trinity pioneer aco - the duke endowment … · source: “fischbeck, paul. “us-europe...

Trinity Pioneer ACO

Pam Halvorson UnityPoint Health – Fort Dodge Executive Sponsor ACO Vice President, Clinic Operations

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Trinity Pioneer ACO UnityPoint Health Map

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Trinity Pioneer ACO

Presenter

Presentation Notes

Our Pioneer work was in the Fort Dodge region only. This slide displays our locations in north-central Iowa. We are located about 100 miles north-northwest of the states largest city, Des Moines. Our main rural referral hospital is located in Fort Dodge, 106-bed Trinity Regional Medical Center. Our physician group, UnityPoint Clinic includes Primary care clinics in Fort Dodge, as well as surrounding rural communities. It also includes specialists that do satellite in many of the same rural communities. We have a partnership with the Iowa Heart Center to provide Cardiology services in our region. Lastly, we have management agreements with 5 CAH in our region, which are displayed on the next slide.

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Trinity Pioneer ACO

Presenter

Presentation Notes

We have management agreements with 5 CAH’s in our region: Humboldt County Memorial Hospital in Humboldt, Pocahontas Community Hospital in Pocahontas, Buena Vista Regional Medical Center in Storm Lake, Loring Hospital in Sac City, and Stewart Memorial in Lake City. UnityPoint Clinic provides the majority of the primary care medical staff in all of those CAH, with the exception of Stewart Memorial, which employs it’s own Primary care physicians. We take our role in these rural communities very seriously and firmly believe a strong medical staff needs a strong hospital, and a strong rural hospital needs a strong medical staff.

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Pioneer– ACO Service Area

8-county service area in Northwest Central Iowa Population: 20,567

Median Income: $46,947 Rank: 35

Population: 7,154 Median Income: $42,138 Rank: 50







Trinity Pioneer ACO

Presenter

Presentation Notes

Slide 5 illustrates just how rural our region is. There are about 120,000 people in the 8-county area, or an average about 27 people per square mile in our market. Our main hospital and medical group is located in Webster County in the lower row, second from the right. At about 37,000 people, it’s the largest county in our service area; but also the poorest and least health counties in Iowa, ranking 93 in terms of public health. We are also one of the oldest regions of the state, with total Medicare payor mix around 60%. Keep this graphic in mind as we walk through the population health initiatives we’ll describe and the remaining challenges.

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Health Risk Comparisons The Case for Care Coordination

U.S. Health care is only expensive when you use it!

Source: “Fischbeck, Paul. “US-Europe Comparisons of Health Risk for Specific Gender-Age Groups.” Carnegie Mellon University; September, 2009.

Trinity Pioneer ACO

Presenter

Presentation Notes

So, why did UnityPoint Fort Dodge decide to apply for, and join the Pioneer program in 2012? Slide 6 is a chart most of us have probably seen before. The point of this chart is that the current rate of healthcare expenditures in the U.S. is unsustainable. We knew, in 2010, when Medicare started getting serious about moving healthcare expenditures into Value-based payment models, that we wanted to be involved in influencing those models, particularly in rural America.

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Trinity Pioneer ACO

A Year in the Life of a Patient

Source: Johns Hopkins, RWJ 2010 (G Anderson)

• The Case for Care Coordination

6 Social

Workers

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Admissions

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Care

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22 13

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2 Nursing Homes 4

Occupational Therapists

19 Clinic Visits

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5 Physical

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6 Community

Referrals 2

Home Care Agencies

16 Physicians

Presenter

Presentation Notes

We all have family members that have experienced the healthcare system, and this illustration is probably pretty close to what those loved ones experienced. Even though we thought we were pretty good at care coordination, we knew there were opportunities to improve. We knew that the messy, uncoordinated care causes high-cost readmissions; it causes non-compliant patients, resulting in high ER utilization; and miscommunication among physicians causes duplication of expensive services. In a few slides will describe how we’ve been able to improve the care coordination, not just within our system, but also outside the four walls of our buildings.

