The ABCs of ACOs for MCH
May 30, 2013
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4
Evaluation
Attendees will receive a link to a survey evaluation upon
completion of this webinar. Please take a few minutes to
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Objectives
Webinar attendees will:
1) Increase their knowledge of ACOs and ACOs that
include MCH populations
2) Increase their understanding of how public health can
play a role in ACOs
3) Will be able to identify strategies and resources to
collaborate with, ACOs in their state
Featuring:
Colleen A. Kraft, M.D., FAAP, Carilion Clinic, VA
Cate Wilcox, MPH, Maternal & Child Health Section
Manager, Public Health Division, Oregon Health Authority
Don Ross, Policy & Planning Section Manager, Division of
Medical Assistance Programs, Oregon Health Authority
Marilyn Hartzell, M.Ed., Director, Oregon Center for Children
and Youth with Special Needs
7
The ABCs of ACOs: Making
Them Work for
Maternal-Child Health
Colleen A. Kraft, M.D., FAAP
Family-Centered Medical Home
Parenting Support
Early
Intervention
Home-visiting
network
Prevention,
Building
Health
Vulnerable
children and
families
Early Child
Mental Health
Services
Acute
Care
Child and Family
Developmental
Services
Medically
Complex
Children
Developmental
Services
Lactation Support
Early
HeadStart
& HeadStart
Chronic
Care
Child Care
Resource &
Referral
Agency
Accountable Care Organizations
ACO
Coordinates care
for shared patients
Hosp
Medicare, Medicaid
Or private insurer
PCP
Spec
Financial bonus
from savings
ACO Attributes
• Coordinates care for shared population of patients with the goal of
meeting and improving on quality and cost benchmarks
• Hires an administrator and establish a formal legal structure to work with
payers, monitor performance, and collect any shared savings
• Receives a financial bonus that is divided among its participants
according to their agreement.
Traditional Medical Care and Financing
“Un-accountable” care
Low Cost Care
• Primary Care
• Preventive Care—
Screenings, Immunizations,
Anticipatory Guidance
• “Gatekeeper”
• Health/Lifestyle counseling
• Home-based care
• Home visiting
• Primary Care access for
evenings and weekends
Low Cost Care
Payment poor =
No incentive
No Coordination
of Care
• No incentive for communication
and collaboration
• No care coordinators
• No measurement of outcomes
• No comparative effectiveness
Research
• No focus on population health
• No co-location of services
• No self management services
• No transportation
Transparency of
Finances?
Outcome Measures?
Quality Reporting?
Aligned incentives?
High Cost Care
• Hospitalizations
• Procedures
• Duplication of labs, studies,
procedures
• Transportation = Ambulance
• Complications of Chronic
Disease
• End of life care in an ICU
High Payment =
Plenty of Incentive
Accountable Care
Reduce Cost
of Care
Improve Coordination
of Care--Investments
• Develop robust primary care
access
•.Streamline administrative
tasks
• Co-management between
primary care and subspecialty
to avoid hospitalization
• Greater use of palliative care
• Greater use of home care
and home visiting
• Patient/Family portals
• Avoid duplication of care/HIT
Fair Payment for
Low Cost Care
• HIT that promotes
communication and interaction
• Office Care Coordinators
• Home Visiting/Home Care
• Primary Care-Ancillary Health
co-location, including therapists,
dieticians, psychology
• Electronic portal for patient
communication/collaboration
• Support for advanced primary
care and Q/I initiatives
• Data management infrastructure
to evaluate processes and
outcomes
Transparency of ACO Finances
Patient/Family-Centered
Investment in Infrastructure
Improve Quality of Care
• Improving Scientific Basis of
Healthcare Decisions
• Based on Comparative
Pediatric Effectiveness
Research
• Measurement of Outcomes
• Longitudinal data collection
and evaluation
• Payment Tied to Patient
Outcomes
• Based on Quality Measures
Shared System Savings
Aligned Incentives
Improved Outcomes
Accountable Care “Three-Part
Aim”
Better Health
Better Care
Lower Cost
Pediatric Accountable Care
Prevention of
Adult Disease
Optimize
Health and
Development
Reduce High
Cost Care
Factors Affecting Child Health
Medical
Services
10%
Health
Behaviors
50%
Environment
20%
Genetics
20%
SOURCE: Healthy People 2010, US Department of Health and Human Services, 2000.
