Update Primary Care Innovation Model (PCIM) Patient Centered Medical Home (PCMH) Care Transformation Council August 30,

1. Update Primary Care Innovation Model (PCIM) Patient Centered Medical Home (PCMH) Care Transformation Council August 30, 2012 Samuel A. Skootsky, M.D., CMO UCLA Faculty Practice Group and Medical Group

2. UCLA Health System • Hospital System (Acute Care, Child, Psychiatric) • 40,000 discharges • 806 Licensed Beds • UCLA Faculty Practice Group (1214 physicians; 247 primary care; W2 model) • UCLA Medical Group (Internal and External Networks & Contracting) • 58 faculty ambulatory practice locations/29 primary care site (additional sites coming on-line) • 1.6 Million visits/year • 2.3 million encounters/year • 323,000 unique patients FY12 H H August 2012

3. The UCLA Health System PCIM Journey Design Teams Implementation Teams Leadership Team Design Retreats Practice Re-Design Increase Covered Lives Expanded capability Collaborations Replication Geisinger BSVa Baylor Johns Hopkins Ascension Health August 2012

4. 5/10/2012 Shaping the Future Strategic Plan 2011-2015 Strategic Evolution CICARE/Systemic Innovation Cultural Evolution CareConnect & Telehealth Technology Evolution Care Transformation Health System Evolution Primary Care Innovation Model Program Evolution Planning Phase Design Phase Implementation Phase Operations Phase • Primary Care Innovation Model • Increase Managed Populations • UCOP • Medicare Advantage/FFS • Commercial/HMO/PPO • MSSP “ACO” Application • Expand Primary Care System • UCLA Collaborative with others • Replicability Internal/External Shaping the Future Strategic Plan 2011-2015 Organizational Design • Primary Care Innovation Model • Implementation Teams: • Transitions of Care • ED/Urgent Care • Community Programs • CMMI Innovation Funded • Geriatrics Dementia • Primary Care Innovation Model • Practice Re-Design (PCMH) • MyMeds in-office PharmD • Expand Primary Care System (CVS) • Growth Strategy • UCLA-MG Existing Population Management • DSRIP • CMS/CMMI Challenge • CMS/Shared Savings Context: (Oct 2011 – July 2012) August 2012

5. PCIM Progress-to-Date: PCMH • Started design Oct 2011 and on-track to have 50% of current primary care sites in PCMH practice-redesign model by end of this year, goal is all current and future sites. • Established method for replication (Design Team & Retreats) • Established new roles & and responsibilities (care coordinators and leadership) • Established linkages with other components of UCLA System (e.g. Transitions & ED) • Developed new IT support and registries (e.g. prior 24 hour ED and inpatient discharges) • Metrics established and being refined (e.g. facility use, panel size) As of August 2012 August 2012

6. PCIM Progress-to-Date: Other features • Established Growth Strategy Design Team to frame PCIM expansions • Relationship with retail clinics being operationalized • Articulated a Value-Based Care Model (HRA-based) Phase I applicable initially to: • Commercial HMO (UCLA Employees) • Medicare Advantage HMO • Medicare Shared Savings Plan Implementation • Established collaborative with UCOP on development of new UC care medical plan that includes features of PCIM & HRA-based models HRA-based =Health Risk Assessment & biometric screening & coaching model As of August 2012 August 2012

7. Value-Based Care: HRA-based model for Enrollee HRA, Health & Biometric Screenings & Risk Assessment Choose a Primary Care Provider Health Coaching/ Linkage to Care Coordination . . “Triple Aim” & IOM “Triple Aim” and IOM Guidance Medical Home/ Establish PCP System/ EHR Pharma Utilization & Formulary Compliance Chronic Condition Management August 2012

8. Primary Care Innovation Model Team Members • Samuel Skootsky, MD, Chair, FPG CMO • Jordan Hall, FPG Director Care Coordination • Laurie Johnson, FPG Dir Ambulatory Services • Molly Coye, MD, Chief Innovation Officer • Patricia A. Kapur, FPG CEO • Stephanie McCutcheon, Innovation Advisor CPN • Mark Grossman, MD, Medical Director CPN • Christina Catipay, Director Operations • Donna Robinson, CPN Brentwood Manager • Patricia Alarcon, CPN W. Washington Manager • Jeff Bernal, CPN Manhattan Beach Manager SMBP • Bernard Katz, MD Medical Director • Mark Needham, MD Medical Director • Lorena Douille, Director Operations • Celina Lomeli, 20th St. Manager • Jessika Harris, Ocean Park Manager Family Medicine • Michelle Bholat, Medical Director • Lynne Stevens, NP • Wendy Songer Medicine-Geriatrics Internal Medicine • Matteo Dinolfo, MD, Medical Director • David Reuben, MD Chief of Geriatrics • Brandon Koretz, MD Medical Director • Lillian Martinez, Director Operations • Tony Michaelis, Director Operations • Mari Lynne Kennedy, Med Suite 455/490 Manager • Joe Brown, Medicine SM Internal Med • Eve Glazier, MD Medical Director • Janet Pregler, MD Ambulatory Director Additional Team Members • Debora Davis, RN, BSN, CCM Managed Care • Alice Kuo, MD, Medicine • Sandra Lavin, RN, Managed Care • Janine Knudsen, MHA, Innovation Intern, Harvard • Anahit Khacheryan, Ed Dir Oper Improvement • Shirley Wong, PharmD, MYMEDS • Richard Maranon, MSA Geriatrics, MYMEDS • Gerardo Moreno, MD, Family Medicine, MYMEDS • Shawn Lee & Albert Duntugan, Dir Business Analytics • Beth TenPas & Kaiding Zhu Decision Support & Fin Srvs • Marcia Colone & Mary Noli, Care Coordination • Nasim Afsar, MD, Dir Quality/Safety/Medicine • Crystal VanDeventer, Innovation Model Support • Others August 2012