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Trinity Pioneer ACO

Medicare Spending Payment Reform Characteristics:

• The Case for Care Coordination

Presenter

Presentation Notes

Side 8 demonstrates the increasing levels of risk and payment options. UnityPoint – Fort Dodge jumped from Fee for Service, all the way to Shared Savings. If our belief that our payment system was going to move away from FFS, toward VBP, we knew we couldn’t make that jump overnight. So, in addition to influencing the payment model transition in rural America, another motivation was to educate ourselves in the care-redesign and financial modeling of the new model. I should note, being part of a larger health system was a great advantage in our situation. Without the talent, technology, and financial resources of a larger system, we would not have been able to be successful at this transition. I would also note, for those that have not entered some kind of shared savings, or ACO, work, that the most important first step is to educate, and gain the support of, your organization’s board of trustees. As Pam will demonstrate in a couple minutes, this work is not for the faint-of-heart.

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Trinity Pioneer ACO

Accountable Care Organization (ACO) Model

The Case for Care Coordination

Performance Incentives for Physicians &

Hospitals

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Projected cost based on medical inflation trends

Actual costs based on ACO and Medical Home collaboration

Presenter

Presentation Notes

We use this slide in frequent presentations in our organization to help explain the ACO payment model. I usually explain that for the first time in my 25 year career, the incentives between the purchasers of healthcare and the providers of healthcare are starting to align. And, while this is not a long-term sustainable model, it does at least rewards systems for doing the right thing for patients; preventing illnesses, producing high-quality outcomes, and reducing the total cost of care.

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Contract Attributed Members

Pioneer ACO 12,000

Wellmark ACO 18,000

Iowa Wellness ACO 1,500

Self-Insured Health Plan 1,800

United Healthcare ACO

800 (estimated)

Trinity Pioneer ACO

Contracts and Aligned Lives

Presenter

Presentation Notes

Adnan will do this one

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Trinity Pioneer ACO

Better Care for Individuals Better Health for Populations Decreased Cost of Care

Triple Aim

Presenter

Presentation Notes

Mike three slides Initial Goals – Transformed Goals Major accomplishments Best learnings - advise

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Trinity Pioneer ACO

Achieving our Aim

• Health-Risk Assessment

• Iowa’s Healthiest State initiative

• Preventive screening

• Health Education and Literacy

• Wellness Program

• Patient access to PCP

PCMH and IHH • Common

screening and assessment tools

• Single, patient-centric care plan

• Med Therapy Management

• Mental Health Action Team

• Care transitions – Extended Care Facilities

• ICCDM – all care settings

• Advanced Medical Team

• Telephonic-Telemonitoring

• Strategic Healthcare Partners

• Critical Access Hospitals

• Risk stratification • Med Therapy

Management • Disease

Management Coaching

• Strategic Community Partners

Palliative Care: • Inpatient • Home-based • Clinic • Integration with

PCP

Hospice: • Hospice Home • Home-based

Primary Care Community

AIM: Leverage every aspect of our “community” to achieve Best Outcome for Every Patient Every Time

Home/Neighborhood - Schools - Business - Healthcare Agencies - Government -Recreation - Church/Spiritual

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Trinity Pioneer ACO

Function is the Strategy – Operational Capacity and Cultural Appetite is the Execution

• Science of Change – Adaptive Design • Approaching Chronic Care with a common language – ICCDM

• Integrated Chronic Care Disease Management • Finding Leaders and Providers and Teams dedicated to the vision

• Chemistry is important – so is forgiveness • SMEs have a role • Collaborators get the most done • The work gets more complicated, so stamina is an important attribute

of people doing the work • Telling and sharing experiences and patient stories reenergizes the

work • It is not a “program” thus the work will never end

Presenter

Presentation Notes

Introduction to the work groups and governance Several names have to be changed

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Trinity Pioneer ACO

Put the Patient at the Center Put the Population Strategy in place to

get the impact

Understanding the Financial Costs

Then understand how the financial impact will flow

Presenter

Presentation Notes

Our goal with each strategy was to first put the patient at the center of the initiative, and prove or disprove our hypothesis of what would happen to the cost of care. Now, I would caution that we are not in the practice of evaluating the ROI of each population health strategy or initiative. All of the strategic initiatives that have been described work concurrently with each other. Having just one initiative in place, without any development of the rest of the intiative, will cause frustration and confusion by the providers and the patients. Initial Goals – Transformed Goals Major accomplishments Best learnings - advise

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Trinity Pioneer ACO

Understanding the Financial Costs

Develop an understanding of the financial calculations of the PMPM targets and results, as well as the nuances of the attribution methodology and the financial impact

Use CMS reports and claims data to estimate our PMPM performance.

