For more information contact: Slideshare@marcusevans.com Presentation delivered by Donna Medina, Regional Director,OSF Hospice and Homecare Foundation at the marcus evans Home Care Leadership Summit held on July 13 & 14 2015 in Palm Beach FL.

1. Managing ACO PopulationsManaging ACO Populations
Across the Continuum
Fi i ll d Cli i llFinancially and Clinically
Donna Medina MS, BSN,RN, CHA.

2. Objectivesj
Id tif th k t d t t f h t tiIdentify the key components and structure of each tactic
Identify the tactics feasible and appropriate for your organization
Identify barriers to success
Identify mitigation solutions for each barrier
Develop the framework for monitoring outcomes and success for each tactic

3. ACO Defined
Managing patients across continuum clinicallyManaging patients across continuum clinically
1. Beyond walls of facility
2. Engaging ambulatory and physicians
3. Engaging patientsg g g p
4. Maximizing reports through EMR
Managing patient costs across continuum
1. Physician offices
2. Home Health and Hospice
3. Nursing Homes
4 I th i h4. In their own home

4. Needed Support Structurespp
Ministry Supportive Care Model
Must develop infrastructure first
1. Governing Board
2. Regional Committeesg
3. Operational Committees
4. Front line staff
Services within Supportive CareServices within Supportive Care
1. Care Decisions
2. Inpatient Palliative Care
3 Hospice3. Hospice
4. Outpatient Palliative Care

5. Care Decisions
B d L th G dBased program on Lutheran Gunderson program
More than 200 trained facilitators in all regions and facilities
Not about a signed document, it is all about the discussion
Have completed more than 22,000 since 2005
Target high risk, chronically ill, and over 60 years of age
Allocate resources/time
Computerized tracking/data entry
Access to documents in EMR
Approach for hospital, physician offices, and home care

6. Care Decision Impact Analysisp y
St ti ti ll d d i i i k h 49 th i bl t ll dStatistically reduces readmission risk when 49 other variables are controlled
Risk Total
Enco nters
Readmits Expected
Readmits
Difference
Encounters Readmits
Low to
medium low
899 33 33 0
Medium low to 895 37 59 22Medium low to
Medium high
895 37 59 22
Medium high
to high risk
320 21 37 16
Summary 2114 91 129 38

7. Inpatient Palliative Carep
St d di d b t i t h h it l i l ti d itStandardized, but unique to each hospital size, population, and community
Interdisciplinary approach
Achieving this outcome 80% of time
Improved clinical outcomes for pain, dyspnea, nausea and vomiting
Patients with Inpatient Palliative Care referral had decreased LOS by 2 days
Cost avoidance and opened beds for new admissions
Increased referrals to Hospice
These patients had longer hospice LOS
Better patient satisfaction

8. Ambulatory Palliative Carey
I iti l Pil t 2• Initial Pilot 2 years ago
• Serious issues/challenges/failures
• New Pilot 2015 successful
• Implementation plan in development for 2016
• APN and interdisciplinary team driven
• Number was 128 patients from Inpatient Palliative Care
• 20% came into pilot
• Others went to hospice, lived outside geographic area, rehab, L tach, or died
• 56% of patients in pilot had multiple disciplines involved

9. OPC disciplinesp
APN 75 FTEAPN .75 FTE
MSW, Chaplain, RN, Aide, Care Manager combined to equal .4 FTE
Total cost for 3 months was $19,000
Time included 15 minute huddles 2-3 times per week (done with Lync), IDT,
chart audits, scheduling/emails, coordination, travel time, telephone time,
visits and charting
44% of these were medium risk and 56 % high risk patients44% of these were medium risk and 56 % high risk patients
33% had Care Decisions completed prior to their referral to Inpatient
Palliative Care. 76% completed during their stay.
88% of them were Medicare or Medicaid

10. Out Patient Palliative Care
G l D h it l d i iGoals; Decrease hospital readmissions
Avoid ED visits
Pulled historical data for previous 12 months on these patients and compared
it to their pilot data Avoided 13 ED visits during pilot and annualized wouldit to their pilot data. Avoided 13 ED visits during pilot and annualized would
be 52 Ed visits.
Avoided 6 readmissions for pilot 3 months and annualized would be 24
readmissions.
Freed up 342 bed days for these readmissions avoided.
Avoided costs of $571,140.00 annually at a cost of $76,000 for OPC staff and
freed these bed days for other paying patients.
One team can manage 267 patients per year.

11. Home Care Services
Home Health Initiatives:
1 Case Management Model1. Case Management Model
2. Nurse and buddy: case load of 25 and buddy 10
3. Continuity, care improvement.
Continuity increased from 3.5 or greater to 1.5y g
Nursing productivity improved, mileage increase of less than 1 mile per visit.
Satisfaction scores improved from less than 30 percentile ranking to above
80th percentile.
4. Physician relationship
5. Using data alerts to identify and transition patients form HH to hospice

12. Hospice Initiativesp
I f ti l i itInformational visits
EMR report identifying all potential HH patients with hospice diagnosis
Collaboration with HH
Identification with HH admission visit and transition
Successful transition of more than 450 patients from HH to hospice
96% of patients admitted day of referral
More than 250 community education events

13. SNF Practice for ACO patientsp
Ph i i d APN d iPhysician and APN driven
35% of discharges go to HH, Hospice or SNF
15.4% discharged to SNF
$13 million in claims of OSF ACO patients made to Preferred Network SNF
Preferred SNFs: 14 of current 18 used are preferred.
Criteria includes CMS Star rating, willingness to collaborate, accept patients
24/7 dit d d i i fi t d bilit ll di ti24/7, expedited admission process, first dose capability, all medications
within 3 hours of order, RN on site, offer therapy 6 days a week, all ACO OSF
patients followed by OSF physician and services.
Why would they partner?

14. Preferred SNF Metrics
2013 2014 20152013 2014 2015
Average LOS 42 29 24
% ED visits 24% 23% 11%
% 30 day readmissions 33% 27% 19%
% flu shot 15.74% 53%
% HH/HO referral 62% 68%
% pneumonia vaccine 70% 81% 82%

15. Physician Practicey
E Ph i iEngage Physicians:
* Using ACO data
* Focused story telling
* Reducing their work load where possible
* Earning RVU for advance care planning and End of Life discussions
Medical Home
* Care Coordinators assigned to high risk patients
* Collaboration between entities, hand offs
Hospitalists

16. IMPACT of EMR
I f ti AInformation Access
Visibility across continuum
One medication record
OSF My Health Chart
Amazing reporting abilities and potential
Real time data

17. Ministry Wide Roundingy g
H it lHospitals
Ambulatory centers
Physician Offices
Home Health
Hospice
HME
HIP
Ministry wide, structure unique

18. Eating The Elephantg p
A lAnalyze
Identify Quick Wins
ROI
Prioritize
Long range Strategy

19. Barriers
O i ti l C ltOrganizational Culture
IC2IT
Beliefs:
1. Patient First
2. Be One
3. Align Priorities
4. Embrace Decisions
5. Be Accountable
6. Live It

20. Culture
Pyramid
Change experience to change belief to move to new actions and new
outcomesoutcomes.
Tools

21. Barriers ContinuedBarriers Continued
Ph i i E tPhysician Engagement
Associated costs
ACO outmigration
Understanding and adoption of Cost avoidance benefit

22. Outcomes
C D i iCare Decisions
Cost avoidance
Reduction in re-admissions
Reduction in repeat ER visits
Reduction in inpatient mortality
Improved scores in CAPC and Press Ganey
Admitted to appropriate level of care

23. How Can I Help?p
D M M di MS BSN RN CHADonna M. Medina MS, BSN, RN, CHA.
donna.medina@osfhealthcare.org
(309) 683-7745