Improving Quality Through the Accountable Care Organization (ACO) Cheryl Jansen RN BSN Clinical Application Analyst II University Hospitals Candace L. McGovern RN Manager, IT Clinical Applications Susan Semrau RN, CPHQ Senior Quality Improvement Nurse Institute for Healthcare Quality & Innovation Elizabeth R. Hammack Associate General Counsel University Hospitals Health System, Inc. William W. Steiner II, MD PhD Interim President, University Hospitals ACO Nathan Hunt Director, University Hospitals Accountable Care Organization Eric M. Yasinow, M.D. Medical Director, UHACO Corinne Hurley Director Clinical Management UHPS Michele Lemonovich RN Clinical Liaison, UHCare University Hospital Geauga Medical Center

Objectives Provide introduction to ACO Present ACO quality measures Understand how using the AEMR can improve quality Be aware of shared Savings and Financial Incentives for Physicians 4/16/2017 University Hospitals 2

UH Accountable Care Organization Strategy & Initiatives 4/16/2017 University Hospitals

Total Expenditures and % Gross Domestic Product (GDP) 17.2% 2.8T Trillions 2010 – 1) Medicare spending lower due to increase in private plans (Medicare advantage). 2) Loss of employment and insurance Projecting ~5.8% increase in annual health expenditures. 2015 – 2020: Employers Drop Insurance, Cadillac Tax, Projected 4/16/2017 University Hospitals

4/16/2017 University Hospitals 4

UHACO Strategy Achieve improved outcomes for patients of all ages: Quality of care, Patient experience, and Cost of care Maximize value of high quality patient-centered care Remain ahead of the ‘health reform curve’ Pilot new models of care delivery and reimbursement Leverage expanded system to coordinate care: Large primary care network Outpatient facilities Technology 4/16/2017 University Hospitals

UH ACO Objectives & Strategies Increase preventive care and wellness activities Expand clinical care protocols built around UH Centers of Excellence Improve Population Health Coordinate care across health system Increase role of Primary Care Physician (PCP) Engage patients and families Enhance Patient Experience of Care Deliver care in appropriate settings by appropriate providers Minimize waste & duplication Reduce And Control Cost of Care 4/16/2017 University Hospitals

Attributed Membership: UHACO Initiatives University Hospitals Coordinated Care Organization University Hospitals Rainbow Care Connection University Hospitals Accountable Care Organization ACO: Pediatric ACO Center for Medicare & Medicaid Innovation (CMMI) Employee/ Commercial ACO Medicare ACO Centers For Medicare & Medicaid Services (CMS) Attributed Membership: 70,000 80,000 50,000 Payer: Ohio Medicaid Self-Insured Plans/ Commercial Payers Medicare Traditional Attributed lives account for over $1 Billion in annual medical expenditures 4/16/2017 University Hospitals

UH Accountable Care Organization Quality 4/16/2017 University Hospitals

Medicare ACO Quality Reporting Quality reporting of 33 measures in 4 domains required for shared savings Patient/Caregiver Experience Care Coordination/Patient Safety Preventative Health At-Risk Populations Replaced PQRS Reporting for Physician Incentive Achieved for all UH Physicians 2012 & 2013 2014 Reporting begins January 26, 2015 Select results published on Physician Compare 4/16/2017 University Hospitals

2012 & 2013 Quality Results: 2014 Percentiles 4/16/2017 University Hospitals **Confidential** 11 11

2012 & 2013 Quality Results: 2014 Percentiles Patient/Caregiver Experience Measure Description ACO #1 Getting Timely Care, Appointments, and Information ACO #2 How Well Your Doctors Communicate ACO #3 Patients’ Rating of Doctor ACO #4 Access to Specialists ACO #5 Health Promotion and Education ACO #6 Shared Decision Making ACO #7 Health Status/Functional Status 4/16/2017 University Hospitals **Confidential** 12 12

2012 & 2013 Quality Results: 2014 Percentiles Care Coordination/Patient Safety Measure Description ACO #8 Risk Standardized, All Condition Readmissions ACO #9 ASC Admissions: COPD or Asthma in Older Adults ACO #10 ASC Admission: Heart Failure ACO #11 % of PCPs Qualified for EHR Incentive Payment ACO #12 Medication Reconciliation ACO #13 Falls: Screening for Fall Risk 4/16/2017 University Hospitals **Confidential** 13 13

2012 & 2013 Quality Results: 2014 Percentiles Preventive Health Measure Description ACO #14 Influenza Immunization ACO #15 Pneumococcal Immunization ACO #16 Adult Weight Screening and Follow Up ACO #17 Tobacco Use Assessment and Cessation Intervention ACO #18 Depression Screening ACO #19 Colorectal Cancer Screening ACO #20 Mammography Screening ACO #21 Proportion of Adults who had blood pressure screening in last 2 years 4/16/2017 University Hospitals **Confidential** 14 14

2012 & 2013 Quality Results: 2014 Percentiles Diabetes Composite Measure Description ACO #22 Hemoglobin A1c Control (<8%) ACO #23 Low Density Lipoprotein (<100mg/dL) ACO #24 Blood Pressure <140/90 ACO #25 Tobacco Non Use ACO #26 Aspirin Use 4/16/2017 University Hospitals **Confidential** 15 15