Identify opportunities to reduce PMPM from a cost and utilization perspective

Presenter

Presentation Notes

From a financial standpoint, we had 3 goals as we entered the Pioneer. We know we had to develop a new financial vocabulary. PMPM and attribution became part of our normal financial discussions. We use those terms during monthly board finance committee meetings, as well as monthly manager’s meetings. If we were going to change the culture away from FFS to Population Health, we had to change the financial metrics we were monitoring. For the first time in my career, we were given access to claims data. Yes, we’ve used it to monitor our PMPM performance, but some other learnings from the claims data are that we need to retrain our financial professionals to deal with ‘big data’ and translate that data to clinical professionals that can influence the care delivery. Lastly, where the ‘rubber hits the road’ is when we can use the data analytics to identify opportunities to improve quality and/or reduce cost of care; AND educate and influence the providers to redesign the care delievery. Initial Goals – Transformed Goals Major accomplishments Best learnings - advise

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Trinity Pioneer ACO

Pioneer Overall (PY2 – 2013) Note: Cost data is not risk adjusted

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Trinity Pioneer ACO

Inpatient – PMPM (PY2)

UnityPoint Trinity Pioneer ACO

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Presenter

Presentation Notes

Slide 19 compares our Inpatient PMPM to the 2013 Pioneer average. As you can see, our PMPM is below the average for acute care hospitals.

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Trinity Pioneer ACO

Outpatient and ED (PY2)


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Observation stays Outpatient facility Total

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My ACO ACO Average

Presenter

Presentation Notes

Outpatient facility utilization is all including ED utilization – the ED service is cost of not admitted patients. We have some of the highest ED without admissions due to our lack of accessSlide 20 illustrates what we suspected would happen. Due to our access issues in Primary care in rural areas, we knew that patients were using our ER’s in lieu of clinic visits. We’ll describe what we’ve done about that in a few minutes. But, this data confirmed what we suspected with regard to the impact of access issues on our cost of care.

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Trinity Pioneer ACO

Quality Score for Care Coordination Metrics (PY2)


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Trinity Pioneer ACO

Quality – High Risk Populations (PY2)


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Trinity Pioneer ACO

Quality - CAHPs Patient Experience (PY2)


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(ACO-1) (ACO-2) (ACO-3) (ACO-4) (ACO-5) (ACO-6) (ACO-7)Timely Care CAHPS Communication CAHPS Provider rating CAHPS Specialists CAHPS Education CAHPS Shared decision CAHPS Health status CAHPS

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Presenter

Presentation Notes

An area of vulnerability – talk about access? Relate to impformation about medications – ahared deicsion – health education

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Trinity Pioneer ACO

Access to Care

Prevent Illness and Disability

Presenter

Presentation Notes

Doris, Michelle and CAHPs scores with Ashley May want to talk about the challenges here and what’s ahead. Adnan to also help with the statistics around ED utilization where we do not have after hours clinic

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Trinity Pioneer ACO

What Do Patients Want? • According to the 2014 Primary Care Consumer Choice Survey: • 4,000 patients were asked what is most important to them when they

have flu like symptoms.

• The top 10 responses were: • I can walk in without an appointment and be seen within 30 minutes. • If I need lab tests or x-rays, I can do them in the clinic. • The clinic is open 24/7. • I can get an appointment for later today. • The visit will be free. • The provider is in-network for my insurer • The provider explains possible causes of my illness and helps me to plan

ways to stay healthy in the future. • Each time I visit the clinic, the same provider will treat me. • If I need a Rx, I can get it filled at the clinic instead of going to another

location. • The clinic is located near my home.

• Prevent Illness and Disability - Access to Care

Access Convenience

Cost Service

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Trinity Pioneer ACO

What the data shows: • Today we are short 8 Family Medicine providers. (22% of all primary

care providers) • We have been recruiting for Family Medicine physicians for over 4

years. • 15 mid-level providers have been hired since 2011. • No extended Hour clinics in 6/8 counties • No tertiary care hospitals • No pharmacies open past 8:00 in 7/8 counties • 1 urgent care open until 9:00 in one community

• Additional services to support access include:

• Opened and then Expanded Urgent Care by adding another mid-level during peak hours.

