Update
Primary Care Innovation Model (PCIM)
Patient Centered Medical Home (PCMH)
Care Transformation Council
August 30, 2012
Samuel A. Skootsky, M.D., CMO
UCLA Faculty Practice Group and Medical Group
UCLA Health System
•Hospital System (Acute Care, Child, Psychiatric)
•40,000 discharges
•806 Licensed Beds
•UCLA Faculty Practice Group (1214 physicians;
247 primary care; W2 model)
•UCLA Medical Group (Internal and External
Networks & Contracting)
•58 faculty ambulatory practice locations/29 primary
care site (additional sites coming on-line)
•1.6 Million visits/year
•2.3 million encounters/year
•323,000 unique patients FY12
August 2012
The UCLA Health System PCIM Journey
Primary Care
Innovation
Model
Objectives
Defined
I.
II.
III.
IV.
V.
External Visits
&Research
Practice ReDesign
Increase Covered
Lives
Expanded
capability
Collaborations
Replication
August 2012
I.
II.
III.
IV.
Geisinger
BSVa
Baylor
Johns
Hopkins
V. Ascension
Health
Design &
Refinement of
Design & Phasing
I.
II.
Pilot
Implementation
Design Teams
Implementation
Teams
III. Leadership
Team
IV. Design Retreats
Replication of
Successful Practice
Customized to
UCLA
Internally/Externally
5/10/2012
Planning Phase
Shaping the Future
Strategic Plan 2011-2015
• UCLA-MG Existing
Population
Management
• DSRIP
• CMS/CMMI Challenge
• CMS/Shared Savings
August 2012
Design Phase
Primary Care Innovation Model
•Increase Managed Populations
•UCOP
•Medicare Advantage/FFS
•Commercial/HMO/PPO
•MSSP “ACO” Application
•Expand Primary Care System
•UCLA Collaborative with others
•Replicability Internal/External
Implementation
Phase
Primary Care Innovation Model
Implementation Teams:
•Transitions of Care
•ED/Urgent Care
•Community Programs
CMMI Innovation Funded
• Geriatrics Dementia
Context: (Oct 2011 – July 2012)
Operations Phase
Organizational Design
Primary Care Innovation Model
•Practice Re-Design (PCMH)
•MyMeds in-office PharmD
•Expand Primary Care System
(CVS)
•Growth Strategy
PCIM Progress-to-Date: PCMH






Started design Oct 2011 and on-track to have 50% of
current primary care sites in PCMH practice-redesign model
by end of this year, goal is all current and future sites.
Established method for replication (Design Team &
Retreats)
Established new roles & and responsibilities (care
coordinators and leadership)
Established linkages with other components of UCLA
System (e.g. Transitions & ED)
Developed new IT support and registries (e.g. prior 24 hour
ED and inpatient discharges)
Metrics established and being refined (e.g. facility use,
panel size)
August 2012
As of August 2012
PCIM Progress-to-Date: Other features



Established Growth Strategy Design Team to frame
PCIM expansions
Relationship with retail clinics being operationalized
Articulated a Value-Based Care Model (HRA-based)
Phase I applicable initially to:




Commercial HMO (UCLA Employees)
Medicare Advantage HMO
Medicare Shared Savings Plan Implementation
Established collaborative with UCOP on development of
new UC care medical plan that includes features of
PCIM & HRA-based models
HRA-based =Health Risk Assessment & biometric screening & coaching model
August 2012
As of August 2012
Value-Based Care: HRA-based model for Enrollee
HRA, Health &
Biometric
Screenings
& Risk Assessment
Health Coaching/
Linkage to
Care
Coordination
Choose a
Primary Care
Provider
.
.
“Triple Aim”
and
IOM
“Triple
Guidance
Aim”
& IOM
Medical Home/
Establish PCP
System/
EHR
August 2012
Chronic
Condition
Management
Pharma
Utilization &
Formulary
Compliance
Primary Care Innovation Model Team Members






Samuel Skootsky, MD, Chair, FPG CMO
Jordan Hall, FPG Director Care Coordination
Laurie Johnson, FPG Dir Ambulatory Services
Molly Coye, MD, Chief Innovation Officer
Patricia A. Kapur, FPG CEO
Stephanie McCutcheon, Innovation Advisor
CPN





Mark Grossman, MD, Medical Director CPN
Christina Catipay, Director Operations
Donna Robinson, CPN Brentwood Manager
Patricia Alarcon, CPN W. Washington Manager
Jeff Bernal, CPN Manhattan Beach Manager
SMBP

