Mass Home Care’s
2012 Network Conference
Community Care Linkages
SM
A Division of Mass Home Care
September 11, 2012
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Topics
 Implementation of ACA
– New Models of Care and Payment Reform
 Community Care Linkages Year 2
 The COMMUNITY LIVING Program
 Next Steps
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Health Care Delivery System Transformation
Acute Health Care
System 1.0
Coordinated
Seamless Health
Care System 2.0
Community
Integrated Health
Care System 3.0
• High quality acute care
• Accountable care systems
• Shared financial risk
• Case management and
preventive care systems
• Population-based quality and
cost performance
Population-based health
outcomes
Care system integration with
community health resources
Innovation Center Portfolio
Primary Care Transformation
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Comprehensive Primary Care Initiative (CPC)
Multi-Payer Advanced Primary Care Practice (MAPCP)
Demonstration
Federally Qualified Health Center (FQHC) Advanced
Primary Care Practice Demonstration
Independence at Home Demonstration
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Partnership for Patients
Community-Based Care Transitions
Million Hearts
Innovation Advisors Program
Health Care Innovation Challenge
Initiatives Focused on the Medicaid Population
ACOs
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Medicare Shared Savings Program
Pioneer ACO Model
Advance Payment ACO Model
PGP Transition Demonstration
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Dual Eligible Beneficiaries
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Bundled Payment for Care Improvement
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Model1: Retrospective Acute Care
Model 2: Retrospective Acute Care Episode & Post Acute
Model 3: Retrospective Post Acute Care
Model 4: Prospective Acute Care
Capacity to Spread Innovation
Medicaid Emergency Psychiatric Demonstration
Medicaid Incentives for Prevention of Chronic Diseases
Strong Start Initiative
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State Demonstration to Integrate Care for Dual Eligible
Individuals
Financial Models to Support State Efforts to Integrate Care
Demonstration to Reduce Avoidable Hospitalizations of
Nursing Facility Residents
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Health Care’s BLIND SIDE
The Overlooked Connection between
Social Needs and Good Health
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85% physicians surveyed say unmet social needs are directly
leading to worse health.
85% physicians surveyed say patients’ needs are as important
to address as their medical conditions.
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Especially true (more than 9 in 10, or 95%) for patients in low-income,
urban communities.
76% would like the health care system to cover the costs
associated with connecting patients to services that meet
their social needs; and
80% are not confident in their capacity to address their
patients' social needs.
Robert Wood Johnson Foundation summary reviews key findings from an online survey of 1,000 American
physicians in the American Medical Masterfile who agreed to be invited to participate in the survey. The participation
rate was 5 percent (1,000 physicians completed the survey out of 20,000 invited to participate); 690 were primary
care physicians and 310 were pediatricians.
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Health Care’s BLIND SIDE Con’t
• Top social needs they would write a prescription
for include:
– Fitness program 75%
– Nutritional food 64%
– Transportation assistance 47%
• For patients in mostly urban and low-income
communities
– Employment assistance 52%
– Adult education 49%
– Housing assistance 43%
http://community.rwjf.org/community/healthcaresblindside
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Bridging medical care
and long term services
and supports (LTSS) is a
critical component to
meeting the needs of
individuals with chronic
conditions and
functional limitations,
and improving system
outcomes. Riskbearing
entities present a
unique avenue to
pursue this integrated
vision.
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Aging Network – An Infrastructure that Supports 11 Million
Older Adults and Caregivers
AoA
56 State Units on Aging
629 Area Agencies
246 Tribal organization
20,000 Service Providers & 500,000 Volunteers
Provides Services & Supports to 1 in 5 Seniors
242 million
meals
28
million rides
29 million
69,000
4 million hours
hours of
caregivers trained
of case
personal care 855,000 assisted management
81,759
0ver 22,000
individuals
individuals
completing
transitioned
CDSMP
ASAP Strategy:
Link Primary Care to Community Home Care Services
Achieve triple aim objectives by
linking primary care practices to
community care management
services
– Reduce costs through prevention
and/or reduction of unnecessary
utilization of health care services
– Improve health outcomes
through better care coordination
and patient education
– Improve patient experience and
satisfaction by aligning with goal
of remaining functionally active
at home
Community Care Linkages SM
A Division of Mass Home Care
Getting to:
Community
Integrated Health
Care System 3.0
 High quality acute care
 Accountable care systems
 Shared financial risk
 Case management and preventive care
systems
 Population-based quality and cost
performance
 Population-based health outcomes
 Care system integration with
community health resources
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Pioneer ACOs
CMMI selected 32 in US,
5 in MA:
1. Atrius Health
2. Beth Israel Deaconess
Physician Organization
3. Mount Auburn
Cambridge
Independent Practice
Association (MACIPA)
4. Partners Healthcare
5. Steward Health Care
System
 Experienced in coordinating care
across all care settings
 Allow rapid movement from a
shared savings payment model to
a population-based model
 Separate track from Medicare
Shared Savings Program
 Coordinated with private payers to
align provider incentive to achieve
triple aim
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Medicare Shared Savings/
Advanced Payment ACOs
Jordan Community ACO, Plymouth
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100+ physicians from Plymouth Bay
Medical Associates, Jordan Physician
Associates, and a number of specialty
physicians from Jordan Hospital to
coordinate the healthcare of 6,000
Medicare beneficiaries in Plymouth and
Barnstable Counties.
Physicians of Cape Cod ACO
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Physicians of Cape Cod ACO to serve
approximately 5,000 beneficiaries living
in Cape Cod, Massachusetts.
Harbor Medical Associates PC, South
Weymouth
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Circle Health Alliance, LLC , Lowell
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Comprised of partnerships between
hospitals and ACO professionals,
with 353 physicians. It will serve
Medicare beneficiaries in
Massachusetts and New
Hampshire.
Coastal Medical, Inc. (Providence,
RI)
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ACO group practices, with 100
physicians to serve Medicare
beneficiaries in Massachusetts and
Rhode Island
ACO group practices, with 116 physicians,
to serve Medicare beneficiaries in
Massachusetts.
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Integrated Care Entities (ICOs)
for Dual Eligibles
Primary Care
Independent LTSS Coordinator
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Primary care and behavioral health
will be integrated
All members will choose a provider
Primary care providers may be at
varying levels of capability to
perform as person-centered
medical homes (PCMHs); ICOs are
ultimately accountable for all care,
and must support primary care
providers to become medical
homes and/or Health Homes
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ICO will be required to contract with
community-based organizations to provide
independent LTSS Coordinators
LTSS Coordinator must have no financial
interest in the determination of an
enrollee’s type or amount of services
LTSS Coordinator is a member of the care
team, at the enrollee’s discretion
After initial assessment, if enrollee has
specific needs outside the designated LTSS
Coordinator’s expertise, ICO will arrange
for assignment of a more appropriate LTSS
Coordinator
LTSS Coordinator will work with enrollee to
incorporate community-based services as
appropriate into care plan
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Community Care Linkages
Community Care Linkages is a strategic
initiative to effectively integrate services
of the Massachusetts Aging Services
Access Points (ASAPs) into the evolving
healthcare delivery system.
Who are the MA ASAPs?
– 27 Not-for-Profit Organizations
– A 35 year old statewide network linking community resources
to individuals and their families
– Managing 70,000 covered lives annually in home care
programs (~$340m of services across MA)
– Bring value to evolving community based health care systems.
Community Care Linkages SM
A Division of Mass Home Care
www.Communitycarelinkages.org
www.masshomecare.org
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MEMBER-CENTERED LONG
TERM SERVICES &
SUPPORTS FOR DUAL
ELIGIBLES
A Mass Home Care Initiative for
Integrated Care Organizations
The COMMUNITY LIVING Program
– Statewide network
– Successful partnering with
community agencies and
medical providers
• ILCs, ADRCs, SCOs, ACOs
– Key Services
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Initial Assessment
Basic Coordination
Complex Care Coordination
RN Assessments
Network Management
Evidenced-Based Healthy Living
Programs
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Community-based Care Transitions Program (CCTP)
47 partners announced in three rounds, 4 in Massachusetts
1. Elder Services of Berkshire
County
– Berkshire Medical Center and
the Berkshire Visiting Nurse
Association
2. Elder Services of
Worcester & BayPath
Elder Services
– MetroWest Medical Center; St.
Vincent Hospital; UMass
Memorial Medical Center; Wing
Memorial Hospital; Marlborough
Hospital; Clinton Hospital, and
HealthAlliance Hospital
3. Somerville-Cambridge Elder
Services & Mystic Valley Elder
Services
– Cambridge Health Alliance and
Hallmark Health System
4. Merrimack Valley of
Massachusetts and Southern
New Hampshire Elder
Services
– Anna Jacques Hospital, Saints
Medical Center, Holy Family
Hospital, Lawrence General
Hospital, and Merrimack Valley
Hospital
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http://innovation.cms.gov/initiatives/Partnership-for-Patients/CCTP/partners.html
FY11 ASAP Spending ~$340m
2011 People Served
Statewide
On Behalf of MA Executive Office of Elder Affairs
55,800 Clinical
Assessment &
Evaluation
66,200 Home
Care/Respite
Care, Enhanced
Community
Options & CM,
Community
Choices & CM
18,282 Protective
Services reports
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Many Partnering Initiatives Underway
Selected Partners
Activities
Hospitals:
Physicians:
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Services:
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Baystate Health System
Berkshire Medical Center
BIDMC
Brockton
Cambridge
Cooley Dickinson
Emerson Hospital
Health Alliance
Gardner
Lahey Clinic
Milford Regional
Partners Healthcare
Northeast Health System
Steward Norwood
Hospital
Tufts Medical Center
UMass Medical Center
Vanguard Health Systems
Winchester
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Acton Medical
Atrius Health
Family Practice Group
HCA (BIDMC)
Lahey Medical Group
Meeting House Family
Practice
The Medical Group
Somerville Primary
Care
Dedicated Link
CTI/Enhanced Coleman
Community Liaison
On-site Options Counseling
Meetings:
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Inpatient interdisciplinary
team
STAAR Teams
PCMH Multi Payer Initiative
Continuum of Care Quality
Assurance Initiative
Emergency Dept.