• Virtual Care • Using Telemedicine in RHC and CAH locations • Call Center Triage

• Prevent Illness and Disability - Access to Care

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Trinity Pioneer ACO

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Trinity Pioneer ACO

3-Day Waiver and SNF

Post Acute Care

Presenter

Presentation Notes

Doris, Michelle and CAHPs scores with Ashley May want to talk about the challenges here and what’s ahead. Adnan to also help with the statistics around ED utilization where we do not have after hours clinic

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3-Day Waiver Gathering Claims Data

• Financial Analyst pulled claims data from the warehouse “cube” Source Description: Pioneer ACO

Performance Year: PY02

Service End Date Year: (Multiple Items)

Note: Claims files through Feb 2014 are loaded in the cube

Part A and B Payment Amount

Claim Type: Non swing bed SNF claim, Swing bed SNF claim, Outpatient claim, Hospice claim, Inpatient claim

• Manual work to separate claims into “episodes/cases” • Data analysis performed using custom pivot tables • Future opportunity to automate claims data analysis and

develop new system to track, analyze and report “real-time” data from PAC providers

Trinity Pioneer ACO

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6.7% of Trinity ACO Benes had a SNF Claim in PY2 (2013)

Trinity Pioneer ACO

96 128 524

Swing Non-Swing

# Benes # Cases ALOS Cost ($MM)

Cost/ Case

Cost/ Day

Total 748 1,068 19.7 8.76 8,204 417 Non-Swing

620 818 23.6 6.04 7,380 313

Swing 224 250 6.9 2.73 10,904 1,585

Swing Non-Swing % Cases 23% 77% % Cost 31% 69%

# ACO Beneficiaries Source: UnityPoint data warehouse (the "cube") Pioneer Claims with end dates in 2013

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Example Report: SNF Quality &Utilization Measures

Trinity Pioneer ACO

Trinity Pioneer ACO

BOLD RED ≥20% higher than average Cost or ALOS

RED 10%+ higher than average Cost or ALOS

• UnityPoint data warehouse (the "cube")

• Pioneer Claims with end dates in 2013

• CMS Rating: Nursing Home Compare at Medicare.gov

Facility Name City CMS Overall

Rating# ACO Benes

# Cases/ Admissions Cost/Case ALOS/Case

Friendship Haven Fort Dodge 5 91 112 8,170 22.04

Villa Care Center Fort Dodge 2 79 99 5,693 19.61

Methodist Manor Storm Lake 3 50 56 6,834 18.93

Park View Rehabilitation Center Sac City 3 49 64 6,598 27.33

Marian Home Fort Dodge 3 42 61 6,714 21.00

Fort Dodge Health & Rehabilitation Fort Dodge 2 37 45 6,756 21.80

Rotary Senior Living (Rotary Ann Home) Eagle Grove 3 30 34 8,106 21.38

Black Hawk Life Care Center Lake View 1 27 47 9,906 33.06

Pocahontas Manor Pocahontas 1 23 29 8,281 33.07

Humboldt Care Center North Humboldt 4 22 29 6,071 20.83

Newell Good Samaritan Center Newell 4 18 19 7,020 22.74

North Lake Manor Storm Lake 1 16 20 11,056 40.05

Humboldt Care Center South Humboldt 5 13 17 6,678 24.82

Twilight Acres Wall Lake 5 11 11 6,518 18.36

Fonda Nursing & Rehab Center Fonda 5 10 14 8,630 29.93

Laurens Care Center Laurens 4 9 13 2,461 8.62

Pleasant View Home Albert City 5 8 7 8,495 22.86

Sunset Knoll Care & Rehab Center Aurelia 4 7 9 3,423 11.89

Odebolt Nursing & Rehab Center Odebolt 5 7 12 5,156 18.08

Manson Good Samaritan Center Manson 5 7 7 7,628 23.29

Pomeroy Care Center Pomeroy 2 7 7 6,544 26.71

Good Samaritan Holstein 4 4 6 9,551 35.67

Sioux Care Center Sioux Rapids 4 3 3 3,871 13.33

Milford Nursing Milford 4 2 2 21,589 58.50

Sunny Knoll Care Center Rockwell City 3 1 1 3,220 11.00

St. Lukes Lutheran Home Spencer 3 1 3 3,549 20.00

Crestview Nursing & Rehabilitation Webster City 3 4 6 3,812 13.83

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Trinity Pioneer ACO

Example Report: SNF Utilization

# Cases

LOS

Source: UnityPoint data warehouse (the "cube") Pioneer Claims with end dates in 2013

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Potential Trinity ACO Savings Reducing ALOS from 23.6 to 15 days would result in ACO potential savings per year of $2,200,341 or 17.29 PMPM.

