DME, Home Care, Home Infusion, Hospice, etc.
– D/c planning based on checklist, incl. med list, sharing ACP directives, teach back
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Preferred SNF Provider Standards
• Discharge Planning
– Templated summary; sent w/i 24h to Atrius Med Records
– Ensure that f/u care is appropriate and that patient returned to Atrius
Health PCP
• 24/7 coverage by experienced and responsive clinicians
• Timely communication to PCP if unexpected change in patient’s status
• Newly admitted patients seen w/i 48h of admission by physician
• Utilize Atrius Health preferred providers during stay
• Participate in team and family meetings
• Participate in quality and INTERACT or other related readmissions
reviews
• Comply with all payer minimum requirements
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Standards and Metrics to Define our Hospital/SNF Strategy
• Relationship structure
• Care coordination, including case
management and transitions of care
• On-site functions
• IT interoperability
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Improved Care Coordination & Work in the “Neighborhood”
• Differential process for discharge to ECF, home with
services, and home without services, plus care
coordination’s link with elder care services
– Standards & Metrics, incl. IT interoperability
• Post ED and hospitalization follow up within 7d, w focus
on medication reconciliation
• “Call First” campaign – encourage follow-up at our
facilities if ambulatory-sensitive, or use of our preferred
inpatient facilities, if that is level of care that is appropriate
• Data: post-facility f/u, readmissions trending (3d, 7d, 30d),
high risk patient reviews, etc…
• Direct liaison with our hospital/SNF/homecare partners
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Open Time
Questions
&
Discussion
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