9. PCMH Pilot Practices • Started Five Pilots (33,000 patients) • Santa Monica Bay Physicians Plaza Office • CPN Parkside SM Office • Family Medicine SM Family Health Center • Department of Medicine SM 2020 • Department of Medicine SM Geriatrics • Department of Pediatrics has separate related program • Nolack of provider and staff enthusiasm! August 2012

10. Expansion Sites/ Sep 2012 Start New Cohort of Eight Practices & Lead MD • SMBP/20th Street 3rd Floor - Michael Nagata, MD and Caroline Close, MD • SMBP/Ocean Park - Richard Ross, MD • SMBP/20th Street 10th Floor - Richard Greenspun, MD • CPN/Brentwood - Dr. Mark Grossman • CPN/W Washington - Dr. Soheil Azimi • CPN/Manhattan Beach - Dr. Thuy Tran • Med/Primary Care Suite 455/490 – TBN • Med/ SM Internal Medicine Lead - Eve Glazier, M.D. With this expansion, will have total 13 sites in program Represents 50% of all Adult Primary Care Sites August 2012

11. UCLA Population Management Plan • Ensuring Care Implementation in the Community & at Home • Home Social/Environmental Factors • Patient Coaching • Transitions of Care • Use of Community Resources • Comprehensive Care Centers Traditional Benefit-Based Home Health Patient- Centered Shared Decision Making SNFist and SNF Program Optimal Discharge (Hospital, ER, SNF, other) • Hospital & Hospitalist-Extensivist Programs • Communication • Care Transitions • ER interventions • Efficient hospital use “System” Support: EHR, Data aggregation, Population Registries, Predictive Modeling, Decision Support , Practice Standards, Quality Measurement and Reporting, Accountability, Tele-Medicine, Tele-Health August 2012

12. What does Practice Re-Design mean? • Defined practice populations by MD and Site • Having timely & actionable data • Team based care • Risk prioritization, practice huddles, care coordination, transitions management, and navigation-“linkages” within Health System • Advanced Primary Care Practice • Continuity • Access • Active Panel Management Primary Care Innovation Model August 2012

13. What is Medical Home Functionality? Physician or other Providers Care Coordination Medical Assistant/LVN Office Manager Case Management Office Staff Panel Management August 2012

14. Our approach embraces “System” attributes and synergy Health System PCMH 2.0 PCMH 1.0 August 2012

15. Practice Re-Design, Advanced Primary Care, and Health System Re-Design = PCMH UCLA Health System ED Services Hospitalist Program Needed Specialists and Ancillaries Defined Care Management MD Led Team: Advanced Primary Care/PCMH Practice Clinical Advisor- Case manager New FTE and roles noted in light green Physician & MA-LVNs Other staff ED Services Comprehensive Care Coordinator In-home services, including palliative care Advanced Medication Management Urgent Care Centers & Retail clinics August 2012

16. UCLA PCMH/PCIM Metrics of Success • Reduction in Facility Use (increase use of alternatives) • Discharges & optimal LOS • All cause readmissions • ED visits • Ambulatory Care Sensitive Admissions • Generic Drug Use • Attenuation or Reduction in “Total Cost of Care” • Quality measures (standardized, valid, nationally endorsed) at 90th%tile • Patient Experience (Clinician Group - CAHPS) at 90th%tile • Provider & Staff Satisfaction (maintaining the workforce) • Increased efficiency in operations (e.g. panel size) • Success of care coordination system August 2012

17. Practice Population Registry with Multiple Ways Clinical Risk Ranking August 2012

18. Practice & Patient Care Gaps and Registries Action Lists = Care Gaps Registries = Whole Population August 2012

19. PCIM Population Access Mednet Site Recent addition: Past 24 hour ED discharges, Inpatient Admissions & Discharges August 2012

20. August 2012

21. Layered approach to PCIM population management Affiliations UCOP Plan ACO Commercial Plan ACO MSSP: Government sponsored ACO Delivery System Reform Incentive Payments (DSRIP) and PCMH expansion Expand 30+ year history of UCLAMG capitation [Medicare Advantage and Commercial] & “wrap around” population & care management August 2012

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