The ABCs of ACOs for MCH May 30, 2013

1. The ABCs of ACOs for MCHMay 30, 2013 For assistance: Please contact cmccoy@amchp.org or for web support 888-447-1119 option 2

2. Brief Notes about Technology Audio Audio is available through your computer speakers or earphones. For assistance, contact cmccoy@amchp.org or for web support 888-447-1119 option 2 2

3. Brief Notes about Technology Continued Questions To submit questions at any time throughout the webinar, type your question in the chat box at the lower left-hand side of your screen. • Send questions to the Chairperson (AMCHP) • Be sure to include to which presenter/s you are addressing your question. 3

4. Technology Notes Continued Recording Today’s webinar will be recorded The recording will be available in a week on the AMCHP National Center for Health Reform Implementation website at www.amchp.org A PDF version of the presenters' slides will also be available on the AMCHP website 4

5. Evaluation Attendees will receive a link to a survey evaluation upon completion of this webinar. Please take a few minutes to share your feedback.

6. Objectives Webinar attendees will: 1) Increase their knowledge of ACOs and ACOs that include MCH populations 2) Increase their understanding of how public health can play a role in ACOs  3) Will be able to identify strategies and resources to collaborate with, ACOs in their state

7. Featuring: Colleen A. Kraft, M.D., FAAP, Carilion Clinic, VA Cate Wilcox, MPH, Maternal & Child Health Section Manager, Public Health Division, Oregon Health Authority Don Ross, Policy & Planning Section Manager, Division of Medical Assistance Programs, Oregon Health Authority Marilyn Hartzell, M.Ed., Director, Oregon Center for Children and Youth with Special Needs 7

8. The ABCs of ACOs: Making Them Work for Maternal-Child Health Colleen A. Kraft, M.D., FAAP

9. Parenting Support Early Intervention Early Child Mental Health Services Home-visiting network Early HeadStart & HeadStart Child Care Resource & Referral Agency Developmental Services Lactation Support Family-Centered Medical Home Vulnerable children and families Prevention, Building Health Child and Family Acute Care Developmental Services Chronic Care Medically Complex Children

10. ACO Attributes • Coordinates care for shared population of patients with the goal of meeting and improving on quality and cost benchmarks • Hires an administrator and establish a formal legal structure to work with payers, monitor performance, and collect any shared savings • Receives a financial bonus that is divided among its participants according to their agreement. ACO Hosp Spec PCP Financial bonus from savings Coordinates care for shared patients Medicare, Medicaid Or private insurer Accountable Care Organizations

11. Traditional Medical Care and Financing“Un-accountable” care Low Cost Care Payment poor = No incentive Transparency of Finances? Outcome Measures? Quality Reporting? Aligned incentives? High Payment = Plenty of Incentive • Low Cost Care • Primary Care • Preventive Care—Screenings, Immunizations, Anticipatory Guidance • “Gatekeeper” • Health/Lifestyle counseling • Home-based care • Home visiting • Primary Care access for evenings and weekends • No Coordination • of Care • No incentive for communication and collaboration • No care coordinators • No measurement of outcomes • No comparative effectiveness Research • No focus on population health • No co-location of services • No self management services • No transportation • High Cost Care • Hospitalizations • Procedures • Duplication of labs, studies, procedures • Transportation = Ambulance • Complications of Chronic Disease • End of life care in an ICU

12. Accountable Care Fair Payment for Low Cost Care Transparency of ACO Finances Patient/Family-Centered Investment in Infrastructure Shared System Savings Aligned Incentives Improved Outcomes • Reduce Cost • of Care • Develop robust primary care access • .Streamline administrative tasks • Co-management between primary care and subspecialty to avoid hospitalization • Greater use of palliative care • Greater use of home care and home visiting • Patient/Family portals • Avoid duplication of care/HIT • Improve Coordination • of Care--Investments • HIT that promotes communication and interaction • Office Care Coordinators • Home Visiting/Home Care • Primary Care-Ancillary Health co-location, including therapists, dieticians, psychology • Electronic portal for patient communication/collaboration • Support for advanced primary care and Q/I initiatives • Data management infrastructure to evaluate processes and outcomes • Improve Quality of Care • Improving Scientific Basis of Healthcare Decisions • Based on Comparative Pediatric Effectiveness Research • Measurement of Outcomes • Longitudinal data collection and evaluation • Payment Tied to Patient Outcomes • Based on Quality Measures

13. Accountable Care “Three-Part Aim” Better Health Better Care Lower Cost

14. Pediatric Accountable Care Optimize Health and Development Prevention of Adult Disease Reduce High Cost Care

15. Factors Affecting Child Health SOURCE: Healthy People 2010, US Department of Health and Human Services, 2000.

16. Health Innovation can be funded through an ACO • Extension of the Medical Home • In-home care management • Early Childhood • Oral Health • Prenatal • Asthma • Development/Behavioral Health

17. Carilion Clinic-Aetna Partnership Carilion Clinic ACO Carilion Clinic Physicians Private Practice Physicians

18. Virginia Medicaid Regions Update: 12/08/2011

19. ACO System Savings • Co-management between primary care and specialty • Less duplication of services • Tracking of “high utilizers” with care coordination to provide proactive care • Access to primary care, less use of ED and hospitalization

20. CORE Predictive Modeling from Aetna A Venn diagram, combining top 1% general risk with ED and IP risk, is used to help illustrate what risk groups a member falls into, and are they falling into multiple groups… Members who are top 1% general risk AND medium/high risk for IP admit next 12 mos. Members who are Top 1% AND high risk for an ED visit next 12 mos. Mbrs who are Top 1% Members who are Top 1% , high risk for an ED visit, AND medium/high risk for IP admit next 12 mos. Mbrs who are Medium/High Risk IP Mbrs who are High Risk ED Members who are high risk for an ED visit AND medium/high risk for IP admit next 12 mos.

21. ED Risk Only Personalize the Profile for Medical HomesIncreasing Medical and Behavioral Complexity 3 ED Risk/IP Risk Only Top 1%/ED Risk/IP Risk Top 1%/IP Risk Only • Group 3: • Ave age 33 • 72% female • PMPM $962 • 5 ED visits, 0.2 admits • 32% asthma prevalence; 25% med adherence (asthma) • 85% MH prevalence • 58% co-occurring mental health and substance abuse • 52% with 5+ Rx classes • 5 Specialist visits • 10 PCP visits 6 4 5 • Group 6: • Ave age 43 • PMPM $2425 • 1.6 admits • 7 IP bed days • 6 ED visits • Low medical disease prevalence • 85% MH prevalence • 62% co-occurring MH and SA • 12 Specialist visits • 9 PCP visits • Group 4: • Ave age 49 • PMPM $3908 • 2.6 admits • 12 IP bed days • 7 ED visits • 51% diabetes prevalence • 73% MH prevalence • 87% with 5+ Rx classes • 20 Specialist visits • 10 PCP visits • Group 5: • Ave age 53 • PMPM $3202 • 2 ED visits • 2 admits • 10 IP bed days • 56% diabetes prevalence • 41% MH prevalence • 84% with 5+ Rx classes • 19 Specialist Visits • 7 PCP visits

22. Home Visiting Partner • Child Health Investment Partnership of the Roanoke Valley • Home Visiting with a Health Focus • Parents As Teachers • Oral Health • Asthma Management • Pregnant Moms • Behavioral Health

23. Home Visiting • Pediatric Asth

24. Care Management Design • Home Visiting Contract • Paid per member/per month • “High Touch”, in-person, in-home • Data Collected in home • HEDIS metrics • Health Outcomes • Reduced costs

25. Medical Home

26. Oral Health and Fluoride Varnish • Begin with a Grin!

27. Asthma Case Management • Assess environment, modifications • Smoking cessation • Observe inhaler use • Asthma control assessment • Asthma action plan and education • Transportation to visit

28. Behavioral Health • Prenatal to age 7 • Perinatal/postpartum depression screening • Connection to services for parents and children at-risk and diagnosed • Transportation to visits

29. Results

30. In-Home Screening

31. Ready for School?

32. Pediatric Asthma

33. Home Visiting Intervention Pilot

34. Home Visiting = In-Home Prenatal Care Management IDEA AIM STATEMENT Reduce the number of infants born at <37 weeks gestation and low birth weight (<2500 grams) by 30% by December 2012 utilizing home visitors as in-home case managers. • Poverty is a risk factor for poor maternal and newborn outcomes. • What if every mother with Medicaid had a Home Visitor to provide support, education, transportation? • How would this impact health of the next generation?

35. National Benchmark=March of Dimes Virginia Roanoke/Allegheny Metrics worse for this region Prematurity = 12.2% Late preterm (34-36 wk) = 10.1% Uninsured =15.6% Maternal smoking = 24.4% • “C” grade for premature birth • Total prematurity = 11.3% • Late preterm (34-36 wk) = 8% • Uninsured = 17.2% • Maternal smoking = 15.2%

36. Measures

37. 1st Trimester—Goal =90% Percent Goal = 90%

38. All Visits-Goal = 60% Percent Goal = 60%

39. Reduce Maternal Smoking by 1/3 Percent Goal = 16%

40. Perinatal Depression

41. Reduce Percentage of Infants born <37 weeks by 30% <37wk 34-36 wk Goal

42. Reduce Percentage of Term Infants born < 2500g by 30%

43. Cost of Care Note: One premature infant March 19-May 10

44. Next Steps • Continue current project, data analysis • Continue Home Visiting Contract after birth • Expand Asthma and Behavioral Health HV models • Assess • HEDIS measures • Compliance with Asthma guidelines, ER and hospital admissions, missed school and work days • Co-locate HV teams in OB and Pediatric practices • Feasibility of project replication as ACO expands • Development and school readiness of birth cohort

45. Other Outcomes • 92% of children with asthma are well controlled with minimal inhaler use • 90% of all pregnant mothers attended all their prenatal visits, starting in first trimester • 57% of pregnant moms who smoked were able to stop smoking • 100% of children with behavioral health problems improved on PECFAS

46. Care Connection for Children

47. Special Families

48. Special Families • 42 families with successful IEP meetings • 10 families connected with waiver services • 10 hospitalizations avoided due to connection to home health services • 8 support group meetings • Special Families facebook page • Respite program

49. Accountable Care • Health of a population • Pregnancy outcomes? • Decrease in hospitalizations and ED visits? • School attendance, grades? • Parental education and employment • Function and performance of the Medical Home

50. CONCLUSION: It is easier to build strong children than to repair broken men. Frederick Douglass