Provider Insider

Issue 3

Table of Contents

Network News

  • Welcome new members
  • Engagement Summit
  • Shared savings update

 

 

Welcome new members.

Coordinated Care is composed of primary care and specialty practices from Pueblo to Steamboat Springs and includes UCHealth Medical Group, CU Medicine, Associates in Family Medicine and several independent practices. These entities represent more than 3,000 providers and 150,000 attributed lives.

 

In this issue, we are pleased to welcome Northern Colorado Hospitalists PLLC to the Network. An independent, locally run hospitalist program comprised of internal medicine and board-certified physicians, this group of 37 providers is supported by more than a dozen registered nurses and administrative staff. They offer hospitalist services at UCHealth Poudre Valley Hospital in Fort Collins and UCHealth Medical Center of the Rockies in Loveland.

 

As we continue to grow Coordinated Care’s footprint in Colorado, we improve patient accessibility and increase our value to those whom we serve.

 

 

Engagement Summit.

To better serve our partners, Coordinated Care will reschedule its Engagement Summit, currently planned for November 1, 2018. The new date will be after the first of the year; once confirmed, we will send additional correspondence with those details. We apologize for any inconvenience this may cause, and hope you are able to join us in the new year.

 

 

Shared savings update.

Anthem Commercial EPHC 2017 final performance results are in. Our final network quality score was 64 percent—an improvement over last year’s 55 percent. And, we earned a shared savings of $1.78 million This represents approximately half of the total dollars issued to Colorado’s nine participating accountable care organizations or empaneled provider groups that produced shared savings for the 2017 calendar year.

 

Payer’s Perspective

Sixty-five. The magic number. The birthday that delivers a golden ticket… Medicare.

 

Unfortunately, many new beneficiaries find themselves lost when they qualify for the program. There are a multitude of coverage options and they do not know where to go, what questions to ask or where to find the answers.

 

To help primary care physicians and staff better serve their patients, Coordinated Care has partnered with independent advisors who can help navigate Medicare’s complexities by offering non-biased educational options that consider multiple solutions from various partners.

 

Some benefits of working with independent Medicare advisors:

  • Advisors are trained and vetted to understand the needs of patients and providers.
  • Advisors represent multiple insurance options; information presented to patients is objective and free of bias toward payer and program.
  • Advisors have completed extensive training and certifications allowing them to provide customized care with independent consideration for financial and estate planning, caregiver training, federal and state programs for retirees, etc.
  • Advisors will assist members in qualifying for other government programs such as Medicaid and low-income subsidies.
  • Advisors are flexible in how information is communicated to patients – they can partner with providers to educate patients, and prospective patients, via community outreach programs or events. Or they can work independently with patients on the provider’s behalf.
  • Providers may elect to receive mid-year updates explaining anticipated changes in the Medicare environment – information that can be proactively passed on to patients.

Medicare’s 2019 Open Enrollment period is from October 15 – December 7, 2018. During this time, individuals may make various changes to their coverage like switching from Original Medicare to Medicare Advantage (or vice versa) and switching from one Medicare Advantage or Medicare Part D plan to another.

 

If you would like to participate in a community outreach program giving your patients, and prospective patients, an opportunity to learn more, please contact Paul.Staley@uchealth.org or Austin.Bailey@uchealth.org.

Pharmacy Integration Insights

Statins are among the most effective medications in reducing risk of cardiovascular disease. Overwhelming data from the past 20-30 years has proven statin therapy can reduce risk of vascular events and cardiovascular mortality in high-risk patients, particularly those with CV risk factors, existing vascular disease or diabetes.

 

Given the known and clear benefit of statin therapy to patients, Coordinated Care is working collaboratively with providers, clinical pharmacists and other members of the health care team to improve the use of statins in patients with diabetes. Currently, there are two interventions to support this effort:

    1. Statin therapy for diabetes patients will be added to Epic’s health maintenance tools this fall to alert providers and staff when a patient is indicated, but not receiving therapy.
    2. The Network’s clinical pharmacists have begun to pilot patient outreach, chart review and to provide recommendations for therapy initiation to providers.

To date, Coordinated Care’s clinical pharmacists have provided medication recommendations to providers for more than 600 patients, and 100+ statins have been initiated.

 

 

Statin-associated muscle symptoms.

A significant barrier in the initiation of statin therapy is a past history of statin-associated muscle symptoms (SAMS) in some patients. SAMS include muscle symptoms ranging from myalgia, defined as muscle aches or pain, to myonecrosis, defined as muscle breakdown resulting in muscle enzyme elevation.1 Myalgia is the most common muscle symptom and has been shown to occur in 11 to 29 percent of patients in observational trials.

 

To optimize the use of statin therapy, clinicians should educate patients on the risk of SAMS, proactively identify risk factors for developing SAMS and resolve when possible, and modify therapy if symptoms develop. The goal is to ensure high-risk patients can utilize this beneficial tool to the greatest extent possible.

 

 

Risk factors.

