ACOs: Where Are We At?

ACOs: Where are We At?
Presented by:
Kris Mastrangelo, OTR/L, MBA, NHA
President & CEO
Harmony Healthcare International
(HHI)

Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 2
“Widen Your Gaze”
~Sherlock Holmes
Welcome & Thank You

The learner will be able to summarize
goals of ACOs
The learner will be able to identify and
articulate examples of the ACO process
The learner will be able to identify
strategies for interdisciplinary
management of ACOs
Objectives

Accountable Care Organizations
“It is not the strongest of the species
that survive, nor the most intelligent
that survive. It is the one that is the
most adaptable to change.”
~Charles Darwin

Accountable Care Organizations
“Voluntary groups of physicians, hospitals, and other health
care providers that are willing to assume responsibility for the
care of a clearly defined population of Medicare beneficiaries
attributed to them on the basis of patients’ use of primary care
services.
If an ACO succeeds in both delivering high-quality care or
improving care and reducing the cost of that care below what
would otherwise have been expected, it will share in the
savings it achieves for Medicare.”
The New England Journal of Medicine (NEJM), October 20, 2011
Making Good on ACOs’ Promise – The Final Rule for the Medicare Shared Savings Program
Donald M. Berwick MD, Administrator, CMS

Team Medicine
First building blocks of integrated
team medicine: Model, data and
leadership
Create a care team that maximizes
impact for patients
Build a physician culture of
multidisciplinary practice

Team Medicine
1. An integrated, flexible physician
model
“Multispecialty group medical practice
maximized physicians’ abilities to care for
patients through doctor-to-doctor
consultation, through the training and
mentoring of young physicians, and through
the inherent quality controls built into the
group”

Team Medicine
2. Physician-Friendly Data
Yields evidence-based medicine

Team Medicine
3. Rethink physician leadership
“We recruit physicians with a sense that we’re a
group practice. We stand for quality. We measure
quality and results. We think it’s important that we
tell patients we’re going to give them the kind of
quality they deserve. You then orient, evaluate, and
promote people based on the same set of values and
expectations. Eventually you end up with a culture
that is very comfortable with a focus on quality,
measurement, comparison, and improvement.”
Jack Cochran, MD

Healthy Bones:
Tests and Prescriptions to Prevent
Problem:
In 2010, osteoporosis was the ninth most costly major illness
among the top 5% highest cost Medicare beneficiaries
In 2005, 2 million fractures cost the United States $17 billion
for both acute and long-term care. By 2025, the annual
fracture rate is expected to increase by 50% to about 3 million
at a cost of $25 billion per year.
On average, 24% of patients presenting with a osteoperosis-
related fracture die within one year, and the mortality rate of
men exceeds women
Only 21% of women age 67 or older who have had an
osteoporosis-related fracture had a bone mineral density test
or a drug prescription to treat or prevent osteoporosis in the
six months after the fracture
* Information provided by Kaiser Permanente

Healthy Bones
Solution:
Care managers, primary care physicians, and surgeons
use daily reports generated from the electronic health
record to identify members at risk for osteoporosis
and fractures
Care managers coordinate care for these patients to
close care gaps
Working together, the team provides patients with
education, screening, treatments, and monitoring as
needed. The multidisciplinary team includes:
Orthopedic surgeons, endocrinologists, gerontologists,
family practitioners, internists, rheumatologists,
gynecologists, physical therapists, disease/care
managers, radiologists and member education

Healthy Bones
Impact:
Annual bone density screening rates increased by
474% from 2002 to 2009
People on anti-osteoporosis medications
increased by 214% from 2002 to 2009
Over 45% reduction in rate of hip fractures
(preventing >1400 hip fractures) by 2010
If the Healthy Bones approach were adopted in
the United States, the country could achieve a 25%
reduction in the rate of hip fractures, preventing
75,000 hip fractures per year

Improvement Standard
As the New York Times reported on its front page Tuesday,
Reuters (10/24, Morgan) reports that the Obama
Administration has proposed a settlement to a class-action
lawsuit, promising to broaden current Medicare regulations
to allow coverage to "maintain the patient's current
condition or ... prevent or slow further deterioration."
Previously, beneficiaries had to demonstrate improvement to
continue to receive coverage, the change will likely benefit
thousands of Americans with degenerative conditions like
multiple sclerosis, Parkinson's, and cerebral palsy.
An HHS spokeswoman said the settlement merely "clarifies"
current policy, and continued, "We expect no changes in
access to services or costs."