CMS CMP
Community Connections
Group
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Hospital/ASAP Collaboration
“Emerson Hospital
and Minuteman
Senior Services have
banded together with
the goal of preventing
unnecessary repeat
hospital stays.”
Atrius Health/ASAPs Practice-Based Pilots
1.
Chelmsford & Elder Services
of Merrimack Valley
2. Peabody & North Shore
Elder Services
3. Southboro & Baypath
4. West Roxbury & Ethos
5. Concord & Minuteman
Senior Services
6. Watertown & Springwell
Currently expanding to new sites
Community Care Linkages SM
A Division of Mass Home Care
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Atrius Health
 100% on an electronic medical record
combined with corporate data warehouse,
used for managing quality and cost.
 Long history with global payments: greater
than 50% of patients under global risk across
Commercial, Medicare and Medicaid
 Widespread use of rosters in population
management
 Track record of quality measurement and
reporting
 Over 30 NCQA certified Level 3 PatientCentered Medical Homes
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Why Pioneer? “Reason for Action”
Participating in the Pioneer ACO will help Atrius Health achieve highquality, high-value care for all Medicare-eligible patients across the care
continuum.
Successful implementation for Medicare-eligibles will improve
performance for commercial risk patients with similar clinical needs.
Access to full claims data set for Pioneer population offers true
opportunity to be accountable for quality and cost across the
continuum.
Contracting for Medicare Fee for Service patients under a global budget
through Pioneer ACO maintains our position as a market leader in
payment reform, moving towards 100% global payment.
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Atrius Health – ASAP Collaboration
 Expansion of the “Care Team” to include the patient’s home and
community-based networks
 Requires: effective communication for timely and efficient referrals, hand
offs, and “closing the loop”
 Results in: patient centered care plans with realistic goals and resources
for implementation
 Collaboration through:
 Practice-based Pilots
 Population-based Interventions
Community Care Linkages SM
A Division of Mass Home Care
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Atrius Health – ASAP Practice-based Pilot
 Practice referral to ASAP with brief description of
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patient/needs
Referral form completed and faxed along with the problem
list, medication list and the latest office visit
ASAP contacts the patient and arrange an intake interview,
updating practice on barriers and services recommended
ASAP provides services, closes the loop with practice via
phone call
Practice documents care coordination note and routes to
PCP pool. Epic flag notes patient receiving care from ASAP.
Community Care Linkages SM
A Division of Mass Home Care
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Population-Based Intervention:
Falls Risk Assessment
 Identify population appropriate for homebased FRA
 Develop standard work for non-medical ASAP
intervention (population based, rather than
practice or ASAP dependent)
 Develop data capture in Epic to meet Pioneer
quality measure
Community Care Linkages SM
A Division of Mass Home Care
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Current ASAP/ACO Contracts
Atrius Health/Southboro Medical Group (SMG) &
BayPath for “Community Social Services”
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Social Worker from BayPath to support SMG 24 hours per week
Access to SMG EpicCare (EHR)
Provide general community social services
Participate in case management, quality assurance and quality improvement,
utilization review and peer review activities
– Metrics:
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Number of patients referred
Number of ED admissions
Number of hospital readmissions
Pre- and post-intervention costs
Number of cases on-going
Number of resistant patients referred – must define non-compliant
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Current ASAP/ACO Contracts
“one woman
I&R
department”
Beth Israel Deaconess Physician Organization (BIDPO)/
Springwell for “Community Care Linkages”
– a Springwell-employed Community Resource Coordinator (CRC) to work on
site at BIDPO’s office located in Westwood, MA, 3 days per week
– identify the most affordable community resource options available to meet
the identified needs of any referred Patient regardless of age or ASAP
eligibility
– educate the BIDPO’s CNCMs and other staff as to range of community
resources available, including the abilities of ASAPs, so that CNCMs are fully
aware of potential supports available to Patients
– identify ASAP clients receiving services by any of the 27 ASAPs in MA and
work with BIDPO staff to identify additional services that may be helpful to
Patients who are receiving services from a Massachusetts ASAP
– establish a community resources catalogue or reference library
– participate with BIDPO staff in case conferences
– Options Counseling visits
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Next Steps
• Expand partnering opportunities
• Share learnings from 4 Care Transitions (CCTP)
projects
• Prepare for ICO LTSS coordination opportunity
• Develop “The COMMUNITY LIVING Program” for all
providers/payers
• Successfully contract with healthcare providers and
payers under new health reform models
• Continue to share best practices and support ASAP
collaborative efforts
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