It is important to identify potential risk factors associated with SAMS and, if possible, correct before prescribing a statin. Some of these may include statin characteristics, hypovitaminosis D, hypothyroidism and concomitant medication use leading to potential drug interactions.

 

 

 

Evaluation and management.

Since myalgias and myopathies are patient-reported symptoms that may be associated with several different causes, it is essential to critically evaluate the presentation to determine if these symptoms are SAMS. The Statin Muscle Safety Task Force proposed the “statin myalgia clinical index score” shown below.2

 

 

Clinical Symptoms Points
Symmetric hip flexors/thigh aches 3
Symmetric calf aches 2
Symmetric upper proximal aches 2
Nonspecific, asymmetric, intermittent 1
Temporal Pattern
Onset <4 weeks 3
Onset 4-12 weeks 2
Onset >12 weeks 1
Dechallenge
Improves upon withdrawal (<2 weeks) 2
Improves upon withdrawal (2-4 weeks) 1
Does not improve upon withdrawal (>4 weeks) 0
Rechallenge
Same symptoms reoccur <4 weeks 3
Same symptoms reoccur 4-12 weeks 1
Statin Myalgia Clinical Index Score

Probable: 9-11 points

Possible: 7-8 points

Unlikely: <7 points

 

The initial evaluation should rule out predisposing factors and a blood draw to determine creatine kinase (CK) should be performed to appropriately characterize the symptom(s). If SAMS are intolerable or the CK is greater than three times the upper limit of normal, the statin should be discontinued for 2-4 weeks. Further management of SAMS is dictated by the resolution or persistence of the symptoms during this washout period. If symptoms persist, a more in-depth workup is warranted and may necessitate referral to a neuromuscular specialist for advanced testing.

 

Management of patients in whom their symptoms resolve is summarized in the algorithm below, which has been adapted from the Statin Muscle Safety Task Force’s “Algorithm for the evaluation of statin-associated muscle injury.”

 

 

The bottom line.

SAMS are commonly reported by patients in clinical practice. Considering the magnitude of cardiovascular benefit that statin therapy confers, it is essential to critically evaluate each patient with SAMS with the goal to maintain statin therapy as an alternative agent or dosing regimen.

Questions or comments? Please contact Joseph.VandeGriend@uchealth.org.

 

 

Ian Hatlee, PharmD and former PGY2 resident with the University of Colorado Skaggs School of Pharmacy contributed to this article.

 

References:

      1. Rosenson R, Baker S, Jacobson T, Kopecky S, Parker B. An assessment by the Statin Muscle Safety Task Force: 2014 update. J Clin Lipidol. 2014;8(3):S58-S71. doi:10.1016/j.jacl.2014.03.004.
      2. Ahmed W, Khan N, Glueck CJ, et al. Low serum 25 (OH) vitamin D levels (,32 ng/mL) are associated with reversible myositis-myalgia in statin-treated patients. Transl Res. 2009;153:11–16.
      3. Duyff R. Neuromuscular findings in thyroid dysfunction: a prospective clinical and electrodiagnostic study. Journal of Neurology, Neurosurgery & Psychiatry. 2000;68(6):750-755. doi:10.1136/jnnp.68.6.750.
      4. Kellick KA, Bottorff M, Toth PP. A clinician’s guide to statin drug-drug interactions. J Clin Lipidol. 2014;8(3):S30-S46. doi:10.1016/j.jacl.2014.03.004.

Quadruple Aim Progress Report

From the beginning, one of Coordinated Care’s key operating objectives has been to share performance reports with its members. The Network began development of a dashboard that would measure against broad Key Performance Indicators (KPIs) in October 2016. And today, it publishes monthly quality performance reports that utilize a data aggregator to analyze performance by Network entity, region, value-based program and more. Each member partner has the ability, via Power BI, to view its performance against key quality metrics.

 

This progression, and the insights that can be gleaned from custom reporting, has allowed the Network to determine where opportunity resides, design transformation work plans to address those opportunities, and witness how interventions have impacted performance over time.

 

Delivering against KPIs.

Targeted outreach to patients has shown a steady increase in colorectal cancer screenings over the last eight months. And last year, Network partners agreed to dedicate resources to improve care for the diabetic population. As a result, nephropathy screenings and treatment continuously exceed target.

 

The following charts illustrate the Network’s performance over time:

 

 

 

 

 

But our journey to optimal quality performance is just that – a journey. It is not a project with a start date and an end date. Coordinated Care will continue to look to the future and strive for excellence.

 

Coming this fall.

Diabetes hemoglobin A1c has been revised to follow national quality standards and therefore allow the Network to compare its performance with that of its peers. The diabetes statin measure will reflect the percentage of diabetic patients age 40-75 who are on a statin medication and allow the Network’s clinical pharmacists to address opportunities for improvement.

 

This information, along with any additional dashboard insights or enhancements, will be delivered to providers with the regular cadence of data already reported.

