Atrius Health as a Patient-Centered Medical Home: Successful Strategies to Reduce Readmissions

1. Atrius Health as a Patient-Centered Medical Home:Successful Strategies to Reduce Readmissions MassPro October 30, 2012 3:00p-3:30p Kate Koplan, MD, MPH Director of Medical Management Atrius Health

2. Atrius Health – Background Non-profit alliance of six leading independent medical groups Granite Medical Dedham Medical Associates Harvard Vanguard Medical Associates Reliant Medical Group Southboro Medical Group South Shore Medical Center Provide care for ~ 1,000,000 adult and pediatric patients in almost 50 ambulatory sites 1000 physicians, 1450 other healthcare professionals across 35 specialties NCQA-Level 3 Certified Patient-Centered Medical Home at all Groups • Long history with global payments, currently managing 50% of our patients with global payments. • Strong infrastructure to manage risk • One of first to sign BCBSMA Alternative Quality Contract (AQC) and One of 32 Medicare Pioneer ACOs nationally

3. Elements of Patient Centered Medical Home • Personal physician • Physician-led care team • Whole person orientation • Coordinated Care  HOSPITAL/SNF/HOME CARE • Enhanced access • Quality • Safety • Patient and family centered

4. Comprehensive PCMH work must extend to the “Neighborhood” • 20% of Medicare beneficiaries hospitalized at least 1x/yr • They require services at discharge: • 41.1% to SNF • 37.4% to Home Health • 10.3% to In-patient rehab facility • 9.1% to outpatient/ambulatory therapy • 2.0% to long term care hospital Source: Gage et al (2009). Examining post- acute care relationships in an integrated hospital system, ASPE.

5. Preferred hospitals will have at least two of the following: • Unique contracting relationship • High-volume or at least a regionally high-volume • Site or Group preference, with supportive communication strategy • Formal collaborative relationship between Atrius Health and Hospital, including steering, clinical collaboration, and IT committees • Standards and metrics agreed upon and regularly reviewed, including discharge coordination and use of Atrius’ preferred network • Mutual agreement that Atrius and Hospital will collaborate on IT interoperability, including Atrius patient identification at registration and notification to primary team of admission and discharge • Atrius Health and Hospital physician and administrative leads to guide relationship

6. Preferred SNF Facility Standards • General: • Staffing/HR requests, incl. credentialing • Facility agrees to use Atrius Health preferred providers (DME, VNA, specialists) • Pre-Admission: • Patient screen and bed availability streamlined • Patients are identified as Atrius Health patients • Able to accept direct admits from home/ER/clinician office. • During stay: • Facility comfort for pts and staff • INTERACT tool (or comparable quality tool) • Therapies are available seven days per week; Mental Health coverage • Team and care planning meetings; facility case manager responsibilities • Radiology, Lab, Pharmacy expectations • At Discharge and Post-Discharge: • Patient experience survey • Atrius preferred vendors utilized for DME, Home Care, Home Infusion, Hospice, etc. • D/c planning based on checklist, incl. med list, sharing ACP directives, teach back

7. Preferred SNF Provider Standards • Discharge Planning • Templated summary; sent w/i 24h to Atrius Med Records • Ensure that f/u care is appropriate and that patient returned to Atrius Health PCP • 24/7 coverage by experienced and responsive clinicians • Timely communication to PCP if unexpected change in patient’s status • Newly admitted patients seen w/i 48h of admission by physician • Utilize Atrius Health preferred providers during stay • Participate in team and family meetings • Participate in quality and INTERACT or other related readmissions reviews • Comply with all payer minimum requirements

8. Standards and Metrics to Define our Hospital/SNF Strategy • Relationship structure • Care coordination, including case management and transitions of care • On-site functions • IT interoperability

9. Improved Care Coordination & Work in the “Neighborhood” • Differential process for discharge to ECF, home with services, and home without services, plus care coordination’s link with elder care services • Standards & Metrics, incl. IT interoperability • Post ED and hospitalization follow up within 7d, w focus on medication reconciliation • “Call First” campaign – encourage follow-up at our facilities if ambulatory-sensitive, or use of our preferred inpatient facilities, if that is level of care that is appropriate • Data: post-facility f/u, readmissions trending (3d, 7d, 30d), high risk patient reviews, etc… • Direct liaison with our hospital/SNF/homecare partners

10. Open Time Questions & Discussion