1. Post-Acute Care Partnership Development for ACOs
Lisa P. Shock, MHS, PA-C
Presentation to the Carolinas Society for Post-Acute and Long Term Care Meeting
November 5, 2016

2. Purpose of Post Acute Outreach
To claim ownership and accountability as providers for the processes of population health management, to evaluate process issues, and to collaborate with our community partners to enable high quality, affordable care
How do we ensure successful collaboration across an ACO?

3. Post Acute Care Business Problem
Post-acute care costs are one of the fastest growing areas of Medicare spending (Hegwer, 2013)
Rational for Prioritizing
Ability to add value and quality to this area of care.
APMs offer some unique payment waivers that would require specific SNF partners. Providers within the ACO that are managing these patients are requesting support.
Solution
Have skilled facilities partner with ACOs to work on clinical and quality priorities.
Utilize existing clinical team members to manage transitions from acute and post-acute facilities.
Competitive Advantage
Medical cost savings; Post Acute initiative allows for a comprehensive solution to those patients requiring long-term care; leverages community activities around transitions of care and collaboratives for post-acute providers; apply proven, national models to this local concern.
Impact
30 Day Readmissions
ED Visits for this population
Quality scores
Patient and Provider satisfaction
Average Length of Stay
Physician
Practice Staff
Wake Internal Medicine - Dr. Meier - Matt Johnson
Newman - Dr. Newman - Jennifer Seas
WakeMed Garner - TBD  (From Klaunser) - TBD (Jamie Landrum to confirm)
WakeMed Briar Creek - John Holly - Jamie Landrum (Jamie Landrum to confirm)

4. Evidence Based Post-Acute Strategies

5. PRODUCTIVE INTERACTION
Success Is Contingent upon a Culture of Change to Support and Improve Health
Successful population health management requires highly engaged physicians, patients, families and leaders.
Strong patient engagement is created through productive interactions between informed, activated patients and families, and a prepared, proactive physician team.
OPTIMIZES CHOICES
AND CARE
PRODUCTIVE INTERACTION
Informed, activated
patient and caregiver
Prepared, proactive physician team
Population health goals: higher quality, lower costs, better patient experience
Model of care delivery requires productive interactions for success, we want to imbed culture of health and proactive change management throughout organization
Evolent delivers its Model of Care by making the interaction between the patient and the physician, or the patient and the care advisor productive
We support the productive interaction by giving physicians the tools, people, and a team to support them so that they can do what they're supposed to be doing, and what they love doing
The same thing goes for our extended team when we talk about care advisors; having them do what they should be doing as a nurse, or a diabetic educator, etc.

6. Characteristics of a Successful Post Acute Partnership
FACILITIES
Lowest readmit rate?
Lowest cost?
Fewest publicly reported (survey) deficiencies?
Relative to specific diagnoses?

7. Characteristics of a Successful Post Acute Partnership
PATIENTS
Highest medical cost?
Medication spend?
Most office visits?
Most ED visits?
Most hospitalizations?
Specific diagnoses?

8. Working with the Acute Hospital Setting
Understand Current State Workflow
Patient Awareness
Management and Implications of
Direct from ED
Early Discharge
Waivers

9. Care Management
The care management team supports the transition of the patient into the SNF
(typically done from an inpatient setting but patients can also be directly admitted to the SNF)
as well as during the transition from the SNF to home.
The care transitions program includes the following elements:
Identification of the high risk member through stratification or provider referral
Working with the patient and family to increase engagement and understanding of the process
Development of the transitions care plan and medication reconciliation
Facilitating communications between the hospitalist, SNF, and PCP
Coordinating home visits and follow up care as needed
Telephonic follow up as needed
The timeline for care management actions upon SNF admission are as follows:
Care Managers outreach to facilities within hours of admission of patient to facility
Ensure that prior level of function and therapy evaluations are completed within hours of admission
Reviews completed every 3 business days to ensure that patient individualized plans of care are consistent
Referral to appropriate care management programs as necessary for continuity of care upon discharge
Transition care management is most effective when strong relationships can be built with the SNFs to
encourage consistent communications and shared goals.

10. Flex Complex Care Delivery Model
Identification and outreach
Care Plan development
Physician partnership
Ongoing patient support
Care Advisor (CA) discusses identified patients with physician
CA sends letter to patient introducing program
Physician encourages patient engagement during office visits
CA follows up letter with phone call to introduce self
CA works with patient over the phone to complete a health assessment
Together, CA and patient come up with health goals and complete Care Plan
CA shares care plan with physician
Physician reviews care plan and revises if needed
CA attends at least one physician visit with patient
CA reviews care plan with physician quarterly
CA works together with patient to complete goals and make progress on care plan
CA updates care plan as progress is made

11. Transition Care Objectives
Decrease avoidable readmissions by creating a streamlined transition process and a productive environment at home
Team Engaged
Patient, Family and care giver
Physician
Care Advisor
Inpatient Care Advisor
Case Manager
Engagement Specialist
Pharmacist
Program Coordinator