 

The Population Health Services Organization remains committed to working with all member providers to accomplish the Network’s Quadruple Aim, and looks forward to celebrating future accomplishments and persevering through ongoing improvements.

 

Please contact Michelle McLeod, PHSO clinical transformation, with questions and comments at michelle.mcleod@uchealth.org.

Transformation Insights

Behavioral health continually surfaces as an area of opportunity for the medical community. It is estimated that 25 to 30 percent of all primary care patients could benefit from behavioral health interventions, yet the health care system has struggled to provide the resources required to meet this need.

 

There are a number of primary care providers within the Coordinated Care that have narrowed this gap by exploring solutions like co-location, integration and telehealth. This has allowed those providers to further enrich patient experience by improving access to behavioral health care and reducing associated stigma.

 

Starting with co-location of services.

Co-location refers to services or providers that are located in the same physical space but may not be fully integrated with one another. Because this model presents opportunities to streamline referrals, diversify payer mix and improve communication between providers, many behavioral health professionals see co-location at primary care practices as an appealing arrangement.

 

Licensed clinical social workers offer the most versatility in these types of relationships. They may dedicate a few hours each week to see patients at a primary care provider’s office, or they may agree to be on-site full time if patient volume is sufficient to support that level of service. Having a specialist on-site allows the treatment team to communicate directly with the behavioral health provider.

 

Co-location is not without challenges, however. While primary care and behavioral health clinicians occupy the same space, they often practice independently, relying on traditional referral models and maintaining separate systems for medical record-keeping and billing. Providers must prioritize communication or risk the benefits a treatment team provides.

 

Graduating to integrated care.

The primary goal of most integrated care programs is to improve communication between primary care providers and behavioral health specialists to address mental health and physical problems in a comprehensive, coordinated and collaborative manner.

 

Cost and reimbursement remain the biggest barriers to adoption. But as health care moves away from fee-for-service payment models and providers are given responsibility for the overall health of patient populations, those barriers are slowly becoming surmountable.

 

A growing number of Coordinated Care medical practices are finding success in embedding a behaviorist as a full-time staff member. Much like co-location, this solution delivers team-based collaborative care; however, it also allows group providers to draw upon shared knowledge, principles and care plans to work toward patient goals. Shared clinical records and billing systems help close any potential gaps that may otherwise occur.

 

Testing telehealth.

The most innovate health systems are piloting telehealth as a resource for mental health care – UCHealth among them.

Primary care practices that have been unable to successfully co-locate or embed a behaviorist can offer this as an alternative resource for patients requiring mental health care. To effectively execute this strategy, physicians should first establish strong rapport and understanding with their preferred behaviorist. And then take it slow, easing into the relationship and having patients engage via telehealth with the mental health professional from the familiar surroundings of the primary care physician’s office.

 

Key takeaways.

In any of these situations, it is critical that the behavioral health provider be very accomplished in all behavioral health resources available to patients. Some patients may require more intensive services like inpatient care, partial hospital care, intensive outpatient care or individual care. The clinicians must also be very flexible about being interrupted, working as part of a care team and have the ability to perform cognitive behavioral therapy.

 

Coordinated Care is committed to enriching patient experience, improving health care outcomes, increasing provider satisfaction and reducing cost of care, and will continue to work with practices to acquire the resources required to be successful in this realm.

 

We invite you to share your practice’s success with the population health team. Please feel free to direct any questions to Paul.Staley@uchealth.org or Austin.Bailey@uchealth.org.

 

 

Click here to learn how one patient’s life was dramatically improved by a team of integrated providers, Integrated primary care: help for both Alzheimer’s and anxiety.

Leadership Message

Coordinated Care members share a common belief that collaboration and innovation can enrich patient experience, improve health care outcomes, increase provider satisfaction and reduce the overall cost of care. To transform that belief into a reality, it takes time. Your time. And a collective, determined effort.

 

Please allow me to take this opportunity to say thank you. On behalf of the entire Population Health Services Organization, thanks to all of you for your engagement and hard work this year – your efforts have paid off and are yielding positive results across all of our value-based programs.

 

Some of our accomplishments worth noting: there are participating providers employing advanced scheduling methods, thereby ensuring access for their patients and thereby decreasing ED utilization. Practices reaching out to patients after every ED visit and hospitalization. Whiteboards and data walls keeping clinical teams focused on priority metrics. Across the state, everyone is trying something new, and our combined efforts are delivering improved quality scores and growing shared savings pools. It has been an amazing transformation.

 

But our work is just beginning. Our Network development team is learning from you. We also encourage you to learn from one another. Early next year, we will be hosting our second Coordinated Care Engagement Summit in metro Denver and highlighting some of the best practices from around the Network. We hope that you will join us. Get to know your colleagues and what each one is doing to improve care for our patients so we can continue to grow and thrive together.

 

Again, thanks to each and every one of you for making this Network a successful venture. We’re looking forward to another great year ahead.

 

Austin Bailey, MD
Population Health Services Organization
Medical Director, Coordinated Care