Comprehensive Complex Care Model for Central Oregon

An Innovative Community Collaborative

Patient Story

Rebecca is a 53-year-old patient who moved to Prineville a few years ago. She came to Mosaic with multiple medical issues including Type 2 diabetes, high blood pressure and the effects from a debilitating stroke a few years ago. Additionally she had severe social anxiety, depression and had made multiple suicide attempts.

Rebecca’s Mosaic provider began by sorting out her 28 medications and multiple medical issues while a Community Health Worker (CHW) helped Rebecca start the process to sign up for Medicaid. The CHW also started helping her look for housing and furniture to go with it so she could get out of an unsupportive home situation. Rebecca also started seeing the Mosaic behavioral health consultant for her anxiety and depression. Additionally, the Mosaic RN Care Coordinator started checking in with her monthly to help her manage her diabetes

With all these team efforts, Rebecca’s mental and physical health started improving drastically. The behavioral health consultant and the CHW went so far as to work with Rebecca’s new housing manager to help her keep a dog for mental health support in her new apartment. Rebecca is also successfully checking her own blood sugar for the first time in many years.

Central Oregon Complex Care Strategy –Centered Around the Patient

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Pharmacy Management

Team-based Care

CustomizedComprehensive

EvalShared

Action Plan

Transitions ofCare

Specialist Coordination

Proactive, between visit care

Virtual Visits

NutritionCounseling

Multi-faceted Approach

Community CollaborativeActionable datain the hands of

caregivers

Patient Education

Socio-behavioral RiskModification

Patient

Developing a Complex Care Strategy:Serving Rebecca, Addressing Community Opportunity

Healthcare Spend Limiting Resources: Healthcare costs continue to increase; reducing resources for education, housing, security and other public services.

Unique Stakeholder Dialogue: Of the spend, 50% of the expenditures account for 5% of the population. X percent of the spend is considered “waste” or avoidable costs. Common pain points and recognition of need for sustainable economics has brought new collaboration energy

Opportunity to Catalyze: Catalyze community partnership. Provide a starting point for innovation: evolving central and distributed complex care competencies (hub and spoke)

Growing Evidence Base: Multiple initiatives suggest significant outcome improvement and cost reduction opportunity in focused complex care center:- High levels of quality outcomes – 90th percentile HEDIS measures, improvement on chronic disease markers- High levels of patient experience (CG-CAHPS), SF12- 10-20% per capita spending below comparison group or regional average

Bridges Health

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A Community Vision

Developing custom solutions that facilitate concentrated complex care services and community wide distributed complex care services

Taking on the challenge of complex care head on – building an integrated strategy to better manage complex (and costly) Medicare, Medicaid, Commercial and Uninsured populations

Central Oregon collaborating within the existing strong healthcare infrastructure to develop innovative care models to address community-wide challenges

Part of a journey towards better health and sustainability for Central Oregon

Bridges HealthSupporting Patients and Providers

Vision: World class complex care center coupled with strong distributed network of services to provide community with comprehensive model

• Primary Care referral center for complex and intensive care (Ambulatory ICU): Comprehensive care for patients including primary care, behavioral health, social work, physical therapy, pain, nutrition, education, etc.

• An “Innovation Hub”; Starting point for a robust community strategy: developing workforce and competencies --- helping the medical groups build internal competencies; delivering high dose of intervention in the central location, and expanding to a distributed model

• A Community Referral Point - Patients would be referred by their primary care physician to seek care at the Complex Care Center – where they would meet a physician and integrated team to address health (and life) needs. Strong communication processes with the referring physician would be hardwired

• Patient-led: A spirit of patient-centeredness would be embodied in the care model, the staffing, cultural sensitivities. More formally, a patient advisory council is being formed

The Basics

What: Develop a comprehensive complex care strategy, a component of which is a dedicated outpatient complex care clinic called Bridges Health

When: Open Bridges Health in August 2013, with evolution of community distributed complex care services between now and go live

Who: A community collaborative, with an investment from PacificSource and Mosaic as an operating partner. Led by advisors to guide the innovation and spread.