The case, Jimmo v. Sebelius, resulted in a focus on
skilled service delivery in the context of maintenance
programs
Historically, patients with chronic conditions and
anticipated functional deterioration were considered
skilled for the establishment of a maintenance
program
This settlement now allows for coverage of the actual
delivery of maintenance therapy by licensed nurses
and therapy professionals

Current Medicare skilled guidelines state:
The services must be provided with the expectation,
based on the assessment made by the physician of the
patient’s restoration potential, that the condition of the
patient will improve materially in a reasonable and
generally predictable period of time,
Or the services must be necessary for the establishment
of a safe and effective maintenance program

The Proposed Settlement:
“Instead, providers, contactors, and adjudicators must recognize
“maintenance” coverage and a beneficiary’s need for skilled care that is
performed or supervised by professional nurses and therapists.”
The manual revisions will clarify that, under the Skilled Nursing Facility,
Home Health, and Outpatient Therapy maintenance coverage standards,
skilled therapy services are covered when an individualized assessment of the
patient’s clinical condition demonstrates that the specialized judgment,
knowledge, and skills of a qualified therapist (“skilled care”) are necessary for
the performance of a safe and effective maintenance program
Such a maintenance program to maintain the patient’s current condition or to
prevent or slow further deterioration is covered so long as the beneficiary
requires skilled care for the safe and effective performance of the program

Quality Care is our number one objective
Harmony embraces the OBRA 87 regulations which
require facilities to provide services to meet “the
highest practicable physical, medical and
psychological well-being” of every resident
This practice has been our standard since its inception.
This new Improvement Standard, further supports
our core values as providers of specialized services
to the post acute care population.

Continuum of Care Post Discharge
“When the asthma attack is done, the
patient goes home, and the game’s
over. No one is accountable for any of
the follow-up care.”
George Halvorson , Chairman & CEO
Kaiser Permanente

Integrated Follow-up
Call patient to make sure they are
accurately taking their medications
Call patient to make sure they are
avoiding any allergic trigger

Prevention
Problem:
One in eight women develops breast cancer, and
nearly 40,000 die from it every year
Regular mammograms – which can identify breast
cancer early, when it is most treatable – can reduce
breast cancer deaths by more than 30 percent
The United States Preventive Services Task Force
recommends screenings every one to two years
for women aged 50-74 years. However, current
screening rates fall short of these guidelines, and
they have been steadily declining

Prevention
Through the Proactive Office Encounter
program, the health care team identifies
and targets patients with care gaps
(including whether a patient is due for a
mammography) or chronic medical
conditions and encourages them to
actively participate in own care

Proactive Office Encounter and
Mammography
The program engages all members of the clinical
care team in a coordinated and collaborative effort
to encourage and support patient health
Automated creation of care checklists for all patients
whose records indicate gaps in care
At every point of contact with patients, clinical care
teams review checklists and help patients get the care
they need
Based on identified gaps in care, medical assistants
during office visits discuss with patients the need for
preventive screenings and routine care, such as cancer
screenings and tests for abnormal blood sugar or
cholesterol levels, and schedule appointments on the
spot

Proactive Office Encounter Also Helps
Along with other concurrent
improvement initiatives, the Proactive
Office Encounter has contributed to:
30% increase in colon cancer screening
11% increase in breast cancer screening
5% increase in cervical cancer screening
13% improvement in cholesterol control

Data, Data, Data
“You cannot make bricks without clay.”
~Sherlock Holmes

Better Patient Management
Using Evidence-Based Medicine
Patient Registry and Concurrent Tracking
System
Identifies all members in the population
Risk stratifies population for targeting
interventions and resources
Tracks and monitors each patient for key
indicators (lab, pharmacy, encounters,
clinical indicators)
Easy access (web-based)

Better Patient Management
Using Evidence-Based Medicine
Care Management Systems
Flags/alerts
Supports telephone management and
documentation
Identifies all members in the population
Supports Automated Clinical Decision
Support and Practice Tools
In-reach/outreach
Health Education and Self-Care Support

Evidence-based Medicine/Prevention
Proactive care instead of reactive care
Patients who have the largest “gaps” in
recommended care do not routinely visit their
primary care physicians
Specialty clinics must play a role to achieve
optimal results. Fewer than 40% of patients
needing a mammogram or testing for
diabetes visited their primary care physician.
Appointments can be made on the spot or
referrals generated so gaps can be readily
addressed

Beyond the Patient: Widen Your Gaze
Focus on primary care and prevention, and
addressing chronic disease requires looking
at larger communitywide issues
Behavioral factors are as important as
specific treatments: better diet, promoting
physical activity, and reducing smoking
Community education for adults and
children in recognizing bad health habits and
taking action to create a better health outlook

What is an Accountable Care Organization
Healthcare organization with a coordinated set of
providers…
Provider mix dependent on whether federal or commercial
ACO structure
Who share responsibility for the continuum of care…
Clinical accountability – Quality of care
Financial responsibility – Cost of care
By providing the highest possible value of care…
Increase quality
Decrease costs

