ACOS: Where Are We At?

Accountable Care Organizations:
Where Are We At?

HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc. (HHI)
Presented by:

Kris Mastrangelo, OTR/L, LNHA, MBA
President & CEO

“Widen Your Gaze”
~Sherlock Holmes

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Objectives

The learner will be able to summarize
goals of ACOs
The learner will be able to identify and
articulate examples of the ACO process
The learner will be able to identify
strategies for interdisciplinary
management of ACOs

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Accountable Care Organizations

“It is not the strongest of the species
that survive, nor the most intelligent that
survive. It is the one that is the most
adaptable to change.”
~Charles Darwin

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Accountable Care Organizations

“Voluntary groups of physicians, hospitals, and other health care
providers that are willing to assume responsibility for the care of a
clearly defined population of Medicare beneficiaries attributed to
them on the basis of patients’ use of primary care services.
If an ACO succeeds in both delivering high-quality care or
improving care and reducing the cost of that care below what
would otherwise have been expected, it will share in the savings it
achieves for Medicare.”

The New England Journal of Medicine (NEJM), October 20, 2011
Making Good on ACOs’ Promise – The Final Rule for the Medicare Shared Savings Program
Donald M. Berwick MD, Administrator, CMS

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Team Medicine

First building blocks of integrated
team medicine: Model, data and
leadership
Create a care team that maximizes
impact for patients
Build a physician culture of
multidisciplinary practice

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Team Medicine

1. An integrated, flexible physician
model

“Multispecialty group medical practice
maximized physicians’ abilities to care for
patients through doctor-to-doctor
consultation, through the training and
mentoring of young physicians, and through
the inherent quality controls built into the
group”

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Team Medicine

2. Physician-Friendly Data
Yields evidence-based medicine

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Team Medicine

3. Rethink physician leadership
“We recruit physicians with a sense that we’re a group
practice. We stand for quality. We measure quality and
results. We think it’s important that we tell patients we’re
going to give them the kind of quality they deserve. You
then orient, evaluate, and promote people based on the
same set of values and expectations. Eventually you end
up with a culture that is very comfortable with a focus on
quality, measurement, comparison, and improvement.”
Jack Cochran, MD

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Healthy Bones:
Tests and Prescriptions to Prevent
Problem:
In 2010, osteoporosis was the ninth most costly major illness
among the top 5% highest cost Medicare beneficiaries
In 2005, 2 million fractures cost the United States $17 billion for
both acute and long-term care. By 2025, the annual fracture rate is
expected to increase by 50% to about 3 million at a cost of $25
billion per year.
On average, 24% of patients presenting with a osteoperosis-
related fracture die within one year, and the mortality rate of men
exceeds women
Only 21% of women age 67 or older who have had an
osteoporosis-related fracture had a bone mineral density test or a
drug prescription to treat or prevent osteoporosis in the six
months after the fracture
* Information provided by Kaiser Permanente

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Healthy Bones
Solution:
Care managers, primary care physicians, and surgeons use
daily reports generated from the electronic health record to
identify members at risk for osteoporosis and fractures
Care managers coordinate care for these patients to close
care gaps
Working together, the team provides patients with
education, screening, treatments, and monitoring as
needed. The multidisciplinary team includes:
Orthopedic surgeons, endocrinologists, gerontologists,
family practitioners, internists, rheumatologists,
gynecologists, physical therapists, disease/care managers,
radiologists and member education

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Healthy Bones
Impact:
Annual bone density screening rates increased by
474% from 2002 to 2009
People on anti-osteoporosis medications increased by
214% from 2002 to 2009
Over 45% reduction in rate of hip fractures
(preventing >1400 hip fractures) by 2010
If the Healthy Bones approach were adopted in the
United States, the country could achieve a 25%
reduction in the rate of hip fractures, preventing
75,000 hip fractures per year

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Improvement Standard
As the New York Times reported on its front page Tuesday, Reuters
(10/24, Morgan) reports that the Obama Administration has
proposed a settlement to a class-action lawsuit, promising to
broaden current Medicare regulations to allow coverage to
"maintain the patient's current condition or ... prevent or slow
further deterioration." Previously, beneficiaries had to
demonstrate improvement to continue to receive coverage, the
change will likely benefit thousands of Americans with
degenerative conditions like multiple sclerosis, Parkinson's, and
cerebral palsy.

An HHS spokeswoman said the settlement merely "clarifies"
current policy, and continued, "We expect no changes in access to
services or costs."

