1. Update Primary Care Innovation Model (PCIM) Patient Centered Medical Home (PCMH) Care Transformation Council August 30, 2012 Samuel A. Skootsky, M.D., CMO UCLA Faculty Practice Group and Medical Group

2. UCLA Health System Hospital System (Acute Care, Child, Psychiatric) 40,000 discharges 806 Licensed Beds UCLA Faculty Practice Group (1214 physicians; 247 primary care; W2 model) UCLA Medical Group (Internal and External Networks & Contracting) 58 faculty ambulatory practice locations/29 primary care site (additional sites coming on-line) 1.6 Million visits/year 2.3 million encounters/year 323,000 unique patients FY12 August 2012

3. The UCLA Health System PCIM Journey Primary Care Innovation Model Objectives Defined External Visits &Research Design & Refinement of Design & Phasing Pilot Implementation Replication of Successful Practice Customized to UCLA Internally/Externally I.Practice Re- Design II.Increase Covered Lives III.Expanded capability IV.Collaborations V.Replication I.Geisinger II.BSVa III.Baylor IV.Johns Hopkins V.Ascension Health I.Design Teams II.Implementation Teams III.Leadership Team IV.Design Retreats August 2012

4. Planning PhaseDesign Phase Implementation Phase Operations Phase Primary Care Innovation Model Increase Managed Populations UCOP Medicare Advantage/FFS Commercial/HMO/PPO MSSP “ACO” Application Expand Primary Care System UCLA Collaborative with others Replicability Internal/External Shaping the Future Strategic Plan 2011-2015 UCLA-MG Existing Population Management DSRIP CMS/CMMI Challenge CMS/Shared Savings Organizational Design Primary Care Innovation Model Practice Re-Design (PCMH) MyMeds in-office PharmD Expand Primary Care System (CVS) Growth Strategy Context: (Oct 2011 – July 2012) 5/10/2012 Primary Care Innovation Model Implementation Teams: Transitions of Care ED/Urgent Care Community Programs CMMI Innovation Funded Geriatrics Dementia August 2012

5. PCIM Progress-to-Date: PCMH Started design Oct 2011 and on-track to have 50% of current primary care sites in PCMH practice-redesign model by end of this year, goal is all current and future sites. Established method for replication (Design Team & Retreats) Established new roles & and responsibilities (care coordinators and leadership) Established linkages with other components of UCLA System (e.g. Transitions & ED) Developed new IT support and registries (e.g. prior 24 hour ED and inpatient discharges) Metrics established and being refined (e.g. facility use, panel size) As of August 2012 August 2012

6. PCIM Progress-to-Date: Other features Established Growth Strategy Design Team to frame PCIM expansions Relationship with retail clinics being operationalized Articulated a Value-Based Care Model (HRA-based) Phase I applicable initially to: Commercial HMO (UCLA Employees) Medicare Advantage HMO Medicare Shared Savings Plan Implementation Established collaborative with UCOP on development of new UC care medical plan that includes features of PCIM & HRA-based models HRA-based =Health Risk Assessment & biometric screening & coaching model As of August 2012 August 2012

7. Value-Based Care: HRA-based model for Enrollee Health Coaching/ Linkage to Care Coordination. “Triple Aim” & IOM HRA, Health & Biometric Screenings & Risk Assessment Medical Home/ Establish PCP System/ EHR Chronic Condition Management Pharma Utilization & Formulary Compliance Choose a Primary Care Provider “Triple Aim” and IOM Guidance August 2012

8. Primary Care Innovation Model Team Members Samuel Skootsky, MD, Chair, FPG CMO Jordan Hall, FPG Director Care Coordination Laurie Johnson, FPG Dir Ambulatory Services Molly Coye, MD, Chief Innovation Officer Patricia A. Kapur, FPG CEO Stephanie McCutcheon, Innovation Advisor CPN Mark Grossman, MD, Medical Director CPN Christina Catipay, Director Operations Donna Robinson, CPN Brentwood Manager Patricia Alarcon, CPN W. Washington Manager Jeff Bernal, CPN Manhattan Beach Manager SMBP Bernard Katz, MD Medical Director Mark Needham, MD Medical Director Lorena Douille, Director Operations Celina Lomeli, 20 th St. Manager Jessika Harris, Ocean Park Manager Family Medicine Michelle Bholat, Medical Director Lynne Stevens, NP Wendy Songer Medicine-Geriatrics Internal Medicine Matteo Dinolfo, MD, Medical Director David Reuben, MD Chief of Geriatrics Brandon Koretz, MD Medical Director Lillian Martinez, Director Operations Tony Michaelis, Director Operations Mari Lynne Kennedy, Med Suite 455/490 Manager Joe Brown, Medicine SM Internal Med Eve Glazier, MD Medical Director Janet Pregler, MD Ambulatory Director Additional Team Members Debora Davis, RN, BSN, CCM Managed Care Alice Kuo, MD, Medicine Sandra Lavin, RN, Managed Care Janine Knudsen, MHA, Innovation Intern, Harvard Anahit Khacheryan, Ed Dir Oper Improvement Shirley Wong, PharmD, MYMEDS Richard Maranon, MSA Geriatrics, MYMEDS Gerardo Moreno, MD, Family Medicine, MYMEDS Shawn Lee & Albert Duntugan, Dir Business Analytics Beth TenPas & Kaiding Zhu Decision Support & Fin Srvs Marcia Colone & Mary Noli, Care Coordination Nasim Afsar, MD, Dir Quality/Safety/Medicine Crystal VanDeventer, Innovation Model Support Others August 2012

