1. AMDIS Fall Symposium
Boston, MA
Sept. 29, 2013
Claus Hamann MD, MS, FACP
Accenture LLP

2. Big Institution to Community:
Accountable, Collaborative, Disruptive Care
Agenda and Summary
 To accomplish the Triple Aim (Health, Care, Costs), we need to
focus on the care of patients with complex illnesses
 To succeed at the care of patients with complex illnesses, we
embrace collaborative, coordinated care
 How do we succeed?
 Adopt proven models into accountable care
 Implications for Clinical IT
 Documentation
 Content, Decision support
 Interoperability, HIE

3. Why Focus on the Care for Complex Patients?
 To accomplish the Triple Aim (Health, Care, Costs), we need to
focus on the care of patients with complex illnesses
 Hospitals – “That’s where the money is.”
 Post-Acute Care: “That’s where the variation is.”
 73%, in nursing facilities, home health care and long-term-care hospitals
 Compared to 27% for hospitals and 14% tests/procedures (Newhouse,
2013)
 Dementia hospitalization ↑ 10 x from 2000 → 2050
 Accountable Care aligns incentives
 Efficient Care is key: overtreatment, failures of care
coordination, failures in execution of care processes,
administrative complexity, pricing failures, fraud and abuse
(Berwick, 2012)

4. Collaborative Care for Complex Patients
http://www.improvingchroniccare.org/
 Team care
 Patients with multiple diseases,
functional impairments and
social challenges
 Professionals from several
health disciplines
 Multi-  Inter-disciplinary
processes
 Team decision-making
 Chronic care model
 Historically: Pediatrics,
Physiatry, Psychiatry, Geriatrics
 Now mainstream with
aligned incentives ?

5. Accountable Care Meets Geriatric Care
 15 successful geriatric
care models based on
123 high-quality studies
with positive outcomes
(Boult, 2009)
 “Fee-for-service payment
is anathema to effective
chronic disease care…
to improve chronic care
[we need] accountability
and payment in
synchrony.” (Kane, 2009)
http://www.ncbi.nlm.nih.gov/pubmed/20121991
• Interdisciplinary primary care: 1
• Supplement primary care: 8
• Transitional care: 1
• Acute care in patients' homes: 2
• Nurse-physician teams for
residents of nursing homes: 1
• Comprehensive hospital care: 2

6. Collaborative Care for High-Risk and Vulnerable
Populations
Socially Disadvantaged Clinically Vulnerable
Highly
Vulnerable
Source: High-Risk and Vulnerable Populations Workgroup: http://www.acolearningnetwork.org/
Socially Disadvantaged Clinically Vulnerable
• Racial, ethnic minority
• Native American community
• Immigrant
• Impoverished neighborhood
• Low incomes
• Low levels of education
• Low health literacy
• Rural area
• Homeless
• Non English-speaking
• Dual–eligible beneficiaries
• Uninsured/underinsured
• Have low social supports
• Complex chronic illnesses
• Acute serious illnesses
• Multiple chronic conditions
• Disabled
• Mentally ill
• Substance abusers
• Cognitively impaired
• Frail elders
• Patients nearing the end of life
• Pregnant women
• Very young children
• High-utilizer patients
• High-cost patients
• Dual-eligible beneficiaries

7. CareMore Succeeding at Complex and Post-Acute Care
 Medicare Advantage “+”
 Av. age 72, 50% <$30k income; DM
33%, HTN 40%
 Intensive management of frail and
chronically ill: 15% members → 70%
costs,
 Monitoring, management of chronic
conditions to delay the onset of
frailty
 Costs 15% less; profitable
Reuben, 2011
 Contract with PCPs; handle non-urgent
illness
 NP’s, MA’s: evidence-based protocols
 1-hr. Healthy Start visit, MA + NP/MD,
comprehensive evaluation; annually
 Extensivists: inpatient + post-discharge
care including SNF
 Specialist management
 Transportation, fitness, home
intervention team, caregiver support,
respite care, high-intensity
management for frailest 2%
 EHR + wireless home monitoring
 Culture of conservative management
Outcomes
 DM: av. A1C 7.08; amputation
78% < national av.
 Hosp.: ALOS 3.0 d.; ESRD 42% Re-
Hosp.: 13.6% vs. 20%
 CAPHS > CA, US

8. Collaborative Care for Complex Patients
 Patient and caregiver
at the center
 Collaboration
 Communication
“…health system performance
will increasingly depend
on high-functioning, team-based
approaches to care.” (Dzau, 2013)

9. Enabling Success with Care of Complex Patients
Role of Clinical IT
 Implications for Clinical IT
 Documentation
 Care planning, including patient/resident choice
 Minimum Data Set; Resource Utilization Groups
 Decision support
 Interoperability, HIE
 Unique features of Nursing Home care
 Not part of MU
 Slower EHR adoption
 Help on the way: Center for Aging Service Technologies, 2013
 Needs assessment and EHR Selection Matrix comparing 36
products on ~200 features and functionalities
http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Apr/1380_Klinger_lessons
_HIT_New_York_nursing_homes_case_study.pdf, Commonwealth Fund, 2010

10.  “Last week Mrs. S. spiked a fever of 100.2 and was not eating much.
 The nursing supervisor immediately contacted the resident’s physician offsite
 Viewed via Internet Mrs. S.’s full clinical record over the last week
 Real-time data being entered at the bedside by the nursing team and direct-care staff
 Record of all her medications and when she had taken them
 Plan made between the nursing home care team and physician to give Mrs. S.
intravenous fluids for 24 hours to avoid dehydration
 “Give fever-reducing medication, monitor her vital signs, inform physician.”
 Physician viewed progress from offsite
 If hospitalization were indicated, it could have immediately been carried out.
 Mrs. S.’ temperature became normal over 24 hours and she began to eat, drink.
 Treatment plan appropriate
 No hospitalization.”
Enabling Success with Care of Complex Patients
Role of Clinical IT – Patient Vignette
http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Apr/1380_Klinger_lessons
_HIT_New_York_nursing_homes_case_study.pdf, Commonwealth Fund, 2010

11. Transitions of Care
Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 1 of 3
 Health IT adoption spectrum for long-term post-acute care
(LTPAC): systems for federally required assessments for payment
and quality >> systems for care
 Health IT-enabled facilities: Data feeds to an exchange, secure
messaging
 Low/no IT-adopted facilities
 Web-based portals for secure messaging, information query with hospitals and other care
partners
 Simple clinical documentation tools to facilitate electronic capture of LTPAC data shared at
transitions
 EHRs: integrated connectivity is evolving; CCHIT modular
certification growing
 Standards: 5 Transition of Care data sets to meet needs of most
types of transitions

12. Transitions of Care
Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 2 of 3
 Clinical Workflow: paper/fax  electronic solutions
 To assess patient acuity, service needs and staffing levels, on-
site administrator and nursing leader and off-site medical
director all need access to information
 Better identify and ensure services for patients with high
medical complexity and resource utilization patterns with data
from multiple episodes of care and settings
 Urgent ED evaluations: via DIRECT
 Secure message and change in condition documentation earlier in the care episode,
detailing symptoms and events leading up to the transfer
 Communicate assessments performed in the ED to both the nursing facility and the
attending medical provider, for safe transition to sending facility

13. Transitions of Care
Clinical IT Challenges for Long-Term Post-Acute Care (LTPAC) 3 of 3
 Staffing and User Access
 Core team: administrator, director of nursing, assistant director of
nursing, compliance leader and senior charge nurse vs. Care managers
or Nursing coordinators
 High staff turnover: train multiple staff, work with very small user
groups in well-defined phases
 Value Proposition: Too early in adoption phase for ROI
 Avoid penalties for readmissions, improve staff efficiency and reduce
staff time, reduce burden on patients and families
 More accurate and timely medication reconciliation, better access to
all anticoagulation results, fewer missed wound/therapy treatments
http://www.healthit.gov/sites/default/files/challengegrantslessonslearnedltpac_paper.pdf 2013

14. Supporting Collaborative, Coordinated Care
Socially Disadvantaged Clinically Vulnerable
Clinical
Documentation
Care Planning
Practice Technology
EHR
• Software /
database
• Functionality
• Configuration
tools
http://www.nationalehealth.org/ckfinder/userfiles/files/Improving%20Care%20Coordination%20Slide%20Deck.pdf
Content
• Evidence-based
• Intentional
automation
• Integrated
interprofessional
care
Workflow Design
Culture
Change

15. Conclusion
Incentives are aligned !
Complexity
is us !
Culture is ready ?

16. References
 Newhouse JP, et al. (2013). Variation in health care Spending: Target Decision Making, Not
Geography: http://www.nap.edu/catalog.php?record_id=18393
 Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA. 2012;307(14):1513-1516.
doi:10.1001/jama.2012.362
 Zilberberg MD, Tjia J. Growth in Dementia-Associated Hospitalizations Among the Oldest Old in the
United States: Implications for Ethical Health Services Planning. Arch Int Med 2011; 171; 1850-1851.
 Boult C, et al. (2009), Successful Models of Comprehensive Care for Older Adults with Chronic
Conditions: Evidence for the Institute of Medicine's “Retooling for an Aging America” Report. Journal
of the American Geriatrics Society, 57: 2328–2337. doi: 10.1111/j.1532-5415.2009.02571.x
 Kane RL (2009), What Can Improve Chronic Disease Care? Journal of the American Geriatrics Society,
57: 2338–2345. doi: 10.1111/j.1532-5415.2009.02569.x
 Reuben DB (2009), Better Ways to Care for Older Persons: Is Anybody Listening?. Journal of the
American Geriatrics Society, 57: 2348–2349. doi: 10.1111/j.1532-5415.2009.02574.x
 Reuben DB (2011). Physicians in Supporting Roles in Chronic Disease Care: The CareMore Model.
Journal of the American Geriatrics Society 59:158–160
 Dzau VJ, et al. Transforming Academic Health Centers for an Uncertain Future. N Engl J Med 2013
369;991-992.
 CareMore, 2012:
http://www.wellpoint.com/prodcontrib/groups/wellpoint/@wp_news_main/documents/wlp_assets
/pw_e181475.pdf
 Center for Aging Service Technologies, 2013:
http://www.leadingage.org/uploadedFiles/Content/About/CAST/Resources/2013_CAST_EHR_For_LT
PAC_A_Primer_on_Planning_and_Vendor_Selection.pdf