How: Two pronged approach:• Centralized: a center with physicians, nurses, health coaches, behavioral health specialists,

pharmacy, community health workers, and pain specialists providing comprehensive complex care to 1600-2000 members of our community

• Distributed: provision of community resources to support complex care needs within community practices in more dispersed geographic areas

Where: PacificSource Building, near the St Charles campus, directly above the St. Charles Family Care clinic

• A dedicated Bridges Health team member to:

– Engage with the patient and support their care needs, concerns, answer questions and provide education

– Support care and partner with the patient in providing comprehensive access to meet their healthcare needs

– Facilitate and enable effective communication across the continuum for the patient

– Be a health coach and guide the patient in meeting his/her goals, motivating the patient to take steps towards improved health

• Additional team resources include behavioral health, pharmacy, pain management, community health coaching, etc. – all with partnership with the Bridges Health Medical Directors

• 24/7 access to Bridges Health team via phone, email or in person• Bridges Health enables an engaged community of family / caregivers• Holistic care that centers on bettering the patient as a whole – physical and mental

health, community resources, family services, etc.

Bridges Health Benefits for the Patient

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Provider Feedback From Initial Eligible Patient Review

• High burden of clinical conditions

• Significant level of social and behavioral health challenges

• Claims review identifies frequent utilization unknown to PCP

• Significant gaps in care – especially Rx adherence

• Recognition that these patients are challenging and often not progressing in health –

however unclear pathway on how to change that paradigm

• Recognition that many identified patients have “stable chronic conditions”

Key Success Elements• Analytics – Data/Metrics – Targeted population

– Patients with persistent and Actionable disease, disease burden or utilization pattern

– Opportunity for outcomes impact, meaningful patient service and financial sustainability rests on identifying the right members; predictive model + clinical intelligence rules + utilization triggers

• Other Analytics – Data/Metrics– Enhanced Data Transparency– Robust evaluation of the model to understand effectiveness of model

• Member Engagement– Care model to “meet patients where they are”

• clear articulation of value; open access; superb service; “Surprise and delight” elements, smooth transitions; no additional cost to member

– Primary referral source will be the patients’ community PCP; members without PCPs may be invited in through other mechanisms

• PCP key referral source and most trusted relationship for most patients.

• Strong communications key to transitions, co-management of patients

Essential Care Model Elements• Complex Care Model

– Dedicated Team-Based Care:• MD + Care Manager + Multi-disciplinary team

– Supervisit• Initial visit sets shared trust

– Shared Action Plan • Standard, active, dynamic document keeps everyone on same page

– Rules-based Proactive Care Management• Ongoing proactive care partnership with patient

• Bridges Health Payment Model– Beyond Fee For Service Reimbursement at Center; Shared Incentive to

Community Providers• Community/Provider Partnership Development

– To facilitate transitions, appropriate use of community resources• Communications

– Thoughtfully developed patient communication materials to achieve targeted enrollment in Bridges Health

• Space Readiness: Design and Buildout– Develop a patient centered space to achieve optimal patient engagement

Bridges Health Staffing Model

Dedicated Team:• Bridges Health Medical Director• Bridges Health Clinic Administrator• 1 Additional Physician• 1 Nurse Practitioner• 3 Care Managers• 4 Community Health Workers• 1 Administrative Assistant• 1 Receptionist• Social Worker that can provide behavioral health services• Additional Behavioral Health Specialist with prescribing capabilities• Pharmacist• Nutritionist

Bridges Health Patient Identification Process

PacificSource will use specific risk modeling tools to identify eligible Bridges Health patients using claims data.

Patients will also be referred into Bridges Health by their primary care providers using specific defined criteria or following a health event (e.g. hospitalization).

Specific variables for risk identification include:• Diagnostic Criteria

– Comorbid Behavioral Health Accelerators• Provider Referral• Patient Wellness Assessments• Truven Prospective Risk Scores

– Diagnostic detail– Demographics– Claims Experience

• Inpatient Experience• ED Experience

Patient Engagement Process

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Patient receives care with Bridges Health as a specialty resource, ultimately graduating in most cases upon reaching strong self-management

Bridges Health team reaches out to PCP team before and after visit to align care

Patient visits Bridges Health for Supervisit

PCP refers patient to have a Supervisit at Bridges Health

Patient is identified for opportunity with Bridges Healthinformation communicated with PCP

