C-TAC 2015 National Summit on Advanced Illness Care - Master Slide Deck

N a t i o n a l S u m m i t o n

A d v a n c e d I l l n e s s C a r e

D r i v i n g C h a n g e t h r o u g h

L e a d e r s h i p , E v i d e n c e a n d

A c t i o n

Welcome and Goals

Leonard D. Schaeffer

Judge Robert Maclay Widney Chair and Professor

University of Southern California

M a r c h 2 , 2 0 1 5

Conference Hosts

• Bill Novelli: Board Co-Chair and

Professor, McDonough School of

Business, Georgetown University and

former CEO, AARP

• Tom Koutsoumpas: Board Co-Chair

and President, Caring Foundations

• Jon Broyles: Executive Director,

C-TAC

C-TAC Vision

All Americans with advanced illness, especially the sickest and most vulnerable, will receive comprehensive, high-quality, person- and family- centered care that is consistent with their goals and values and honors their dignity.

Advanced IllnessC-TAC’s Goal

Chronic and Curative Care

Healthy or with

reversible illness

Disease Progression

Advance Directive Advance Care Planning

Early onset, chronic

conditions

Progressive, frequent

complications

Hospice

Eligible

Palliative Care

Hospice

Phase 4Phase 3Phase 2Phase 1

All persons with advanced illness

receive high quality care

Key C-TAC Initiatives

• Comprehensive, Consensus-Based

Policy Agenda: Guides C-TAC’s activities

on the Hill and with Administration

• Proof-in-Concept Community Action

Pilot (Oakland, CA): Fosters partnerships

between health systems and community

organizations to fill gaps in care delivery

• Advanced Care Project: Partnership with

AHIP Foundation to engage health plans and

health systems in implementing advanced

illness care programs

Key C-TAC Initiatives

• Serves as a guide for

transforming advanced

care illness across all

disciplines

• Analyzes key issues,

challenges and solutions

• Identifies action steps for

achieving high-quality,

advanced illness care

• Provides a “Call to

Action”

Conference Goals

• Increase provider and consumer readiness

to implement, evidence-based tools &

approaches to AIC

• Connect consumers, clinicians, health

systems and health plans to deliver high

quality, person-centered care and commit

to improved performance

• Disseminate information and support

implementation of evidence-based AIC

models

We’re here to learn what’s working

and what’s not, and use these

lessons to move forward

• Identify gaps in evidence that need to be

addressed to further the adoption of better

AIC

• Expand comparative effectiveness

research to support transformational

change in the field

Conference Goals

How You Can Contribute Today

One degree of change can make

all the difference

• Be candid about what’s working, what’s

not, and why

• Join in catalyzing action and energy

around effective programs and ideas

• Help identify programs and concepts with

the greatest potential to improve AIC

• Offer ideas on how to scale up what’s

working

IOM (Institute of Medicine). 2014. Dying in America: Improving quality and honoring individual

preferences near the end of life. Washington, DC: The National Academies Press.

Introduction

Please join me in

welcoming:

Victor Dzau, MD

President,

Institute of Medicine

A d v a n c e d I l l n e s s C a r e :

T h e I O M P e r s p e c t i v e

V i c t o r J . D z a u , M D

P r e s i d e n t ,

I n s t i t u t e o f M e d i c i n e

Dr. Victor Dzau, MDPresident, Institute of Medicine

Advanced Illness and End of Life Care: The IOM Perspective

Advanced Illness Care

“Occurring when one or more conditions become serious enough that general health and functioning decline, and treatments begin to lose their impact.

The process that continues to the end of life.”

-Coalition to Transform Advanced Care

Trends & Background

Aging

Americans over age 65

9% in 1960

20% in 2050

Growing ethnic and cultural diversity

Disease Burden

Multiple chronic conditions

2/3 of people over 65

New cancer cases

45% increase from 2010 2030

Alzheimer’s disease and dementias

5.5 million in 2010 8.7 million in 2030

Parkinson’s disease

Prevalence to double in the next 30 years.

Care

People dying in acute care hospitals

Deaths in nursing homes

and hospice

• # of Americans needing long-term care: more than double by 2050 • Medicare deaths in acute care hospitals: 33% 2000 25% in 2009• Growing number of deaths in nursing homes• Hospice care: 1995, 17% of US deaths 2011, 45% • By 2011, 85% hospitals with 300+ beds had palliative care services

Costs

Medicare spent 28 percent of 2011 spending, or about $170 billion, on patients’ last six

months of life.

Decision-Making

40% of adult medical inpatients incapable of making their own treatment decisions

Among nursing home residents, 44-69% cannot make their own medical decisions

70% of decedents aged 60 and older who faced treatment decisions in the final days of their lives were incapable of participating in these decisions

IOM’s Role

Independent, Apolitical | Multidisciplinary | Evidence-based

Maintaining high quality of life until

death

Care Delivery

Clinician-Patient

Communication

Policies and Payment Systems

Professional Education

Research and

Information Sharing

Public Education

and Engagement

Care Delivery

Cover provisions for individuals nearing end of

life

Provide access to palliative care,

with an integrated team

Publically report quality and cost

measures

Comprehensive Care• Seamless, patient-centered,

family-oriented, high-quality, integrated

• Accessible 24/7• Considers physical,

emotional, social, and spiritual needs

• Consistent with individuals’ values, goals, and informed preferences

Care delivery organizations

Government health insurers



Specifically for Children:

• Need clinical practice guidelines and protocols for palliative, end-of-life, and bereavement care that meet the needs of children and families.

Proposed Core Components of Quality EoL Care

• Frequent assessment of patient’s physical, emotional, social, and spiritual well-being

• Management of emotional distress • Offer referral to expert-level palliative care • Offer referral to hospice if the patient has a prognosis of 6 months or less • Management of care and direct contact with patient and family for

complex situations by a specialist level palliative care physician• Round-the-clock access to coordinated care and services• Management of pain and other symptoms• Counseling of patient and family • Family caregiver support• Attention to the patient’s social context and social needs• Attention to the patient’s spiritual and religious needs• Regular personalized revision of the care plan and access to services

based on the changing needs of the patient and family

Clinician Patient Communication

In a national survey, clinicians asked for patients’ preferences in medical decisions only

about ½ the time.

25% of patients reported that their clinician failed to share important information about

their test results or medical history with others involved in their care

Develop

Adopt

Tie to reimbursement

Facilitate tying to reimbursement,

licensing, credentialing

Quality Standards encouraging: • Individuals to

participate in decision-making

• Clinicians to initiate conversations

• Clinicians to revisit discussions

Professional Societies

Professional Societies and others

Payers

Health care delivery organizations

Payers


• Need better policies and procedures to ensure child’s involvement in treatment discussion and decisions.

• Hospitals should not abruptly end contact with the family after the death.

IOM Roundtable on Value and Science Driven Health Care

Evidence Communication Collaborative

Good Communication Needs:• Respectful culture• Nurturing and secure decision making

climates• Good clinician teamwork• Access to high-quality evidence for

decision-making• Transparency and candidness around

constraints and unknowns.

Co-chaired by George Halverson & Bill Novelli

Policies and Payment Systems

Seek and enact

legislation

Implement

Integrated Financingof medical and social services to support care at the end of life.• Financial incentives

for coordinated care• EHR that incorporate

advance care planning

Administration,

Congress

Federal government and.its programs(e.g., Medicare, .Medicaid, VA),Other health care systems

Federal, state, and.private insurance and care delivery programs

Require public reporting on quality, cost,

outcomes


• Clinicians should be reimbursed for fully informing and counseling parents.

• Bereavement services for parents and siblings of children who die should be reimbursed.

Professional Education

Provide training throughout professional

careerRequire

education and experience in

training programs

Strengthened Knowledge and Skills• Palliative care• Communication skills• Interprofessional

Collaboration• Symptom

management

Educational institutions

Professional societies

Accrediting organizations

Certifying bodies

State regulatory agencies

Include in licensure requirements for

health professionals, chaplains, social

workers, etc.

Create pathways to certification

Entities that certify /specialty-level providers

Care delivery organizations, medical centers, teaching hospitals

Increase number of training

positions for specialization

Research and Information Sharing

Research Needs

• Prevalence and nature of care that is neither beneficial nor wanted.

• Effect of palliative care on longevity.

• Elements of palliative care likely to offer the greatest improvements in quality of life.

• Evidence-based measures of quality end-of-life care.

• Family caregivers’ roles, needs, behavior, health risks, success in performance, interaction with other members of the health care team, and use of respite care and other support services.

• Reliable approaches to prognosis that start earlier in the disease trajectory, and assessment of whether more accurate prognoses. lead to improvements in quality of life and other outcomes of care.

• Effects and value of specific types of clinical innovations in delivering end-of-life care.

Research needs for children

• Comparative effectiveness studies of different approaches to symptom management and bereavement support.

• Analyses of care received in emergency departments, outpatient settings, and hospices and through home health agencies.

• Cohort studies examining the effect of palliative care on outcomes and on the patient experience.

• Studies of how best to staff, manage, and finance hospital-based pediatric palliative and community-based pediatric hospice services.

Public Education and Engagement

People don’t speak with loved ones about end of life wishes because…

Too many other things to worry about right now.

Don’t want to think about death or dying.

Family member did not want to discuss it.

Provide information, encourage dialogue

Research consumer

perception, test message

effectiveness

Encourage members to

engage patients

Engaged and Informed Constituents

Civic leaders, governments, community organizations, …faith-based organizations, consumer groups, employers, care providers

Health care

professional

societies

Government agencies

Payers

Moving Forward

Wealth of knowledge How do we act on it?

Many roles Need everyone to contribute

R E S E A R C H T H AT D R I V E S

C H A N G E

Joe V. Selby, MD MPH

Executive Director

Patient-Centered Outcomes Research Institute

W h a t D r i v e s C h a n g e ?

What Drives Change?

• Getting the Research Question Right

• Rigorous Research Methods

• Community-led Dissemination Plan

Engagement is the key to finding the research question that

leads to research that can be disseminated and implemented

Evaluation

Proposal Review; Design and Conduct of Research

Topic Selection and Research Prioritization

Dissemination and Implementation of Results

Rigorous methods - did the intervention

really work – and would it work again?

• Believable Benefit – or Bias?

– Randomization

– Multiple randomized Units

• Compared to What?

