ACO Population Health: Raising the Bar Along the Journey

1. ACO Population Health: Raising the Bar Along the Journey Dianne Wasson, MSN, RN, CPHQ Iowa Health Information and Management Systems Society May 6, 2015

2. Healthcare changing to stronger patient, quality focus Participation in ACOs – In the Beginning Emphasizes a team approach focusing on measurable quality, rather than quantity. Certification relies on meeting several criteria: extended access, care management, follow-up, performance reporting, electronic prescribing, etc. Emphasizes using Electronic Health Records (EHR) to improve the quality of health care. E-prescribing, improving coordination through electronic exchange, quality reporting, engaging patients and providing privacy and security are all requirements to incentivize providers. Emphasizes coordination as a way to improve the quality of health care. Groups of health care providers form ACOs to better coordinate their efforts, the model ties reimbursement to quality metrics and cost reduction. Patient

3. UI HealthCare ACO Participation • Medicare Shared Savings ACO – July 2012 • There are 5 other participating ACOs in Iowa • Wellmark ACO – May 2013 • There are 12 other participating ACOs in Iowa • Iowa Health & Wellness ACO – July 2014 • There are 4 other participating ACOs in Iowa

4. UI HealthCare Partnerships in ACOs UI Affiliated Health Partners, P.C. A Partnership between two Health Care Organizations: • Academic Health Care System in Iowa City University of Iowa Hospitals & Clinics University of Iowa Physicians • Community Hospital in Cedar Rapids Mercy Medical Center Mercy Care Community Physicians

5. UI HealthCare Partnerships in ACOs University of Iowa Health Alliance A Collaboration between four Health Care Organizations: • UI Health Care, Iowa City • Mercy Medical Center, Cedar Rapids • Genesis Health System, Davenport • Wheaton Franciscan Healthcare, Waterloo

6. ACO Quality Measures: Not the Same • Medicare 33 quality measures in 2014 34 quality measures in 2015 (7 new, 6 discontinued) • Wellmark 18 quality measures • Iowa Health & Wellness 2 priority measures in 2014 18 quality measures in 2015 (same as Wellmark)

7. Population Health – Two Successful Strategies • Reducing 30-day Readmissions • Care Model development • LACE scoring • Managing patients at high risk • Integration of External Health Risk Assessments • HRA Workflow • Using the HRA as a foundation for the problem list • Building a common HRA

8. Reducing 30-Day Readmissions

9. Reducing 30-day Readmissions • Development of a Care Model for Transitions • ID those at greatest risk during the inpatient stay • Multidisciplinary huddle to facilitate discharge planning & resources needed • Follow-up call within 2 business days of discharge • Provider visit within 7 days, 14 days, or 30 days • Care management follow-up • HIM tools • LACE built to auto calculate • Reports to track success along the way

10. Care Model for Transitions of Care

11. What is LACE? Length of stay Acuity of the admission Co-morbidities Emergency Department visits in the previous 6 months 0-4: low risk 5-8: moderate risk 9+: high risk

13. Inpatient List Flagged LACE Details Accessible in a Flowsheet LACE Calculation inside EPIC

14. Tracking Progress: High Risk Visits in 7 Days = UI Health Care

15. Medicare All Cause Readmissions • 2012: 15.03% • 2013: 14.62% • *Lower is better • Wellmark Potentially Preventable Readmissions • 2013: 38.5 • 2014*: 39.4 • *Through October paid claims • Higher is better - Percentile comparison Tracking Progress: 30-Day Readmission Rates

16. Integration of External Health Risk Assessments http://www.improvingpopulationhealth.org/blog/2011/01/unpacking_triple_aim.html

17. Integration of External HRAs All patients should have a Health Risk Assessment reviewed annually by the PCP Internal HRA vs. External HRA Providers have preferred HRA survey/questions Some Payors mandate use of their HRA – Medicaid is the first Value of the HRA review Providers get to know “total patient” Guides active problem list Useful in determining the patient’s risk score

18. Sample External HRA

19. Sample HRA, Section 2

20. Development of HRA Workflow • Collaboration with HIM for special identification in EMR

21. Development of HRA Workflow • Building a Best Practice Alert for Primary Care Providers

22. Development of HRA Workflow • Build in automatic PCP billing notification after HRA is reviewed

23. Use of HRA as Foundation for Problem List • Identify conditions and other social determinants needing further evaluation for care plan support • Engagement of the patient in lifestyle modifications and goal setting conversations • Accurate problem list and detailed documentation supports IDC10 coding • The more accurate the diagnosis coding, the more accurate the patient’s health risk score • Population health goal is to proactively manage care to impact a lower cost associated with the health risk score

24. Plan of Care – Key to Population Health

25. References • https://www.ncqualitycenter.org/wp-content/uploads/2014/07/NoCVAReadRiskWebinar_Amanda508FINAL_508.pdf • http://qio.ipro.org/wp-content/uploads/2013/01/LACE_toolNEW.doc • http://www.ajmc.com/journals/issue/2013/2013-11-vol19-sp/redesigning-the-work-of-case-management-testing-a-predictive-model-for-readmission/P-1 • http://www.actuary.org/pdf/health/Risk_Adjustment_Issue_Brief_Final_5-26-10.pdf • http://ihealthtran.com/pdf/PHMReport.pdf • http://www.cdc.gov/policy/ohsc/HRA/FrameworkForHRA.pdf Contact information: Dianne Wasson dianne-wasson@uiowa.edu 319-356-7067

26. Questions?