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Angelo Sinopoli, MD VP, Clinical Integration Chief Medical Officer

Value-Based Healthcare Through Care Coordination and Clinical Integration. Angelo Sinopoli, MD VP, Clinical Integration Chief Medical Officer. Strategic Positioning Multi-Year Goals . “Population Based Care”. The new mantra of healthcare. Beyond the Medical Home.

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Angelo Sinopoli, MD VP, Clinical Integration Chief Medical Officer

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  1. Value-Based Healthcare Through Care Coordination and Clinical Integration Angelo Sinopoli, MDVP, Clinical Integration Chief Medical Officer

  2. Strategic PositioningMulti-Year Goals

  3. “Population Based Care” The new mantra of healthcare.

  4. Beyond the Medical Home

  5. Strategic Positioning Accountable Care Organization The Care Continuum Emergency Medical Services Collaboration Emergency Department Case Management Outpatient Care Management Department Clinical Advisory Teams Project RED CHF Observation Unit AccessHealth SC Nursing Home Relationships Palliative Care Employer On-site Pharmacy LTACH Medical Weight Management Program Sub-Acute Units Employer Health Risk Assessments Rehab Hospital Smoking Cessation CHF Clinic Graphic: Sg2 Employer On-site Nurse Practitioner Wellness Way Home Outreach and Case Management Pulmonary Rehab Diabetes Self Management Program Nurse Family Partnership Information Systems Care Coordination Competencies

  6. Clinical Integration Initiatives • Duke Innovation Grant • ER Care Management • GHS/EMS Partnership • Community Care Outreach • GHS Employee Care Management • Readmission Projects • Nurse Family Partnership • Centering Pregnancy • Business Health • BlueChoice Medicaid

  7. Duke Innovation Grant Overview: • $2.7 million grant for delivery innovation Eligibility: • Initial pilot focused on Medicaid clinic population and subsequently the unfunded population • Developed a stratification process based on ER and hospital utilization

  8. Duke Innovation Grant

  9. Duke Innovation Grant Results to-Date: • In year one, there was a 26% decrease in Emergency Department visits and a 55%decrease in inpatient days • For Diabetes, the number of patients with HgA1c High values (>9%) decreased 14% • LDL-C Abnormal values decreased 15% • For Hypertension, Non-Diabetic, the number of patients with readings within 140/80 parameters improved approximately 13% • For Asthmatics, the number of patients appropriately receiving corticosteroid/acceptable alternative therapy improved approximately 11%

  10. ER Care Management • 130 Patients Enrolled • Active Case Management • Connecting to a Medical Home • Addressing Social Issues

  11. GHS/EMS Partnership Awarded a $300,000 grant to reduce unnecessary ER and EMS utilization by: • Creating an innovative nurse triage call center that is currently being used in only two other locations in the US • Providing care coordination to ER and EMS high utilizers so they receive the right care at the right time and place • Developing patient-centered medical neighborhoods within the community

  12. EMS Nurse Triage Monthly DataJune through April

  13. Community Care Outreach Collaboration between GHS, GCEMS, and Greenville City Fire Department to create patient-centered medical neighborhoods within the Greenville Community.

  14. BlueChoice MedicaidPartnership

  15. BlueChoice Medicaid • Partnership with BCBSSC • 14,000 covered lives in Greenville county • Joint Operating Committee • Care Management/Coordination by GHS/UMG • Shared-savings program

  16. BlueChoice Medicaid • Inpatient utilization/1000 decreased by 11.2% • Professional utilization/1000 decreased by 4.5% • Script/member decreased by 12% • Percent generic utilization increased by 2% • Total cost PMPM decreased by 12.1% for CY 2013 compared to CY 2012 • Significant shared savings realized at year end

  17. Accountable Communities Patient-Centered Medical Homes (PCMH) Patient-Centered Medical Neighborhoods (PCMN)

  18. Medical Neighborhoods • Health System and Safety-net Collaboration • Providing Access to Care within Communities • Community Paramedic and Health Worker Models • Home Health • Care Management • Care Coordination

  19. Accountable Communities • Community-led Innovation • Community Volunteer Programs • Community Paramedics • Community Resources (Faith-Based Organizations, Schools, EMS, Police and Fire Districts) • Patient Education and Social Determinants • Population Health Management • Social Service Providers

  20. Other Community Health Initiatives • Persons with Nonmedical Needs Policy Implementation • Ending Chronic Homeless Task Force • Partnership with New Horizon • SCDHHS and SCHA Partnerships • Proviso, Coordinated Care Incentives Group, Heart Committee, Medicaid Transportation • Governmental Policy Development

  21. On the Horizon • Restructure of AccessHealth Greenville County • Develop Community Paramedic Program • Proviso 33.26 • Mobile Health Clinic • Evolving Role of EMS as an Integrated Mobile Health Delivery System

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