Bangor Beacon Community has built an integrated organization to test new payment and care delivery models through grant and other funding. As a result, CMS selected EMHS, the lead agency for the Bangor Beacon Community, to be one of 32 Pioneer ACOs in the United States. Figure J-5 illustrates the building blocks for EMHS's progression from an integrated health system to an ACO. Having an IT infrastructure and focus on quality improvement were instrumental building blocks in the migration.
FIGURE J-5. Progression to an ACO
This section describes in more depth two care coordination and payment models -- the EMHS Pioneer ACO program and PCMH initiative -- and how home care and telehealth are engaged. It also discusses two other grant programs that have supported care transitions.
Eastern Maine Health System Pioneer Accountable Care Organization
EMHS was selected as one of 32 ACOs under the Center for Medicare and Medicaid Innovation Pioneer ACO initiative,14 which started in January 2012. Under this five-year arrangement with CMS the EMHS ACO bills Medicare under existing fee-for-service (FFS) rules for their attributed patients during the first two years of the project and then transitions into capitated payment in year 3 of the pilot. The ACO shares Medicare savings in year 1 and then move to a shared savings/shared loss mode in year 2. In year 3 the Pioneer ACOs will chose a portion of the Medicare spend for per member per month payment, and continue with shared savings/losses for the remaining Medicare revenue. Throughout the pilot shared savings are based upon financial performance and 33 quality measures reported to CMS.
1st Performance Year: Report 33 measures to receive up to 50% or 60% (depending on their model) of Medicare shavings.
2nd Performance Year: Report eight measures and paid for performance on 25 measures.
3rd Performance Year: Pay for performance on 32 measures and pay for reporting on one survey measure related to functional status.
The 33 quality measures used to assess performance have been endorsed by the National Quality Forum (NQF) and reported across all 32 Pioneer ACOs. Attachment J-1 provides a detailed list of measures, NQF measure ID, method of submission and reporting or performance requirement. The following list summarizes the primary domains that the 33 measures fall under:
Patient/Caregiver Experience such as timely appointments, education, access to specialists. There are seven measures in this domain that are submitted via a survey.
Care Coordination/Patient Safety such as medication reconciliation after discharge from an inpatient facility, hospital readmissions, falls screening. There are six measures in this domain that are submitted by EHR Incentive Program Reporting or a special web interface.
Preventive Health such as influenza immunizations, pneumococcal vaccination, certain screenings. There are eight measures in this domain submitted through the GPRO web interface.
At-Risk Populations (Diabetes, Hypertension, Ischemic Vascular Disease, Heart Failure, Coronary Artery Disease) such as specific clinical measures. There are 12 measures in this domain all submitted through the GPRO web interface.
The EMHS ACO has begun to look at home care pathways based on disease process and how to integrate community services and supports for non-homebound patients (such as the CHF telehealth program described above). They are also evaluating the value added contribution of the CCTs (related to PCMH), home care and hospice to the ACO. EMHC reports that for every dollar invested in home care during the first year of the pilot, they save $3 as an ACO.
EMHS utilizes a system called Arcadia to manage and report quality measurement data. The ACO quality measure data is pulled into the Arcadia system through direct interface from either the EHR or other import mechanism. All provider organizations that are part of the ACO are required to collect and report quality measure data. For those organizations that are not part of the EMHS technical infrastructure are required to report quality measures in a spreadsheet format for importing. Arcadia is also used for other quality reporting processes including Meaningful Use (MU) required reporting.
14. CMS Pioneer Accountable Care Organization (ACO) Model Program Frequently Asked Questions. See http://innovation.cms.gov/Files/x/Pioneer-ACO-Model-Frequently-Asked-Questions-doc.pdf.
Patient-Centered Medical Home
In 2009, Maine established 22 PCMH projects state including the EMHS Primary Care Medical Home Demonstration Project. One year later in 2010 CMS issued a demonstration project -- Multi-Payer Advanced Primary Care (MAPCP) -- in which Maine was selected as one of eight states to have Medicare participate as a payer.
The PCMH's are reimbursed by three types of payers: Medicare, MaineCare (state Medicaid Program) and commercial insurers. Medicare pays $7/member/month for PCMH services and $3/member/month for CCT. Maine is projecting to achieve budget-neutrality by decreasing patient inpatient admissions by 6%-7%, decreasing ED visits by 5%, and decreasing specialty consultations and imaging by 5%.