Bernard Katz, MD Medical Director

Mark Needham, MD Medical Director

Lorena Douille, Director Operations

Celina Lomeli, 20th St. Manager

Jessika Harris, Ocean Park Manager
Family Medicine

Michelle Bholat, Medical Director

Lynne Stevens, NP

Wendy Songer
August 2012
Medicine-Geriatrics Internal Medicine

Matteo Dinolfo, MD, Medical Director

David Reuben, MD Chief of Geriatrics

Brandon Koretz, MD Medical Director

Lillian Martinez, Director Operations

Tony Michaelis, Director Operations

Mari Lynne Kennedy, Med Suite 455/490 Manager

Joe Brown, Medicine SM Internal Med

Eve Glazier, MD Medical Director

Janet Pregler, MD Ambulatory Director
Additional Team Members

Debora Davis, RN, BSN, CCM Managed Care

Alice Kuo, MD, Medicine

Sandra Lavin, RN, Managed Care

Janine Knudsen, MHA, Innovation Intern, Harvard

Anahit Khacheryan, Ed Dir Oper Improvement

Shirley Wong, PharmD, MYMEDS

Richard Maranon, MSA Geriatrics, MYMEDS

Gerardo Moreno, MD, Family Medicine, MYMEDS

Shawn Lee & Albert Duntugan, Dir Business Analytics

Beth TenPas & Kaiding Zhu Decision Support & Fin Srvs

Marcia Colone & Mary Noli, Care Coordination

Nasim Afsar, MD, Dir Quality/Safety/Medicine

Crystal VanDeventer, Innovation Model Support

Others
PCMH Pilot Practices

Started Five Pilots (33,000 patients)
•
•
•
•
•
Santa Monica Bay Physicians Plaza Office
CPN Parkside SM Office
Family Medicine SM Family Health Center
Department of Medicine SM 2020
Department of Medicine SM Geriatrics

Department of Pediatrics has separate related
program

No lack of provider and staff enthusiasm!
August 2012
Expansion Sites/ Sep 2012 Start
New Cohort of Eight Practices & Lead MD



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
SMBP/20th Street 3rd Floor - Michael Nagata, MD and Caroline Close, MD
SMBP/Ocean Park - Richard Ross, MD
SMBP/20th Street 10th Floor - Richard Greenspun, MD
CPN/Brentwood - Dr. Mark Grossman
CPN/W Washington - Dr. Soheil Azimi
CPN/Manhattan Beach - Dr. Thuy Tran
Med/Primary Care Suite 455/490 – TBN
Med/ SM Internal Medicine Lead - Eve Glazier, M.D.
With this expansion, will have total 13 sites in program
Represents 50% of all Adult Primary Care Sites
August 2012
UCLA Population Management Plan
Traditional
BenefitBased Home
Health
SNFist
and SNF
Program
Hospital & HospitalistExtensivist Programs
Communication
Care Transitions
ER interventions
Efficient hospital use
Ensuring Care Implementation
in the Community & at Home
•Home Social/Environmental
Factors
•Patient Coaching
•Transitions of Care
•Use of Community Resources
•Comprehensive Care Centers
Optimal
Discharge
(Hospital,
ER, SNF,
other)
Palliative &
Hospice Care
Complex Chronic
Illness
Home Care &
High Risk Clinic
Patient- Centered
Shared Decision
Making
Mild Chronic Illness & Care
Support for Self
Management
Episodic & Expected Care
Preventive Services & Urgent Care
Self-Care & Wellness Programs & Health
Education & Self-Serve Preventive Services
“System” Support: EHR, Data aggregation, Population Registries, Predictive Modeling, Decision Support , Practice
Standards, Quality Measurement and Reporting, Accountability, Tele-Medicine, Tele-Health
August 2012
What does Practice Re-Design mean?



Defined practice populations by MD and Site
Having timely & actionable data
Team based care
•

Risk prioritization, practice huddles, care
coordination, transitions management, and
navigation-“linkages” within Health System
Advanced Primary Care Practice
•
•
•
August 2012
Continuity
Access
Active Panel Management
Primary Care Innovation Model
What is Medical Home Functionality?
Care
Coordination
Case
Management
Panel
Management
August 2012
Physician or other
Providers
Medical Assistant/LVN
Office Staff
Office Manager
Our approach embraces “System” attributes and synergy
PCMH
2.0
PCMH
1.0
August 2012
Health System
Practice Re-Design, Advanced Primary Care, and Health
System Re-Design = PCMH
UCLA Health System
MD Led Team:
Advanced
Primary
Care/PCMH
Practice
New FTE and roles noted in light green
ED Services
Defined
Care Management
Comprehensive
Care
Coordinator
ED Services
Hospitalist Program
Physician &
MA-LVNs
Other staff
Advanced
Medication
Management
Clinical
AdvisorCase
manager
In-home services, including
palliative care
Needed Specialists and
Ancillaries
Urgent Care Centers & Retail
clinics
August 2012
UCLA PCMH/PCIM Metrics of Success

Reduction in Facility Use (increase use of alternatives)
•
•
•
•







Discharges & optimal LOS
All cause readmissions
ED visits
Ambulatory Care Sensitive Admissions
Generic Drug Use
Attenuation or Reduction in “Total Cost of Care”
Quality measures (standardized, valid, nationally
endorsed) at 90th%tile
Patient Experience (Clinician Group - CAHPS) at 90th%tile
Provider & Staff Satisfaction (maintaining the workforce)
Increased efficiency in operations (e.g. panel size)
Success of care coordination system
August 2012
Practice Population Registry with
Multiple Ways Clinical Risk Ranking
Patient Detail
Med/SM 2020 PCP
PCMH/DSRIP Attributed Population
Date of Service 06/01/2009 ~ 05/31/2012
Based on Professional Charges through 05/31/2012
Patients with No Risk Ranking is Related to Patient Data Errors (e.g. Invalid Birth Date, Diagnosis Codes, Gender)
ER Visits: CPTs 99281-99288
Hospital Visits: CPTs 99221-99223
Payor
Provider name
UCLA MEDGRP - Medicare Advantage
MD1
UCLA MEDGRP - Commercial MD2
UCLA MEDGRP - Commercial MD3
UCLA MEDGRP - Medicare Advantage
MD4
PPO&POS
UCLA MEDGRP - Commercial
PPO&POS
MEDICARE FFS
UCLA MEDGRP - Commercial
MEDICARE FFS
UCLA MEDGRP - Commercial
MEDICARE FFS
PPO&POS
August 2012
Medical
Record
Number
11111111
22222
33333
44444
Patient name
Name
Name
Name
Name
CMS
CMS
ED
Chronic
Hosp
Total RAF
ER Visits
Model
RAF
Visits
Score
Score
Score
9.37
9.13
8.86
8.42
7.82
6.95
6.40
6.37
6.30
6.16
5.72
5.64
5.63
3.711
2.821
2.463
2.215
0.975
1.691
1.341
2.623
1.236
1.819
0.627
0.978
0.823
0
5
6
0
1
1
0
0
0
2
0
1
0
3
25
2
16
6
9
3
5
9
14
6
1
9
3.3
7.8
3.2
1.4
8.1
1.9
2.8
7.8
8.0
6.5
3.2
5.9
11.1
Hospitalization Admission
Model Score
Model
Score
2.1
63.4
15.4
2.3
53.6
25.0
17.7
57.8
72.9
51.7
32.8
43.3
31.8
31.1
56.3
14.4
15.6
42.5
37.7
9.2
47.4
53.4
50.6
19.2
57.5
23.9
Admission
Advance
Due to
Imaging
ACSC
Risk Rank
Model
model
Score
score
50.7
13.8 L5 - Very High Risk
118.2
9.7 L5 - Very High Risk
1.7
16.8 L5 - Very High Risk
1.7
9.8 L5 - Very High Risk
32.6
24.2 L5 - Very High Risk
27.1
11.5 L5 - Very High Risk
1.0
8.3 L5 - Very High Risk
39.8
17.2 L5 - Very High Risk
29.5
38.8 L5 - Very High Risk
77.6
21.5 L5 - Very High Risk
0.1
6.4 L5 - Very High Risk
21.0
42.1 L5 - Very High Risk
4.2
17.9 L5 - Very High Risk
Practice & Patient Care Gaps and Registries
Action Lists = Care Gaps
Registries = Whole Population
August 2012
PCIM Population Access Mednet Site
Recent addition:
Past 24 hour ED discharges, Inpatient Admissions & Discharges
August 2012
August 2012
Layered approach to PCIM population management
Affiliations
UCOP Plan ACO
Commercial Plan ACO
MSSP: Government sponsored ACO
Delivery System Reform Incentive
Payments (DSRIP) and PCMH expansion
Expand 30+ year history of UCLAMG capitation
[Medicare Advantage and Commercial] & “wrap
around” population & care management
August 2012
End