12. Transition Care Follows High-Risk Patients Post-Discharge to Reduce Readmissions
Transition Care Combined Model
Coleman’s Care Transitions Intervention®
Project RED
Team Approach
Collaboration amongst the physician, the Transition Care Advisor and the pharmacist
Collectively focuses the transition on four key mechanisms
Health coaching and care coordination
Complete medication reconciliation and education
Patient-centered health record
Strong home support post-discharge
Differentiation
Transition Care Advisors partner with hospitalists
Enhanced patient engagement and activation (e.g., PAM measurement)
Caregiver inclusion throughout the transition
Pharmacy support for medication safety
Reduce readmissions and safe care transitions by using evidence- based models for all patients admitted

13. Care Management Case Management & Coordination of Care Metrics
Roles
Program Description
Communications
Hand offs
Metrics
SNF days / 1,000
Average SNF length of stay
Unplanned Readmissions
Reporting

14. Ideal Process Includes Both a Hospital and Post-Discharge Component of Care
Last 24–48 hours
Follow-up appt. scheduled
Medications reconciled
Risk reassessed
First 48 hours
Home visit if high risk
In-home medication reconciliation
Day 7, 14, 21
Telephonic follow-up
Assess progress toward personal goals
Hospital
Home
Stable Health
4 hours pre-discharge
Patient understands red flags and action plan
48–72 hours
Telephonic follow-up (moderate risk patients)
First 24–48 hours
Hospitalist & TCA collaborate
Transition Care process introduced
First 24 hours
Confirm receipt of meds
Discharge summary to PCP
Day 28
Patient moved to Complex Care
Quality and satisfaction of transition is assessed

15. Skilled Nursing Facility (SNF) Health Rounds
Physicians, APPs, SNF leadership, nurses, CMAs
Interdisciplinary staff as needed – PT/OT/Speech/Dietary/Pharmacy
ACO Care Advisor

16. Data Integrated for a Patient-Centric Stratification Approach
Clinical rules engine, predictive models and clinical judgment are used to identify patients for care advising
Primary Data
Patient Profile
Clinical Judgment
Clinical Rules Engine Predictive Models
Medical Costs
Risk Scores
Utilization Trends
Chronic Conditions
Medications
Demographics
Biometrics / Labs
Engagement
Gaps in Care
Health Status
Administrative Data
Med / Rx claims
Eligibility
Provider files
Consumer data
Clinical Data
Lab values
Biometric screenings
EHR integration
ADT feeds
3 Types of data we get
Differentiator for Evolent: The completeness of data we get. We then take that data, we drive it into the clinical rules engine, it runs into our predictive models; and then, we apply on it clinical judgment.
All three are important and integral to painting the entire picture within a patient profile – we can use all three to drive the system
Ex: The big data technology solutions can push data through and pull out predictive models, but if it is not taken back to the physician and layer on their clinical judgment, then you're not actually going back and building rules that are more advanced and have more precision to them.
No computer can replace a physician's judgment of their own patient. Physicians feel very strongly about this. It's what makes our model very unique.
Survey Data
Health risk assessments
Patient activation
Patient experience
Physician referral

17. Team Roles & Responsibilities
Core Responsibilities
Site Medical Director
Helps to organize the meeting and set the agenda
Leads the discussion
Utilizes why questions to identify root causes
Keeps the focus on actionable barriers and potential solutions
Prevents the discussion from becoming about clinical decisions as much as possible
SNF Leadership Administrator
Arranges for special guests as needed
Helps keep the meeting on track and on time
Follows up to ensure tests of change initiated and facilitates any other communications
Keeps notes during the meeting to facilitate solution conversation (if designated)
Care Manager
Helps to identify specific patients that may be good for in depth discussion
Drives the review of hospitalized, recently discharged and Complex Care patients
Notifies the PCPs prior to the conference if they have a patient to be discussed
Follows up immediately on solutions identified, and/or future solutions; post-barriers 5

18. ACO Update Communication with SNFs1
Since the last meeting…
New Clinical Initiatives: implication/ benefits 2 3 4 5 6 7 8

19. Monthly Metric Review: Admissions and Discharges1
Since the last meeting…
Any elective admissions?
If so, were they medical optimized before this admission?
Barriers to this?
Any pending elective admissions?
Non-elective admission?
Avoidable? (assume avoidable until proven otherwise)
Root Cause Analysis (focus on process)
Transition plan and follow up in place?
Readmits?
May be none
Root Cause Analysis 2 3 4 5 6 7 8

20. Monthly Metric Review: ED Visits
Since last meeting…
Any ED visits, especially for ACSC conditions?
Follow up in place?
Plan to avoid ED in place?
Evaluate for enrollment in programs – Complex Care, TC, Behavioral Care, etc.
“Make their last ED visit their last ED visit”

21. Thank You!! THANK YOU!!! Not everything that counts can be measured
Not everything that can be measured counts
Lisa P. Shock, MHS, PA-C
Managing Director, Clinical Operations – Eastern Region