Payer, providers collaborate on ACO

Initiative to reduce waste and variance in care

In Cheyenne, WY, a regional medical center, a small health plan, and a community-based provider group are working together to develop an accountable care organization with the goal of reducing fragmentation, waste, and variance in care.

Cheyenne Accountable Care Organization LLC is a partnership between Cheyenne Regional Medical Center, Southeast Wyoming IPA, and WIN Health Partners, a health plan owned jointly by the hospital and the provider group.

"We are part of one big infrastructure, and while we historically had different employers, now we all have the same parent organization," says Victoria Choate, RN, CCM, RN-BC, CCP, PAHM, vice president of performance excellence and chief quality officer at Cheyenne Regional Medical Center.

Cheyenne is a small city (60,000) in a sparsely populated state of about half-a-million residents.

The hospital started conversations with the IPA and the health plan about two years ago under the leadership of John Lucas, MD, MPH, FACPE, CEO of the medical center.

"We knew that a lot of changes were coming down the pike and that our past efforts to create a seamless continuum of care had been less successful than we would like them to be. We knew that we had to be positioned to optimally manage chronic diseases and coordinate care for patients through the continuum," Choate says.

The hospital started by bringing together the key stakeholders, educating them on what accountable care means, working together to develop a business plan, and designing the model.

"The partnerships and unification of the vision is happening here in Cheyenne. We have moved beyond having separate camps and have built partnerships and relationships where they've never existed. We have a widespread understanding among all the participants that our success is going to be achieved through unification and collaboration," Choate says.

The organization has a three-year plan to develop and implement the accountable care organization.

"We are moving into acting as a collaborative model. In two years, we will be in an integrated model and ready for accountable care across the entire organization. It's been evolutionary, and it continues to be evolutionary. We are learning every day as we build an accountable care structure," Choate says.

The organization is managed by committees that include members of the boards of all three entities.

Choate is a member of the medical home pilot committee and chair for the organizationwide population and health data committee, which held its first meeting in mid-November. Members of that committee include case managers from all the entities, hospital physicians, physicians from the community, and data specialists.

"Care coordinators across the continuum have interfaced with each other daily for long periods of time, but we've never sat down and talked about what we do. When care coordinators from all levels of care get together, they can talk about the challenges and the needs at each level of care and set meaningful goals," she says.

The committee will use population and health data to make informed decisions as the initiative progresses, Choate says.

Committee members are sharing what patient data they currently are collecting, how they are measuring it, how frequently they are measuring it, and what they do when they find outliers.

"We are looking at where we are duplicating the effort and identifying gaps in the collection of data. Our committee will work with all of the entities to ensure that we are measuring quality appropriately and we are truly building the continuum of care that allows us to create a seamless experience for every patient," she says.

For instance, most physician practices don't collect quality or utilization data. The hospital and health plan collect quality data; the health plan collects utilization data and the hospital clinical outcome data.

"There are suites of metrics for every level of care. Our goal is to use the data collected by all entities to address population health outcomes. We need to decide as a group what metrics we will review to ensure that we are successful. We will all own the outcomes of these metrics," she says.

For instance, if a physician practice is treating 3,000 diabetics, the team can analyze the entire population's hemoglobin A1c and identify the outliers. Then case managers can come in through the medical home to support the physicians in seeing that the diabetics get the recommended care and lower their blood sugar levels.

"In order to be accountable, all entities have to have quality-focused programs. At this point, we're very much in the building stage," Choate says.

The initiative gets the stakeholders together to look at evidence-based resources to guide what care a patient needs from the home health nurse to the nurse in the hospital to the provider who orders the treatment, she says.

"One of the goals is to decrease variances in care. For instance, if the treatment of heart failure patients in the hospital varies by provider, we are not assured that every patient is getting the best treatment. We are going to start using evidence-based treatment protocols so that the case manager and the rest of the team can be assured that the patient is receiving the best practices," she says.

As part of the accountable care initiative, the hospital has completely redesigned its case management model, incorporating the Milliman care guidelines, an evidence-based clinical decision-making tool for case managers.

The guidelines can be used to determine whether a patient should be admitted as an inpatient or receive observation services. They outline what the treatment plan should be on each day of the stay, what the clinical improvement should be, where the patient should be discharged, and what level of service he or she should receive at the next level of care, she says.

"This is not a cookie-cutter approach to health care. The guidelines are used through the lens of individual patients and clinical providers. The providers still have to write orders implementing the evidence-based order set," she says.

The hospital began using the guidelines Nov. 1, 2010. The goal is to have them used systemwide when the accountable care organization becomes fully operational.

"The guidelines can be an evidence-based resource, whether they're being used by a hospital physician, a primary care provider, or a home health nurse. They are one way to promote accountability by all the clinicians throughout the continuum," she says.

The ACO model is still in the development stage, but some components have already been rolled out.

For instance, the hospital's inpatient heart failure program follows patients into the outpatient setting.

The case manager starts educating heart failure patients about their disease and how to manage it in the hospital and gives patients a set of scales at discharge.

"An integral part of the heart failure management program is follow-up calls to make sure that the patient is weighing himself. If he keeps gaining weight, we may connect him with home health or the primary care physician," she says.

The goal of the program is to ensure that heart failure patients have optimal health management and reduce unnecessary utilization.

"If we catch an exacerbation early enough, it can be treated at home or through the medical home office and eliminate a trip to the emergency room or a hospitalization," she says.

Coordination of care throughout the continuum is a key component of the accountable care model, Choate points out.

"If the patient is getting care in his or her medical home, the case manager may be there. If they are in the hospital, the case manager may be at the bedside. As they transition to other levels of care, we'll follow them, if not in person through case review and contact with the person following the care," she says.

The hospital and physician group are working together on a medical home model, which is being piloted at the Cheyenne Health and Wellness Center, the area's federally qualified health center.

The pilot, which began Oct. 1, 2010, is beginning to focus on patients with chronic conditions who are discharged from the hospital and who have no source of ongoing primary care.

"We are calling it a 'health home' model instead of a 'medical home' because we want to promote health and wellness," Choate says.

In Cheyenne, the health plan is providing business support for the model, helping with designing the reimbursement structure, the claims payment piece, and providing outpatient case management and disease management.

The project is still in the early stages, but already it's making a difference, Choate says

"Health care reform has been a great launching pad for this initiative. Reimbursement reform and pay for quality is changing the landscape for how health care is delivered. The health plan, medical center, and provider group are combining their vision and talent to create a single, state-of-the-art accountable care system," she says.