– Evaluation vs. research

– Carefully specified, high quality usual care comparator

PCORI-funded Projects

Health System Intervention to Improve Communication About End-of-Life Care for Vulnerable Patients – RCT – Washington State

Improving Palliative and End-of-Life Care in Nursing Homes – RCT - Rochester NY

Improving Advanced Cancer Patient-Centered Care by Enabling Goals of Care Discussions – RCT – New York City

Computerized PAINRelieveIt Protocol for Cancer Pain Control in Hospice – RCT –Chicago

Relapsed Childhood Neuroblastoma as a Model for Parental End-of-Life Decision-Making – Observational and qualitative – Boston MA

Improving Communication in the Pediatric Intensive Care Unit for Patients Facing Life-Changing Decisions – RCT - Chicago

Pragmatic Clinical Studies

Opportunity Snapshot

• Number of cycles per year: two

• Number of Anticipated Awards Per Funding Cycle: Six to Nine

• Funds Available Per Cycle: Up to $90 Million

• Maximum Project Duration: 5 Years

• Costs per Project: Up to $10 million direct costs

Seek to produce information that can be directly adopted by providers:

• Compare two of more options for prevention, diagnosis, treatment, or management of a disease or symptom

• Address critical clinical choices faced by patients, caregivers, clinicians, systems

• Conducted in routine clinical settings

• Protocols less complex than traditional trials

• High-priority topics identified by:

• PCORI’s Advisory Panels

• Institute of Medicine CER 100

• Agency for Healthcare Research and Quality

Contact Us

[email protected]

E n g a g i n g M u l t i p l e

G e n e r a t i o n s

E n g a g i n g M u l t i p l e

G e n e r a t i o n s

I n t r o d u c t i o n b y :

M a r g a r e t M a g u i r e , J D , S V P

C o r p o r a t e A c c o u n t a b i l i t y a n d

C h i e f o f S t a f f

C a m b i a H e a l t h S o l u t i o n s

P r e s i d e n t a n d B o a r d C h a i r

C a m b i a H e a l t h F o u n d a t i o n

Engaging Multiple Generations

• Ellen Goodman, Moderator Co-Founder and DirectorThe Conversation Project

• Kenyon C. Burke, Ed.D.PresidentKenyon C. Burke Consulting

• Rev. Rosemary LloydAdvisor to the Faith-Based CommunityThe Conversation Project

• Lennon FlowersCo-Founder and Executive DirectorThe Dinner Party

T h e I m p e r a t i v e f o r C h a n g e

The Imperative for Change

• Rich Umbdenstock

President and CEO

American Hospital Association

• Jeannine English, CPA, MBA

President

AARP

T h a n k Yo u

A Time for Caring Reception

We look forward to seeing you at tonight’s reception,

located at:

The Four Seasons Hotel

2800 Pennsylvania Avenue, NW

Washington DC 20007





A c t i o n

Welcome and Recap

Leonard D. Schaeffer

Judge Robert Maclay Widney Chair and Professor

University of Southern California

M a r c h 3 , 2 0 1 5

Conference Hosts

• Bill Novelli: Board Co-Chair and

Professor, McDonough School of

Business, Georgetown University and

former CEO, AARP

• Tom Koutsoumpas: Board Co-Chair,

President and CEO, National

Partnership for Hospice Innovation

• Jon Broyles: Executive Director,

C-TAC

C-TAC Vision

All Americans with advanced illness, especially the sickest and most vulnerable, will receive comprehensive, high-quality, person- and family- centered care that is consistent with their goals and values and honors their dignity.

Recap From Day One

• Where advanced illness care is heading

• How to build urgency around change

• How to effectively engage multiple

generations in advanced illness care in

community and clinical settings

• How to build on successful innovations

to achieve further progress

Speaker themes included:

How You Can Contribute Today

One degree of change can make

all the difference

• Be candid about what’s working, what’s

not, and why

• Join in catalyzing action and energy

around effective programs and ideas

• Help identify programs and concepts with

the greatest potential to improve AIC

• Offer ideas on how to scale up what’s

working

Introductions

Please join me in welcoming:

Karen Ignagni, President and CEO, America’s

Health Insurance Plans

Jeff Burnich, MD, Senior Vice President

Medical and Market Networks Sutter Health

Amy Berman, BS, RN, Senior Program Officer

John A. Hartford Foundation

D r i v i n g C h a n g e

A C o m p r e h e n s i v e A p p r o a c h t o

C a r e Tr a n s f o r m a t i o n :

I n t e g r a t i n g C o m m u n i t y a n d

C l i n i c a l M o d e l s

A Comprehensive Approach to Care

Transformation

• Rev. Diane C. SmalleyPatient and Community Engagement Council, Saint Joseph Mercy Hospital, Trinity Health

• Chris Dawe, Managing Director Evolent Health

• Bud HammesDirector of Medical Humanities,Gunderson Health System

• Daniel Johnson, MD, FAAHPMNational Clinical Lead for Palliative Care, Care Management Institute, Kaiser Permanente

• Rev. Cynthia Carter Hill, MPAExecutive Director, Alameda County Care Alliance

H o w a S h a r e d - D e c i s i o n

M a k i n g A p p r o a c h C a n

C o n n e c t t h e C l i n i c a l a n d

C o m m u n i t y

B e r n a r d “ B u d ” H a m m e s , P h D

G u n d e r s e n H e a l t h S y s t e m

w w w . r e s p e c t i n g c h o i c e s . o r g

2014 IOM Report: Dying in America

Shared decision making encompasses:

• Eliciting and understanding the patient’s perspective;

• Understanding the patient’s psychosocial and emotional context;

• Developing a shared understanding of the clinical problem and its appropriate treatment, given the patient’s goals, preferences, and values; and

• Empowerment, which is achieved through active involvement of patients in decision making.

LeBlanc, T. W., and J. A. Tulsky. In press. Communication with the patient and family. In Oxford textbook of palliative medicine, 5th ed., edited by N. Cherney, M. Fallon, S. Kaasa, R. Portenoy, and D. Currow. Oxford, England: Oxford University Press.

This description is useful, but we need

more detail for folks with advanced

illness…

To get to shared decision-making and planning

requires (for persons with advanced illness)…

1. …a shift from a primary focus on goals of

medical care, to a thoughtful exploration and

clarification of personal goals and values;

2. …a specific exploration of fears and concerns

as well as gaps in knowledge and

understanding;

3. …a realization that this not just about the

individual but also about the individual’s

“family” and community relationships.

When Care Planning uses this person-

centered, shared decision-making model,

it can tie the clinical and the community

together in two important, related ways…

Through a common:

1. process and structure of planning and decision

making; and,

2. ethical footing.

A Common Process and Structure for

Share Decision-Making

• Focused on the person and family perspectives,

the planning and any decision that follow

centers around a single, key question: How do

the explored values and goals of the person and

family, tied to the clinical realities, help define

what it means to provide good care for this

person?

• To thoughtfully answer this question requires

the intentional input and contribution of the

person, those closest to this person, their

broader community, and the clinical.

The Shared Ethical Basis:

Care Relationships

The ethical footing of this approach is the ethic of

caring relationships:

Relationship Ethical Value

Health professional/patient Beneficence…acting in the best interest of the patient

Individual/family or loved ones Love

Individual/community Respect, Sanctity of Life

The Respecting Choices® Model

This model is a systematic approach to care planning

that uses person-centered, shared decision-making

decision making and is designed to:

1. Provide a standardized process for care planning

that may be used in both the clinical and

community settings;

2. Build care planning into the routine of all care;

3. Create processes so care plans are stored,

revisited, and communicated so that they are

always available and up-to-date;

4. Prepare both patients and their appointed

surrogates to make decisions when the time arises;

5. Improve care and outcomes for all involved.

Helping Community and Health

Organizations Implement this Model

• Respecting Choices has created a

implementation pathway that provides a means

for health organizations to develop this care

planning approach so that it can become part of

the routine of care and can be integrated into

community engagement.

• RC has been successfully implemented in 5

countries and over 120 health organizations in

the USA.

A C o m p r e h e n s i v e A p p r o a c h

t o C a r e T r a n s f o r m a t i o n :

T h e C l i n i c a l P e r s p e c t i v e

D a n i e l J o h n s o n , M D , F A A H P M

C a r e M a n a g e m e n t I n s t i t u t e

K a i s e r P e r m a n e n t e

William

• 77 y/o male

• Advanced gastric cancer, diabetes, anemia, COPD

• Prior surgery, XRT

• Third line chemotherapy

• Intractable nausea, pain

• Recurrent bleeding

• 3rd admission in 6 w

• Two prior SNF stays

• Request: “No death talk”

“What is spoken of as a

“clinical picture” is not

just a photograph of a

man sick in bed; it is an

impressionistic painting

of the patient surrounded

by his home, his work, his

relations, his friends, his

joys, sorrows, hopes and

fears….”

The Care of the PatientFrancis W. Peabody, MD, JAMA 1927

Edvard Munch, The Sick Child, 1927

“The difficulty is that in the hospital one gets into the habit of using the oil

immersion lens instead of the low power, and

focuses too intently on the center of the field.”

Francis W. Peabody, MD

Daily Bread, Otto Betteman, 1936

Girls at the Piano, Renior, 1892

William – Through a Wider Lens

• Needs transport help

• Recurrent bleeding

• Not filling meds ($$)

• 3rd admission in 6 w

• Greatest joy: dog Max

• Two prior SNF stays

• Hope: back to Iowa

• “No death talk”

• Fears: “quitting too soon”, questions: faith and God

• 77 y/o male

• Lives alone, friends help

• Advanced gastric cancer,

diabetes, COPD, anemia

• Values independence

• Prior surgery, XRT

• Former US Veteran

• On 3rd line chemo

• Helping son “get sober”

• Intractable nausea, pain

• Increasingly anxious

About Kaiser Permanente…

Nation’s largest non-profit health plan

Integrated health caredelivery system

9.1 million members

16,000+ physicians

174,000+ employees(including 48,000+ nurses)

Serving 8 states and the District of Columbia

38 hospitals

More than 600 medical offices

$53.1 billion operating revenue*

Scope includes ambulatory, inpatient, ACS, behavioral health, SNF, home health, hospice, pharmacy, imaging, laboratory, optical, dental, and insurance

Mid-Atlantic Region

Georgia Region

Colorado Region

Northern

California Region

Hawaii Region

Northwest Region

Southern

California Region

*Kaiser Permanente 2013 Press Release

KP-Colorado

Slide 85

Multiple contracts and community partnerships:

Hospitals (2 core + others), SNF (25 facilities), LTACH (5)

Home Health, hospice (7 preferred, PC support)

Integrated system serving over 600K members

Rocky Mountain Front Range

Insured pop: Commercial, Medicare Advantage (90K), Medicaid (50K), Duals (2K)

Case management (adult + kids)

Our Promises

For us to achieve the “best care possible” for persons with serious illness we must:

Deliver,

for each individual,

personalized

“best care”

Palliative and

Community Support

Discover,

for each individual,

what “best care”

looks like

Goal Setting and

Care Planning

AND

87

Building “Layers of Support”

1 2 3 4

Advance Care Planning (ACP)

10 PC

20 PC

Increasing Complexity and Needs →

Sup

po

rt→

LAYER KEY FEATURES

Specialty PC Provide specialized support for most complex needs

Primary PC Assess needs → personalize care; basic support

ACP Assure systematic, competent discussions for all

Population ID Identify risk groups, population-based care

Leveraging Community Resources and Expertise

Foundational Studies of Palliative

Support at Kaiser Permanente

Three randomized control trials of palliative care in

hospital, home and clinic settings – outcomes: Improved patient-family satisfaction

Improved quality (communication, death at home)

Increased hospice admissions and LOS

Decreased hospital, ER utilization and costs

Added matched- controlled analysis of inpatient PC: Less hospital(40%), ICU (56%) and ER (24%) admissions

Higher hospice admissions (51%) and LOS (55%)

Gade G et al. J Palliative Med, 2008. Brumley R. et al. J Palliative Med, 2003. Englehardt

J. et al. J Managed Care, 2009. Bellows J, Johnson D et al, Kaiser Permanente, 2012

A Continuum of

Specialty Support

Hospital

Home

Assisted LivingLong Term Care

LTACSNF

Primary Care Clinic

Specialty Care Clinic

Inpatient PC

Home PC

PC SW

Clinic PC

NH PC

Hospice “One Stop

Shop”

KPCO Specialty Palliative Care ServicesService Setting Team #/year Access Model

IPC Hospital MD, RN, SW, Chap,Pharm

1800 7 d/w with 24/7 call

Hybrid staffing model – KP + hospital; referrals + alerts using LACE

HBPC Home/ ALF

MD, RN, SW, Chap,Pharm

500 7 d/w with 24/7 call

Hybrid staffing model – KP +partner; referrals

CBPC Clinic MD, RN,SW

400 5 d/w KP staff; referrals + integration pilots in high risk pulmonology and oncology

PC-SW Clinic SW 300 5 d/w KP staff, referrals + integration pilots

NH PC (KSS)

SNF/LTC SW, RN or chap prn

400 5 d/w Contracted partners, referrals + integration in LTACH, NH

Hospice All Full IDT 2000 7 d/w Contracted partners, Commercial and Medicare

What Elements Worked (or Not)?