What is an Accountable Care Organization
For financial incentives or “shared savings”
Value-based payments
Reimbursement for achieving cost and quality goals
From participating payors
Public payors (e.g., Medicare, Medicaid)
Commercial payors (e.g., BCBS of MA)

Key Principles and Elements of ACOs
Local accountability
Ability to provide and manage continuum of care
Responsible and accountable for quality and cost of care
Incentivize providers for quality – not quantity
Shared Savings
Legal entity and governance structure that allows
receiving/distributing shared savings payments
Invest shared savings in delivery system improvements
Capable of financial and resource planning
“AC0 Model Principles,” The Accountable Care Organization Learning Network,
http://www.acolearningnetwork.org/why-we-exist/aco-model-principles (Accessed 09/16/2011)

Key Principles and Elements of ACOs
Performance Measurement
Ongoing metrics to obtain evidence of meaningful
outcome improvements and cost impacts
Measurements must be transparent and accessible
Essential cost savings are result of meaningful
improvements
“AC0 Model Principles,” The Accountable Care Organization Learning Network,
http://www.acolearningnetwork.org/why-we-exist/aco-model-principles (Accessed 09/16/2011)

Why Accountable Care?
National Health Expenditures per Capita, 1960-2009
Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see
Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).

Why Accountable Care?
Hospital Care
31 %
Physicians & Clinics
20%
1. Includes Research (2%) and Structures and Equipment (4%)
2. Includes expenditures for residential care facilities, ambulance providers, medical
care delivered in non-traditional settings (such as community centers, senior citizens
centers, schools, and military field stations, and expenditures for Home and
Community programs under Medicaid
3. Includes Durable (1%) and Non-durable (2%) goods
Dental Services and
Other Professionals
7%
Government Administration
& Net Cost of Health
Insurance
7% Nursing Care Facilities &
Continuing Care Retirement
Communities
6%
Rx Drugs
10%
Other – 14%
Other Health, Residential,
and Personal Care2 5%
Home Health Care 3%
Government Public Health
Activities
3%
Other Medical Products3 3%
Investment1
6%
Note: Sum of pieces may not equal 100% due to rounding.
Centers for Medicare & Medicaid Services,
Office of the Actuary, National Health Statistics Group.

ACOs by Sponsoring Entity
60%
16%
23%
99
Hospital
Systems
27
Health Plans
38
Physicians
Groups
Note: Percentages don’t total 100% due to rounding. Source: Leavitt Partners

Perspective: Final Rule for Medicare
Shared Savings Program
“We believe that today’s ACO rule is the next step
in our shared commitment to a better, more
lasting health care system. We look forward to
being a trusted partner in our nation’s journey
toward patient-centered, coordinated care.”
Donald M. Berwick MD, Administrator, CMS
The New England Journal of Medicine (NEJM)
October 20, 2011
Making Good on ACOs’ Promise
The Final Rule for the Medicare Shared Savings Program

Medicare Shared Savings Program
ACO Requirements
Legal Entity
Formal legal structure established
To receive and distribute any shared savings
Proposed rule modified to allow participation of
entities organized under Federal or tribal law
Sufficient Size
Sufficient number of primary care physicians
To provide care for at least 5,000 beneficiaries
“Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule” Federal Register, Vol. 76, No. 212 (November 2, 2011), p.
67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.

ACO Requirements
3-Year Commitment
Must commit to participate in the program for at
least three years
Must provide CMS with 60 days advance notice
if terminating agreement
Participating ACO will not share in any savings
in the performance year for which it notifies
CMS of termination
67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.

ACO Requirements
Leadership & Governance
Must have a mechanism for shared governance and
responsibility
Management structure must include both clinical and
administrative systems
ACO participants must hold at least 75% control of the
ACO’s governing body
Where ACO comprises multiple, otherwise independent
entities not under common control, governing body must
be separate and unique to the ACO
Must provide for beneficiary representation on governing
body
67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.

ACO Requirements
Leadership & Governance (Cont.)
If governing body does not meet requirements, ACO must
describe why it seeks to differ from requirements and how it will
involve ACO participants in governance in innovative ways and/or
provide for meaningful governance participation by Medicare
beneficiaries
ACO’s operations must be managed by an executive, officer,
manager, or general partner, whose appointment and removal
are under the control of the governing body
Clinical management and oversight must be managed by a senior-
level medical director who is one of the ACO’s physicians, is
physically present in an established ACO location on a regular
basis, and is board-certified and licensed in one of the states in
which the ACO operates
67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.

ACO Requirements
Performance Measurement
Must define, establish, implement, and periodically update
processes to promote evidence-based medicine
Guidelines must cover those diagnoses with significant
potential for achieving quality improvements, while taking into
account individual beneficiaries’ circumstances
Must define, establish, implement, and periodically update
processes and infrastructure for ACO participants and
providers/suppliers to internally report on quality and cost
measures
Must report data on 33 quality measures for each year of
performance agreement
67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.

