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Slide 1: 

Comprehensive Organized Medicine Provided Across a Seamless System COMPASS Paving the Way: To Clinical Integration From Physician Group Practice Demonstration Nan L. Holland, RN, BSN, MPH,CPHRM Senior Director, Clinical Resource Services Novant Medical Group

Slide 2: 

PGP Group 300 Physicians 137 Physician extenders 437 Overall providers 62 Practices

Paying for Quality, Not Quantity : 

Paying for Quality, Not Quantity “It is time we pay for the quality of the healthcare provided, not simply the amount. We are working to apply this to every setting in which Medicare and Medicaid pays for care” Mark B. McClellan, MD, PhD, CMS Administrator

CMS PGP Objectives : 

CMS PGP Objectives Encourage coordination of Part A & Part B Coordinate care for chronically ill and high cost beneficiaries in an efficient manner Decrease the growth in Medicare spending over the next 3 years

The demonstration uses a total of 32 measures that focus on common chronic illnesses and preventive services : 

The demonstration uses a total of 32 measures that focus on common chronic illnesses and preventive services

CMS PGP Quality Measures : 

CMS PGP Quality Measures Year 1: Diabetes Year 2: Year 1 plus HF and CAD Year 3: Year 2 plus Hypertension and colorectal and breast cancer screenings + flu and pneumonia vaccines Total 32 Outpatient Taken from the Doctor’s Office Quality measurement set in 1992. Thus some of the target measurements are not the current quantitative benchmark.

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CMS PGP Patient Focus Areas METABOLIC DISEASE: DIABETES HTN CARDIOLOGY: HF CAD Needless Admissions: 5 Wishes Nursing Home Psychiatry Medication Reconciliation PREVENTIVE CARE: Colorectal & Breast Cancer Screening Immunizations

Disease Management Drives the Chronic Care Model in Physician Practice : 

Disease Management Drives the Chronic Care Model in Physician Practice Supports the physician or practitioner/patient relationship and plan of care; Emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies; and Evaluates clinical, humanistic, and economic outcomes on an on-going basis with the goal of improving overall health. Disease Management Association of America 2010

Chronic Care Model : 

Chronic Care Model Community Productive Interactions Prepared Practice Team Informed, Activated Patient Health System Self-Management Delivery Decision Clinical Support System Support Information Systems Developed by the MacCall Institute

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Forsyth Novant Group Results : 

Forsyth Novant Group Results PY1: Achieved 10/10 Diabetes targets, 22/22 total points (100%) NMG growth rate flat Inpatient costs lower than Comparison Group PY2: Achieved 10/10 Diabetes targets, 10/10 HF, 7/7 CAD, (100%) Same growth rate in risk score and decreased IP expenditures PY3: Achieved 30 of 32 quality measures overall (97% of points) Did not exceed the 2% threshold, thus no bonus received in first 3 years

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Shared Medical Appointment and Educational Classes

Slide 23: 

Safe Med Program

Fit To Life : 

Fit To Life Making Healthy Choices That FIT Your LIFE

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Retooling Care: Physician and Patient Perspective Improving Decision Support and Patient Engagement in Chronic Care Initiatives to Assist Physicians Initiatives to Assist Patients Disease Registries Specialty Clinics Outreach Patient Navigators Chronic Care Collaboratives Chart-Based Patient Management Tool Name: J. Smith Address: 5 Main Doubling, TX Phone:123-4567 Patient tracking made simple through online registries for all major chronic conditions Phone calls, e-mail and postal reminders to help change behavior ● Safe Med ● COMPASS ● Health Vault Outreach reminders embedded in charts and patient records to assist physicians in care Provide additional support in patient monitoring and management ● Coumadin ● Lipid ● Diabetes Adopt best practices from shared learning to improve office operations Patient Self Management tools Navigators coach, educate, and encourage select patients in making difficult lifestyle changes ● Safe Med ● COMPASS

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Organizational Readiness Clinical Integration Hospital Infrastructure Performance Improvement Physician Partnership Payer Supportiveness Focus on Care Coordination Physician Engagement in achieving strategic goals Create IT infrastructure capable of sharing information across care sites Leverage performance data system Identify opportunities to continuously improve performance across the continuum of care Engage physicians interest in performance improvement Develop understanding of the value of system alignment Create a compelling business case for payers

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Change is difficult but possible Collaboration is critical Community Partnerships extend the reach Leadership is essential Don’t re-invent the wheel EMR is helpful but not essential to get started Lessons Learned

Slide 28: 

PGP Experience Patient-Centered Model ACO

Many Thanks : 

Many Thanks Questions?