Health Innovation can be funded
through an ACO
• Extension of the Medical Home
• In-home care management
– Early Childhood
– Oral Health
– Prenatal
– Asthma
– Development/Behavioral Health
Carilion Clinic-Aetna Partnership
Carilion Clinic
ACO
Carilion
Clinic
Physicians
Private
Practice
Physicians
17
Virginia Medicaid Regions
Update: 12/08/2011
ACO System Savings
• Co-management between primary care and
specialty
• Less duplication of services
• Tracking of “high utilizers” with care
coordination to provide proactive care
• Access to primary care, less use of ED and
hospitalization
CORE Predictive Modeling from Aetna
A Venn diagram, combining top 1% general risk with ED and IP risk, is
used to help illustrate what risk groups a member falls into, and are
they falling into multiple groups…
Members who are Top
1% AND high risk for
an ED visit next 12
mos.
Members who are top 1%
general risk AND
medium/high risk for IP
admit next 12 mos.
Mbrs who are
Top 1%
Members who are Top
1% , high risk for an ED
visit, AND
medium/high risk for
IP admit next 12 mos.
Mbrs who are
High Risk ED
Mbrs who are
Medium/High
Risk IP
Members who are
high risk for an ED
visit AND
medium/high risk for
IP admit next 12
mos.
Personalize the Profile for Medical Homes
ED Risk Only
3
Group 3:
•Ave age 33
Increasing Medical and Behavioral Complexity
ED Risk/IP Risk Only
6
•72% female
Top 1%/
ED Risk/IP Risk
4
Top 1%/
IP Risk Only
5
•PMPM $962
Group 6:
•5 ED visits, 0.2
admits
•Ave age 43
Group 4:
Group 5:
•PMPM $2425
•Ave age 49
•Ave age 53
•32% asthma
prevalence; 25% med
adherence (asthma)
•1.6 admits
•PMPM $3908
•PMPM $3202
•7 IP bed days
•2.6 admits
•2 ED visits
•85% MH prevalence
•6 ED visits
•12 IP bed days
•2 admits
•58% co-occurring
mental health and
substance abuse
•Low medical disease
prevalence
•7 ED visits
•10 IP bed days
•51% diabetes prevalence
•56% diabetes prevalence
•52% with 5+ Rx
classes
•62% co-occurring MH
and SA
•73% MH prevalence
•41% MH prevalence
•87% with 5+ Rx classes
•84% with 5+ Rx classes
•5 Specialist visits
•12 Specialist visits
•20 Specialist visits
•19 Specialist Visits
•10 PCP visits
•9 PCP visits
•10 PCP visits
•7 PCP visits
•85% MH prevalence
Home Visiting Partner
• Child Health Investment
Partnership of the
Roanoke Valley
• Home Visiting with a
Health Focus
–
–
–
–
–
Parents As Teachers
Oral Health
Asthma Management
Pregnant Moms
Behavioral Health
Home Visiting
• Pediatric Asth
Care Management Design
• Home Visiting Contract
– Paid per member/per month
• “High Touch”, in-person, in-home
• Data Collected in home
– HEDIS metrics
– Health Outcomes
– Reduced costs
Medical Home
Shared Inbasket with
EHR
Oral Health
Ed and
Fluoride
Electronic
Referral to
CHIP
Child and
Family
Anticipatory
Guidance
reinforced inhome
Transport
to visits
Develop
Screening
results
shared
Oral Health and Fluoride Varnish
• Begin with a Grin!
Asthma Case Management
• Assess environment,
modifications
• Smoking cessation
• Observe inhaler use
• Asthma control
assessment
• Asthma action plan and
education
• Transportation to visit
Behavioral Health
• Prenatal to age 7
• Perinatal/postpartum
depression screening
• Connection to services
for parents and children
at-risk and diagnosed
• Transportation to visits
Results
100% children have a Medical
Home
90% 2yr olds UTD on well
visits and immunizations
100% children are screened
for lead, Hgb, development
100% children have a Dental
Home
145 children in program
2011-2012
66% of children have had a
dental visit by age 3
84% well controlled
97% have had an oral health
assessment and fluoride
varnish
84% minimal inhaler use
90% decrease in ED visits
82% decrease in school
absence due to asthma
In-Home Screening
Ready for School?
