Koplan_outpt_inpt tr.. - Massachusetts Coalition for the Prevention of

Atrius Health as an ACO/PCMH:
Strategies to coordinate with our patients across
the continuum (Hospitals, SNF’s, Home Care)
February, 2013
Kate Koplan, MD, MPH
Director of Medical Management
Atrius Health
Atrius Health – Background
Non-profit alliance of six leading
independent medical groups
– Granite Medical
– Dedham Medical Associates
– Harvard Vanguard Medical
– 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
• 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
Personal physician
Physician-led care team
Whole person orientation
Coordinated Care Across Continuum 
Enhanced access
Patient and family centered
Comprehensive ACO/PCMH work must extend to the “continuum”
~20% of Medicare patients hospitalized at least
1x/yr (Medicare Preferred and ACO)
They require services at discharge:
» 20-45% hospital discharges
lead to SNF or Rehab stay
» 1/3 receive Home Health
» 1/10 receive
outpatient/ambulatory therapy
Preferred hospitals will have at least two of the following:
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
– Standards and metrics agreed upon and regularly reviewed,
including discharge coordination and use of Atrius’ preferred
– 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
Preferred SNF Facility Standards
– Staffing/HR requests, incl. credentialing
– Facility agrees to use Atrius Health preferred providers (DME, VNA, specialists)
– 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
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
• Comply with all payer minimum requirements
Pioneer ACO SNF-based Collaboration
• Representatives from the five Eastern Massachusetts
began regular meetings in November 2012.
• The group has recently expanded to include
representatives from Leading Age and Mass. Senior
Care Federation.
• The first initiative was to create expectations for both
SNF Facilities as well as for SNF Providers. So that
SNFs would have one set of common expectations and
not five.
• Expect that they will be released in the next few weeks.
• The next effort will be develop a set of expectations for
hospitals when transferring a patient to a SNF.
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
• Unique contracting opportunities
• Preferred providers/vendors post-dischargee
Improved Care Coordination & Work across “Continuum”
• Differential process for discharge to SNF, 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 and care coordination
• “Call First” campaign – encourage follow-up at our
facilities if ambulatory-sensitive, or use of our preferred
inpatient facilities, if level of care 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
Open Time
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