2012 & 2013 Quality Results: 2014 Percentiles At-Risk Populations Measure Description ACO #27 % of beneficiaries with diabetes whose HbA1c in poor control (>9%) ACO #28 % of beneficiaries with hypertension whose BP <140/90 ACO #29 % of beneficiaries with IVD with complete lipid profile and LDL control <100mg/dl ACO #30 % of beneficiaries with IVD who use Aspirin or other antithrombotic ACO #31 Beta-Blocker Therapy for LVSD 4/16/2017 University Hospitals **Confidential** 16

2012 & 2013 Quality Results: 2014 Percentiles Coronary Artery Disease (CAD) Composite Measure Description ACO #32 Drug Therapy for Lowering LDL Cholesterol (Removed From Program) ACO #33 ACE Inhibitor or ARB therapy for patients with CAD and Diabetes and/or LVSD 4/16/2017 University Hospitals **Confidential** 17

2015 Medicare ACO Quality Measures Description Status ACO #34 CAHPS Stewardship of Patient Resources NEW ACO #35 Skilled Nursing Facility 30-Day All Cause Readmission Measure ACO #36 All-Cause Unplanned Admissions for Patients with Diabetes ACO #37 All-Cause Unplanned Admissions for Patients with Heart Failure ACO #38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions ACO #39 Documentation of Current Medications in Medical Record ACO #40 Depression Remission at Twelve Months 4/16/2017 University Hospitals

2015 Medicare ACO Quality Measures Description Status ACO #22 Diabetes Composite: Hemoglobin A1c Control (<8%) REMOVED ACO #23 Diabetes Composite: LDL (<100mg/dL) ACO #24 Diabetes Composite: Blood Pressure <140/90 ACO #25 Diabetes Composite: Tobacco Non Use ACO #26 Diabetes Composite: Aspirin Use ACO #27 % of beneficiaries with diabetes whose HbA1c in poor control (>9%) RESCORED ACO #41 Diabetes: Eye Exam % of patients 18-75 with Type 1 & 2 Diabetes with retinal/dilated eye exam in measurement period or negative in the year prior NEW 4/16/2017 University Hospitals

UHACO Commercial Programs Shared savings targets based on lower cost of care and quality targets met Quality measured for preventative, disease-specific, & hospital care Quality alignment across programs where possible UHACO to provide population health services to improve quality and help manage cost Provider network includes University Hospitals employed providers Fee for service reimbursement to providers with potential for shared savings 4/16/2017 University Hospitals 20

Commercial ACO Programs UHACO Commercial Programs Quality Measures Medicare ACO Commercial ACO Programs Colorectal Cancer Screening  Breast Cancer Screening Cervical Cancer Screening Chlamydia Screening Pediatric Measures Diabetic preventive screenings Diabetic HbA1c controlled Heart Failure/CAD Hospital Re-Admissions Hospital Length of Stay Pregnancy Management 4/16/2017 University Hospitals 21

UH Accountable Care Organization Infrastructure & Support 4/16/2017 University Hospitals

UHACO Population Health Management Centralized and practice-based team focused on coordinating care for ACO populations: Patient Navigators (Central & Embedded) Nurse Care Coordinator Health Educators & Dietitians Social Worker Pharmacist Network Administrator Data Analyst Analyze Population Identify Engage Connect 4/16/2017 University Hospitals 23 University Hospitals

UHACO Population Health Management Health Education & Wellness Programs for broad population needs Preventative Care Adherence Align primary care physicians & protocols All Members Screening Campaigns Resolve gaps in care Disease Management Address chronic illnesses Targeted Outreach Case Management Individualized care Highest Risk © 2013 University Hospitals Health System, Inc. All rights reserved. 4/16/201701/15/2013

UHACO Population Health Management Health Education & Wellness: Programs for broad population needs Preventative Care Adherence: Align primary care physicians & protocols UHACO Physician & Provider Update 4/16/2017 University Hospitals

Leveraging Resources & Technology Utilizing Electronic Medical Record (EMR) for ACO- specific functions Tasking Health maintenance log Quality documentation Expanding ability to schedule directly 4/16/2017 University Hospitals 26 26

Colonoscopy Campaign: Initial Telephonic Outreach 1,040 commercial ACO members 1,632 call attempts 4/16/2017 University Hospitals

Colonoscopy Campaign: Fecal Immunochemical Testing (FIT) 4/16/2017 University Hospitals

UHACO Mammogram Campaign Compile ACO member/beneficiary data emmi scheduling outreach & warm transfers to 216-844-BRST UHACO Patient Navigator in-office outreach UHACO Network Administrator to organize physician orders for mammograms Outreach to ACO members/beneficiaries to schedule UHACO follow up with ordering physicians on documentation Coordinate with UH #WomanUp Marketing Campaign 4/16/2017 University Hospitals

ACO Population Indicator UHACO Master Patient Index ACO Population Indicator 4/16/2017 University Hospitals

UHACO Transitions of Care During Hospitalization: Visit selected beneficiaries Post-Hospitalization: Contact beneficiary within 72 hours of discharge Confirm Primary Care Provider (PCP) appointment Review medications & discharge notes Document needs assessment Conduct follow up coordination as indicated 4/16/2017 University Hospitals

UHACO Transitions of Care 4/16/2017 University Hospitals

Discussion 11/22/14 University Hospitals 33

2/08/2010 4/16/2017 University Hospitals University Hospitals 34 34