Pediatric Asthma
Home Visiting Intervention Pilot
Home Visiting = In-Home Prenatal
Care Management
IDEA
AIM STATEMENT
• Poverty is a risk factor for
• Reduce the number of
poor maternal and newborn
infants born at <37 weeks
outcomes.
gestation and low birth
weight (<2500 grams) by
• What if every mother with
30% by December 2012
Medicaid had a Home Visitor
utilizing home visitors as into provide support,
home case managers.
education, transportation?
• How would this impact health
of the next generation?
National Benchmark=March of Dimes
Virginia
• “C” grade for premature
birth
• Total prematurity = 11.3%
• Late preterm (34-36 wk) =
8%
• Uninsured = 17.2%
• Maternal smoking = 15.2%
Roanoke/Allegheny
• Metrics worse for this
region
• Prematurity = 12.2%
• Late preterm (34-36 wk) =
10.1%
• Uninsured =15.6%
• Maternal smoking = 24.4%
Measures
Measure
Health
Percent of infants born at < 37 weeks gestation
O
Percent of infants born between 34 and 36 weeks gestation (late preterm)
O
Birth weight term infants <2500 grams
O
Percent of Pregnant Moms participants who smoke that stopped smoking
O
Care
Percent of Pregnant Moms participants who start prenatal care in the first trimester
P
Percent of Pregnant Moms participants who attend all the recommended prenatal visits
P
Percent of Pregnant Moms participants who are uninsured
P
Percent of Pregnant Moms participants identified with depression
P
Percent of Pregnant Moms participants connected to treatment for depression
P
Cost of Care
Cost
C
1st Trimester—Goal =90%
Percent
Goal = 90%
All Visits-Goal = 60%
Percent
Goal = 60%
Reduce Maternal Smoking by 1/3
Percent
Goal = 16%
Perinatal Depression
Reduce Percentage of Infants born <37
weeks by 30%
<37wk
34-36 wk
Goal
Reduce Percentage of Term Infants born <
2500g by 30%
Cost of Care
Note: One premature infant March 19-May 10
Next Steps
•
•
•
•
Continue current project, data analysis
Continue Home Visiting Contract after birth
Expand Asthma and Behavioral Health HV models
Assess
– HEDIS measures
– Compliance with Asthma guidelines, ER and hospital
admissions, missed school and work days
– Co-locate HV teams in OB and Pediatric practices
– Feasibility of project replication as ACO expands
– Development and school readiness of birth cohort
Other Outcomes
• 92% of children with asthma are well
controlled with minimal inhaler use
• 90% of all pregnant mothers attended all their
prenatal visits, starting in first trimester
• 57% of pregnant moms who smoked were
able to stop smoking
• 100% of children with behavioral health
problems improved on PECFAS
Care Connection for Children
Special Families
Special Families
• 42 families with successful IEP meetings
• 10 families connected with waiver services
• 10 hospitalizations avoided due to connection
to home health services
• 8 support group meetings
• Special Families facebook page
• Respite program
Accountable Care
• Health of a population
– Pregnancy outcomes?
– Decrease in hospitalizations and ED visits?
– School attendance, grades?
– Parental education and employment
– Function and performance of the Medical Home
CONCLUSION:
It is easier to build strong children
than to repair broken men.
Frederick Douglass
Coordinated Care Organizations
Health System Transformation and
Opportunities for Preconception Health
Don Ross
Oregon Division of Medical Assistance Programs
Cate Wilcox
Oregon Public Health Division
Marilyn Hartzell
Oregon Child Development and Rehabilitation Center, OHSU
What we’ll talk about today
 Basics of Coordinated Care Organizations
 Public Health Role in CCOs (ACOs)
 MCH Metrics
 Preconception Health (One Key Question)
 Opportunities for Children and Youth with Special
Health Care Needs to work with CCOs (ACOs)
www.health.oregon.gov
Oregon Health Plan
50% of babies born in Oregon
16% of Oregonians
85% of Oregon providers
11% percent of total state budget
5
Fastest growing portion of state budget
www.health.oregon.gov
Triple Aim:
A new vision for Oregon
www.health.oregon.gov
56
Changing health care delivery
Benefits and
services are
integrated and
coordinated
One global budget
that grows at a
fixed rate
Local
accountability for
health and budget
Metrics: standards
for safe and
effective care
Local flexibility
www.health.oregon.gov
Benefits & services are
integrated and coordinated
 Physical health, behavioral health, dental health
 Get better outcomes:
 Health equity
 Prevention
 Social determinants of health: education, employment
 MH: Supported Employment
 Community health workers/non-traditional health
workers
 Collaborate and Integrate with other health and
human services (e.g. long term care; public health;
schools)
www.health.oregon.gov
Global budget
 Current system
 MCO/MHO/DCO/FFS
 Payments based on actions
 No incentives for health outcomes
 CCO global budget
 One budget
 Accountable to health outcomes/metrics
 Local vision, shared accountability, shared savings
 Flexibility to pay for the things that keep people healthy
www.health.oregon.gov
CCOs: governed locally
State law says governance must include:
Major components of health care delivery system
Entities or organizations that share in financial risk
At least two health care providers in active practice
 Primary care physician or nurse practitioner
 Mental health or chemical dependency treatment
provider
At least two community members
At least one member of Community Advisory Council
www.health.oregon.gov
ACOs vs CCOs-What’s Different?
