MA - Many Partnering Initiatives Underway

1. MA - Many Partnering Initiatives Underway • Physicians: • Acton Medical • Atrius Health • Family Practice Group • HCA (BIDMC) • Lahey Medical Group • Meeting House Family Practice • The Medical Group • Somerville Primary Care Selected Partners Activities Services: 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 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

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

3. Atrius Health/ASAPs Practice-Based Pilots • Chelmsford & Elder Services of Merrimack Valley • Peabody & North Shore Elder Services • Southboro & Baypath • West Roxbury & Ethos • Concord & Minuteman Senior Services • Watertown & Springwell Currently expanding to new sites Community CareLinkagesSMA Division of Mass Home Care

4. 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

5. 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.

6. Atrius Health – ASAP Collaboration Community CareLinkagesSMA Division of Mass Home Care • 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

7. Atrius Health – ASAP Practice-based Pilot Community CareLinkagesSMA Division of Mass Home Care • 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.

8. Population-Based Intervention:Falls Risk Assessment Community CareLinkagesSMA Division of Mass Home Care • 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

9. 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

10. “one woman I&R department” 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