What Worked…

A compelling “why”

Evidence

Invest – not just “stretch”

Partnership (seek win-win)

Layers and triage

Embedded support

Value team- and self-care

Harness non-PC champions

Think “learning system”

…Not So Much

Seeking perfection

“Prove it” mentality

Silos – thinking too narrowly

Demands on referring MDs

Failing to assess needs

Failing to triage

“Auto-referrals”

Leaving out community

Slow to standardize

or

Examples of Positive Shared Outcomes

Documented goals, values and care preferences

More concordant care (i.e., delivery matches wishes)

Care plan communication across care settings

Increased access to specialty PC support

More hospice use

Less unwanted (by all) hospital, ER or ICU care

Less total costs (for patients, family and system)

Greater meaning around the work we do

Asking and honoring “what matters most”

Rev. Cynthia Carter Hill, MPA

Executive Director

Alameda County Care Alliance

Alameda County Care Alliance

Vision: All those in Alameda County living with advanced illness

will receive person- and family-centered care that acknowledges

their spiritual and cultural integrity, regardless of race, religion,

origin, or creed.

Mission: Build on community-based resources and health

system partnerships to provide a new paradigm of care through:

care coordination, spiritual care, and decision-making support for

the person needing care, their family/caregiver.

ACCA: Who We Are

A dynamic and collaborative partnership among faith-

based and community organizations with long history

of working together to transform the Alameda

Community.

Current focus - Advanced Care:

Launched in 2014

Represents 35,000+ people

Supported by Kaiser Permanente and California

HealthCare Foundation.

ACCA HUB Partners

Strategically located Community Partnerships :

• Allen Temple Baptist Church

• Glad Tidings Church of God in Christ

• Family Bible Fellowship

• Center of Hope

• Greater St. John

• Beebe Memorial

• Community Organizations – Catholic Ecumenical & Asian Health Services

Completed (2/15)

Training of pastors (3/18)

Training of navigators

(3/18)

Patient and Caregiver

enrollment (4/16)

ACCA 18 Month Pilot

Progress and Next Steps

Hub Church surveys

Pastoral training team &

curriculum (Dr. Guess &

team)

Navigator curriculum

Caregiver curriculum and

partnerships (Family

Caregiver Alliance)

Evaluation and key

partnerships (UC Davis,

UC Berkeley-Citris)

ACCA Proposed Outcomes: Process

Strengthening community capacity for

advanced care through:

– Improved decision support for caregivers/and

persons needing care

– Trained clergy, community leaders, Care

navigators

– Identify and Increase access to care services

for caregivers/patients

ACCA Proposed Outcomes: Impact

– Increased care satisfaction among

patients/families

– Reduced caregiving burden for advanced

illness

– Reduced ER visits

– Reduced readmission rates

– Improved Quality of Life for ill person and

caregivers

ACCA Finding #1: Build on Community

Resources

• Integrate current initiatives among faith

communities through collective

commitment and sharing resources such

as trained volunteers across communities.

ACCA Finding #2: Build on Shared

Outcomes Among Health Systems and

Community

Examples:

• Reduced unwanted hospitalizations

• Provide care in the community

• Increased connection to spirituality

• Improved quality of life

ACCA Finding #3: It’s Takes Time: Building

Trusting Relationships between the Medical

and Community Members

• Honor the vast resources within churches

and in community

• Respect culture, spirituality, and traditions

• Transparent communications amongst

stakeholders

Transforming Care and Serving Most

Vulnerable

Whatever you do for one the least of these

my brethren ones, you have done unto me. Matthew 25: 35-40

ACCA Firmly Believes That…..

Ta k i n g E v i d e n c e - B a s e d

M o d e l s t o S c a l e

J e f f S e l b e r g , M H A ,

E x e c u t i v e D i r e c t o r

P e t e r s o n C e n t e r o n

H e a l t h c a r e

M o r n i n g W o r k s h o p S e s s i o n s

L e c t u r e R o o m : C o m m u n i t y a n d F a i t h - B a s e d

P a r t n e r s h i p s

R o o m 1 2 0 : M e t r i c s f o r S u c c e s s

R o o m 1 2 5 : E n g a g i n g P a t i e n t s i n D i s s e m i n a t i o n a n d

I m p l e m e n t a t i o n

C O M M U I T Y A N D FA I T H

B A S E D PA R T N E R S H I P S

Te r e s a C u t t s , P h D

A s s i s t a n t P r o f e s s o r , S o c i a l

S c i e n c e s a n d H e a l t h y P o l i c y

D i v o f P u b l i c H e a l t h a n d t h e M a y a

A n g e l o u C e n t e r f o r H e a l t h E q u i t y

W a k e F o r e s t S c h o o l o f M e d i n c e

R e v . D r . T y r o n e P i t t s

C o - C h a i r I n t e r f a i t h a n d D i v e r s i t y

W o r k g r o u p , C - T A C

T h a n k y o u

M E T R I C S F O R S U C C E S S

Advanced Illness Care Coordination:

A Case Study on Aetna

Compassionate CareSM Program:

What Metrics Can Demonstrate

Randall Krakauer, MDVP, National Medical Director, Aetna

Geriatric Conditions and Quality Scores:1

How Does Advanced Illness Rate?Assessing Care of Vulnerable Elders (ACOVE) quality indicators: in 2000 identified significant quality and care gaps, and opportunities that might be addressed in managing care in Medicare populations

1Wenger NS, Solomon DH, Roth CP. et al. Annals of Internal Medicine. 2003; 139 (9) 740-747. Availableat: www.mms.org/workilies/mmc services/geriatrics/Quality Medical Care Provided Vulnerable-Dwelling Older Patients.pdf. Accessed June 6, 2013.

Geriatric conditions and quality indicators

Condition % QIs Passed

Malnutrition 47

Pressure ulcers 41

Dementia 35

Falls, mobility disorders 34

Urinary incontinence 29

End-of-life care 9

Variations In End-of-Life Care:

Dartmouth Atlas of Health CarePercent of decedents enrolled in hospice during the last 6 months of life (2003-2007)

Rates are adjusted for age, sex, race, primary chronic condition, and the presence of more than one chronic condition using ordinary least squares regression.

Arizona: 54.5%

New York: 23.8%

• U.S. State

Variations In End-Of-Life Care:

Dartmouth Atlas of Health CareHospice days per decedent during the last 6 months of life (2003-2007)

Rates are adjusted for age, sex, race, primary chronic condition, and the presence of more than one chronic condition using ordinary least squares regression.

• Hospital Referral Region

McAllen, TX 3.9 days

Ogden, UT 35.5 days

Where are we?

•Shortage of specialized expertiseCompare: 1 oncologist to every 141 newly diagnosed cancer patients

vs. 1 palliative medicine doctor to every 1,200 patients with serious or life-threatening illnesses.1

•Hospital-based palliative care — increasing access Since 2008, 19% increase in palliative care teams in hospitals.85% of large (>300 beds) hospitals have teams.1

• Resources: Approximately 25-30% of Medicare costs incurred in last year of life; in last month, 80% of expenditures are for hospitalization.2

1 Center to Advance Palliative Care. America’s Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. NY: 2011. Available at: reportcard.capc.org/pdf/state-by-state-reportcard.pdf. Accessed May 28, 2013.

2 Lubitz J, Riley GF. Trends in Medicare payments in the last year of life. New England Journal of Medicine1993; 328 (15): 1092-1096. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2838161/pdf/hesr0045-0565.pdf. Accessed May 29, 2013.

Aetna Compassionate Care (ACCP)

•Goals of the program:

• Provide additional support to members

• with advanced illness and their families/caregivers

• Help them access optimal care

• The goal is not to create or encourage hospice,

although hospice can be a choice when appropriate

and requested by the member.

Holistic, Member-Centric Case Management

Help member understand options, with nurse case managers who are trained to:•Assess and manage members’ care in a culturally sensitive manner •Identify resources to make members as comfortable as possible, addressing pain and other symptoms•Help coordinate medical care, benefits and community-based services•Inform the member about treatment options, continuity of care and advanced care planning•Provide personal support•Consult and coordinate with the members’ treating physicians and staff (including other care coordinators where available)

Results: Member Discussion

Example of Why Compassionate Care

Shows Impact: Depth of Connection•Wife stated member passed away with hospice. Much emotional support given to spouse. She talked about what a wonderful life they had together, their children, all of the people's lives that he touched. They were married 49 years last Thursdayyand each year he would give her a piece of jewelry. On Tuesday, when she walked into his room, he had a gift and card laying on his chest, a beautiful ring that he had their daughter purchase. She was happy he gave it to her on Tuesday--- on Thursday, he was not alert. She stated that through his business he touched many peoples lives, and they all somehow knew he was sick, and he has received many flowers, meals, fruit, cake. She stated her lawn had become overgrow and the landscaper came and cleaned up the entire property, planted over 50 mums, placed cornstalks and pumpkins all around. She said she is so grateful for the outpouring of love. Also stated that hospice was wonderful, as well as everyone at the doctor’s office, and everyone here at Aetna. She tells all of her friends that "when you are part of Aetna, you have a lifeline.” Encouraged her to call CM with an issues or concerns. Closed to case management.

Results

Favorable impact aligning patient goals with outcomes

• 82% of engaged decedents choose hospice

• 82% reduction in acute inpatient days

• 77% reduction in emergency room visits

• 86% reduction in intensive care unit days

Improved quality of life for Aetna members and their families

Data for 2010 Medicare Advantage members enrolled in Aetna’s Compassionate Care program.

Resulting (in Medicare Advantage) in savings of over $12,500 per engaged member

Summary: Metrics Demonstrate Opportunity

• Improving the quality of care for those with advanced illness represents a tremendous opportunity for the country’s health system, for individual patients, and for families and caregivers.

• Programs that provide expert assistance such as Aetna Compassionate Care can increase awareness of the care options available to patients and caregivers, thereby aligning patient choice more closely with desired types of health services and care.

• This care management program favorably impacts advanced illness, with very high rates of satisfaction. Metrics can demonstrate, particularly in Medicare, dramatic impact on Palliative Care and Hospice election, acute and intensive care utilization, cost and other metrics.

• These metrics create an imperative that such services become more widely available.

Quality Measures as Drivers

of Change

National Summit on


Metrics for Success Workshop

122

Quality Results

Making Hospital Safer

Quality Results

Healing at Home

NQF Action Teams

• Build on NQF’s role as an objective convener

• Leverage NQF’s deep membership of 400+ organizations

• Work collaboratively and in partnership to collectively impact health and healthcare quality

• Promote uptake of existing NQF-endorsed performance measures

• Influence important stakeholders to makemeaningful and authentic commitments to action

NQF Maternity Action Team Results

Measurement Opportunities for Advanced

Illness Care

• Advanced Illness care generally does not follow patient goals and preferences

• Palliative care can be used more broadly to alleviate suffering

• Geriatrics finds that some of the most important care is outside of the traditional organ-system based clinical specialties.

• Experience from caregivers as well as patients

Measurement Challenges for Advanced

Illness Care

• Individual condition-based guidelines often conflict for patients with multiple chronic diseases

• Health affected by sociodemographic factors

• Vulnerable populations may have difficulty accessing consistent source of care

• Coordination of care among multiple sites/providers

NQF’s Aging Related Work

Current Work:

Prioritizing Measure Gaps: Alzheimer’s Disease

and Related Dementias

Measure Applications Partnership (MAP)

Dual-eligibles beneficiary workgroup

Post-acute care/long-term care workgroup

Past Work:

Multiple Chronic Conditions Framework

Nursing home measures

Home healthcare measures

Recent NQF Initiatives to Improve Care for

Advanced Illnesses and Vulnerable

Populations

Current Work:

• Prioritizing Measure Gaps: Alzheimer’s Disease and Related Dementias

• Measure Applications Partnership (MAP)– Dual-eligibles beneficiary workgroup

– Post-acute care/long-term care workgroup

Past Work:

• Multiple Chronic Conditions Framework

• Nursing home measures

• Home healthcare measures

Improving Care for Dual Eligible

Beneficiaries

• Considers the unique needs of population subgroups (e.g., individuals with ID/DD, frail elders)

• Maintains a Family of Measures for Dual Eligible Beneficiaries

• Gathers experience of state agencies, health plans, and other stakeholders in using MAP’s recommendations on measures to make them more accurate and actionable

• Explores quality of life outcomes and how various system stakeholders share responsibility for supporting better outcomes for vulnerable beneficiaries

Big Opportunity Areas in Healthcare:

What the Health System Needs Now

Criteria for ImpactCredible

Timely

Useable

Meaningful

Incubator

Components Concept

Technical expertise

Data sources

Analytics and feedback

Resources

DATA

ANALYTICS

MEASURES

INFORMATION

IMPACT

T h a n k y o u

E N G A G I N G PAT I E N T S I N

D I S S E M I N AT I O N A N D

I M P L E M E N TAT I O N

P a t r i c i a A . G r a d y, R N , P h D

FA A N , D i r e c t o r ,

N a t i o n a l I n s t i t u t e o f N u r s i n g

R e s e a r c h

Research Translation

General Public

Educational

InstitutionsPublic Interest

Groups

Federal Agencies

State AgenciesLocal Agencies

Professional

SocietiesIndustry

Community Groups

Patient Advocacy

Groups

Public Advisory

Councils

Health Professionals

Volunteer

Organizations

ScientistsScientific Advisory

Groups

Stakeholders

NINR’s Areas of Research

Scientific Focus Areas to

Implement NINR’s Strategic Plan

• Symptom Science

• Wellness

• Self-Management

• End-of-Life and

Palliative Care


NINR Hosts NIH Briefing on IOM Report –

Dying in America

http://www.ehospice.com/usa/ArticleView/tabid/10708/ArticleId/12676/language/en-GB/View.aspx

http://www.ehospice.com/usa/ArticleView/tabid/10708/ArticleId/12676/language/en-GB/View.aspx

https://www.youtube.com/watch?v=lPD4iJl1Gpg

https://www.youtube.com/watch?v=lPD4iJl1Gpg


Hospice enrollment increases

Medicare savings and decreases

hospital usage

Palliative Care Research

Co-Operative (PCRC)

o Comprehensive, multicenter

resource

o Developing structures and

processes to enable and support

end-of-life and palliative care

research nationwide

NINR-Supported Research to Improve /

End-of-Life Care

Implementation and Dissemination

Research Support

Selected NIH-Sponsored

Funding Opportunities• Innovative Measurement Tools for Community Engaged

Research Efforts

• Development and testing of tools to measure trust,

capacity, collaboration, empowerment, sustainability

• Dissemination and Implementation Research in Health

• Understanding and overcoming barriers to translating

research discovery into clinical and community practice

www.ninr.nih.gov

http://www.ninr.nih.gov/

http://www.ninr.nih.gov/

R e g i n a G r e e r - S m i t h ,

M P H F A C H E

Guidance

PCORI’s ENGAGEMENT RUBRIC

PCOR GUIDING PRINCIPLES• Reciprocal Relationships• Co-Learning• Partnership• Trust, Transparency, Honesty

DISSEMINATING THE STUDY RESULTS• “Patient partners are involved in plans for disseminating

the study’s findings to patient, stakeholders, and research audiences so that the findings are communicated in understandable, usable ways.”

Developing Infastructure

From Existing Relationships

and Building Capacity

Partnerships and Collaborations with Stakeholders

For co-learning and trust-building

Development of Programs and Initiatives to enable engagement

activities

Providing resources to empowering Priority Populations including:

• Racial & Ethnic Minorities• LTBT• Persons with Disabilities• Low literary/numeracy• Rural populations

More engagement resources at our website:http://www.healthcarera.com/

http://www.healthcarera.com/

Develop Opportunities for

Engagement, Dissemination

& Implementation

Exhibits and In-Person PresentationsSocial Media & Smartphones

Use of Social Networking, Care Giver Support Groups &

S.T.A.R. Initiative Engagement Clusters©

Through partnerships and collaborations with patients, families, caregivers, faith-based partnerships, and all

stakeholders

T h a n k y o u

A f t e r n o o n W o r k s h o p S e s s i o n sL e c t u r e R o o m : S h a r e d D e c i s i o n

M a k i n g

A u d i t o r i u m : T r a n s l a t i n g E v i d e n c eB a s e d P r a c t i c e I n t oC o m p e l l i n g

M e s s a g e s

R o o m 1 2 0 : F a m i l y C a r e g i v e r S u p p o r t

R o o m 1 2 5 : B u i l d i n g t h e B u s i n e s s

C a s e f o r A d v a n c e dI l l n e s s C a r e

S h a r e d D e c i s i o n M a k i n g :

H o n o r i n g I n f o r m e d P a t i e n t

C h o i c e

Practice Variation: Evidence for Poor Decisions

150

Red dots indicate HRRs served by U.S. News 50 Best Hospitals for Geriatric Care

2,500

3,500

4,500

5,500

6,500

7,500

8,500

AS

R A

dju

ste

d M

ed

ica

re S

pe

nd

ing

Forces Sustaining Poor Quality

151

Patients & physicians view trade-offs differently

Decision:

Goal

% top 3

Patient

% top 3

Provider

Surgery: Keep

your breast 7% 71%

Reconstruction:

Look natural

without clothes

59% 80%

Chemotherapy:

Live as long as

possible

33% 96%

Reconstruction:

Avoid using

prosthesis

33% 0%

Sepucha K, et al. Patient Education and Counseling 2008 and Lee et al. 30th Annual Society for Medical Decision

Making Conference, Philadelphia, 2008.

153

154

23 Patient vs. 25 Physician States

2 Hybrids

Patient

Standard

Physician Standard

Hybrid (NM &

MN)

Health Policy Relating to SDM

SDM has become a standard part of the language of US health reform

– Affordable Care Act

– Definition requirement for Medicare ACOs– Requirement for Comprehensive primary Care

Initiatives

– State-based health care reform

– Meaningful use of HIT

– Informed Consent

– Professional societies, practice guidelines

155

WA State Passed Three Bills

• Passed legislation in 2007

• Explicitly recognizes SDM is an enhanced informed consent for Preference-Sensitive Conditions if provider uses a “certified aid”

• Led to Group Health demonstration project

• 2009 Passed Bree Collaborative—SDM promoted

• 2012 Passed legislation allowing CMO of HCA to “certify aids” moving forward with criteria

• Payment of providers for SDM being considered

156

157

Involvement

Values Concordance

Decision Quality

Knowledge

Did the patient know what he or she needed to know?

Did the decision reflect the patient’s goals and concerns?

Did the patient know a decision was being made?

Did the patient know the pros and cons of the treatment options?

Did the provider elicit the patient’s preferences?

Health Policy Reasons for Adoption of SDM on Large Scale

• Ethical imperative to do the right thing

• Perfected Informed Consent-Aligning

preferences, values and lifestyle with

individual’s clinical decision

• Bridging Health Disparities

• Conservative Utilization of surgical

interventions

W h a t M a t t e r s t o Y o u

M a t t e r s t o U s

H M S A’ s A C P V i d e o P r o j e c t

R a e S e i t z , M D

M a r c h 2 0 1 5

HMSA’s ACP Video Project

• How the ACP Video Project advances HMSA’s mission

and vision of keeping members at the center of, in

control of, and responsible for their own well-being

• Review some preliminary outcomes

• The strategy applied to spreading the use of ACP video

decision aids

• What have we learned about ACP, what works and what

challenges remain

0%

10%

20%

30%

40%

50%

4Q2012 1Q2013 2Q2013 3Q2013 4Q2013 1Q2014 2Q2014

Advance Care Planning at a Hospital “A”N=2668 across all time periods

Percentage of Discharged with Completed POLSTS

Percentage of Patients Discharged with Referral to Hospice

VideosIntroduced

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

4Q2013 1Q2014 2Q2014

POLST CompletionAmong Seriously Ill Patients

N=845 across all time periodsConversation + Video vs Conversation Only

ACP Video Use in Palliative Care Pilot (n=56)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PC Patient

POLST Before POLST After

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Before After

Life Prolonging Limited Comfort

Advance Care Planning Completion Rates for Members 75+

HMSA P4Q Measure 10/1/2013 to 9/30/2014

0%

10%

20%

30%

40%

50%

Medicar Advantage PPO/HMO

Using Video Not Using Video

37 Doctors identified using the videos; 250 doctors not using the videoDenominator include 18000 for Medicare Advantage; 20,000 PPP/HMO Members

Our Approach

Co-opetition

Setting Standards

Small Scale

Testing & Spread

Hospital/Hospice/SNF

Health Plans

Primary Care

Community

A new video campaign gives patients a voice on treatment options By Susan Essoyan

D i s c u s s i o n P o i n t s ?

ICU Code Order ChangesAfter Patients/Families Watch ACP Videos

n=14

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre-Video Post-Video

Full Code Partial Code DNR

Advance Care Planning Outcomes

ACP Outcomes

Death at

Home Hospice Use

EOL ICU Days

EOL

Inpatient Use

EOL

ED UseTreatment at EOL

EOL QOL

FAMCARE

Decisions

Honored

ACP Docum

ents

T r a n s l a t i n g E v i d e n c e - B a s e d

P r a c t i c e s i n t o C o m p e l l i n g

M e s s a g e s

Better Stor ies ,

Best Pract ices

success starts with the story you tell

• stories change brains, beliefs and behaviors

• stories are survival instruments

• storytelling is a competitive sport

• if you want to change your outcome, start

by changing your narrative

I think we’re gonna need a better narrative

If we want to do better, first we have to feel better

Change begins when you give people a new feeling about the issue. In this case, we

want to replace fear of loss and helplessness with a promise of power, purpose and

hope.

Engage the Emotions

AIM Strategies

176

Engage the adversary: the

revolving door

The deep need: Reconnect

with the “why”

Capital Caring Strategies

177

Envision our success: provide

personal stories of positive

outcomes

Speak to identity: we are

innovators

Stories are survival instruments. After you get the audience emotionally engaged, you have to give them practical tools to drive change.

Stories are first and foremost survival instruments for a VUCA world. And advanced

care - serious illness, the probable “third act” of life — is possibly the greatest VUCA

of all. It requires that we come to terms with our ultimate mortality, life’s ultimate

unknown, and it sets up a series of obstacles (financial, practical, emotional, physical)

that make it hard for us to perform at the time we most need to.

Empower Action

179

A new model: Built on patient

experience and needs, not

system structure

Eliminate uncertainty:

one way, one team

AIM Strategies

180

Empower caregivers, Build confidence


• allow autonomy with caregivers in implementing the program

• build mastery: program builds confidence with caregivers

• each positive interaction creates

confidence and a better

outcome

Build Resilience

Stories are setbacks.

The last act of life is not easy. There will be suffering. There will be sorrow. And no matter how powerful your program, there will be setbacks.

People are often tempted to give up when they have a bad experience. Much of what we as leaders can do is to build resilience in ourselves and our communities, to help persevere through the hard times. The growth mindset is about getting people to recognize the truth that failure is a necessary stepping stone on the way to success.

182

Coach the growth mindset:

“We’re all still learning how to

do this.”

Everyone worries about

risk. The best strategy is

to tell the truth.

AIM Strategies

183

Openly share successes and

setbacks - address issues

Remember we are all learners

and teachers


• set clear, immediate metrics

• be transparent in identifying what doesn’t work

• be proud in reporting on what

does

Capi ta l Car ingF o r n e a r l y 4 0 y e a r s , c o o r d i n a t e d , c o m p a s s i o n a t e

c a r e w h e r e v e r o n e c a l l s h o m e

Capital Caring at a Glance

• One of the nation’s oldest and largest non-profit providers of hospice and palliative care, Capital Caring cares for over 1,200 families each day.

• Our service area includes The District of Columbia, Northern Virginia, and Prince George’s County, Maryland.

• World-class, high quality care is at the heart of our business strategy.

• Our mission? To simply improve care.

A commitment to people

• In order to ‘simply improve care’- and with high-quality care at the heart of our strategy, Capital Caring’s key metrics allow us to measure and demonstrate improving care.

- e.g. Capital Caring is committed to reducing a patient’s pain to a

comfortable level within 48 hours; we achieve this in nearly every case.

• We focus on culture, people development & training- Capital Caring instituted Standards – clear, impressive, and sustainable rules for achieving world-class care and results

- We are committed to meeting 100% of our standards, 100% of the time

C a p i t a l C a r i n g : I n n o v a t i o n s

i n C a r e

Capital Caring is committed to innovation. • In 2014, we opened our state-of-the art Adler Center for Caring on the Van

Metre Campus in Loudoun County, Virginia. This first-of-its-kind in the nation facility is home to Capital Caring’s Center for Pain and Palliative Care, a 21-bed world-class inpatient facility, Capital Caring’s home care team and palliative care. The Center even boasts a spa and gift shop.

• Capital Caring’s Center for Pain and Palliative Care (CPPC) is on the forefront of innovation. The Center’s ability to perform procedures using state-of-the-art real-time imaging to alleviate debilitating pain on-site, complementing or even replacing pharmacotherapy, provides a vast improvement for patients dealing with pain associated with an advanced illness.

TeleCaring ™

• In 2011, Capital Caring launched TeleCaring™, an innovative care support program, where trained professionals, including nurses, place proactive, outbound calls to patients and caregivers.

• TeleCaring™ is an extension of Capital Caring’s home care team that empowers caregivers—and provides rapid response to emerging issues or to answer questions.

“I feel like every one of them is an extension of our family. Sometimes, when we have questions, when the Telecaring nurse calls, they take 5 minutes, 10 minutes to help me focus and address what matters most. The calls reassure me, and are a valuable extra layer of care.”-----

Barry, Caregiver

Caring in the nation’s capital

-By virtue of being in the nation’s capital, Capital Caring’s mission to simply improve care includes public education and advocacy to expand access to person-centered hospice care.

-Since 2006, hospice utilization in D.C. has increased from 2% to over 30% in part because of our Hospice Comes to Washington awareness event. Our “In Good Faith” initiative has been instrumental in building trust among faith community leadership, their ‘parishioners’, and Capital Caring, in order to identify patients/families at risk in order to increase timely access to palliative care and hospice services.

-Our program is centered on earlier, easier access to care with clearly defined standards and measurable quality of care as our business strategy.

Overview of AIM®

Where we are today within Sutter Health

• Betsy Gornet, FACHE

• Sutter Health and Sutter Care at Home

• March 3, 2015

“This publication was made possible by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid

Services.”

"The contents of this publication are solely the responsibility of the authors and do not necessarily

represent the official views of the U.S. Department of Health and Human Services or any of its agencies."

HEALTH CARE INNOVATIONS AWARDS

• Non-for-Profit health system serving

Northern California

• Includes 24 hospitals and over

5000 aligned physicians

• Sutter Center for Integrated Care

• Health care research,

• 28 Home Care locations

• AIM – System level; over 7300

Enrollments through Dec 2014; plus

1500 during pilot

192

SUTTER HEALTH AT A GLANCE

Pending Luanch

Defining Advance Illness Management (AIM®)

AIM is a Care Management Model that Employs Evidence Based Principles of:

Care Coordination & Transitions Management

Palliative CarePatient

Engagement

Health Literacy

Self Management

Support

193

What Else Defines AIM?

Improve Patient/Family/Caregiver Experience& Provider Experience; All payers, all diseases

Fill in Gaps of Care – Between MD appointments and Between Home

Health Care and Hospice

Strengthen Relationship Between

Patient & Physician

Focus on Personal Goals and Revisiting

Them as Illness Progresses

Focus on Last 12-18 Months of Life

Coordinate Care Across all Sites of Care; Continuous; Team Navigation

194

• AIM Home Health (Skilled Episode)

• AIM Transitions (Non-Skilled Care needs, short term)

AIM In-Home Visit Based Care

• Outbound, frequency acuity adjusted; Some inbound

• Maintains MD Connection

AIM In-Home Telesupport • Hospitalization

• ED Visit

• AIM Care Liaison

AIM Acute Care Support

• AIM Home Health (Skilled episode)

• AIM Transitions (Non-Skilled Care needs, short term)

AIM In-Home Visit Based Care

Maintain Physician Communication and Connection with Patient;

AIM Triage After Hours and Weekends

IF

Then cycle repeats

CLOSER LOOK AT INTEGRATION

Advance

Care

Planning (Personal

Goals)

Dual Approach to Care: Curative + Palliative

Red Flags &

Symptom

Management

Plans

Medication

Management

Follow Up

Visits

Patient

Engagement

& Self

Management

Support

AIM Care Pillars

196"The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department

of Health and Human Services or any of its agencies."

Key AIM Outcome HighlightsResults not yet validated independently by CMMI

Results July 2012- June 2014

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q3 2014

74%

62%

91%

Advance Care Plan (ACP) Documentation

% of AIM Patients withACPs at Enrollment

% of AIM Patients withACPs at Enrollment whoMade Modifications tothe ACP within 90 Daysof Enrollment

% of AIM Patients whohad ACPs DocumentedWithin 90 Days ofEnrollment (Target =90%)

0

200

400

600

800

1000

1200

1400

1600

1800

Hospitalizations ED Visits ICU Days

Change in Utilization 90 Days Post AIM Enrollment9 of 10 Sites Reporting; Q3 2013 - Q2 2014; n=1761Results not yet validated independently by CMMI

Pre

Post57%

Reduction

22% Reduction

66% Reduction

The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies."

Health Care Innovations Awards

•“The project described was supported by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.”

B u i l d i n g t h e B u s i n e s s

C a s e f o r A d v a n c e d I l l n e s s

C a r e

Tr a n s f o r m i n g t h e C a r e o f

S e r i o u s I l l n e s s : T h e

B u s i n e s s C a s e

Diane E. Meier, MD

Director, Center to Advance Palliative

Care

[email protected]

www.capc.org

www.getpalliativecare.org

@dianeemeier

mailto:[email protected]

http://www.capc.org/

http://www.getpalliativecare.org/

No Disclosures

Objectives

• The case for integrated palliative care

strategies

• What works to improve quality and

subsequently reduce costs for vulnerable

people?

• How to face outwards towards needs of:

– Our patients, their families

– Policymakers, payers, health system

leadership

Concentration of Spending

Distribution of Total Medicare Beneficiaries and Spending, 2011

10%

63%

37%

90%

Total Number of FFS Beneficiaries: 37.5 million

Total Medicare Spending: $417 billion

Average per capita Medicare spending (FFS only): $8,554

Average per capita Medicare spending

among top 10% (FFS only): $48,220

NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service beneficiaries, excluding Medicare managed care enrollees. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2011.

Concentration of Risk/$

Concentration of Risk/$

Value = Quality/Cost

Because of the Concentration of Risk and

Spending, and the Impact of Palliative

Care on Quality and Cost, its Principles

and Practices are Central to Improving

Value

Mr. B

• An 88 year old man with

dementia admitted via the ED for

management of back pain due

to spinal stenosis and

arthritis.

• Pain is 8/10 on admission, for

which he is taking 5 gm of

acetaminophen/day.

• Admitted 3 times in 2 months for

pain (2x), falls, and altered

mental status due to

constipation.

• His family (83 year old wife) is

overwhelmed.

Mr. B

• Mr. B: “Don’t take me to

the hospital! Please!”

• Mrs. B: “He hates being

in the hospital, but what

could I do? The pain was

terrible and I couldn’t

reach the doctor. I

couldn’t even move him

myself, so I called the

ambulance. It was the

only thing I could do.”

Modified from and with thanks to Dave Casarett

Before and After

Usual Care

• 4 calls to 911 in a 3 month period, leading to

• 4 ED visits and

• 3 hospitalizations, leading to

• Hospital acquired infection

• Functional decline

• Family distress

Palliative Care

• House calls referral

• Pain management

• 24/7 phone coverage

• Support for caregiver

• Meals on Wheels

• Friendly visitor program

• No 911 calls, ED visits, or hospitalizations in last 18 months

The Modern Death Ritual:

The Emergency Department

Half of older Americans visited ED in

last month of life and 75% did so in

their last 6 months of life.

Smith AK et al. Health Affairs 2012;31:1277-85.

Who Are These Patients?

• Functional Limitation

• Frailty

• Dementia

• Exhausted overwhelmed family caregivers

• +/- Serious illness(es)

Gómez-Batiste X, et al. BMJ Supportive & Palliative Care 2012;0:1–9. doi:10.1136/bmjspcare-2012-000211

Functional Limitations as a

Predictor of Risk

http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf

http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf

Dementia As A Predictor of Risk

• Prospective

• Cohort of

community

dwelling older

adults

• Callahan et al.

JAGS 2012;

60:813-20.

Dementia No Dementia

Medicare SNF use 44.7% 11.4%

Medicaid NH use 21% 1.4%

Hospital use 76.2% 51.2%

Home health use 55.7% 27.3%

Transitions 11.2 3.8

Dementia And Total Spending

• 2010: $215 billion/yr

• By comparison: heart disease $102

billion; cancer $77 billion

• 2040 estimates> $375 billion/yr

Hurd MD et al. NEJM 2013;368:1326-34.

In case you are not already worried…

The Future of Dementia Hospitalizations

and Long Term Services+Supports

10 fold growth in dementia related

hospitalizations projected between 2000 and

2050 to >7 million.Zilberberg and Tija. Arch Int Med 2011;171:1850.