9. PCMH Pilot Practices Started Five Pilots (33,000 patients) Santa Monica Bay Physicians Plaza Office CPN Parkside SM Office Family Medicine SM Family Health Center Department of Medicine SM 2020 Department of Medicine SM Geriatrics Department of Pediatrics has separate related program No lack of provider and staff enthusiasm! August 2012

10. Expansion Sites/ Sep 2012 Start New Cohort of Eight Practices & Lead MD SMBP/20th Street 3rd Floor - Michael Nagata, MD and Caroline Close, MD SMBP/Ocean Park - Richard Ross, MD SMBP/20th Street 10th Floor - Richard Greenspun, MD CPN/Brentwood - Dr. Mark Grossman CPN/W Washington - Dr. Soheil Azimi CPN/Manhattan Beach - Dr. Thuy Tran Med/Primary Care Suite 455/490 – TBN Med/ SM Internal Medicine Lead - Eve Glazier, M.D. With this expansion, will have total 13 sites in program Represents 50% of all Adult Primary Care Sites August 2012

11. UCLA Population Management Plan “System” Support: EHR, Data aggregation, Population Registries, Predictive Modeling, Decision Support, Practice Standards, Quality Measurement and Reporting, Accountability, Tele-Medicine, Tele-Health Patient- Centered Shared Decision Making Traditional Benefit- Based Home Health Hospital & Hospitalist- Extensivist Programs  Communication  Care Transitions  ER interventions  Efficient hospital use SNFist and SNF Program Ensuring Care Implementation in the Community & at Home Home Social/Environmental Factors Patient Coaching Transitions of Care Use of Community Resources Comprehensive Care Centers Optimal Discharge (Hospital, ER, SNF, other) August 2012

12. What does Practice Re-Design mean? Defined practice populations by MD and Site Having timely & actionable data Team based care Risk prioritization, practice huddles, care coordination, transitions management, and navigation-“linkages” within Health System Advanced Primary Care Practice Continuity Access Active Panel Management Primary Care Innovation Model August 2012

13. What is Medical Home Functionality? Care Coordination Case Management Panel Management Physician or other Providers Medical Assistant/LVN Office Staff Office Manager August 2012

14. Health System PCMH 1.0 PCMH 2.0 Our approach embraces “System” attributes and synergy August 2012

15. Practice Re-Design, Advanced Primary Care, and Health System Re-Design = PCMH UCLA Health System MD Led Team: Advanced Primary Care/PCMH Practice ED Services Hospitalist Program In-home services, including palliative care Needed Specialists and Ancillaries Urgent Care Centers & Retail clinics Comprehensive Care Coordinator Physician & MA-LVNs Other staff Advanced Medication Management Clinical Advisor- Case manager ED Services Defined Care Management New FTE and roles noted in light green August 2012

16. UCLA PCMH/PCIM Metrics of Success Reduction in Facility Use (increase use of alternatives) Discharges & optimal LOS All cause readmissions ED visits Ambulatory Care Sensitive Admissions Generic Drug Use Attenuation or Reduction in “Total Cost of Care” Quality measures (standardized, valid, nationally endorsed) at 90 th %tile Patient Experience (Clinician Group - CAHPS) at 90 th %tile Provider & Staff Satisfaction (maintaining the workforce) Increased efficiency in operations (e.g. panel size) Success of care coordination system August 2012

17. Practice Population Registry with Multiple Ways Clinical Risk Ranking August 2012

18. Practice & Patient Care Gaps and Registries Action Lists = Care Gaps Registries = Whole Population August 2012

19. PCIM Population Access Mednet Site Recent addition: Past 24 hour ED discharges, Inpatient Admissions & Discharges August 2012

21. Layered approach to PCIM population management Expand 30+ year history of UCLAMG capitation [Medicare Advantage and Commercial] & “wrap around” population & care management Delivery System Reform Incentive Payments (DSRIP) and PCMH expansion MSSP: Government sponsored ACO Commercial Plan ACO UCOP Plan ACO Affiliations August 2012

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