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The ABCs of ACOs for MCH May 30, 2013 For assistance: Please contact or for web support 888-447-1119 option

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Presentation on theme: "The ABCs of ACOs for MCH May 30, 2013 For assistance: Please contact or for web support 888-447-1119 option"— Presentation transcript:

1 The ABCs of ACOs for MCH May 30, 2013 For assistance: Please contact or for web support 888-447-1119 option

2 Brief Notes about Technology Audio Audio is available through your computer speakers or earphones. For assistance, contact or for web support 888-447-1119 option 2 2

3 Brief Notes about Technology Continued Questions To submit questions at any time throughout the webinar, type your question in the chat box at the lower left-hand side of your screen. – Send questions to the Chairperson (AMCHP) – Be sure to include to which presenter/s you are addressing your question. 3

4 Technology Notes Continued Recording Today’s webinar will be recorded The recording will be available in a week on the AMCHP National Center for Health Reform Implementation website at A PDF version of the presenters' slides will also be available on the AMCHP website 4

5 Evaluation Attendees will receive a link to a survey evaluation upon completion of this webinar. Please take a few minutes to share your feedback.

6 Objectives Webinar attendees will: 1) Increase their knowledge of ACOs and ACOs that include MCH populations 2) Increase their understanding of how public health can play a role in ACOs 3) Will be able to identify strategies and resources to collaborate with, ACOs in their state

7 Featuring: Colleen A. Kraft, M.D., FAAP, Carilion Clinic, VA Cate Wilcox, MPH, Maternal & Child Health Section Manager, Public Health Division, Oregon Health Authority Don Ross, Policy & Planning Section Manager, Division of Medical Assistance Programs, Oregon Health Authority Marilyn Hartzell, M.Ed., Director, Oregon Center for Children and Youth with Special Needs 7

8 The ABCs of ACOs: Making Them Work for Maternal-Child Health Colleen A. Kraft, M.D., FAAP

9 Family-Centered Medical Home Child and Family Developmental Services Home-visiting network Early Intervention Child Care Resource & Referral Agency Early HeadStart & HeadStart Early Child Mental Health Services Prevention, Building Health Acute Care Chronic Care Developmental Services Parenting Support Lactation Support Vulnerable children and families Medically Complex Children

10 Accountable Care Organizations ACO HospPCPSpec Coordinates care for shared patients Medicare, Medicaid Or private insurer Financial bonus from savings ACO Attributes Coordinates care for shared population of patients with the goal of meeting and improving on quality and cost benchmarks Hires an administrator and establish a formal legal structure to work with payers, monitor performance, and collect any shared savings Receives a financial bonus that is divided among its participants according to their agreement.

11 Traditional Medical Care and Financing “Un-accountable” care Low Cost Care Primary Care Preventive Care— Screenings, Immunizations, Anticipatory Guidance “Gatekeeper” Health/Lifestyle counseling Home-based care Home visiting Primary Care access for evenings and weekends No Coordination of Care No incentive for communication and collaboration No care coordinators No measurement of outcomes No comparative effectiveness Research No focus on population health No co-location of services No self management services No transportation High Cost Care Hospitalizations Procedures Duplication of labs, studies, procedures Transportation = Ambulance Complications of Chronic Disease End of life care in an ICU Low Cost Care Payment poor = No incentive Transparency of Finances? Outcome Measures? Quality Reporting? Aligned incentives? High Payment = Plenty of Incentive

12 Accountable Care Reduce Cost of Care Develop robust primary care access.Streamline administrative tasks Co-management between primary care and subspecialty to avoid hospitalization Greater use of palliative care Greater use of home care and home visiting Patient/Family portals Avoid duplication of care/HIT Improve Coordination of Care--Investments HIT that promotes communication and interaction Office Care Coordinators Home Visiting/Home Care Primary Care-Ancillary Health co- location, including therapists, dieticians, psychology Electronic portal for patient communication/collaboration Support for advanced primary care and Q/I initiatives Data management infrastructure to evaluate processes and outcomes Improve Quality of Care Improving Scientific Basis of Healthcare Decisions Based on Comparative Pediatric Effectiveness Research Measurement of Outcomes Longitudinal data collection and evaluation Payment Tied to Patient Outcomes Based on Quality Measures Fair Payment for Low Cost Care Transparency of ACO Finances Patient/Family-Centered Investment in Infrastructure Shared System Savings Aligned Incentives Improved Outcomes