Supervisit PhilosophyA key success element for Bridges Health is the initial patient on-boarding and first visit with the Care Coordinator, Bridges Health Medical Director and the Patient

• Provides an opportunity for MD, Care Coordinator and patient to share trust• Provides platform for deeply assessing patient’s health and multi-domain

assessment of life challenges getting in the way of achieving optimal health

• Enables start of Action Plan

• Allows for longer face-to-face time, which later facilitates email and telephonic interactions

• Provides (and forces) an intentional, structured opportunity to discuss many of the patient’s goals/concerns

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Supervisit Timeline - Intensivist Model

Total Time = ~ 1hour and 30 minutes

Patient Time: 60 minutesCare Coordinator Time: ~90 minutes

Intensivist Time: 45-60 minutes

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Pre-visit planning

15-20 min

Care Coordinator, Intensivist and Patient visit

45-60 min

Care Coord - Patient

end visit 15-20 min

Domains for Assessment

A critical goal of the Supervisit is to evaluate the patient for areas of risk, so that you may over time together develop actions steps to

address risks.

Examples of risk areas include:1. Medical Risk Domains – Complexity of disease, complexity of

treatment, unstable disease, etc. 2. Behavioral Risk Domains3. Social Risk Domains4. Utilization/Access Risk Domains5. Functioning Risks: Physical Functioning Risks6. Self-efficacy, Confidence Risks (including an assessment of Patient

Activation)

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Different Models that Lift from Supervisit

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Bridges and Referring PCP Have Close Communication Channels

The Bridges Health team serves as a referral extension to the community PCP. As such – the Bridges Health team commits to regular communication and updates to the referring PCP, and also will look for input and feedback from the referring PCP as the patient receives care at Bridges.

• Template Referral tool and process• Pre-Supervisit planning agenda • Post-Supervisit communication• Shared Action Plan• Ongoing structured communication• Graduation templated communication• Open access for discussion

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Economics of Complex Care Model

Assumptions

1. Current Annual Medical Expense for target population

Commercial$21,410

Medicaid$16,470

MCR$45,226

Average$25,000

2. Payor Mix Uninsured5%

Commercial5%

Medicaid60%

Medicare30%

3. Total Spend for 2,000 Patients in Complex Care Model $40 Million

4. Avg. Annual Clinic Subsidy over 5 years

$1.25 Million

5. Cost Savings to Achieve Breakeven

3.1%

Where the Savings Accrue

Assumptions

1. Current Annual Medical Expense for target population

Commercial$21,410

Medicaid$16,470

MCR$45,226

Average$25,000

2. Payor Mix Uninsured5%

Commercial5%

Medicaid60%

Medicare30%

3. Total Spend for 2,000 Patients in Complex Care Model $40 Million

Category Medical Spend (PMPM) PMPM Savings at 10% Annual Savings per 600 Members % of Total Savings

IP Hosp $ 1,930.00 $193.00 $1,389,600.00 52%

OP Hosp $399.00 $39.90 $287,280.00 11%

ER $31.00 $3.10 $22,320.00 1%

Physician $722.00 $72.20 $519,840.00 19%

RX $376.00 $37.60 $270,720.00 10%

Other $285.00 $28.50 $205,200.00 8%

Total $3,743.00 $2,694,960.00 100%

Modeling savings: 600 Medicare members in complex care

Complex Care ModelFFS Revenue Shift Risk Model Economics*

• 5% savings on 1600 Complex Patients = $2M

• 10% Savings = $2M• 5% Savings Spread among 400 COIPA

Providers = $5,000/pt.• 10% = $10,000/pt.

PCP Level Economics for Referrals to Complex Care

PSHP Medicare Top 10%

PSHP Commercial Top 10%

PSHP Medicaid Top 10%

PCP Practice

• Payor Mix 60% Medicaid/30% Medicare/ 10% Commercial• $45 PMPM revenue shift •$540 Annual revenue loss

$70 PMPM

$30 PMPM $35 PMPM

*Assumes minimum medical loss ratio targets are achieved during contract year

Estimated return to PCP per patient referral:* 9:1 to 18:1

Impact on PCP office

Soft Costs Avoided• Front office burden• No show rate and

noncompliance• Frequent Rx refills and

other requests• Staff burnout• Narcotic management