In addition to PCMHs, MaineCare developed health homes that serve individuals with:
The care management infrastructure in the PCMH includes at a minimum a nurse patient care manager embedded in each primary care practice who works with high-risk/high cost patients in the four priority diagnoses established under the Beacon project: diabetes mellitus, chronic heart failure, COPD, and asthma. The primary care managers also target patients who are in risk corridor populations identified under the ACO program as well as high cost patients. If they cannot be effectively managed in the primary care practice, then a referral is made to the CCT to address the patient's need in the community.
Referrals for the PCMH care management come from a variety of sources including:
- Provider referrals;
- Hospital discharge referral;
- Predictive modeling reports from payers;
- Specialized queries and reports that target patients in the four priority diagnoses and look for clinical measures such as certain lab values; and
- Registry data.
The patient care managers work directly with individuals to develop a personalized POC. They collaborate with other relevant care coordination teams such as inpatient care managers, cardiology care managers, mental health care managers, home care and home health service, and palliative care to manage risk, costs and transitions. The personalized POC includes individualized services, custom plans based on patient needs, co-management goals and self-management plans. The patient care managers also perform outreach to other services and providers such as community-based services and LTPAC providers. They share information through various tools such as Cerner's PowerChart, e-fax, etc.
PCMH care managers utilize the Centricity EHR system used by all EMHS primary care providers. The patient care managers utilize a number of standardized protocols and have other embedded tools and templates in the EHR. The care managers have developed a care management visit template for documenting in the EHR and have customized the templates based on the patient's condition.
The patient care managers tracking quality and performance improvement indicators for both primary care practices and for care managed patients in the areas of:
- Clinical outcomes;
- Preventive measure outcomes;
- Health care utilization; and
- Patient reported outcomes.
As noted above, EMHS PCMH may receive reimbursement for community-based care management. Phase II of their medical home program included the development of CCTs. The CCTs manage "super users" (high-risk/high cost patients) with frequent hospitalizations and/or ED visits. Overall health care savings are expected to be realized through reductions in these types of visits.
Eastern Maine HomeCare Patient-Centered Health Home Project -- Community Care Teams
CCTs are multidisciplinary, community-based care teams that provide support for the most complex, high-risk, high-need and/or high cost patients served by the PCMH Pilot Sites. The CCT assists patients overcome barriers to care, improve health compliance and outcomes, and reduce avoidable ED use and hospital admissions. The CCT managers are Licensed Clinical Social Workers, the teams include MSWs, RNs, and pharmacy students who work out of the EMHC office. They are actively engaged with community partners including the Area Agency on Aging, Local Healthy Maine Partnerships, and Bangor Public Health.
There are approximately 800 EMHS patients in this CCT program with a variety of challenges that impact their health outcomes and utilization such as mental health conditions, substance abuse, frequent ED use, medication compliance, or psychosocial concerns (e.g., senior housing issues, transportation issues). While dedicated to specific PCMHs, the CCT receives referrals from various sources including care managers at the PCMH, EMHC and hospital. They also identify potential patients be regularly analyzing data from the hospital EHR and HIN looking for individuals who have been in the ED and had multiple ED visits, individuals with complex conditions (medical and/or behavioral health co-morbidities) and targeting based and payer.
The following list provides an example of the type of criteria used to identify potential patients for the program:
- Two or more ED visits for chief complaint that is readily identified as non-emergent;
- Transitions of care;
- History of medication non-compliance; and
- Two or more chronic illnesses or one chronic illness with a co-morbid behavioral health diagnosis.
CCTs use the document remotely to the primary care setting EHR. The CCTs develop an individualized treatment plan and are working on getting the plan on HIN. One of the challenges for the CCT is the lack of a centralized record -- they must log into multiple systems to conduct their work, which is time consuming. A project is in development to allow the CCT information to flow into HIN.
Transitional Care Project (No Longer Funded)
The Beacon grant helped in supporting a transitional care project providing telehealth for patients who were not homebound and did not qualify for home care. Currently there is no funding to sustain the transitional program for patients who do not qualify for home care. When patients do meet home health qualification (i.e., homebound, skilled need) then EMHC uses telehealth partnered with nursing care managers to support home care services, with the goal of reducing ED visits and rehospitalizations.