13 Accountable Care “Three-Part Aim” Better Care Better Health Lower Cost

14 Pediatric Accountable Care Prevention of Adult Disease Optimize Health and Development Reduce High Cost Care

15 Factors Affecting Child Health SOURCE: Healthy People 2010, US Department of Health and Human Services, 2000.

16 Health Innovation can be funded through an ACO Extension of the Medical Home In-home care management – Early Childhood – Oral Health – Prenatal – Asthma – Development/Behavioral Health

17 Carilion Clinic-Aetna Partnership 17 Carilion Clinic ACO Carilion Clinic Physicians Private Practice Physicians

18 Update: 12/08/2011 Virginia Medicaid Regions

19 ACO System Savings Co-management between primary care and specialty Less duplication of services Tracking of “high utilizers” with care coordination to provide proactive care Access to primary care, less use of ED and hospitalization

20 CORE Predictive Modeling from Aetna Mbrs who are Top 1% Mbrs who are High Risk ED Mbrs who are Medium/High Risk IP A Venn diagram, combining top 1% general risk with ED and IP risk, is used to help illustrate what risk groups a member falls into, and are they falling into multiple groups… Members who are Top 1% AND high risk for an ED visit next 12 mos. Members who are Top 1%, high risk for an ED visit, AND medium/high risk for IP admit next 12 mos. Members who are top 1% general risk AND medium/high risk for IP admit next 12 mos. Members who are high risk for an ED visit AND medium/high risk for IP admit next 12 mos.

21 Personalize the Profile for Medical Homes Increasing Medical and Behavioral Complexity Group 3: Ave age 33 72% female PMPM $962 5 ED visits, 0.2 admits 32% asthma prevalence; 25% med adherence (asthma) 85% MH prevalence 58% co-occurring mental health and substance abuse 52% with 5+ Rx classes 5 Specialist visits 10 PCP visits Group 4: Ave age 49 PMPM $3908 2.6 admits 12 IP bed days 7 ED visits 51% diabetes prevalence 73% MH prevalence 87% with 5+ Rx classes 20 Specialist visits 10 PCP visits Group 6: Ave age 43 PMPM $2425 1.6 admits 7 IP bed days 6 ED visits Low medical disease prevalence 85% MH prevalence 62% co-occurring MH and SA 12 Specialist visits 9 PCP visits 3 6 4 Group 5: Ave age 53 PMPM $3202 2 ED visits 2 admits 10 IP bed days 56% diabetes prevalence 41% MH prevalence 84% with 5+ Rx classes 19 Specialist Visits 7 PCP visits 5 ED Risk Only ED Risk/IP Risk Only Top 1%/ ED Risk/IP Risk Top 1%/ IP Risk Only

22 Home Visiting Partner Child Health Investment Partnership of the Roanoke Valley Home Visiting with a Health Focus – Parents As Teachers – Oral Health – Asthma Management – Pregnant Moms – Behavioral Health

23 Home Visiting Pediatric Asth

24 Care Management Design Home Visiting Contract – Paid per member/per month “High Touch”, in-person, in-home Data Collected in home – HEDIS metrics – Health Outcomes – Reduced costs

25 Medical Home Child and Family Shared In- basket with EHR Electronic Referral to CHIP Transport to visits Develop Screening results shared Anticipatory Guidance reinforced in- home Oral Health Ed and Fluoride

26 Oral Health and Fluoride Varnish Begin with a Grin!

27 Asthma Case Management Assess environment, modifications Smoking cessation Observe inhaler use Asthma control assessment Asthma action plan and education Transportation to visit

28 Behavioral Health Prenatal to age 7 Perinatal/postpartum depression screening Connection to services for parents and children at-risk and diagnosed Transportation to visits

29 Results 100% children have a Medical Home 90% 2yr olds UTD on well visits and immunizations 100% children are screened for lead, Hgb, development 100% children have a Dental Home 66% of children have had a dental visit by age 3 97% have had an oral health assessment and fluoride varnish 145 children in program 2011-2012 84% well controlled 84% minimal inhaler use 90% decrease in ED visits 82% decrease in school absence due to asthma

30 In-Home Screening

31 Ready for School?

32 Pediatric Asthma

33 Home Visiting Intervention Pilot

34 Home Visiting = In-Home Prenatal Care Management IDEA Poverty is a risk factor for poor maternal and newborn outcomes. What if every mother with Medicaid had a Home Visitor to provide support, education, transportation? How would this impact health of the next generation? AIM STATEMENT Reduce the number of infants born at <37 weeks gestation and low birth weight (<2500 grams) by 30% by December 2012 utilizing home visitors as in- home case managers.

35 National Benchmark=March of Dimes Virginia “C” grade for premature birth Total prematurity = 11.3% Late preterm (34-36 wk) = 8% Uninsured = 17.2% Maternal smoking = 15.2% Roanoke/Allegheny Metrics worse for this region Prematurity = 12.2% Late preterm (34-36 wk) = 10.1% Uninsured =15.6% Maternal smoking = 24.4%

36 Measures Measure HealthCareCost Percent of infants born at < 37 weeks gestation O Percent of infants born between 34 and 36 weeks gestation (late preterm) O Birth weight term infants <2500 grams O Percent of Pregnant Moms participants who smoke that stopped smoking O Percent of Pregnant Moms participants who start prenatal care in the first trimester P Percent of Pregnant Moms participants who attend all the recommended prenatal visits P Percent of Pregnant Moms participants who are uninsured P Percent of Pregnant Moms participants identified with depression P Percent of Pregnant Moms participants connected to treatment for depression P Cost of Care C

37 1 st Trimester—Goal =90% Percent Goal = 90%

38 All Visits-Goal = 60% Percent Goal = 60%

39 Reduce Maternal Smoking by 1/3 Percent Goal = 16%

40 Perinatal Depression

41 Reduce Percentage of Infants born <37 weeks by 30% <37wk 34-36 wk Goal

42 Reduce Percentage of Term Infants born < 2500g by 30%

43 Cost of Care Note: One premature infant March 19-May 10

44 Next Steps Continue current project, data analysis Continue Home Visiting Contract after birth Expand Asthma and Behavioral Health HV models Assess – HEDIS measures – Compliance with Asthma guidelines, ER and hospital admissions, missed school and work days – Co-locate HV teams in OB and Pediatric practices – Feasibility of project replication as ACO expands – Development and school readiness of birth cohort

45 Other Outcomes 92% of children with asthma are well controlled with minimal inhaler use 90% of all pregnant mothers attended all their prenatal visits, starting in first trimester 57% of pregnant moms who smoked were able to stop smoking 100% of children with behavioral health problems improved on PECFAS

46 Care Connection for Children

47 Special Families

48 42 families with successful IEP meetings 10 families connected with waiver services 10 hospitalizations avoided due to connection to home health services 8 support group meetings Special Families facebook page Respite program

49 Accountable Care Health of a population – Pregnancy outcomes? – Decrease in hospitalizations and ED visits? – School attendance, grades? – Parental education and employment – Function and performance of the Medical Home

50 CONCLUSION: build strong children repair broken men It is easier to build strong children than to repair broken men. Frederick Douglass

51 Don Ross Oregon Division of Medical Assistance Programs Cate Wilcox Oregon Public Health Division Marilyn Hartzell Oregon Child Development and Rehabilitation Center, OHSU Coordinated Care Organizations Health System Transformation and Opportunities for Preconception Health

52 What we’ll talk about today Basics of Coordinated Care Organizations Public Health Role in CCOs (ACOs) MCH Metrics Preconception Health (One Key Question) Opportunities for Children and Youth with Special Health Care Needs to work with CCOs (ACOs)

53 Oregon Health Plan 53 50% of babies born in Oregon 16% of Oregonians 85% of Oregon providers 11% percent of total state budget Fastest growing portion of state budget


55 Triple Aim: A new vision for Oregon

56 56

57 Changing health care delivery Benefits and services are integrated and coordinated One global budget that grows at a fixed rate Local flexibility Local accountability for health and budget Metrics: standards for safe and effective care

58 Benefits & services are integrated and coordinated Physical health, behavioral health, dental health Get better outcomes: Health equity Prevention Social determinants of health: education, employment MH: Supported Employment Community health workers/non-traditional health workers Collaborate and Integrate with other health and human services (e.g. long term care; public health; schools)

59 Global budget Current system MCO/MHO/DCO/FFS Payments based on actions No incentives for health outcomes CCO global budget One budget Accountable to health outcomes/metrics Local vision, shared accountability, shared savings Flexibility to pay for the things that keep people healthy

60 CCOs: governed locally State law says governance must include: Major components of health care delivery system Entities or organizations that share in financial risk At least two health care providers in active practice Primary care physician or nurse practitioner Mental health or chemical dependency treatment provider At least two community members At least one member of Community Advisory Council

61 ACOs vs CCOs-What’s Different? ACOs have distinct features: ACOs developing around health systems, not payers ACOs in the ACA are aimed primarily at Medicare savings Providers in ACOs share in Medicare savings in: Medicare Shared Savings Model Advance Payment ACO Model Pioneer ACO Model CCOs are accountable to the state, and local community Medicaid enrollment in CCOs is required

62 Community Advisory Council Majority of members must be consumers. Must include representative from each county government in service area. Duties include Community Health Improvement Plan and reporting on progress.

63 CCOs and public health Variety of requirements in statute: o State shall require and approve agreements between CCOs and publicly funded providers for payment for certain services (immunizations, STIs and other communicable diseases) o State shall allow CCO enrollees to receive family planning and HIV and AIDS-related services from fee-for-service providers, as well as maternity case management if CCO cannot do it o State shall encourage and approve agreements between the two entities for authorization and payment of other services including maternity case management, prenatal care, school-based clinics, services provided through schools and Head Start programs, screening services for early detection of health problems in vulnerable populations

64 CCOs and public health (2) Variety of requirements in contract: o Collaborate with local public health authority, local mental health authority, community based organizations and hospital systems for community health assessment and development of community health improvement plan o Actively promote screenings with A or B grades from USPSTF, or recommended in Bright Futures guidelines o Contribute to implementation of state’s plans for physical activity, healthy nutrition, tobacco prevention, suicide prevention, and local public health and health promotion planning efforts o Partner with local public health and culturally, linguistically and demographically diverse community partners to address the causes of health disparities.

65 Accountability Metrics for CCO’s Reduction of disparities - report all other metrics by race and ethnicity Member/patient Experience of care Health and Functional Status among CCO enrollees Rate of tobacco use Obesity rate Outpatient and ED utilization Potentially avoidable ED visits Ambulatory care sensitive hospital admissions Medication reconciliation post discharge All-cause readmissions Alcohol misuse – SBIRT Initiation & engagement in alcohol and drug treatment

66 Accountability Metrics for CCO’s Mental health assessment for children in DHS custody Follow-up after hospitalization for mental illness Effective contraceptive use among women who do not desire pregnancy Low birth weight Developmental Screening by 36 months Planning for end of life care Screening for clinical depression and follow-up Timely transmission of transition record Care plan for members with Medicaid-funded long-term care benefits Metrics in bold can be applied to Preconception Health

67 Initial Metrics Designed to achieve quick return on investment to meet the federal requirements Maternal and Child Health is imbedded in many, but not necessarily called out

68 Second Phase of Metrics Important to be at the table—we have a lot to offer! MCH brings the sustainability factor MCH brings the lifelong wellness factor

69 Possible MCH metrics Look at a broad range of standards of care/practice HP2020, Bright Futures, USPSTF, Title V priorities Include Adolescent measures Look for means of coding/tracking the measure

70 Possible MCH metrics Targeted measures for MCAH populations Oral Health Positive Parenting Sleep hygiene Positive Youth Development Family violence prevention Safety/Injury prevention Pregnancy intendedness

71 Example: One Key Question Do you plan on getting pregnant in the next 12 months? If yes, preconception health care If no, contraceptive health care

72 ACA, Public Health, & Data Pay attention to Electronic Health Record requirements in the ACA The concept of “Meaningful Use” introduces more complex reporting to public health by Electronic Health Record users. Public health needs to be ready to be able to receive data from providers. Public health needs to be ready to be able to provide data to providers.

73 Opportunities for Children and Youth with Special Health Care Needs to work with CCOs (ACOs) Join the conversation – get to know the ACOs/CCOs Educate ACOs about the population of children with special health care needs Who are CYSHN? Complex Broad and inclusive definition Commonalities of needs across the population of individuals Educate ACOs about how to identify CYSHN within a system of care Screeners Complexity Scales

74 Opportunities for Children and Youth with Special Health Care Needs to work with CCOs (ACOs) …and their families Family-Professional Partnerships Patient Engagement is not Family-Professional Partnership Family Professional Partnerships involve: Shared knowledge and expertise Mutual respect Collaborative problem solving

75 Opportunities for Children and Youth with Special Health Care Needs to work with CCOs (ACOs) Advocacy and Education Encourage family leaders, F2F HICs, community leaders to join the Advisory Committees Support family leaders in their work with ACOs The Family Voice #1: Nothing about us without us! #2: Decisions made under Parent/professional partnership involves compromise for both! #3: Please listen to our concerns.

76 Opportunities for Children and Youth with Special Health Care Needs to work with CCOs (ACOs) Effective Systems of Care for CYSHN Family Centered Care Early and continuous screening Medical home with care coordination Ease of Use of Community-based services Youth Transition to adult health care (think specialty care too!) Health care finance Be a resource to ACOs

77 Opportunities for Children and Youth with Special Health Care Needs to work with CCOs (ACOs) Public health programs support ACO aims & metrics Immunizations Flu vaccination Annual well-child visits Annual dental visits Reduced ER usage Build partnership with ACO to help achieve the 3 aims Remember – there are 3 aims!

78 Opportunities for CYSHN to work with CCOs (ACOs) - An expanded model for statewide care coordination Tertiary-based Care Coordination Team CYSHN are assigned to when they are identified through the hospital or clinics CC Team serves as single point of contact for families in the targeted group of children CC Team  nursing, social work, family navigator, psychology – according to the needs of the child and family Regional Unit of Care Coordination (Senior Nurse Coordinator) Regionally based senior nurse coordinator (expert nurse with CYSHN) Child/family referred to/through back into community-based care Links family with PCP and community-based care coordination as needed Senior Nurse Coordinator provides connections between the tertiary care coordinators, PCPs and the community public health services Community-based Care Coordination Child identified within the community through public health nursing or primary care settings; goals identified by PHN and/or PCP Linked to Senior Nurse Consultant for input, and behavioral specialist when needed

79 For More Information: Don Ross, Manager Policy and Program Unit Division of Medical Assistance Programs Oregon Health Authority 503-945-6084 Marilyn Hartzell Director, OCCYSHN OCCYSHN / Oregon Center for Children and Youth with Special Health Needs Institute on Development and Disability (IDD) at OHSU 503-494-6961 Cate Wilcox, Manager Maternal and Child Health Section Public Health Division Oregon Health Authority 971-673-0299

80 Question & Answer 80 Please submit questions through the chat feature and direct them to the chairperson

81 Thank you for attending “The ABCs of ACOs for MCH” Colleen A. Kraft, M.D., FAAP, Carilion Clinic, VA Cate Wilcox, MPH, Maternal & Child Health Section Manager, Public Health Division, Oregon Health Authority Don Ross, Policy & Planning Section Manager, Division of Medical Assistance Programs, Oregon Health Authority Marilyn Hartzell, M.Ed., Director, Oregon Center for Children and Youth with Special Needs The recording will be posted on

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