Building a
Seamless Care System
Doug Thompson
Chief Administrative Officer for ACO Development
Cambridge, MA
CAMBRIDGE HEALTH ALLIANCE
An Integrated, Academic, Public Health Care System in MA
Transforming into an Accountable Care Organization
CHA’s Change Assets
DELIVERY SYSTEM
•
Network of primary and specialty health centers, hospital campuses, employed physicians,
cultural and linguistic expertise, academic programs, and public & community health programs
serving 90,000 primary care patients – 80% public payer
•
Two CHA PCMHs earned Level 3 NCQA accreditation in 2010; remaining are on track for 2012
•
Quality Core Measures are above National and MA benchmarks
•
IT program meets Stage 1 Meaningful Use Standards for eligible providers
HEALTH PLAN
•
State-wide Medicaid and Commonwealth Care managed care plan with 170,000 members
•
A successful Elder Service Plan (PACE model) for Frail Medicare-Medicaid Eligible Seniors
INTEGRATION
•
12,500 members/patients shared between delivery system and health plan
•
Managed under a shared-risk global payment arrangement that includes a range of services
including behavioral health and services provided outside of CHA
•
Strategic relationships and partnerships (State EOHHS, community agencies, other systems)
PATIENT CENTERED CARE IN A PRACTICE WITHOUT WALLS
How do we address the gaps in the health care system?
TECHNOLOGY
•
•
Instant notifications to primary care team when patient “hits” the CHA delivery system
or a note is entered into the EMR
Bi-directional EMR connections with other delivery systems
CLINICAL SYSTEMS
•
Pro-active Planned Care Teams moving toward Population Management
–
–
•
Multi-disciplinary integrated care planning
Actionable, routine reporting delivered to appropriate care team member
PCP to Specialist and Inter-Specialty Collaboration
–
Specialists initiated and agreed on service standards for their interaction with primary care teams
PATIENT ACCESS AND ACTIVATION PROGRAMS
•
•
•
Cultural and linguistic competency and outreach
Patient Navigators
Open access begun in primary and specialty care practices
CASE STUDY: Diabetic Patient, Mr. M
•
Mr. M is a 43 year old gentleman with insulin-dependent diabetes and bipolar
disorder.
•
He is homeless, and can’t keep his insulin in a refrigerator. He has a hard time
remembering to take his medicine on time. He also had multiple ER visits and
hospitalizations for diabetic complications.
•
Complex care management for Mr. M:
– A CHA Community Health Worker (CHW) was assigned to Mr. M and helped him
obtain housing.
– A CHA Nurse Practitioner (NP) helps him manage his medications and educates
him about what foods to eat.
– His CHW also helps him get to appointments with his PCP and mental health
providers.
•
Mr. M now has well-controlled diabetes and bipolar disorder, and is working at
a grocery store.
RESULTS: Comprehensive Care for Childhood Asthma
•
•
Proactive outreach to patients by
Planned Care Team to get them
controlled on asthma
medications (over 99%).
Pilot Sites (PEDO & SOPED)
Rest of CHA
12%
10%
8%
6%
4%
2%
0%
Goal <=0.5%
Jan-2002
Jan-2003
Jan-2004
Jan-2005
Jan-2006
Jan-2007
(N-Pilot =125)
(N-Pilot =369)
(N-Pilot =479)
(N-Pilot =596)
(N-Pilot =926)
(N-Pilot =1097)
(N-Rest =18)
(N-Rest =30)
(N-Rest =209)
(N-Rest =643)
(N-Rest =880)
(N-Rest =889)
Jan-08
Childhood Asthma:
% Patients with Asthma ED Visits
Healthy Homes assessment
through public health
partnership.
Pilot Sites (PEDO & SOPED)
Rest of CHA
25.0%
Result: Disappearance of
inpatient and ED visits for
pediatric asthma – led to closure
of pediatric inpatient unit.
20.0%
% Patient Count
•
Childhood Asthma:
% Patients with Asthma Admissions
Patients identified as having
asthma as soon as anyone (ED,
pediatrician) puts asthma on the
EMR problem list.
% Patient Count
•
15.0%
10.0%
5.0%
Goal <= 2%
0.0%
Jan-2002
(N-Pilot = 125)
(N-Rest = 18)
Jan-2003
(N-Pilot =369)
(N-Rest = 30)
Jan-2004
(N-Pilot = 479)
(N-Rest = 209)
5
Jan-2005
(N-Pilot=596)
(N-Rest = 643)
Jan-2006
(N-Pilot = 926)
(N-Rest = 880)
Jan-2007
(N-Pilot = 1097)
(N-Rest = 889)
Jan-08
Jan-09
Jan-09
PARTNERING WITH PUBLIC HEALTH
Met Definition of Physical Exercise
City of Somerville: 2002 and 2008
80
Moderate Exercise
70
Moderate or Vigorous
48.0
50
41.7
40
34.6
26.8
30
Mobilize effective partnerships to:
• improve physical activity and
decrease obesity
• decrease substance abuse
(including tobacco cessation)
64.0
Vigorous Exercise
60
Percent
Work collaboratively with public
and community health partners
to improve the health of the
public.