ACO Requirements
Patient-Centered
Must adopt a focus on patient-centered care that is
promoted by the governing body and integrated into
practice by leadership and management
67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.

Eligible Entities
Final Rule Designation Potential Provider Organizations
ACO professionals in group practices • Primary Care Physician Practices
Networks of individual practices of ACO
professionals
• Independent Practice Associations (IPA)
• Multispecialty Physician Groups (MSPG)
Partnerships or joint venture
arrangements between hospitals and
ACO professionals
• Integrated Delivery Networks (IDN)
• Clinical Integrated Networks (CIN)
Hospitals employing ACO professionals
• Hospital Medical Staff Organizations
(MSO)
• Physician Hospital Organizations (PHO)
• Extended Hospital Medical Staff
• Critical Access Hospitals
Such other groups of providers of services and suppliers as the Secretary determines
“Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule” Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67812; “Accountable Care
Organizations: A Roadmap for Success: Guidance on First Steps” By Bruce Flareau and Joe Bohn, 1st ed., Virginia Beach, VA: Convergent Publishing, LLC, 2911, pg. 45.

Quality Reporting Requirements
33 quality reporting criteria across 4 domains include:
Domain CMS Criteria
1. Patient/Caregiver Experience Measures 1-7
2. Care coordination/Patient
Safety
Measures 8-13
3. Preventive Health Measures 14-21
4. At-Risk Population Measures 22-33
“Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule” Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67889-67890, 67897.

Patient/Caregiver Experience (1-7):
Getting Timely Care, Appointments, and
Information
How Well Your Doctors Communicate
Patients’ Rating of Doctor Access to Specialists
Health Promotion and Education
Shared Decision Making
Health Status/Functional Status

Care coordination/Patient Safety (8-13):
Risk-Standardized, All Condition Readmission:
The rate of readmissions within 30 days of discharge from an acute care
hospital for assigned ACO beneficiary population.
Ambulatory Sensitive Conditions Admissions:
Chronic Obstructive Pulmonary Disease [AHRQ Prevention Quality
Indicator (PQI) #5]
Ambulatory Sensitive Conditions Admissions:
Congestive Heart Failure [AHRQ Prevention Quality Indicator (PQI)
#8]
Percent of PCPs who successfully qualify for an EHR incentive program
payment
Medication Reconciliation:
Reconciliation After Discharge from an Inpatient Facility
Falls:
Screening for Fall Risk

Preventive Health (14-21):
Influenza Immunization
Pneumococcal Vaccination
Adult Weight Screening and Follow-up
Tobacco Use Assessment and Tobacco Cessation
Intervention
Depression Screening
Colorectal Cancer Screening
Mammography Screening
Portion of Adults 18+ who have had their Blood
Pressure measured within the preceding two
years

At-Risk Population (22-33):
Diabetes Composite (All or Nothing Scoring):
Hemoglobin A1c Control (<8%)
Low Density Lipoprotein (LDL) (<100)
Blood Pressure > 140/90 mmHg
Tobacco Non Use
Aspirin Use: Daily Aspirin use for patients with
Diabetes and Cardiovascular Disease
Diabetes Mellitus:
Hemoglobin A1c Poor Control (>9%)

At-Risk Population (Cont.)
Hypertension (HTN):
Blood Pressure Control: Percentage of patient visits for
patients aged 18 years and older with a diagnosis of HTN
with either systolic blood pressure ≥140 mmHg or
diastolic blood pressure ≥ 90 mmHg with documented
plan of care for hypertension
Ischemic Vascular Disease (IVD):
Complete Lipid Profile and LDL Control <100mg/dl
Ischemic Vascular Disease (IVD):
Use of Aspirin or Another Antithrombotic
Heart Failure:
Beta-Blocker Therapy for Left Ventricular Systolic
Dysfunction (LVSD)

At-Risk Population (Cont.)
Coronary Artery Disease (CAD) Composite (All or
Nothing Scoring):
Drug Therapy for Lowering LDL-Cholesterol
Coronary Artery Disease (CAD) Composite (All or
Nothing Scoring):
Angiotensin-Converting Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB) Therapy for
Patients with CAD and Diabetes and/or Left
Ventricular stolic Dysfunction (LVSD). Percentage of
patients aged 18 years and older with a diagnosis of
CAD who also have Diabetes Mellitus and/or LVSD
(LVEF <40%) who were prescribed ACE inhibitor or
ARB

Payment Mechanism – Shared Savings
ACOs to receive payment for shared Medicare savings
provided it
Meets the quality performance requirements
Demonstrates that it has achieved savings against
benchmark of expected average per capita Medicare FFS
expenditures
An ACO shall be eligible for payment of shared savings
“[O]nly if the estimated average per capita Medicare
expenditures under the ACO for Medicare FFS beneficiaries
for Parts A and B services… is at least the percent specified
by the Secretary below the applicable benchmark.”
“Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule” Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67910,
67927-67930.

Payment Mechanism – Shared Savings
ACOs receive bonuses for achieving resource
use and quality targets over the course of a
year
ACOs face penalties for failing to meet these
requirements
The final rule sets out two risk models with
various incentives for ACOs to receive shared
savings payments
“Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule” Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67910,
67927-67930.

Federal Anti-Kickback Statute (AKS)
Federal Physician Self-Referral Law (Stark Law)
Federal Civil Monetary Penalty (CMP)
Federal Antitrust Law
Federal Tax Law
State Regulations
Antitrust
Fraud and Abuse
False Claims
Corporate Practice of Medicine
Insurance Law
Regulatory Considerations

Federal Anti-Kickback Statute
Definition
Prohibition against soliciting,
receiving, or paying
remuneration in exchange for
the referral healthcare service
billed to Medicare, Medicaid, or
any other federal healthcare
program.
ACO Implication
Current safe harbors to potentially
shield ACOs from possible
violations
Direct employment
Co-management arrangements
Gainsharing
“Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations and Medicare Program: Waiver Designs in Connection With
the Medicare Shared Savings Program and the Innovation Center; Proposed Rule and Notice” Federal Register, Vol. 76, No. 67 (April 7, 2011).

Federal Stark Law
Definition
Prohibition against physician
referrals to providers of
Designated Health Services
with whom the referring
physician has a financial
relationship .
ACO Implication
Compliance with the AKS and
Stark may be waived, “as may be
necessary,” to conduct:
Any payment model for ACOs that
the Secretary determines will
improve the quality and efficiency
of items and services furnished
under the Medicare program
The bundled payment/episode of
care pilot
“Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations and Medicare Program: Waiver Designs in Connection With the
Medicare Shared Savings Program and the Innovation Center; Proposed Rule and Notice” Federal Register, Vol. 76, No. 67 (April 7, 2011).

Federal Civil Monetary Penalties
Definition
Civil penalties against hospital
payments to physicians for
Reducing length of stay
Reducing readmission rates
Other forms of fraud and abuse
ACO Implication
HHS has provided a waiver similar
to those given for Stark Law and
the AKS.
“Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations and Medicare Program: Waiver Designs in Connection With
the Medicare Shared Savings Program and the Innovation Center; Proposed Rule and Notice” Federal Register, Vol. 76, No. 67 (April 7, 2011).

Federal Tax Law
Definition
Integration between
providers coordinating
care may cause nonprofit,
tax exempt providers and
for profit, taxable entities,
to merge.
ACO Implication
Tax-exempt participants in
ACOs should be able to
remain that way as long as
ACO furthers charitable
purposes.
“Accountable Care Organizations: Promise of Better Outcomes at Restrained Costs; Can They Meet Their Challenges?” By C. Frederick Geilfuss and Renate M. Gray, BNA’s Health Law
Reporter, Vol. 19, no. 956 (July 8, 2010).
“Herding Cats? What Health Care Reform Means for Hospital-Physician Alignment and Clinical Integration,” By Daniel H. Melvin and Chris Jedrey, McDermott, Will & Emery (October
13, 2010), p.38.

Federal Antitrust
Definition
Sherman Act, Section 1 prohibits
contracts, combinations and
conspiracies that unreasonably
restrain trade
•Applies to independent, competing providers
•Does not apply to:
•Physicians all within the same group
•A hospital and its full-time, employed
physicians
•A hospital and its controlled subsidiaries
ACO Implication
FTC and DOJ released proposed
rules governing mandatory antitrust
monitoring, based on the percentage
of market share an ACO has for any
specific service line.
“Proposed Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Saving Program” 76 FR 75 (April 19, 2011), p.
21895.

Large health systems may be in best position to form
ACOs
Attract more PCPs
Vertical Integration will likely aid in transition to ACO
May easily meet quality requirements
Greater access to capital and IT requirements
Potential Hurdles:
May need to lower cost or increase private insurers’ cost to
generate shared savings
Reimbursement Considerations
Hospitals
“Investors Not Likely to Provide ACO Funding Under Proposed Rule, Venture Capitalist Says” By Sara Hansard, Bureau of National Affairs, Health Law Reporter, Vol. 20, No.
1026, 2011; “Quality over Quantity” By Bryn Nelson, The Hospitalist (December 2009), www.the-hospitalist.org/details/article/477391/quality_over_quantity.html, (Accessed
2/28/11).; “Will Mayo Clinic save money as an ACO?” By Christopher Snowbeck and Don McCanne, Physicians for a National Health Program (February 8, 2011),
www.pnhp.org/print/news/2011/february/will-mayo-clinic-save-money-as-an-aco, (Accessed 2/28/11).

Technology Considerations
Electronic Medical Records
Significant cost
Help eliminate silos and increase continuity of care
Meaningful use standards
The technological impacts on providers choosing to
participate in an ACO are rooted in the primary issue of
purchasing or updating an EHR system
Costly
Must meet meaningful use standards to be eligible for
savings
EHR integration and alignment among ACO participants is
critical to ensure benefits of HIT utilization are obtained
“Technology Fundamentals for Realizing ACO Success”, Medicity, September 2010,
http://www.himss.org/content/files/Medicity_ACO_Whitepaper.pdf, (Accessed June 30, 2011).

Key Principles of Accountable Care
Underlying Causes of Poor Performance Principles of Accountable Care
Lack of clarity about aims, and about whose
perspectives are most relevant.
Clear aims: better overall health through higher-
quality care and lower costs with a focus on
patients.
Providers are fragmented and unable to
coordinate care well; providers accept
responsibility only for what they directly control.
Establish provider organizations accountable for
achieving better results for all of their patients at a
lower cost.
Payment system drives fragmentation, rewards
unnecessary care, and penalizes care coordination
and overall efficiency.
Align financial, regulatory, and professional
incentives with the aims of better health through
higher-quality care, lower costs.
Inadequate information to support provider and
patient confidence about the value of reforms.
Valid, meaningful performance measures that
support provider accountability for aims and
support informed and confident patient care
choices.

ACOs: The Numbers
The first 32 Medicare ACOs, called “Pioneer
ACOs” were announced in late 2011
In 2012, 27 shared savings ACOs were announced
in April
89 more (later decreased to 87 due to attrition)
joined in July
In January 2013, CMS announced the addition of
106 ACOs

106 Additional ACOs
January 2013
On January 10, 2013 CMS announced that
106 ACOs will join the Medicare Shared
Savings Program
There are 428 ACOs existing in 49 states
Physician groups have overtaken hospital
systems and have now become the largest
backer of ACOs

ACOs by State

ACOs by State
The only state without an ACO is Delaware,
though there have been discussions about
forming an ACO in the state
California, Florida and Texas lead the
nation with 46, 42 and 33 ACOs respectively

ACOs Growth
Growth is focused around population centers,
particularly along the West Coast and the Northeast
In the past year ACO, growth has increased
dramatically around Phoenix, Baltimore/Washington
DC, Indianapolis, Omaha, and Portland Maine.
Minneapolis, Central Ohio and the large Texas cities
continue to have high numbers of ACOs
Boston and Los Angeles have the highest concentration
of ACOs with 19 each, followed by Orlando with 13

ACOs Growth
In 2012 and the beginning of 2013 ACOs have
nearly tripled in number again, with growth
coming among all types of sponsoring entities
Of the 282 new ACOs in this period 158 (56%) are
sponsored by physician groups, 103 (36.5%) by
hospital systems, 17 by insurers (6%) and 4 by
community-based organizations (1.5%)
Research has found similar results among private
sector ACOs, with hospital-led ACOs having, on
average, considerably larger ACO populations
than those led by physician groups

Differences between ACOs
There are significant differences across
ACO models in how they try to achieve
savings and manage their patient
population, particularly between those
sponsored by hospital systems and
physician groups

Physician Groups - ACOs
Have a general approach that ACOs save
money by keeping a patient out of the
hospital
They accomplish this by managing patient
care in outpatient settings, such as by using
patient-centered medical homes to
coordinate care among specialists

Hospital Systems - ACOs
Focus on better managing patients once
they have been admitted to a hospital by
trying to coordinate care among
departments and providers

ACOs: Goal
Both types of ACOs hope to break down
artificial silos so that the appropriate
providers will work together to treat the
patient at the proper time, as well as follow
best practices and more effectively monitor
their patient population
An ideal ACO will focus on keeping
patients from entering a hospital and cost-
effectively treating those that are admitted

Harmony Healthcare International, Inc. 72
Stewart NF Requests
Copyright © 2013 All Rights Reserved

Stewart NF Requests
ACO goal to use shared blueprint for
long-standing quality improvement
efforts between our ACOs and nursing
facilities and their provider teams
The ultimate goal is to help support the
"Triple Aim" of improved patient
health, improved experience of care,
and lower cost of care for the patients
we serve.

Stewart NF Requests
The following provides a common
starting point for discussion and
collaboration

Stewart NF Requests
Performance Expectation /Aspirations

GENERAL
Staffing
a. Low staff turnover
b. Minimal use of agency nursing/nurse's aides
c. A nursing supervisor on all shifts (far preferably on-
site)
d. A primary care RN/LPN on-site 24/7 for short-stay
units
e. Facility has a primary nursing (RN or LPN) model
with consistent assignment for nurses and CNAs
f. Facility has access to adequate interpreter services

GENERAL
System Continuity
a. Facility will offer the group‘s preferred
providers to all of the group's patients
at discharge
b. e.g. DME, VNA specialists

GENERAL
Quality Improvement Efforts
a. Facility will participate in collaborative QI
work with the group (e.g. STAAR Cross-
Continuum meetings, monthly case reviews,
receive warm hand-offs, etc.)
b. Facility will participate in meetings with the
group on an as needed basis to cover related
topics (e.g. customer service, etc.)

Stewart NF Requests
PRE-ADMISSION

Pre-Admission
Screening /Admission
a. Facility will provide patient screens and
determination of bed offer within 2 hours of
referral
b. Facility is willing to collaborate with group on late
evening admissions
c. Facility will both screen and accept patients seven
days per week

Pre-Admission
Screening/ Admission (continued)
d. Facility will accept direct admits for qualified
patients from home/ER/clinician office
e. Facility will identify the patient‘s as group patients
when bed offer is made, as reported by the ACO to
the facility

Pre-Admission
Medical Coverage
a. Facility will assign patients to the group's
selected attending physician at time of bed
offer (unless patient expresses alternative
request)

Pre-Admission
Care Transition
a. Facility will develop and maintain a process
for the nursing staff to receive a "warm hand-off“
from any referral site

Stewart NF Requests
DURING STAY

During Stay
Facility Environment
a. The Facility will provide:
An environment (e.g. food, cleanliness,
noise, comfort, etc.) that meets patient
expectations
Critical medications (e.g. pain,
antibiotics, anticoagulation, cardiac, etc.)
are available at patient's arrival

During Stay
a. The Facility will provide (continued):
DME that is in the patient's room prior to
their arrival when appropriate
Suitable work space available for MD and
APCs as well as computer/printer access
Wireless internet access made available to
both patients and to MD/APCs

During Stay
Care Systems
a. Facility will train staff and implement the
INTERACT program.
If alternative protocols/tools are in place, facility to
make available to group.
b. Facility will provide high quality mental health
coverage:
At a minimum for emergent needs, continuous 24/7
telephonic coverage until resolution of emergency
All other, telephonic coverage, as well as face-to-face
consultation within 2 to 3 days

During Stay
Care Systems (continued)
c. Facility will provide high quality palliative care
consultations
d. Facility will assure STAT Radiology, Laboratory
obtained and resulted within 4 hours
e. Facility will assure STAT prescriptions delivered
within 6 hours

During Stay
Care Systems (continued)
f. Facility will assure PT /OT are provided as ordered at
least six days per week; if patient arrives before 2 pm,
assessment and initial evaluation will be completed
and documented on the day of admission. If admitted
after 2 pm, evaluation must be completed and
documented by the end of the next day. Therapies are
available seven days per week.

During Stay
Care Planning/Coordination
a. Facility will implement care planning meetings
that occur within three days of admissions.
Patients, families, legal representatives and PCP's
care manager are to be notified at least 48 hours
prior the family meeting and are encouraged to
participate.

During Stay
b. Outcomes of this first care planning meeting
include:
Establishing and documenting the functional goal
required for patient to be transferred safely home.
Establishing and communicating to patient, care
team and group designee the estimated discharge
date.

During Stay
c. Facility will establish a consistent day-of-week
and time-of-day (e.g. every Tuesday at 9am) for
the interdisciplinary team for the meetings for the
group’s patients.

During Stay
d. Facility case managers are responsible
for:
Assessment, creation, implementation
and documentation of a discharge plan
that begins at admission. The discharge
plan is revised as appropriate, documents
functional status, delivers notification of
discharge/termination of benefits letters,
etc.

During Stay
d. Facility case managers are responsible
for:
Timely collaboration with the group's
Case/Care Management staff (e.g. Care
Coaches and Case Managers) or their
designee with any significant change in
status or plan, including, discharge date.

During Stay
e. The facility will identify a "point person"
who will be responsible for providing both
rehabilitation and clinical updates [could be
case manager or alternate with easy
availability and access to coordinate with
group's staff or SNF provider team),
including tele-rounding with the group case
manager

Stewart NF Requests
AT DISCHARGE AND
POST-DISCHARGE

At Discharge And Post Discharge
Medication Reconciliation and
Education
a. The facility with assure that patients are
given a typed list - in large font - of current
medications upon discharge from SNF;
medication changes are highlighted and
explained; the list is fully reconciled with
the home and hospital discharge summary
medication lists

Advance Directive Documentation
a. The facility will assure that:
If patient does not arrive to facility with
advance directives documented, these will
be discussed and documented prior to
discharge.

Advance Directive Documentation
a. The facility will assure that:
Of note, if the patient is DNR or a completed
MOLST form is available, the form will be sent
with the patient upon any transfer and through
every area of care (including outpatient
appointments).