Reducing one day = $256,720 annual savings

If 10% of our inpatient hospital cases could be avoided by identifying eligible beneficiaries for direct admission to SNF under this waiver, we anticipate an ACO potential savings per year of $970,890 or $7.63 PMPM.

We estimate 30% of our observation cases could be avoided in eligible Pioneer beneficiaries meeting criteria for direct admit to SNF, resulting in ACO potential savings per year of $345,901 or $2.72 PMPM.

Trinity Pioneer ACO

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Trinity Pioneer ACO

Emergency Department

Consistent Care Program

(ED/CCP)

Provide a Coordinated Care Experience

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Trinity Pioneer ACO

Program Highlights

• Implemented ED RN Navigator position May 2014. • Continue to monitor data to identify patients with high ED

utilization and reason for visit patterns. • Weekly interdisciplinary meetings to review high ED utilizers

and develop care plans • ED Navigator rounds in ED on patients and families to

coordinate needed services and discharge planning. • Works closely with Primary Care providers, Home Health, Public

Health, Berryhill Center and other community resources to coordinate patient care.

• Paramedicine Program Instituted for home visits

Provide A Coordinated Care Experience ED / CCP

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Average Number of ED visits for T1 Patients Per Month Pre-Intervention and Post-Intervention

July 2015 116 Patients

1.75 Visits

.49 Visits

Trinity Pioneer ACO

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Trinity Pioneer ACO

Patient with seizure disorder Forty-two 911 calls and ED visits from 2010-2014 28 ambulance transports – 14 times refused

transport Patient can’t drive, neurologist is 60+ miles away Referred by ED CCP program Made Public Heath referral Patient usually on a bike without a helmet when 911

called

Patient Story

Presenter

Presentation Notes

Case Study 6: Referred by: Emergency Department (ED) Situation: Adult Epileptic client with frequent seizure activity resulting in injury Frequent 911 calls - - Since April 2010 - 42 calls 28 of which client transported to ED by ambulance, 14 times refused transport - From Jan to July 2014 - 10 calls, 5 of which client transported to ED by ambulance ED visits via ambulance due to injury when riding bike Transportation barrier - Neurologist located in another town and county Medication Management/reconciliation issues between doctor, pharmacy, and patient Difficult to contact - no access to phone and is often not available at home ED performed Community Para medicine visit in client’s home and referred to CCT Outcome: Health Promotion visit Reconciled medications with neurologist, pharmacy and client Instructed client on proper medication regimen Provided client with medication planner Follows medication regimen Coordinated transportation to neurology appointment out of town with client’s father Enrolled in Community Care Team June 2014 NO ED visits or 911 calls since July Without CCT Intervention: With CCT Intervention: Multiple Emergency Department Visits due to seizure activity with injury Prevented Emergency Department Visits with coordination between ED and CCT Improper medication reconciliation/medication management Prevented ED/Hospitalization with proper medication reconciliation/medication management

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Trinity Pioneer ACO

Actions First UPH EDCCP Paramedicine visit in July 2014

Reviewed patient’s medications and coordinated PCP visit Referred to Public Health Learned 42 year old patient always used bike for self

transportation and had little support Public Health, Health Promotion visit

Reconciled medications with neurologist, pharmacy and client Instructed client on proper medication regimen Provided client with medication planner Follows medication regimen Coordinated transportation to neurology appointment out of

town with client’s father Enrolled in Community Care Team (Tri-Navigation) in June

2014

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Trinity Pioneer ACO

Estimated Cost Savings

Utilization from January 2014 - June 2014 ED visits - 8 visits x $600 = $4800 Ambulance - 4 trips x $1000 via ambulance to ED = $4000 Ambulance/911 calls without ED visit = 4 trips x $1000 = $4000 Total cost = $12, 800

Utilization since July 2014 - December 2014 ED visits - 2 visits x $600 = $1200 Ambulance - 2 trips x $1000 transport via ambulance to ED = $2000 Hospitalizations – 2 day hospital stay, $2000 per day = $4000 Total costs- $7200

Presenter

Presentation Notes

Deb to check on his admission history

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Trinity Pioneer ACO

Palliative Care Across the Continuum of

Care

Support Choice Through the Lifespan

Presenter

Presentation Notes

Nadine or ?

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Acute Palliative Care Consultation Rate July 2013-June 2014

Support Choice Through the Lifespan - Palliative Care

Trinity Pioneer ACO

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Trinity Pioneer ACO Support Choice Through the Lifespan - Palliative Care

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Cost Savings

Support Choice Through the Lifespan - Palliative Care Trinity Pioneer ACO

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Trinity Pioneer ACO

Current Statistics • Over 400 Community/LTC patients • Average 10 inpatient consults/day • Positive trend with increasing referrals from

various sources i.e. cancer center, ED, pain center, LTC, and family members

• 98% Press Ganey Patient Satisfaction Rate for 3 Consecutive Quarters (2013-2014)


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Trinity Pioneer ACO

Barriers/Challenges Seen With Program Growth

• Need and demand for services outpaces ability to resource with current reimbursement structure

• Need for education ongoing to providers, LTC staff and community

• Lack of trained PC providers and staff to hire


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Trinity Pioneer ACO

Financial and Organizational Data for UnityPoint Health – Fort Dodge

Trinity Pioneer ACO

2009 2010 2011 2012 2013 2014

Number of discharges 5,505 5,621 5,213 4,689 4,540 4,108

Number of discharges excluding newborns 4,967 5,074 4,725 4,157 4,003 3,592

Number of readmissions 522 457 336 287 303

Readmission rate 10.30% 9.70% 8.10% 7.20% 8.40%

Total Staffed Beds (excluding nursery) 115 115 115 115 109 106

Number of Employees (consolidated) 1,284 1,232 1,200 1,152 1,140 1,178

*Net Operating Revenue 153,448 148,298 143,981 142,977 141,038 156,390

*Consolidated Operating Income 2,614 5,080 -2,964 1,445 2,825 3,748

Consolidated Operating Margin 1.70% 3.40% -2.10% 1.00% 2.00% 2.40%

Presenter

Presentation Notes

Like I said earlier in the presentation, we don’t really look at the ROI of each population health initiative or by payor or ACO contract. We look at the value and return on the entire enterprise. As shown on our financial data, we’ve reduced discharges every year since 2010. The ACO work has accelerated that decrease since 2012. Generally, we’ve kept our total FTE’s consistent by ‘repurposing’ staff, or shifting staff to outpatient or other lower-cost environments of care. And, we’ve kept our consolidated operating margin consistent the last few years.

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Trinity Pioneer ACO

Trinity Pioneer ACO

• PY1 (2012) Results Improved quality outcomes, little change in PMPY

• Pioneer PY2 (2013) ACO Results Target PMPY = $8,765 Actual PMPY = $8,527 $238 Difference = 2.7% 8,772 Aligned Lives 70% Shared Savings Rate Quality Score = 82.4% Net Shared Savings = $1,219,000

• PY3 (2014) Results Preliminary results show 1.6% savings, pending final quality

results.

Presenter

Presentation Notes

But, people want to know how we did on the contract…so, here are the high-level results… Performance Year 1, 2012, there was essentially no change in the cost of care, as measured by Per Member, Per Year, or PMPY. And, even though it was a reporting-only year for quality data, we were able to demonstrate improved quality outcomes. Year 2, or 2013, we were able to achieve a 2.7% savings as illustrated on this slide. After adjusting for our quality score of 86%, we achieved $1.2 million in net shared savings for our organization. It should be emphasized, that within the 86% quality score, we were required to meet at least 70% in each of four quality domains, or we wouldn’t have received any of the $1.2 million. In one of the four, we were at about 71.5%. Needless to say, our PY2 experience has caused us to become even more hyper-focused on the quality metrics. Initial Goals – Transformed Goals Major accomplishments Best learnings - advise

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Trinity Pioneer ACO

Remaining Challenges: • Complexity of the financial calculation and estimating

impacts. • New risk and locality adjustments

• Increasing newly aligned members resulting in lowering risk score

• End of the year adjustments reduces predictability • Nature of low population in rural region reduces

predictability and increases risk • Communication with physicians about their members

and overall performance from a cost and quality perspective.

• Next Steps • High-risk patient identification • Identify and evaluate Post-acute partners and identify

opportunities to improve quality and reduce costs

Presenter

Presentation Notes

Initial Goals – Transformed Goals Major accomplishments Best learnings - advise

trinity pioneer aco - the duke endowment … · source: “fischbeck, paul. “us-europe...

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