ACOs have distinct features:
ACOs developing around health systems, not payers
ACOs in the ACA are aimed primarily at Medicare
savings
Providers in ACOs share in Medicare savings in:
Medicare Shared Savings Model
Advance Payment ACO Model
Pioneer ACO Model
CCOs are accountable to the state, and local
community
Medicaid enrollment in CCOs is required
www.health.oregon.gov
Community Advisory Council
 Majority of members must be consumers.
 Must include representative from each county government in
service area.
 Duties include Community Health Improvement Plan and
reporting on progress.
CCOs and public health
 Variety of requirements in statute:
o State shall require and approve agreements between CCOs and
publicly funded providers for payment for certain services
(immunizations, STIs and other communicable diseases)
o State shall allow CCO enrollees to receive family planning and
HIV and AIDS-related services from fee-for-service providers, as
well as maternity case management if CCO cannot do it
o State shall encourage and approve agreements between the two
entities for authorization and payment of other services including
maternity case management, prenatal care, school-based
clinics, services provided through schools and Head Start
programs, screening services for early detection of health
problems in vulnerable populations
www.health.oregon.gov
CCOs and public health (2)
 Variety of requirements in contract:
o Collaborate with local public health authority, local mental health
authority, community based organizations and hospital systems for
community health assessment and development of community
health improvement plan
o Actively promote screenings with A or B grades from USPSTF, or
recommended in Bright Futures guidelines
o Contribute to implementation of state’s plans for physical activity,
healthy nutrition, tobacco prevention, suicide prevention, and local
public health and health promotion planning efforts
o Partner with local public health and culturally, linguistically and
demographically diverse community partners to address the causes of
health disparities.
www.health.oregon.gov
Accountability Metrics for CCO’s
 Reduction of disparities - report all other metrics by race and











ethnicity
Member/patient Experience of care
Health and Functional Status among CCO enrollees
Rate of tobacco use
Obesity rate
Outpatient and ED utilization
Potentially avoidable ED visits
Ambulatory care sensitive hospital admissions
Medication reconciliation post discharge
All-cause readmissions
Alcohol misuse – SBIRT
Initiation & engagement in alcohol and drug treatment
www.health.oregon.gov
Accountability Metrics for CCO’s
 Mental health assessment for children in DHS custody
 Follow-up after hospitalization for mental illness
 Effective contraceptive use among women who do not desire






pregnancy
Low birth weight
Developmental Screening by 36 months
Planning for end of life care
Screening for clinical depression and follow-up
Timely transmission of transition record
Care plan for members with Medicaid-funded long-term care benefits
Metrics in bold can be applied to Preconception Health
www.health.oregon.gov
Initial Metrics
 Designed to achieve quick return on investment to
meet the federal requirements
 Maternal and Child Health is imbedded in many, but
not necessarily called out
www.health.oregon.gov
Second Phase of Metrics
 Important to be at the table—we have a lot to offer!
 MCH brings the sustainability factor
 MCH brings the lifelong wellness factor
www.health.oregon.gov
Possible MCH metrics
 Look at a broad range of standards of care/practice
 HP2020, Bright Futures, USPSTF, Title V priorities
 Include Adolescent measures
 Look for means of coding/tracking the measure
www.health.oregon.gov
Possible MCH metrics
 Targeted measures for MCAH populations
 Oral Health
 Positive Parenting
 Sleep hygiene
 Positive Youth Development
 Family violence prevention
 Safety/Injury prevention
 Pregnancy intendedness
www.health.oregon.gov
Example: One Key Question
 Do you plan on getting pregnant in the next 12
months?