3 fold increase in need for formal LTSS

between now and 2050, from 9 to 27 million. Lynn and Satyarthi. Arch Int Med 2011;171:1852.

Why? Low Ratio of Social to Health Service

Expenditures in U.S.

Bradley E H et al. BMJ Qual Saf 2011;20:826-831

Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.

Surprise! Home and Community Based

Services are High Value

• Improves quality: Staying home is

concordant with people’s goals.

• Reduces spending: Based on 25

State reports, costs of Home and

Community Based LTC Services

less than 1/3rd the cost of Nursing

Home care.

Study: Having meals delivered to

home reduces need for nursing

home

10/14/2013 | HealthDay News

A study published today in Health Affairs found if all 48 contiguous states increased by 1% the number of elderly who got meals delivered to their homes, it would prevent 1,722 people on Medicaid from needing nursing home care. The Brown University study found 26 states would save money because lower Medicaid costs would more than offset the cost of providing the meals.

What is Palliative Care?

• Specialized medical care for people with serious illness and their families

• Focused on improving quality of life as defined by patients and families.

• Provided by an interdisciplinary team that works with patients, families, and other healthcare professionals to provide an added layer of support.

• Appropriate at any age, for any diagnosis, at any stage in a serious illness, and provided together with disease treatments.

Definition from public opinion survey conducted by ACS CAN and CAPC http://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdf

Conceptual Shift for Palliative Care

11%

49%

40%

Costliest 5% of PatientsIOM Dying in America Appendix E http://www.iom.edu/Reports/2014/Dying-In-America-Improving-Quality-

and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx

Last 12 months oflife

Short term high $

Persistent high $

Palliative Care Improves Value

Quality improves

– Symptoms

– Quality of life

– Length of life

– Family satisfaction

– Family

bereavement

outcomes

– MD satisfaction

Costs reduced

– Hospital cost/day

– Use of hospital,

ICU, ED

– 30 day

readmissions

– Hospitality mortality

– Labs, imaging,

pharmaceuticals

Palliative Care Improves Quality in

Office

Randomized trial simultaneous standard cancer care with palliative care co-management from diagnosis versus control group receiving standard cancer care only:

– Improved quality of life

– Reduced major depression

– Reduced ‘aggressiveness’ (less chemo < 14d before death, more likely to get hospice, less likely to be hospitalized in last month)

– Improved survival (11.6 mos. vs 8.9 mos., p<0.02)

Temel et al. Early palliative care for patients with non-small-cell lung cancer NEJM2010;363:733-42.

Palliative Care at

Home for the Chronically Ill Improves Quality, Markedly Reduces Cost

RCT of Service Use Among Heart Failure, Chronic Obstructive Pulmonary Disease, or Cancer Patients While Enrolled in a Home

Palliative Care Intervention or Receiving Usual Home Care, 1999–2000

13.211.1

2.3

9.4

4.6

35.0

5.3

0.92.4

0.9

0

10

20

30

40

Home health

visits

Physician

office visits

ER visits Hospital days SNF days

Usual Medicare home care Palliative care intervention

KP Study Brumley, R.D. et al. JAGS 2007

46 High Quality Studies

2002-11 Palliat Med 2014;28:130-50.

46 Studies: Across settings, patient populations,

and palliative care delivery models, palliative care

improves quality and in so doing, reduces costs.

What Do Patients Want?

Survey of Senior Center and Assisted Living subjects,

n=357, dementia excluded, no data on function.

Asked to rank order what’s most important:

1st Independence (76% rank it most

important)

2nd Pain and symptom relief

3rd Staying alive

Fried et al. Arch Int Med 2011;171:1854

How Can We Help Families Help Patients

Stay Home?

Partner with our

payers.

Innovative Payer Toolkit

• Talk to your payers!

• But first, read this:

• Predictors of successful payer-ACO-provider initiatives

• Case studies

• Checklists

• Worksheets

• Resources

231

www.capc.org/payertoolkit

http://www.capc.org/payertoolkit

Payers Are Bringing Palliative Care Home

www.theatlantic.com 02.25.13 MA Full Risk PMPM contract with HealthCare Partners/DaVita 15%+margin. >700K patients

“Now instead of 30-40 patients/day, Dr. Dougher sees 6-8.”

Treating the person beyond the

disease

T h a n k y o u

F a m i l y C a r e g i v e r S u p p o r t


Susan C. Reinhard, R.N., Ph. D., FAAN

Family Caregivers Taking On More

Complex Tasks

• Partnership between the

AARP Public Policy

Institute and the United

Hospital Fund

• Funded by The John A.

Hartford Foundation

Almost Half of Family

Caregivers Perform Medical/Nursing

Tasks

Medical/Nursing Tasks

Caregiver Advise, Record, Enable (CARE)

Act

What does the CARE Act Do?

• Designation

– Record the name of the family caregiver upon admission into the hospital

• Notification

– Contact the family caregiver(s) prior to discharge to another facility or

home

• Consultation

– Hospital consults with caregiver on discharge plan,

taking into account the caregiver’s capabilities and limitations

• Training

– Hospital gives caregiver the opportunity to receive instruction on all after-

care tasks included in the discharge plan to be performed by the caregiver


Act

• Gives support to nurses

and other health and

social service

professionals to do what

professional standards of

practice require them to

do

• Stimulates new thinking

on how to anticipate

patient and family

questions and pro-actively

support them

• Reduce hospital re-

admissions


Act

Passed and signed in…

It has been introduced in sixteen states (CT, HI, IN, KS, MA, MD, MN, MS, NH, NM, NY, ND, PR, VA, WI, WV).

Reimbursement for Educating Family

Caregivers?

• 2010 Invitational meeting with CMS (Centers for Medicare & Medicaid Services) and other stakeholdersFocus:

– Participants included leaders from nursing and social work professions, family caregiver advocacy organizations, and federal government agencies

– The agenda explored policies around caregiver assessment and reimbursement for caregiver counseling.

– Goal was to provide participants with relevant data on the use of Medicare reimbursement codes for the counseling of family caregivers of Medicare recipients.


Caregivers?

• AARP Public Policy Institute worked with CMS to provide data on use of existing reimbursement codes.– Determine the past and current use of the

reimbursement codes,

– What healthcare professionals (Physicians, Nurse Practitioners, etc.) were using codes

– If usage was low, why?

– What regions of the country were codes used


Caregivers?

• Data run not completed due to

regulations around privacy of Medicare

beneficiary and provider data

Medicare Payment for Clinicians

• The following provide payment for clinicians doing care coordination including family caregivers– Chronic Care Management Fee

– Post-Discharge Transitional Care Management

– Home Health Services for Caregivers of Alzheimer’s Patients

– Patient-Centered Medical Home (Advanced Primary Care Practices)

– Medicare Community-Based Care Transition Program

Care Recipient

Family

Caregiver

CARE TRIANGLE

HealthcareProfessional

“It will take a

movement to join the

three corners of the

care triangle: people

who need care,

families who care for

and about their

members, and people

who give care for a

living.”

Deborah Stone, The Nation,

March 13, 2008

Questions?

Susan Reinhard

[email protected]

@susanpolicy

202-434-3840

mailto:[email protected]


Gail Gibson Hunt

President and CEO

National Alliance for Care Giving

About Alliance

Non-profit coalition of over 50 national organizations focused on family caregiving issues

Established in 1996 to support family caregivers and the professionals who work with them

NAC Activities: Conduct research and policy analysis;

Develop national programs;

Strengthen state and local coalitions;

Increase public awareness;

International work and awareness.

Demographics of Care Giving

65.7 million caregivers make up 29% of the US adult population and 31% of households

48.9 million care for only adult recipients, including people with disabilities

Portrait of Caregiver:

48-year-old woman who works and cares

Average of 20.4 hours of care per week for her mother for an average of 4.6 years

34% care for two or more people

86% provide care for a relative

Who Are Caregivers?

Caregiver Financial Burden

Caregiving costs U.S. employers between $17.1 and $33.6 billion in lost productivity annually

Over $5,500 out of pocket expenses

Seven in 10 working caregivers make workplace accommodations

Loss of wages, pension, Social Security: $324,044—women; $283,716—men

43% of caregivers were affected financially (AHA/ASA 2005)

PCORI End of Life Research

Several studies from PCORI on end-of-life care and caregiving

Includes cancer and heart failure treatment

Pediatric end-of-life care received grants to examine care preferences and communication on care

Shared decision making with patients, families and medical professionals

Impact on caregivers:

• Caregiver burden

• Decision-making (aggressiveness of care, etc.)

• Reduce caregiver conflict/regret

Federal Caregiving Legislation

Previously introduced legislation – yet to be introduced in current term

“FAMILY Act” – Family And Medical Insurance Leave Act of 2013, would create a self-sustaining insurance fund through a payroll tax to provide paid family and medical leave similar to the California Paid Leave program.

Caregiver Corps Act of 2014 (Sen. Casey-PA) and the National Care Corps Act (Rep. Grisham-NM), propose to create volunteer corps to help support families that do not have caregivers to meet long-term care needs

Mental Health Support for Veteran Families and Caregivers Act of 2013 (Sen. Sanders), would have created educational programs to support caregivers and vets with mental health disorders through the VA’s vet centers

In Home CARE Act (Sen. Booker-NJ, Rep. Pascrell-NJ), would have provided in-home caregiver education and training and an assessment with referral to resources for physical and mental Health for both the caregiver and the care recipient

Active Caregiving Initiatives

White House Conference on Aging

Older Americans Act Reauthorization

21st Century Cures

• Accelerates innovation for diseases with unmet needs

President’s Budget

• Proposed increases in NFCSP and Lifespan Respite, among others

• New ACL Family Support Program ($15,000,000)

Thank you

Gail Gibson HuntPresident & CEO

National Alliance for Caregiving4720 Montgomery Lane,

Suite 205Bethesda, MD 20814

[email protected]

www.caregiving.org

T h a n k y o u

T h e C o n t i n u u m o f C a r e :

P a n e l D i s c u s s i o n

The Continuum of Care:

Panel Discussion

• Brad Stuart, MDC-TAC

• Samira K. Beckwith,President and CEO,Hope Healthcare Services

• Robert Sowislo,Board and Government AffairsU.S. Medical Management

• Jean Kutner, MD, MSPH, CMOProfessor of Medicine and Associate Dean for Clinical AffairsUniversity of Colorado School of MedicinePast President AAHPM

• Cheryl Phillips, MD, SVPAdvocacy and Public Policy, Leading Age

• Randy Axelrod, MD, EVPClinical and Patient Services, Providence Health Services

M o d e r a t o r :

B r a d S t u a r t , M D

C - T A C

Toward A Person-Centered

Continuum of Care

Person

Community

HH, Hospice

HealthSystem

MedicalGroup

Agencies

Church

PrivatePayers

LTCare

Government

Physician

Hospital

H o s p i c e A s A n A g e n t f o r

C l i n i c a l I n t e g r a t i o n

S a m i r a K . B e c k w i t h

P r e s i d e n t a n d C E O

H o p e H e a l t h c a r e S e r v i c e s

Hope

Comfort

Care

Hope

PACE

Hope

Healing

HeartsHope

Hospice

Hope

Visiting

Nurses

Hope

Connections

Hope

Parkinson

Program

Hope

Kids Care

Patients

and

Families

U S M M / V P AH o m e B a s e d P r i m a r y C a r e

C o n t i n u u m o f C a r e

R o b e r t S o w i s l oE V P A d v o c a c y / G o v e r n m e n t A f f a i r s

Who We Are…

USMM is the nation's largest physician led provider of in-home medical services for high-risk populations:

• Provide 15% of all in-home physician visits nationally

• Serve over 50,000 complex patients on an annual basis

• Operate >100 local offices across 14 States

Delivers a physician-driven, fully-integrated continuum of care model

~ 225 full time

Physicians, NPs

and PAs

Engage in over 400,000 physician house call visits, 39,000 podiatric house call visits, 139,000 home health visits, and 380,000hospice patient days annually

Centralized administrative, data management, and call center operations

24x7 response to urgent escalations in illness and medical crises

Shared Savings Programs

Provide enhanced access to health services and quality of life for complex populations by removing barriers to receiving care

Pioneer ACOIndependence

at Home

30%

30%

50%

Top Decile

Top Quintile

17% / year

Not

Published

• Reduction in All-Cause 30-Day Readmissions

• Reduction in Hospital Admissions for Ambulatory-Care Sensitive Conditions

• Reduction in ER Visits for Ambulatory-Care Sensitive Conditions

• Patient Satisfaction Scores (CAHPS)

• Quality Scores (ACO Measures / IAH Quality Metrics)

• Cost Reduction (Pioneer 3 Yrs. Experience / IAH Year 1 Not Published)

Results and Outcomes

• Opportunity to expand shared savings participation to remaining FFS population through current CMS MSSP ACO program (First Home Based Primary Care ACO in the U.S.)

• Launched in January 2015; enrolled 20,000+ beneficiaries out of existing USMM/VPA

USMM Accountable Care Partners, LLC

J e a n K u n t e r , M D , M S P H , C M O

P r o f e s s o r o f M e d i c i n e a n d

A s s o c i a t e D e a n f o r C l i n i c a l A f f a i r s

U n i v e r s i t y o f C o l o r a d o S c h o o l o f

M e d i c i n e

P a s t P r e s i d e n t , A A H P M

L o n g - t e r m C a r e a n d

C o m m u n i t y C o n n e c t i o n s

C h e r y l P h i l l i p s , M D

S V P, A d v o c a c y a n d P u b l i c P o l i c y

L e a d i n g A g e

I n t e g r a t e d H e a l t h S y s t e m s

R a n d y A x e l r o d , M D

E V P, C l i n i c a l a n d P a t i e n t S e r v i c e s ,

P r o v i d e n c e H e a l t h a n d S e r v i c e s

A Snapshot of Providence

Caregivers (all employees) 73,018

Employed physicians 3,389

Employed advanced practice

clinicians923

Registered nurses 25,478

Physician clinics 475

Acute care hospitals 34

Acute care beds (licensed) 7,932

Providence Health Plan members 390,596

Hospice and home health programs 19

Home health visits 633,364

Hospice days 640,409

Assisted living and long-term care

facilities (free standing and co-located)22

Supportive housingFacilities: 14

Units: 693

Unique patients served 2,483,462

Community benefit and

charity care costs$951 million

Data is consolidated for Providence and its affiliates based on financial reporting.272

Ques t i on & Answer

Pane l D i scuss ion

F e d e r a l I n i t i a t i v e s

t o D r i v e C h a n g e

Federal Initiatives to Drive Change

• Tom Daschle,

Former U.S. Senator (D-SD)

Founder and CEO,

The Daschle Group

CMS Innovation and Health Care Delivery

System Reform

Dr. Patrick Conway, M.D., MSc

CMS Chief Medical Officer and

Deputy Administrator for

Innovation and Quality

Director, Center for Medicare

and Medicaid innovation

Director, Center for Clinical

Standards and Quality

Better Care, Smarter Spending,

Healthier People In three words, our vision for improving health delivery is about better,

smarter, healthier.

If we find better ways to deliver care, pay providers, and distribute

information, we can receive better care, spend our dollars more wisely,

and have healthier communities, a healthier economy, and a healthier

country.

We understand that it’s our role and responsibility to lead … and we will.

What we won’t do – and can’t do – is go it alone. Patients, providers,

government, and business all stand to benefit if we get this right, and this

shared purpose calls out for deeper partnership.

So we will continue to work across sectors for the goals we share: better

care, smarter spending, and healthier people.

Overview

Early Results

CMS Innovation Center

Delivery System Reform and Our Goals

CMS Support of Health Care Delivery

System Reform Will Result in Better Care,

Smarter Spending, and Healthier People

Historical state

Key characteristics

Producer-centered

Incentives for volume

Unsustainable

Fragmented Care

Systems and Policies

Fee-For-Service

Payment Systems

Evolving future state

Key characteristics

Patient-centered

Incentives for outcomes

Sustainable

Coordinated care

Systems and Policies

Value-based purchasing

Accountable Care Organizations

Bundled payments

Medical Homes

Quality/cost transparency

Population-based

payments

Public

and

private

sectors

Improving the way providers are incentivized, the way care is delivered, and the way information is

distributed will help provide better care at lower cost across the health care system.

Encourage the integration and coordination of clinical and support

services

Improve population health

Promote patient engagement through shared decision making

Pay

Providers

Create transparency on cost and quality information

Bring electronic health information to the point of care for meaningful

use

Focus Areas Description

Deliver Care

Distribute

Information

Promote value-based payment systems

– Test alternative payment models

– Increase linkage of Medicaid, Medicare FFS, and other payments

to value

Bring proven alternative payment models to scale

Delivery System Reform Requires Focusing

On the Way We Pay Providers, Deliver Care,

and Distribute Information

Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online

first.

CMS Has Adopted a Framework That

Categorizes Payments to Providers

Description

Medicare

Fee-for-

Service

examples

Payments are

based on

volume of

services and

not linked to

quality or

efficiency

Category 1:

Fee for

Service – No

Link to Value

Category 2:

Fee for Service

– Link to

Quality

Category 3:

Alternative Payment

Models Built on Fee-for-

Service Architecture

Category 4:

Population-Based

Payment

At least a

portion of

payments vary

based on the

quality or

efficiency of

health care

delivery

Some payment is linked to

the effective management of

a population or an episode

of care

Payments still triggered by

delivery of services, but

opportunities for shared

savings or 2-sided risk

Payment is not directly

triggered by service

delivery so volume is not

linked to payment

Clinicians and

organizations are paid

and responsible for the

care of a beneficiary for

a long period (e.g., ≥1

year)

Limited in

Medicare fee-

for-service

Majority of

Medicare

payments

now are

linked to

quality

Hospital value-

based

purchasing

Physician Value

Modifier

Readmissions /

Hospital

Acquired

Condition

Reduction

Program

Accountable Care

Organizations

Medical homes

Bundled payments

Comprehensive Primary Care

initiative

Comprehensive ESRD

Medicare-Medicaid Financial

Alignment Initiative Fee-For-

Service Model

Eligible Pioneer

Accountable Care

Organizations in years

3-5

Maryland hospitals

Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.

During January 2015, HHS Announced

Goals for Value-Based Payments Within the

Medicare FFS System 30% of Medicare payments are tied to quality or value through

alternative payment models (categories 3-4) by the end of 2016,

and 50% by the end of 2018

85% of all Medicare fee-for-service payments are tied to quality or

value (categories 2-4) by the end of 2016, and 90% by the end of

2018

Goals

Purpose Set internal goals for HHS

Invite private sector payers and Medicaid to match or exceed

HHS goals

Stakeholders

Consumers

Businesses/Purchasers

Payers

Providers

State partners (including Medicaid programs)

Next steps Testing of new models and expansion of existing models is

critical to reaching incentive goals

Creation of the Health Care Payment Learning and Action

Network to align incentives and identify best practices

50%

Target Percentage of Payments in ‘FFS

Linked to Quality’ and ‘Alternative Payment

Models’ by 2016 and 2018

~20

0%

CMS Increasingly Linking FFS Payments to

Quality or Value

1

2

2

1

2

2

1

2

1.75

2

3

2

3

2

2

CMS is Aligning with Private Sector and

States to Drive Delivery System Reform

Convening Stakeholders

Convened payers in 7

markets in

Comprehensive Primary

Care

Convening payers,

providers, employers,

consumers, and public

partners through the

Health Care Payment

Learning and Action

Network

CMS Strategies for Aligning with Private Sector and States

Incentivizing Providers

Pioneer ACOs agreements

required 50% of the ACO’s

business to be in value-

based contracts by the end

of the second program year

Partnering with States

The State Innovation

Models Initiative funds

testing awards and model

design awards for states

implementing

comprehensive delivery

system reform

The Maryland All-Payer

Model tests the

effectiveness of an all-

payer rate system for

hospital payments

Early Results



Source: CMS Office of the Actuary

9.24%

5.99%

4.63%

7.64%7.16%

*27.59%

1.98%

4.91%

4.15%

1.36%

2.25%

1.13%0.35%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Medicare Per Capita Growth Medical CPI Growth

*Medicare Part D prescription drug

benefit implementation, Jan 2006

28%

27%

Results: Per Capita Spending Growth at

Historic Lows

Pioneer ACOS were designed for organizations with experience in

coordinated care and ACO-like contracts

Pioneer ACOs showed improved quality outcomesQuality outperformed published benchmarks in 15/15 clinical quality measures

and 4/4 patient experience measures in year 1 and improved in year 2

Mean quality score of 85.2% in 2013 compared to 71.8% in 2012

Average performance score improved in 28 of 33 (85%) quality measures

Pioneer ACOs generated savings for 2nd year in a row

$384M in program savings combined for two years†

Average savings per ACO increased from $2.7 million in PY1 to $4.2

million in PY2‡

Pioneer ACOs Provided Higher Quality and

Lower Cost Care to Medicare Beneficiaries

in Their First Two Performance Years

19 ACOs operating in 12 states (AZ, CA, IA, IL, MA, ME,

MI, MN, NH, NY, VT, WI) reaching over 600,000 Medicare

fee-for-service beneficiaries

Duration of model test: January 2012 – December 2014;

19 ACOs extended for 2 additional years

† Results from regression based analysis

‡ Results from actuarial analysis

CMS convenes Medicaid and commercial payers to support primary

care practice transformation through enhanced, non-visit-based

payments, data feedback, and learning systems

Across all 7 regions, CPC reduced Medicare Part A and B

expenditures per beneficiary by $14 or 2%*

Reductions appear to be driven by initiative-wide impacts on

hospitalizations, ED visits, and unplanned 30-day readmissions

Comprehensive Primary Care (CPC) is

Showing Early Positive Results

7 regions (AR, OR, NJ, CO, OK, OH/KY, NY)

encompassing 31 payers, nearly 500 practices,

and approximately 2.5 million multi-payer

patients

Duration of model test: Oct 2012 – Dec 2016

* Reductions relative to a matched comparison group and do not include the care management fees (~$20

pbpm)

Spotlight: Comprehensive Primary Care,

SAMA HealthcareSAMA Healthcare Services is an independent four-physician family

practice located located in El Dorado, a town in rural southeast Arkansas

“A lot of the things we’re doing now are

things we wanted to do in the past… We

needed the front-end

investment of start-up

money to develop our teams

and our processes”