Communication of Discharge
Paperwork to the Group
a. The facility will comply with the standard
for completion of page l, 2, 3 referrals and
will include a typed discharge medication
list to be faxed to the appropriate group
and/or PCP fax number for scanning into
electronic medical record.

Communication of Discharge
Paperwork to the Group
b. Will fax Falls Assessment to group's
designee upon discharge.

Standard discharge planning checklist
The facility will use a standard discharge planning
checklist that includes at least the following:
a. Identify family/caregiver availability
b. Discharge medication list:
Determine patient's ability to acquire needed
medications including cost and transportation.
Patient will receive appropriate education on
medications.
Prescriptions for medications.
Technique review for example, for inhaler use.

Standard discharge planning checklist
The facility will use a standard discharge
planning checklist that includes at least the
following (continued):
c. Discharge instructions.
d. Ensure patient can "teach back" using
consistent teaching tools.

Selection of Transfer Facility
a. If patient requires transfer to acute care
facility, patients are to be transferred to
original referring acute care facility unless
medically contraindicated or due to patient
preference.

Stewart NF Requests
Reporting Expectations

During the Relationship with the
Group, Facilities Are Expecting To Have
The Following Data Updated On At
Least A Month Basis (Or Quarterly If
Specified Noted Below) To be Made
Available In Regular Reports To The
Group (Or On Request)

Bed screen outcomes:
a. Bed offer made and bed accepted;
b. Reason bed not offered.

INTERACT QI Review Summary

Clinical Programs
a. Provide list of specific clinical programs
(e.g. cardiac, pulmonary, behavioral)

Patient satisfaction results
a. The facility will survey patients regarding
their satisfaction (at least two questions in
the survey are from the CAHPS surveys
and includes at least and "willingness to
recommend") and share the results
quarterly with the group.

INTERACT QI Review Summary
STAFFING
a. Staff turn-over rate by staff type (e.g. RN,
LPN, CNA, etc.);
b. Nurse staffing ratios by staff type (e.g. RN,
LPN, CNA, etc.) for both short-stay and
long-term patients;
c. Flu vaccination rate

DPH/Joint Commission Results
a. Namely, details of any survey
deficiencies.

QI process measures (as established w/
group)
a. For example, number of admissions w/
completed warm hand-offs.

Functional Improvement Scores
a. Use of MDS measures acceptable.

The following information is expected to be reported
to the group in real-time without prompting:
1) Change in Director of Nursing, Administrator or other senior
leadership.
2) Change in any "point person" per above, including admission
director, case manager etc.
3) If not already employed by the group, any change in staffing
of medical coverage or any concerns regarding the ability of
the medical coverage provider team of meeting the nee ~s of
existing or new patients.
4) If facility is closed for admission (e.g. flu outbreak or other
unforeseen event).

ACOs:
Where Do We Go Next?

ACOs: Next Steps
Between care levels (such as between inpatient
and outpatient), there is less progress being
made
The next step in the accountable care
movement will require a recognition that levels
and locations of care are artificial constructs
Payer source should matter much less than
focusing on connecting patients with the right
provider in the right location for their illness
acuity

ACOs: Next Steps
Large physician groups and hospital
systems (and eventually post-acute and
long term care providers) to work together
and align their goals around patient care

ACOs: Future
While ACO growth will undoubtedly
continue for at least the immediate future, it
still represents a small minority of care
delivered in the United States

ACOs: Future
In 2013, many ACOs will complete their first year
under a risk-based ACO contract, and their early
results will influence how payers, providers and
policymakers experiment with future iterations of
accountable care
If the results are good, then the ACO model may
become the dominant form of health care in the
United States over the next decade
If the results are negative, accountable care may
never gain a permanent foothold in our delivery
system

Impact on the
Skilled Nursing Facility

Impact on SNF
Transparency
Might as well adjust to the fact that entities, other
than surveyors, will be more interested in what
SNFs are doing
Outcomes
Coordinated, efficient, error free “transitions of
care”
Length of Stay
Functional rehabilitation progress: Service
delivery
Re-hospitalization rates
Patient and Family Satisfaction

Impact on SNF
Regulatory Level Outcomes
Clinical QMs (falls, pressure sores, infection,
restraints, pain, psychotropic meds, etc)
Pharmacy Error Rates and Safety
Annual and Complaint Survey Compliance

Depression, PHQ-9
The monitoring and prevention in the
geriatric population requires closer
scrutiny

Questions/Answers
(978) 887 - 8919
www.Harmony-Healthcare.com
Connect with Us!
@KrisMastrangelo
@Harmonyhlthcare
facebook.com/HarmonyHealthcareInternational
H linkedin.com/company/harmony-healthcare
125
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ACOs: Where Are We At?

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