23.6
20
10
0
Somerville 2002
Somerville 2008
Differences between 2002 and 2008 are statistically significant.
*Moderate: Adults w/ 30+ minutes of moderate activity 5 or more days per week.
*Vigorous: Adults w/ 20+ minutes of vigorous activity 3 or more days per week.
Change in Obesity from 2002 to 2008:
Cambridge, Somerville, and MA
40
Percent
36.3 36.6
• support public health
infrastructure (content
providers, extenders of
service)
30.6
30
29.7
2008
2002
35
30.9
27.3
25
21.5
18.3
20
15.2
15
11.7
16.4
10.4
10
5
0
Cambridge
Somerville
Overweight
Massachusetts
Cambridge
Somerville
Massachusetts
Obese
Overweight = BMI between 25.0 and 29.9; Obese = BMI greater than or equal to 30.0
* About 24% of the 2008 survey respondents are missing the weight variable necessary to calculate BMI.
PARTNERING WITH PAYERS - ACO MODELS
How do we optimize resources and gain synergies?
•
SHARED DATAMART
–
–
•
COMPLEX CARE MANAGEMENT PROGRAM (Network Health Alliance)
–
–
–
•
claims, enrollment, referrals, authorizations, EMR
Real-time reporting when appropriate
Community health workers
80/20 of the first 80/20
Community partners – Commonwealth Care Alliance, PACT
GLOBAL PAYMENT ARRANGEMENT
–
–
Focuses budgeted resources on wellness, preventive care, care coordination along the full health
and mental health continuum, and primary care sensitive hospitalizations and emergency room
care
Makes it possible to provide typically poorly reimbursed and non-billable services, which is
especially critical for safety net population needing significant social supports
CASE STUDY: Asthma Diagnosis, Nicholas
•
Nicholas is a 4 year old patient with an asthma diagnosis.
•
In the past year, he had 5 ER visits for asthma and was treated with powerful steroid
medications 5 times. He is sleepy during the day and considered “oppositional.” He has
missed three recent psychiatric appointments.
•
He is the youngest son of a single mother of three. She ensures Nicholas takes his
medications and had her home inspected by the Healthy Homes Program to identify any
asthma triggers in the house. She suffers from PTSD and anxiety, conditions that have
been worsened by the sleepless nights caused by her son’s frequent coughing fits.
•
Nicholas was identified as a candidate for the NHA complex care program. A NP and
Portuguese-speaking CHW met with the family to learn more about Nicholas’ symptoms
and their affect on the family. A diagnosis of reflux was suspected, as it commonly mimics
asthma. Nicholas and his Mom agreed to try a medication to treat reflux.
•
It has been 3 weeks and Nicholas has not had any asthma episodes, ER visits, or need for
his rescue inhaler. Within 24 hours, his Mom had her first full night of sleep. Next, the team
will assess how Nicholas’ lack of sleep may be playing a role in his behaviors. They also
plan to continue coaching his Mom.
EARLY RESULTS: COMPLEX CARE PROGRAM
Cambridge Health Alliance
Revere Family Health Center
Scorecard for January – July 2010
(paid through September 2010)
2009
2010
% change
(January – July, 60-day lag) (January – July, 60-day lag) 2009 – 2010
Member Months
DxCG Risk Score
Facility Inpatient admits per 10004
Outpatient Clinic (facility only)
1,206
2.56
448
8,019
1,247
2.49
385
6,178
3%
-3%
-14%
-23%
1,761
6,606
19,819
1,405
5,832
18,717
-20%
-12%
-6%
encounters per 1000 4
ED (facility only) encounters per 1000 4
Professional-PCP units per 1000 4
Professional-Specialist units per 10004
NHA eligible (age >=18, CDPS2+ or AIDS)
POLICY ISSUES
Initial findings are directional and show great promise in achieving near-term
gains in health and cost effectiveness for complex populations, especially those
relying on Medicaid, Medicare and Other low-income public programs.
•
Need Medicare and Medicaid to move to global payment models quickly and to
collaborate on Dual Eligibles.
•
Need Medicare and Medicaid to provide ACO and PCMH infrastructure funding.
•
Need continuous enrollment (such as 1 year continuous enrollment in Medicaid and
other low-income public programs) to make care management work and worth
investment.
•
Need a partnership to ensure adequate risk adjustment methods to reflect both the social
acuity and behavioral health complexity, including socio-economic adjustments, for lowincome and vulnerable patient populations.
•
Need stronger Behavioral Health - Primary care integration, fostered through new global
payment models that “carve-in” Behavioral Health (BH) to the benefits design. To
promote required access and resource availability, payment reforms must address
chronic inadequacy of BH reimbursement and case mix systems that fail to account for
the resource intensity in providing BH care.
Health Affairs thanks these organizations for their support
of today’s conference and the resulting case studies to be
published in a forthcoming issue of the journal: