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Lawrence M. Preston, CEO

Rena Kantor, Director of Operations & Physician Relations

Rhonda Hamilton, Director of Quality Improvement & Education

Introducing:

©2016 Experian Information Solutions, Inc. All rights reserved. Experian Public.

Engaging Hospitalists & Physician Offices in Care Coordination


Las Vegas Hospitals

UHS-Valley Health System (6) HCA Hospitals (3) Dignity-St. Rose Hospitals (3) UMC Trauma North Vista Hospital


When did the ACO START? ► Formed in 2013 – approved by CMS as a 2014 Medicare Shared Savings

Program (MSSP) Accountable Care Organization (ACO)

► Serves Medicare Fee For Service (FFS) patients state wide, primarily in Southern Nevada

Who Participates? ► Independent doctors, physician groups, and affiliated healthcare providers

► Over 200 primary care physicians and other healthcare providers – 19,000+ lives

What is Silver State ACO?


When is an ACO Successful? ► When it delivers high-quality care and manages costs

► When it helps its provider participants to achieve their clinical and revenue goals

► When it can also share in the savings it achieves from CMS

► You do not have to achieve CMS guideline savings to be successful

What is Silver State ACO? -- Continued


We are a Provider Only organization

Our goal is to help providers keep their private practices and FFS Medicare patients – NOT to convert them to a Senior HMO plan

75% of savings bonus pools to be shared with provider members

Management team with combined 100 years of experience in Nevada

75% of the Board of Directors are participating private physicians

Silver State ACO Participant agreement is the MOST provider friendly in Clark County

What Sets Us Apart from Other ACOs?


2015 14,991 Medicare Beneficiaries –

Attributed by CMS

32,700 Medicare Beneficiaries actively seen in PCP practices

26+ Physician practices/ 165+ Participating providers/ 100+ Specialists

Medicare Annual Spend SSACO ~ $169 million (excludes Rx)

► $11,281/beneficiary/year

2016 19,256 Medicare Beneficiaries –

Attributed by CMS

51,000 Medicare Beneficiaries actively seen in PCP practices

36+ Physician practices/ 225+ Participating providers/ 175+ Specialists

Medicare Annual Spend SSACO ~ $207 million (excludes Rx)

► $10,784/beneficiary/year

SSACO Overview and Growth


NO COST to join and NO RISK

Medicare Fee For Service (FFS) billing continues (as compared to discounts to MCOs)

Assist with immediate revenue to the practice

Access reports re: wellness visits not done in previous 12 months

Identify hospitalized patients, enabling follow-up within 7 days of discharge

Transitional Care Management

Electronic software for Chronic Care Management Program

PQRS / GPRO – SSACO provides the platform, expertise and staff as needed to gather and enter quality measures data and annual filing with CMS

Benefits of Silver State ACO for Providers


Access to Medicare claims data

Which other doctors is your patient seeing?

What other tests have been done?

Is the patient filling their prescriptions?

Did they have their vaccinations?

Assistance from Kindred’s Care Transition Management (CTM) program

Experian Health’s MemberMatch and CareCertainty Messages

And finally-----

Benefits of Silver State ACO for Providers-- Continued


How We Use the CareCertainty Platform with Hospitalists and Physician Offices

Rena Kantor, Director of Operations and Physician Relations


We implemented MemberMatch in 2015, integrated to Health Endeavors

► Eight hospitals in Las Vegas connected to MemberMatch

► UHS & HCA were supportive; worked with Experian Health to improve ADT interface

Our plan was to use MemberMatch notifications for three purposes:

► Alert hospitalists when a beneficiary was admitted

► Alert physician offices when a beneficiary was admitted or discharged

► Kick-off a Transitional Care Management (TCM) program at the UHS hospitals

Unfortunately, our first approach was less than optimal…

Where We Started / Pre-CareCertainty


Initial Workflow for Hospitalist/PCP Notifications

MemberMatch

HealthEndeavors

Emails toHospitalists

EveryMorning

Letters toPCP OfficesEmails toCare Managers



Re: Silver State ACO Inpatient Admissions Members of Medical Group of Las Vegas, Silver State ACO strives to improve communications between healthcare providers in order to improve patient outcomes. Coordinated care helps ensure patients, especially those who are or have been hospitalized, get the right care at the right time. As a Participant Provider with the Silver State ACO, the following information regarding your patient(s) is being provided:

• James Smith was admitted to Mountain View Hospital on 09/19/16 (Jones) Esther Boyle was admitted to Sunrise Hospital on 09/20/16 (Badar)

• Wayne Billings was admitted to Southern Hills Hospital on 09/21/16 (Johnson) This information is given to provide you an opportunity to contact your patient(s) and schedule a follow-up appointment. Timely follow-up with the patient’s Primary Care Provider post hospitalization is significant in decreasing readmissions and improving outcomes. Our goal is that all Silver State ACO beneficiaries are seen by their PCP within seven days of discharge from an inpatient setting. Should you have any questions or require additional information, please feel free to contact our office at



MemberMatch

HealthEndeavors

Emails toHospitalists

EveryMorning

Letters toPCP OfficesEmails toCare Managers

Issues: Inefficient, delayed, incomplete

Was anyone reading, using? We didn’t know.


Agreed in April 2016 to be a beta site for the expanded CareCertainty Platform

Key features for us:

► Real-time, automated communications direct to our clinical partners

► Not a new system for them… via Email

► Closed-loop communications (they reply to our requests and questions)

► Track in real-time and through reports

Wanted to implement as fast as possible…started by automating the existing process

CareCertainty Messages


First CareCertainty Workflow (May-June 2016)

MemberMatch

Admission Notificationsto Hospitalist Offices

Admission NotificationsDischarge Notifications

to PCP Offices

Admission Notificationsto Care Managers

RulesEngine

CareCertainty

More Efficient, More Timely, and Trackable,but not yet perfect


Initial implementation was smooth

► Messages easy to use & intuitive

► Slow roll-out without in-person or even Webex training

► We did 5 groups at a time

Quickly, we started getting very helpful feedback

► The hospitalists liked the notifications, but not all would answer all the questions

● We tweaked the questions and rules

► When the hospitalists learned of the capability, they designed whole new workflows…

Roll-out; Quick Feedback from Hospitalists


Enhanced CareCertainty Workflow (Since July 2016)

MemberMatch

Nevada Hospitalist Group (covers 4 hospitals)

RulesEngine

CareCertaintyNotification of ER

arrival by Silver State ACO beneficiary

Notification of IPadmission by Silver State ACO beneficiary

Direct to the NHG Hospitalistsat Summerlin

…at Centennial

…at Valley

…at Desert Springs


Enhanced CareCertainty Workflow (Since July 2016)

MemberMatch

IPC Hospitalist Company

RulesEngine

CareCertaintyNotification of ERarrival

ER Unit(email)

Notification of ER arrivaland Admission

IPC Coordinators


Screen Shot of Email Sent to ER Unit Clerks

TEST-SMITH, MD

SMI/JO


Send two messages - #1 – Your Patient Admitted

MD Office Engagement


MD Office Engagement-- Continued

Send 2 messages to MD offices:

#2 – Your Patient DischargedHome

Requests (tasks)asked of the MD

offices


As of August, 2016

► 17 Physician Groups agreed to receive CareCertainty messages

As of end of September 2016

► All groups now have availability to look at data

84% of CareCertainty messages to MD offices being read and worked

Interesting data from usage

► 87% success rate in MD offices contacting patient/caregiver post-discharge

► 66% of patients scheduled for a follow-up office visit (74% rate by PCP offices)

► 10% of patients are no-show for follow-up appointment

MD Office Engagement Results & Feedback


Expand Hospitalists ER notification pilot to additional facilities

Turn on sending CCDs/clinical summaries as attachments to Discharge messages

Roll-out messages to more MD Offices, including new provider members as of January 1

Notifications to MD offices of ER visits

► MDVIP practices

► PCP doing their own rounding

Interested in communicating relevant gap in care details to MD offices with other notifications

What’s Next for Hospitalist and MD Office Engagement


Remember your goals

Be engaged with Experian Health

And remember…


Questions?

Silver State ACO 702-608-0417

www.Silverstateaco.com

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