coordinating the “last mile” to succeed at value-based ......1. two strategies involved with...

Coordinating the “Last Mile” to Succeed at Value-based ReimbursementChris Wild, MBAEmerging Healthcare SolutionsExperian Health

2 © Experian

Healthcare Transformation

3 © Experian

Population Health-- improve the health of a population/individual to

reduce the incidence of high cost clinical episodes

Episode Management-- reduce the cost and improve the outcomes when

high-cost clinical episodes occur

Two Strategies for Value-based Care Success

26/07/2017 Private and confidential Presentation Title

4 © Experian

Definition:

“The health outcomes of a group of individuals, including the distribution of such outcomes within the group”

Includes:

- Health outcomes

- Patterns of health determinants

- Policies and interventions that link these two

Defining Population Health


Source: Kindig D, Stoddart G (Mar 2003). "What is population health?" (PDF). American Journal of Public Health.

http://www.ajph.org/cgi/reprint/93/3/380.pdf

5 © Experian

Holistic Responsibility

07/26/2017 Private and confidential

Source; Sg2

6 © Experian

Components of Successful Strategy


Requires:

- Governance among stakeholders

- Positive patient identification

- Ability to engage patients

- Data aggregation and analysis

Source: Kindig D, Stoddart G (Mar 2003). "What is population health?" (PDF). American Journal of Public Health.

http://www.ajph.org/cgi/reprint/93/3/380.pdf

7 © Experian

The Problem:A disconnected ecosystem

Healthcare lacks a universal identifier

8 © Experian

Match, manage, and protect patient identities

It all starts with understanding who your patient is

patients?

9 © Experian

The future state of identity management

Historical Patient Rosters

Lab

EMPI

Identityfields

Matched or new EUID


Medical Group

EMPI

Identityfields

Matched or new EUID


Hospital

EMPI

Identityfields

Matched or new EUID


Pharmacy, etc.

EMPI

Identityfields

Matched or new EUID

Identity Manager

Historical patient rosters

Master patient identity index

Universal Patient ID

Universal Patient ID Universal

Patient IDUniversal Patient ID

10 © Experian

How to Solve This Problem


11 © Experian

“The set of services provided to treat a clinical condition or procedure.

Includes:

- Extended care

- Acute hospital care

- Ambulatory care

- Home care

- Community outreach

- Wellness

- Housing

Defining Episode of Care


Source: Centers for Medicare & Medicaid Services

CMS’ Definition of an Episode

12©2016 Experian Information Solutions, Inc. All rights reserved.Experian Public.

Importance of Episode Management

Episode Management Chronic Care Management/Preventative Health

Six Month Episodes




#1 Source of Shared Savingsfor majority of ACOs

Source: Leavitt Partners

Six Month Episodes




#1 Source of Shared Savingsfor majority of ACOs

Source: Leavitt Partners

CMS paying $160 PMPM tosupport episode management

Episode Management involves care delivery across the community

Not connected,Not coordinated

CMS’ Definition of an Episode

Six Month Episodes


Typical Provider Community in 2017C

hild

ren’

s H

ospi

tal

Standalone Hospital

Dozens of post-acute providers (More than 5x number of hospitals)

1EMR

1 or 2EMRs

1EMR

Big health system #2 health system

Inde

pend

ent,

mul

ti-sp

ecia

lty

Independent MDs, community health centers


Acute Admission

Discharge Planning

Notification of Discharge Discharge Summary

ER Visit

Typical State of Episode Management for Most Health Systems

Post-DischargeCall to Patient

Post-Acute Care

Episodeof Care 30-180 days

PAC Referral

Follow-upVisit

??



Acute AdmissionER Visit

Typical State of Episode Management for Most Health Systems

Follow-upVisit

Post-Acute Care


Discharge Planning

PAC Referral


Lack of VisibilityLack of Certainty

Lack of Data!! RISK !!


Care Management Problems & Needs

For ACOs, IPAs and other at-risk entities

► Don’t know when a member is admitted or discharged from a hospital, or visits ER

► Don’t know when an admission is readmission► Don’t know when a member is admitted to or

discharged from a SNF or LTACH► Don’t know when a member is getting home

health or hospice care► Receive too many notifications – can’t

prioritize clinical intervention / follow-up

► Hospitals & ACOs don’t know if patient has post-discharge visit with PCP

► PCPs don’t know their patient has been admitted to, discharged from a SNF/LTACH

► Hospitals/ACOs don’t know how patient/ member’s rehab is progressing at a SNF

► For NextGen ACOs, manual, labor-intensive process for collecting data for reporting to CMS related to SNF 3 Day Rule Waiver

► Hospitals don’t know the patient they are treating is an ACO member

► Hospitalists don’t know the patient they are attending is an ACO member

► PCPs don’t know their patient has been admitted, discharged, or visits ER

► PCPs inconsistently get discharge summary following discharge and/or not electronically

Information Sharing re: Acute Care Post-Discharge ‘Cloud of Uncertainty’

Internal Care Management ChallengesLack Real-time Info on Member Activity► Our care managers are working too much

from spreadsheets, faxes, and phone calls

► Don’t have tracking into the care transitions-related work performed by our care team

► Don’t have enough care managers to call every member after an ER visit or discharge

► Don’t receive care summaries/documents electronically following ER visits, discharge


Acute AdmissionER Visit

One Solution: Army of FTEs Calling

Care Managers / Care Coordinators

Post-Acute Care



Follow-upVisit

Lack of VisibilityLack of Certainty

Lack of Data!! RISK !!

Discharge Planning

PAC Referral


Not an Ideal Solution


Episodeof Care

30-180 days

Task

Alert

Data

?Qstn

Doc.

Task

?Qstn Task

Data

Doc.Task

Data Alert Alert

?Qstn

Doc.

Task

Data

Task

Risk-bearing entity needsto manage episode


Scenario: Patient Goes to ER, Admitted to Hospital, Admitted to SNF, Discharged Home

Episodeof Care

Recommended Episode Goals for the Risk-Bearing Entity:1. Avoid Readmission2. Avoid Unnecessary Post-acute (PAC) Costs3. Ensure good transition home, adherence to medications and instructions4. Use follow-up PCP visit to strengthen provider-patient relationship and address/

plan for necessary preventative services5. If PCP orders follow-up services, ensure completion and closed-loop

Discharged

Home


Initial Focus:Notify Primary Care Provider

Episodeof Care

Notificationto hospitalof ACO link

Notificationof Discharge

Real-timeNotificationof ER visit, Admission

Ambulatory Or

Hospitalists


Secondary Focus: Coordination with Post-Acute Care

Episodeof Care



Ambulatory Or

Hospitalists

Notification to Post-Acute Provider

Common Challenge: Lack of Post-Acute Care Visibility



Goal: Coordination Across the Continuum of Care

Episodeof Care



Ambulatory Or

Hospitalists

Updates

Utilization Review

Call Patient to Check-in, Schedule

Follow-up visit

HOME

OfficeStaff

Call Patient to Check-in, Schedule

Follow-up visit

Patient atHome

Dis

char

ge

Updates MayTrigger Alerts to

Care Management

Updates

Visibility & Data:- Contacted or not- Scheduled or not- Kept appointment

data



Scenario: Patient Goes to ER, Admitted to Hospital, Admitted to SNF, Discharged Home

Episodeof Care

Recommended Episode Goals for the Risk-Bearing Entity:1. Avoid Readmission2. Avoid Unnecessary Post-acute (PAC) Costs3. Ensure good transition home, adherence to medications and instructions4. Use follow-up PCP visit to strengthen provider-patient relationship and address/

plan for necessary preventative services5. If PCP orders follow-up services, ensure completion and closed-loop

Discharged

Home


1. Two Strategies Involved with Move to Value Based Care

2. Migration and Challenges of Enterprise Data Strategies

3. Importance of Episode Management to Value-based Care Success

4. The “Last Mile” / the Post-Discharge “Cloud of Uncertainty”

5. Need for and Challenge of Automation

Summary: What We Discussed

coordinating the “last mile” to succeed at value-based ......1. two strategies involved with...

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