Care Redesign Value and Innovation Phase I Summary

Elizabeth Mort, MD

v7.0

SoWhat is the Goal of Care Redesign?

Value is the only goal that unites the interests of all parties in the health care system. Value should be defined by the customer. Value improvement should be the goal, not cost containment. Our goal in clinical redesign is to improve value
Produce the same outcome at a lower cost - or Produce better outcomes at the same or lower cost

Source: Michael E Porter, HBS, White Paper What is Value in Health Care, 2008
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What Payment Model will we be Working With?

Exact model is unclear, but we are moving away from unfettered fee for service and focusing on value will matter in all models
Source: Health Care Advisory Board, Promise or Peril? Preparing Your Health System for Success in the New Health Care Economy, 2010
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Elements of the Care Redesign/Trend Management Portfolio

High Risk Strategy

ConditionFocused Care Redesign Strategy

Primary Care Strategy

P4P Program Strategy

Incentives Strategy

Palliative Care Strategy

Readmissi ons Strategy

Patient Safety Strategy

Future Initiatives TBD

Information Systems/Population Management Strategy Strategy for (Operations) Infrastructure Development Performance Measurement Strategy

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Condition focused work: we started with five conditions

NQF Priority Conditions High Cost Pts >65

Prometheus Bundles High Cost Pts <65

Partners Employees High Cost Pts

List of 34 Conditions Leadership Discussion

AMI

CABG

Colon Cancer

Diabetes

Stroke

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Care Redesign Deliverables Phase I

Value Dashboard Version 1.0: outcomes,

processes, service metrics, and cost available currently

Care Redesign Plan Care Plan: process, pause

points, key interventions, and new delivery elements

Financial Plan: plan to Version 2.0 (Future Aspirations): measures

that matter to patients, e.g., outcomes achieve savings of 10% utilization and 5% unit cost

Performance Metrics: measures to monitor

implementation and value

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Care Redesign Methodology

Phase I: Design

1
Documented current state process map
Activities Hand-Offs/ transitions Phases of care Timing

2
Identified 1 pause points1
Alternative options for diagnosis & treatment

Identified opportunities for improvement

Quality improvement Cost savings

4
Analyzed data

Defined recommended care innovations

System-level recommendations Implementation options Performance metrics to monitor implementation

Population mix Quality Cost (internal and market)

Pause points refer to points within the process at which an action or intervention is indicated and where there is an opportunity to influence care

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Care Redesign Patient Population & Episode Duration

Condition
AMI

Patient Population

Episode Duration

Acute myocardial infarction STEMI From 3 days prior to index admission to 30 days post index discharge Isolated CABG procedure 18 years From 30 days prior to index admission to 180 days post index discharge

CABG

Colon Cancer

Colon cancer diagnosis and Biopsy with positive cancer diagnosis colectomy procedure 18 years to 30 days post colectomy

Diabetes

Adult non-pregnant patients 18 One year (365 days) forward from the years with Type 2 Diabetes date of service of the trigger/index claim (ICD coded professional claim) Ischemic stroke and TIA 18 yearsIschemic stroke: From hospital arrival to 45 days after TIA: From first medical presentation to 45 days after

Stroke

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Themes in Care Redesign Recommendations

Implement scheduling and navigation functions

Reduce unwarranted variation in resource use (inpatient care sites, high cost imaging, OR kits, pharmaceuticals, etc.)

Ensure reliable implementation of interventions to reduce adverse clinical events and reduce readmissions

Develop capacity to monitor patients prospectively during care for their condition and longitudinally where appropriate

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Example of data used by teams: Distribution for a Prometheus Diabetes Episode

Based on commercial pts, N = 3,824 bundles
Labs Diagnostic radiology Colonoscopy and biopsy Diagnostic cath Radioisotope scan Anesthesia Lens and cataract procs MRI Decompression peripheral nerve Debridement of wound Excision of skin lesions

Overall PACs rate for Diabetes is 27% with PACs distributed across these groupings of care

Consultation Labs Ophthalmologic and Otologic diag and treatment Electrocardiogram Excision of skin lesions Destruction of lesion of retina and choroid MRI

PACs IP Stay

ED Visits

Ambulatory Care (Hospital)

Prof services

OP Other

Pharmacy

Hospital-billed dollars
Top Potential Avoidable Complications (PACs)
Diabetic emergency, hypo-hyper glycemia Preventative, rehab, and after care Skin and wound care CHF, carditis, cardiomyopathy Cardiac dysrhthmias
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DME//supplies Labs Transportation Home health Medications (injections, infs, etc.)

Coronary atherosclerosis Complications of medical care

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Diabetes Episode Timeframe1:

365 days from the date of service of visit with a Diabetes diagnosis
Prometheus defined

Summary of Key Recommendations

A

Appropriate use of generic medications

B

In accordance with established treatment guidelines, patients can be managed to achieve good clinical outcomes for HbA1c, LDL, and BP using non-brand agents.

Appropriate use of oral agents

C

In accordance with established treatment guidelines, patients on insulin should not be on any oral agents for glycemic control, with the exception of metformin.

Appropriate use of insulin

D

In accordance with established treatment guidelines, patients who are unable to achieve glycemic control on two or more oral agents should be moved to insulin; patients and physicians should have access to resources to facilitate insulin initiation and support ongoing use. Patients should have access to comprehensive diabetes care, including, but not limited to: education, individualized care plans, non-visit care, and support for selfmanagement. Care should be available both during and outside of visits, informed by evidence-based clinical guidelines, and supported by an integrated care team. In accordance with established treatment guidelines, patients should get the recommended frequency of screening tests for HbA1c, LDL, and microalbumin, and other evaluations such as blood pressure readings and eye and foot examinations.
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Access to care

Frequency of screening tests