Category: Leadership Strategy, Clinical Transformation
Houston Methodist Coordinated Care Team: Building a Medicare MSSP Network
In 2017, Houston Methodist healthcare system, which includes one hospital in the Texas Medical Center and six community hospitals, made its first venture into financial risk with a payer in the Medicare Shared Savings Program (MSSP) Track 3, as part of a broader strategy to prepare the organization for value-based care. In one year, the program significantly reduced hospital admissions, readmissions, postacute facility and home health utilization, as well as costs. But getting there involved building an ACO from the ground up.
Houston Methodist Coordinated Care (HMCC) ACO, which is the first MSSP Track 3 program in its market, faced steep goals from the start. Leaders needed to introduce and coordinate value-based care within a seven-hospital system. The team was tasked with developing a primary care network of both employed and independent providers, a nursing care management team with specific patient care programs, and key performance indicators. It also needed to develop a network of collaborations with community partners in order to succeed in value-based care.
The first step was to form Houston Methodist Coordinated Care. Developing a robust data and analytics strategy was central to HMCC. To that end, HMCC's leadership team tapped into claims data that provided key insights into quality, cost, and utilization goals. The population health advisors team also shared quality and utilization data with PCPs and specialists. At the same time, the nursing care management team used predictive analytics to enroll and engage patients in several population health programs.
HMCC also improved patient access and care coordination in key areas, including primary care, urgent care, the ED, postacute care, and home healthcare. Primary care physicians focused on ACO quality metrics and documentation to reflect the complexity of care provided to each patient, as well as making sure patient referrals and hand-offs were tracked. The postacute team engaged more than 19 skilled nursing facilities in the greater Houston area and implemented a home health review strategy with PCPs.
The case management team worked closely with physicians, patients, and home health agencies to make more accurate recommendations, thus reducing home health utilization and providing patients with the services needed. Moreover, the organization's social work/case management team developed a value-based discharge planning model for MSSP patients that takes into consideration the social determinants of health, including both nonclinical and clinical factors, when discharging patients.
As a result of these developments, primary care physician post-discharge follow-up appointments, fall risk screenings, and depression screenings increased. The organization has also bumped up urgent care utilization after hours and on weekends to keep patients out of the ED when appropriate. A high priority patient access line, Call your Nurse, establishes continuity between nurse teams and patients.
Ensuring physicians had connectivity to ACO quality goals was also essential. The team worked with private practice physicians to achieve a level of IT interconnectivity with seven different EHRs. Today, not only are physicians able to access patient medical records, but dashboards enable the team to monitor quality efforts and metrics in real time. The team's focus on quality at the patient, physician, and practice level is directed by real-time data and the review of outcomes.
In the first year, HMCC decreased the following:
- Hospital admissions – 6%
- Hospital readmissions – 0.5%
- Inpatient rehab facility utilization – 14%
- Long-term acute-care utilization –16%
- Skilled nursing facility utilization – 9%
With this success, the ACO is growing its primary care network. The number of primary care physicians has increased from 128 to 164, and Medicare beneficiaries have climbed from 16,299 to 22,500 in the second year.
"Our first year was a real journey for our health system and our ACO team," says Julia Andrieni, MD, FACP, vice president population health and primary care, and president and CEO of HMCC. "Our HMCC team is known for their dedication and data-driven approach to innovation. HMCC took risk in an MSSP Track 3 program, which drove transformative change on a system level."