-Practice Administrator

Services made possible by CPC

investment

Care management

Each Care Team consists of a doctor, a

nurse practitioner, a care coordinator, and

three nurses

Teams drive proactive preventive care for

approximately 19,000 patients

Teams use Allscripts’ Clinical Decision

Support feature to alert the team to missing

screenings and lab work

Risk stratification

The practice implemented the AAFP six-

level risk stratification tool

Nurses mark records before the visit and

physicians confirm stratification during the

patient encounter

Partnership for Patients Contributes to

Quality Improvements and Cost Savings

Ventilator-

Associated

Pneumonia

Early

Elective

Delivery

Central Line-

Associated

Blood Stream

Infections

Venous

thromboembolic

complications

Re-

admissions

62.4% ↓ 70.4% ↓ 12.3% ↓ 14.2% ↓ 7.3% ↓

Data shows a 17% reduction in hospital acquired conditions across

all measures from 2010 – 2013

‒ 50,000 lives saved

‒ 1.3 million patient harm events avoided

‒ $12 billion in savings

Many areas of harm dropping dramatically – patient safety

improving

Leading Indicators, change from 2010 to 2013

Medicare All-Cause, 30-day Hospital

Readmission Rate is Declining

Legend: CL: control limit; UCL: upper control limit; LCL: lower control

limit

Readm

issio

n R

ate

Beneficiaries Move to MA Plans with High

Quality Scores Sent prompt to

beneficiaries

enrolled in

plans with 2.5

star rating or

lower

Letters only

sent to

beneficiaries in

consistently

low-rated plans

Switch rate

44% (prompt)

v. 21% (no

prompt)

9% 9%9%

2012

20%

61%

29%

57%

20142013

9% 5%

45%

45%

1%

5-star

4-star

3-star

2-star

Medicare Advantage (MA) Enrollment Rating Distribution

29

%

71

%

37

%

63

%

55

%

45

%

% 4 or 5 star

% 2 or 3 star

Early Results



The CMS Innovation Center Was Created By

the Affordable Care Act to Develop, Test,

and Implement New Payment and Delivery

Models

The Innovation Center Portfolio Aligns With

Delivery System Reform Focus Areas

CMS Has Engaged the Health Care Delivery

System and Invested in Innovation Across

the Country

Models run at the state levelSites where innovation models are being

tested

Source: CMS Innovation Center website, January 2015

Accountable Care Organizations:

Participation in Medicare ACOs Growing

Rapidly

ACO-Assigned Beneficiaries by County

424 ACOs have been established in the MSSP and Pioneer ACO programs

7.8 million assigned beneficiaries

This includes 89 new ACOS covering 1.6 million beneficiaries assigned to the shared

saving program in 2015

The bundled payment model targets 48 conditions with a single

payment for an episode of care

Incentivizes providers to take accountability for both cost and quality of care

Four Models - Model 1: Retrospective acute care hospital stay only

- Model 2: Retrospective acute care hospital stay plus post-acute care

- Model 3: Retrospective post-acute care only

- Model 4: Acute care hospital stay only

102 Awardees and 167 episode initiators in phase 2 as of January 2015

85 new awardees and 373 new episode initiators will enter phase 2 in

April 2015

Bundled Payments for Care Improvement is

Also Growing Rapidly

Duration of model is scheduled for 3 years:

Model 1: April 2013 to present

Models 2,3,4: October 2013 to present

* Current as of January 2015

CMS is testing the ability of state governments to utilize policy and

regulatory levers to accelerate health care transformation

Primary objectives include

Improving the quality of care delivered

Improving population health

Increasing cost efficiency and expand value-based payment

State Innovation Model Grants Have Been

Awarded in Two Rounds

Six round 1 model test states

Eleven round 2 model test states

Twenty one round 2 model design states

Round 1 States Are Testing and Round 2

States Are Designing and Implementing

Comprehensive Reform Plans

Round 1 States testing APMs

Arkansas

Maine

Massachuset

ts

Minnesota

Oregon

Vermont

Patient

centered

medical

homes

Accounta

ble care Episodes Near term CMMI objectives

Establish project

milestones and success

metrics

Support development of

states’ stakeholder

engagement plan

Onboard states to

Technical Assistance

Solution Center and

SIMergy Collaboration site

Launch State HIT

Resource Center and

CDC support for

Population Health Plans

Round 2 States designing

interventions

Maryland is the nation’s only all-payer hospital rate regulation system

Model will test whether effective accountability for both cost and quality

can be achieved within all-payer system based upon per capita total

hospital cost growth

Quality of care will be measured through

Readmissions

Hospital Acquired Conditions

Population Health

Maryland is Testing an Innovative All-Payer

Payment Model

Maryland has ~6 million residents*

Hospitals began moving into All-Payer Global Budgets in July

2014

- 95% of Maryland hospital revenue will be in global

budgets

- All 46 MD hospitals have signed agreements

Model was initiated in January 2014;

Five year test period* US census bureau estimate for 2013

Awards tested service delivery and payment models that improved

quality and decreased cost in communities across the U.S.

Over 140 projects awarded in round 1 and 2

Ideas tested include

- Enhancing primary care

- Coordinating care across multiple settings

- New types of health care workers

- Improving decision making

- Testing new service delivery technologies

Health Care Innovation Awards Tested A

Broad Range of Delivery System Innovations

Approximately 575,000 Medicare, Medicaid, and CHIP

beneficiaries served

Projects were funded in all 50 states*

Awards ranged from ~$1 M to $30 M

* Darker colors on map represent more HCIA projects in that state

Independence at Home (IAH)• This delivery model utilizes physician and nurse practitioner

directed primary care teams to provide services to certain

Medicare beneficiaries in their homes.

• Participating practices are accountable for providing

comprehensive, coordinated, continuous, and accessible

care to a maximum of 10,0000 high-needs beneficiaries at

home and coordinate health care across all treatment

settings.

• Practices may share in any savings under the Demonstration

program, if specified quality measures and savings targets

are achieved.

Medicare Care Choices Model• Allows terminally ill Medicare beneficiaries to receive

palliative care and hospice services without having to forego

further treatment for their terminal condition

• Designed to test impact of model on patient and family

satisfaction, timing of patients’ enrollment in hospice, and use

of non-palliative services at end of life

• Open to hospice-eligible Medicare beneficiaries with heart

failure, COPD, terminal cancer, or HIV

• Hospices to be paid monthly fees for case-management,

palliative care and related services

Accountable Health Communities• Recognizes that health care costs are influenced by drivers

outside the formal health care delivery system

• Tests whether systematically identifying and addressing

beneficiaries’ health-related social needs (e.g., housing

instability, food insecurity) reduces emergency department

utilization and inpatient hospitalizations.

• Engages payers, local government, and clinical and

community-based service providers in a coordinated effort to

align resources to improve the health of high risk Medicaid

and Medicare beneficiaries, with investments in infrastructure

and data tools to support continuous quality improvement

Transforming Clinical Practice Initiative is

Designed to Help Clinicians Achieve Large-

Scale Health TransformationThe model will support over 150,000 clinician practices over the next four

years to improve on quality, lower costs, and enter alternative payment

models• Two network systems will

be created

1) Practice Transformation

Networks: peer-based

learning networks

designed to coach,

mentor, and assist

2) Support and Alignment

Networks: provides a

system for utilizing

professional associations

and public-private

partnerships to drive

improvement

Phases of

Transformation

We are focused on:

Implementation of Models

Monitoring & Optimization of Results

Evaluation and Scaling

Integrating Innovation across CMS

Portfolio analysis and launch new

models to round out portfolio

Innovation Center – 2015 Looking

Forward

Eliminate patient harm

Focus on better care, smarter spending, and healthier

people within the population you serve

Engage in accountable care and other alternative

payment contracts that move away from fee-for-service

to model based on achieving better outcomes at lower

cost

Invest in the quality infrastructure necessary to improve

Focus on data and performance transparency

Test new innovations and scale successes rapidly

Relentlessly pursue improved health outcomes

What Can You Do to Help Our System

Achieve the Goals of Better Care, Smarter

Spending, and Healthier People?

Contact Information

Dr. Patrick Conway, M.D., M.Sc.

CMS Acting Principal Deputy Administrator and

CMS Chief Medical Officer

410-786-6841

[email protected]

310

S t a t e I n i t i a t i v e s

t o D r i v e C h a n g e

State and Local Operating Balanceas a percentage of GDP

State and Local Health and Non-Healthas a percentage of GDP

314

State Spending by Major Category(In billions of current dollars)

Medicaid

K-12

Corrections

Transportation

GAO Conclusions on Long-Term Fiscal

Outlook

“We calculated that closing the fiscal gap would

require action to be taken today and maintained for

each year equivalent to an 18 percent reduction in the

state and local government sector’s current

expenditures.”

“A primary driver of the decline in the…operating

balance long term is the rising health-related costs of

state and local expenditures on Medicaid and the cost

of health care compensation for state and local

government employees and retirees.”

0% 7% 14% 21% 28% 35% 42% 49% 56% 63% 70% 77% 84% 91% 98%

Medicare-$10,115Average --- $9267 -------------------------------------------------------------------------------------------

Medicaid--$8164

Per Capita Health Costs2013

Percent of U.S. Population

•Average age 49•Percent female 62•Average monthly cost $3,908•Hospital admission 2.6 per year•Hospital bed days 12•Emergency room visits 7 per year•Primary care visits 10 per year•Specialists visits 20 per year•Percent with 5 or more prescriptions 87%•Percent with co-morbidities 100%•Diabetes 51%•Behavioral health diagnosis 73%

Characteristics of Medicaid High-Utilizers

State Policy

Levers

State Purchasing

Power

Governors as

Conveners and

Consensus

Builders

State Wellness

and Prevention

Efforts

State Health Care

Regulation

Education and

Workforce

Market

Competition and

Consumer Choice

Health Care Focus Areas

Core Focus Areas Support and Build on Each Other

Winter

•Webinar on Section 1332 ACA Waiver

•Webinar on Health Insurance Marketplace Issues

•Convening of Existing and New State Innovation

Model (SIM) Testing States

•Montana SAS Project (moving to phase 2)

Spring

•Launch of Medicaid Leadership Institute

•50 State Convening -- Learning from Each Other,

the Role of States In Transforming Health Care

•Maternal and Child Health Learning Collaborative

•Launch TA Bench for Transformation

•Super Utilizer 1.0 and 2.0 Policy Academies

•Coverage Convening (State-Based Marketplaces)

Summer

•Health Policy Advisor Institute

•Medicaid Vendor Policy Academy

•Maternal and Child Health Learning Lab

•Expert Roundtable Population Health

Fall

•Convening of Governors on Health Care

•Completion of Medicaid Transformation Policy

Academy

•Completion of Workforce Policy Academy

Winter 2015

•Launch of Workforce Policy Academy

Ongoing

•State Health Care Leadership Retreats

•Instate TA Visits Population Health

•Learning Labs on Population Health

Papers

Workforce

Prescription Drug Abuse

Super Utilizer Data

New generation drugs

NGA Health Activities

Notes on State Activity for EOL

• Medicare dominant for EOL…in-patient and hospice

• Committee/task force…best practices on palliative care

• Tension between pain meds and abuse of

pharmaceuticals

• MA requirement for conversation on EOL treatment

• ACO’s coordinated care for EOL…reduced intensity and

increased patient satisfaction

P o l i c y F o r u m

Policy Forum

• Leonard D. Schaeffer

• Sen. Johnny Isakson (R-GA)

• Sen. Mark Warner (D-VA)

• Sen. Sheldon Whitehouse (D-RI)

W h a t ’ s N e x t

B i l l N o v e l l i

T o m K o u t s o u m p a s

C o - C h a i r s , C - T A C





A c t i o n