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The case, Jimmo v. Sebelius, resulted in a focus on skilled
service delivery in the context of maintenance programs

Historically, patients with chronic conditions and
anticipated functional deterioration were considered
skilled for the establishment of a maintenance program

This settlement now allows for coverage of the actual
delivery of maintenance therapy by licensed nurses and
therapy professionals

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Current Medicare skilled guidelines state:

The services must be provided with the expectation, based
on the assessment made by the physician of the patient’s
restoration potential, that the condition of the patient will
improve materially in a reasonable and generally
predictable period of time,

Or the services must be necessary for the establishment of a
safe and effective maintenance program

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The Proposed Settlement:
“Instead, providers, contactors, and adjudicators must recognize “maintenance”
coverage and a beneficiary’s need for skilled care that is performed or supervised by
professional nurses and therapists.”

The manual revisions will clarify that, under the Skilled Nursing Facility, Home Health,
and Outpatient Therapy maintenance coverage standards, skilled therapy services
are covered when an individualized assessment of the patient’s clinical condition
demonstrates that the specialized judgment, knowledge, and skills of a qualified
therapist (“skilled care”) are necessary for the performance of a safe and effective
maintenance program

Such a maintenance program to maintain the patient’s current condition or to
prevent or slow further deterioration is covered so long as the beneficiary requires
skilled care for the safe and effective performance of the program

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Quality Care is our number one objective

Harmony embraces the OBRA 87 regulations which require
facilities to provide services to meet “the highest
practicable physical, medical and psychological well-
being” of every resident

This practice has been our standard since its inception. This
new Improvement Standard, further supports our core
values as providers of specialized services to the post
acute care population.
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Continuum of Care Post Discharge

“When the asthma attack is done, the
patient goes home, and the game’s over.
No one is accountable for any of the
follow-up care.”

George Halvorson , Chairman & CEO
Kaiser Permanente

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Integrated Follow-up

Call patient to make sure they are taking their
meds
Call patient to make sure they are avoiding
any allergic trigger

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Prevention
Problem:
One in eight women develops breast cancer, and
nearly 40,000 die from it every year
Regular mammograms – which can identify breast
cancer early, when it is most treatable – can reduce
breast cancer deaths by more than 30 percent
The United States Preventive Services Task Force
recommends screenings every one to two years
for women aged 50-74 years. However, current
screening rates fall short of these guidelines, and
they have been steadily declining

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Prevention
Through the Proactive Office Encounter
program, the health care team identifies
and targets patients with care gaps
(including whether a patient is due for a
mammography) or chronic medical
conditions and encourages them to
actively participate in own care

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Proactive Office Encounter and Mammography
The program engages all members of the clinical care
team in a coordinated and collaborative effort to
encourage and support patient health
Automated creation of care checklists for all patients whose
records indicate gaps in care
At every point of contact with patients, clinical care teams
review checklists and help patients get the care they need
Based on identified gaps in care, medical assistants during
office visits discuss with patients the need for preventive
screenings and routine care, such as cancer screenings and
tests for abnormal blood sugar or cholesterol levels, and
schedule appointments on the spot

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Proactive Office Encounter Also Helps

Along with other concurrent improvement
initiatives, the Proactive Office Encounter has
contributed to:
30% increase in colon cancer screening
11% increase in breast cancer screening
5% increase in cervical cancer screening
13% improvement in cholesterol control

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Data, Data, Data

“You cannot make bricks without clay.”
~Sherlock Holmes

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Better Patient Management
Using Evidence-Based Medicine

Patient Registry and Concurrent Tracking
System
Identifies all members in the population
Risk stratifies population for targeting
interventions and resources
Tracks and monitors each patient for key
indicators (lab, pharmacy, encounters, clinical
indicators)
Easy access (web-based)

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Better Patient Management
Using Evidence-Based Medicine

Care Management Systems
Flags/alerts
Supports telephone management and
documentation
Identifies all members in the population

Supports Automated Clinical Decision
Support and Practice Tools
In-reach/outreach

Health Education and Self-Care Support
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Evidence-based Medicine/Prevention

Proactive care instead of reactive care
Patients who have the largest “gaps” in recommended
care do not routinely visit their primary care physicians
Specialty clinics must play a role to achieve optimal
results. Fewer than 40% of patients needing a
mammogram or testing for diabetes visited their primary
care physician.
Appointments can be made on the spot or referrals
generated so gaps can be readily addressed

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Beyond the Patient: Widen Your Gaze
Focus on primary care and prevention, and
addressing chronic disease requires looking at
larger communitywide issues

Behavioral factors are as important as specific
treatments: better diet, promoting physical
activity, and reducing smoking

Community education for adults and children in
recognizing bad health habits and taking action to
create a better health outlook

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ACOs: Strategies for Interdisciplinary Management
To be continued…

To hear more about these introductory slides,
and all that is still to come, please join me:

Date: Friday, May 3rd
Time: 10:15 a.m. – 11:45 a.m.

Kris Mastrangelo, President & CEO
Harmony Healthcare International
http://www.harmony-healthcare.com/
Tweet me your questions! @KrisMastrangelo

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ACOS: Where Are We At?

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ACOS: Where Are We At?