Comprehensive Primary Care Initiative

1. Comprehensive Primary Care Initiative Redefining value and healthcare delivery in Primary Care

2. “Primary care is critical to promoting health, improving care, and reducing overall system costs, but it has been historically under-funded and under-valued in the United States… Many studies suggest that it costs less to provide healthcare to patients who receive care from primary care practices that offer comprehensive services compared to those that don’t provide such services.” -CMS, 2012

3. What is Cpci? • A four-year pilot program, incorporating both public and private payors, to transform the delivery and reimbursement of primary care by placing emphasis on comprehensive primary care and care coordination/management. 16 TCHP primary care practices Definition Cincinnati/Dayton/N. Kentucky Pilot  10 payors  44,000 lives

4. What is the Cpci value proposition? • Years 1 & 2: • Payers provide additional per-member, per-month (PMPM) payments for investment in infrastructure (practice, staffing, IT) which will enable the provision of more coordinated, comprehensive primary care. • Years 3 & 4: • Less PMPM payments; opportunity for shared savings Step 1 Step 2 Step 3 Enable Comprehensive Primary Care Additional PMPM Payments Achieve Healthcare Triple Aim $ $ $ $ $ $ $ $ $ $ $ $

5. Patient centered medical home • PCMH is a philosophy of patient centered care delivered through a team based approach to provide comprehensive services. • PCMH laid the foundations for comprehensive primary care (CPC) • Key Enhancements to PCMH foundations: • Alternative reimbursement: Additional PMPM funding • Can be used for CPCi purposes only • 5 Core Functions • 9 Milestones for Year 1 aligned with core functions • Quality measures • 19 Measures in Year 1 to establish baseline • 21 Measures in Year 2 to measure improvement • Access to Payor information and internal reports

6. Building a True Medical home Quality Measures Payor Data & Metrics Care Coordination Personnel IT Infrastructure Enhancements PCMH FOUNDATION

7. Why is this important... THE time is now • Reimbursement methodologies are changing • Change from fee-for-service (FFS) to pay-for-performance (P4P) • Government and Payors scrambling to bend the cost curve; many pilots • Provision of Comprehensive Primary Care has been shown to drive down costs • Reduce redundant tests and services • Provide proactive care to keep people healthy and out of more costly sites of care • Puts practices ahead of the curve; at forefront of change • More prepared for more P4P methodologies • Get funding to invest in necessary infrastructures • Care Coordinators, Care Manager • IT Enhancements to allow patient and population management

8. The Framework: 5 core Functions of CPC

9. 9 Milestones for Year 1 • Budget forecast • Care Management of high risk patients • 24/7 access by patients • Improve patient experience • Use data to guide improvement* • Care Coordination • Shared Decision Making • Participation in CPC learning collaborative • Meaningful Use Stage 1

10. Model for change • Improve Care Coordination and Care Management (CCM) by: • Addition of Care Coordination personnel • Care Managers • Care Coordinators • IT Infrastructure Enhancement • Kryptiq’s Care Manager solution • Focus on 5 priority Conditions • Diabetes • CHF • CAD • COPD • Cancer

11. Additional Care Coordination Personnel RN Care Manager Responsible for care management of the high risk population through disease management and care transitions. This will be accomplished through face to face and telephone interactions with patients to promote self management skills through education and support. Care Coordinator Responsible to facilitate pre-visit planning, referral management and proactive outreach for overdue appointments/labs. The care coordinators will also be trained in behavior and lifestyle coaching to help your patients reach their personal health goals.

12. IT Infrastructure Enhancement IT solution needed to allow effective, convenient CCM: • Kryptiq’s Care Manager solution • Comprehensive, point-of-care and population management solution • Fully integrated solution in Epic • Enhances current Epic functionality • Population Dashboards • Point–of-Care (POC) tools • Patient Engagement

13. Care Manager- Population Dashboards

14. Care Manager- POC Patient Management Tool

15. Care Manager- Patient Engagement

16. Challenges • Culture Change for Providers • Team based care • Proactive management • Standardized Care • Culture Change for Patients • Self Management • Empowerment • Continued Funding

17. Is it working? Care Transitions Evelyn is a 72 y.o. with a h/o Angina, HTN and COPD. She admitted to the hospital with c/o HA and R sided weakness. Upon discharge Evelyn was sent home on Atenolol 75 mg/day. Prior to admission Evelyn took Tenormin 75 mg/day and once at home continued to take both medications because she did not understand they are the same drug. The RN Care Manager called the patient, identified the error and educated the patient on Generic vs. Brand named medicines. The Care Manager assisted her in creating an accurate medication list to keep with her at all times. A potential adverse outcome was avoided as a result of this call. Christina is a 52 y.o. female with a recent emergency room visit. The RN Care manager at her PCP office received an alert of the visit and reviewed the patient’s chart. She discovered the patient had not bee seen in the office since January 2012 and is a diabetic. The Care Manager reached out to the patient and discussed diabetes management. Christina had not been caring for herself and was receptive to coming in for an appointment and follow up with the Care manager. She agreed to attend the recommended diabetes education classes and to continue communicating with the Care manager to make needed lifestyle changes.

18. Is it working? Chronic Disease Management Sally is a 64 Y.O female with uncontrolled diabetes. Her PCP asked the RN Care Manager to start working with Sally to control her blood sugar. The Care Manager began calling Sally daily to track her morning blood sugars. Her average readings ranged from 350-400. During their calls they discussed Sally’s diet, medication regimen and activity. It became apparent that Sally did not have a good understanding of how to manage her disease nor did she believe she had any control and was resigned to the idea that nothing could change. The Care Manager starting researching and found her endocrinologist and made a call to his Nurse Practioner. The patient was scheduled for an appointment with endocrinology that week so additional time was added to the appointment to provide education time. After her appointment the Care Manger continued to call the patient and she noticed a dramatic improvement in the blood glucose levels. Today the patient is reporting an average blood glucose of 120 every day and she is feeling empowered to manage her disease.

19. CPCi Recap • 4-year pilot to determine if alternative reimbursements and CPC will accomplish The Triple Aim • Triple Aim: Better Population Health, Better Patient Experience, Lower Costs • CPCi builds upon PCMH foundations • Funding to be invested into practices’ infrastructure • Additional Care Manager and Care Coordinator staff • Epic Enhancements through fully integrated Care Manager tool • Focus on High Risk patients • Will expand to all 5 priority conditions

20. What are your thoughts QUESTIONS?