MA - Many Partnering Initiatives UnderwaySelected Partners

Hospitals:• Baystate Health System • Berkshire Medical Center• BIDMC• Brockton• Cambridge• Cooley Dickinson• Emerson Hospital• Health Alliance• Gardner• Lahey Clinic• Milford Regional • Partners Healthcare• Northeast Health System• Steward Norwood

Hospital• Tufts Medical Center• UMass Medical Center• Vanguard Health Systems• Winchester

ActivitiesServices:• Dedicated Link• CTI/Enhanced Coleman • Community Liaison• On-site Options Counseling

Meetings:• Inpatient interdisciplinary team• STAAR Teams• PCMH Multi Payer Initiative• Continuum of Care Quality

Assurance Initiative• Emergency Dept.• CMS CMP• Community Connections Group

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Physicians:• Acton Medical• Atrius Health• Family Practice Group• HCA (BIDMC)• Lahey Medical Group• Meeting House Family

Practice• The Medical Group• Somerville Primary

Care

Hospital/ASAP Collaboration

“Emerson Hospital and Minuteman Senior Services have banded together with the goal of preventing unnecessary repeat hospital stays.”

Atrius Health/ASAPs Practice-Based Pilots

1. Chelmsford & Elder Services of Merrimack Valley

2. Peabody & North Shore Elder Services

3. Southboro & Baypath4. West Roxbury & Ethos5. Concord & Minuteman

Senior Services6. Watertown & SpringwellCurrently expanding to new sites

Community Care Linkages SMA Division of Mass Home Care

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Atrius Health 100% on an electronic medical record

combined with corporate data warehouse, used for managing quality and cost.

Long history with global payments: greater than 50% of patients under global risk across Commercial, Medicare and Medicaid

Widespread use of rosters in population management

Track record of quality measurement and reporting

Over 30 NCQA certified Level 3 Patient-Centered Medical Homes

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Why Pioneer? “Reason for Action”

Participating in the Pioneer ACO will help Atrius Health achieve high-quality, high-value care for all Medicare-eligible patients across the care continuum.

Successful implementation for Medicare-eligibles will improve performance for commercial risk patients with similar clinical needs.

Access to full claims data set for Pioneer population offers true opportunity to be accountable for quality and cost across the continuum.

Contracting for Medicare Fee for Service patients under a global budget through Pioneer ACO maintains our position as a market leader in payment reform, moving towards 100% global payment.

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Atrius Health – ASAP Collaboration Expansion of the “Care Team” to include the patient’s home and

community-based networks

Requires: effective communication for timely and efficient referrals, hand offs, and “closing the loop”

Results in: patient centered care plans with realistic goals and resources for implementation

Collaboration through: Practice-based Pilots Population-based Interventions

Community Care Linkages SMA Division of Mass Home Care

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Atrius Health – ASAP Practice-based Pilot

Practice referral to ASAP with brief description of patient/needs

Referral form completed and faxed along with the problem list, medication list and the latest office visit

ASAP contacts the patient and arrange an intake interview, updating practice on barriers and services recommended

ASAP provides services, closes the loop with practice via phone call

Practice documents care coordination note and routes to PCP pool. Epic flag notes patient receiving care from ASAP.

7Community Care Linkages SMA Division of Mass Home Care

Population-Based Intervention:Falls Risk Assessment

Identify population appropriate for home-based FRA

Develop standard work for non-medical ASAP intervention (population based, rather than practice or ASAP dependent)

Develop data capture in Epic to meet Pioneer quality measure

8Community Care Linkages SMA Division of Mass Home Care

Current ASAP/ACO Contracts

Atrius Health/Southboro Medical Group (SMG) & BayPath for “Community Social Services”

– Social Worker from BayPath to support SMG 24 hours per week– Access to SMG EpicCare (EHR)– Provide general community social services– Participate in case management, quality assurance and quality improvement,

utilization review and peer review activities– Metrics:

• Number of patients referred• Number of ED admissions• Number of hospital readmissions• Pre- and post-intervention costs • Number of cases on-going• Number of resistant patients referred – must define non-compliant

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Current ASAP/ACO Contracts

Beth Israel Deaconess Physician Organization (BIDPO)/ Springwell for “Community Care Linkages”

– a Springwell-employed Community Resource Coordinator (CRC) to work on site at BIDPO’s office located in Westwood, MA, 3 days per week

– identify the most affordable community resource options available to meet the identified needs of any referred Patient regardless of age or ASAP eligibility

– educate the BIDPO’s CNCMs and other staff as to range of community resources available, including the abilities of ASAPs, so that CNCMs are fully aware of potential supports available to Patients

– identify ASAP clients receiving services by any of the 27 ASAPs in MA and work with BIDPO staff to identify additional services that may be helpful to Patients who are receiving services from a Massachusetts ASAP

– establish a community resources catalogue or reference library– participate with BIDPO staff in case conferences – Options Counseling visits

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“one woman I&R

department”