 If yes, preconception health care
 If no, contraceptive health care
www.health.oregon.gov
ACA, Public Health, & Data
 Pay attention to Electronic Health Record requirements
in the ACA
 The concept of “Meaningful Use” introduces more complex
reporting to public health by Electronic Health Record
users.
 Public health needs to be ready to be
able to receive data from providers.
 Public health needs to be ready to be
able to provide data to providers.
www.health.oregon.gov
Opportunities for Children and Youth
with Special Health Care Needs to work
with CCOs (ACOs)
 Join the conversation – get to know the ACOs/CCOs
 Educate ACOs about the population of children with
special health care needs
 Who are CYSHN?



Complex
Broad and inclusive definition
Commonalities of needs across the population of individuals
 Educate ACOs about how to identify CYSHN within a
system of care


Screeners
Complexity Scales
www.health.oregon.gov
Opportunities for Children and Youth with
Special Health Care Needs to work with
CCOs (ACOs) …and their families
Family-Professional Partnerships
 Patient Engagement is not Family-Professional Partnership
 Family Professional Partnerships involve:
 Shared knowledge and expertise
 Mutual respect
 Collaborative problem solving
www.health.oregon.gov
Opportunities for Children and Youth
with Special Health Care Needs to work
with CCOs (ACOs)
Advocacy and Education
 Encourage family leaders, F2F HICs, community
leaders to join the Advisory Committees
 Support family leaders in their work with ACOs
The Family Voice
#1: Nothing about us without us!
#2: Decisions made under Parent/professional
partnership involves compromise for both!
#3: Please listen to our concerns.
www.health.oregon.gov
Opportunities for Children and Youth
with Special Health Care Needs to work
with CCOs (ACOs)
Effective Systems of Care for CYSHN
 Family Centered Care
 Early and continuous screening
 Medical home with care coordination
 Ease of Use of Community-based services
 Youth Transition to adult health care (think specialty
care too!)
 Health care finance
Be a resource to ACOs
www.health.oregon.gov
Opportunities for Children and Youth
with Special Health Care Needs to work
with CCOs (ACOs)
 Public health programs support ACO aims & metrics
 Immunizations
 Flu vaccination
 Annual well-child visits
 Annual dental visits
 Reduced ER usage
 Build partnership with ACO to help achieve the 3 aims
 Remember – there are 3 aims!
www.health.oregon.gov
Opportunities for CYSHN to work with CCOs (ACOs) - An
expanded model for statewide care coordination
Tertiary-based Care Coordination Team
 CYSHN are assigned to when they are identified through the hospital or clinics
 CC Team serves as single point of contact for families in the targeted group
of children
 CC Team  nursing, social work, family navigator, psychology – according
to the needs of the child and family
Regional Unit of Care Coordination (Senior Nurse Coordinator)
 Regionally based senior nurse coordinator (expert nurse with CYSHN)
 Child/family referred to/through back into community-based care
 Links family with PCP and community-based care coordination as needed
 Senior Nurse Coordinator provides connections between the tertiary care
coordinators, PCPs and the community public health services
Community-based Care Coordination
 Child identified within the community through public health nursing or
primary care settings; goals identified by PHN and/or PCP
 Linked to Senior Nurse Consultant for input, and behavioral specialist when
needed
For More Information:
Don Ross, Manager
Cate Wilcox, Manager
Marilyn Hartzell
Policy and Program Unit
Maternal and Child Health
Section
Director, OCCYSHN
Division of Medical
Assistance Programs
Public Health Division
Oregon Health Authority
Oregon Health Authority
Donald.ross@state.or.us
Cate.S.Wilcox@state.or.us
503-945-6084
971-673-0299
OCCYSHN / Oregon Center
for Children and Youth
with Special Health Needs
Institute on Development
and Disability (IDD) at
OHSU
Hartzell@ohsu.edu
503-494-6961
www.health.oregon.gov
Question & Answer
•Please submit questions
through the chat feature and
direct them to the
chairperson
80
Thank you for attending “The ABCs of ACOs for MCH”
Colleen A. Kraft, M.D., FAAP, Carilion Clinic, VA
Cate Wilcox, MPH, Maternal & Child Health Section Manager, Public Health Division,
Oregon Health Authority
Don Ross, Policy & Planning Section Manager, Division of Medical Assistance
Programs, Oregon Health Authority
Marilyn Hartzell, M.Ed., Director, Oregon Center for Children and Youth with Special
Needs
The recording will be posted on www.amchp.org