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What are the objectives of the program?
Improved care coordination, Improved health outcomes, Reductions in health disparities, Reduced readmissions, Increased use of preventive and primary care, Reduced utilization of post-acute care, Reduced utilization of post-acute care, Reduced transitions from post-acute care/long-term care, Reduced avoidable utilization, Reduced spending
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Please provide a brief description of the program:
The Frederick Integrated Healthcare Network clinically integrated network in Frederick County is contracted with multiple payors under performance based Agreements. One contract is the Medicare Shared Savings Program Track 1 ACO Agreement. The MSSP network has roughly 220 providers and 10,500 Medicare beneficiaries. We achieved a 95% quality score and $11 million in savings for Medicare during the last reported contract cycle in 2016.
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What is the primary source of funding for the program?
The health system provides the operating funding for the ACO.
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Is this program operated as part of HSCRC's Care Redesign Amendment?
No
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What are the major components of the program?
Care coordination/management, Patient assessment tools, Care transitions, Patient education/coaching/self-management, Multidisciplinary care teams, Patient care plans, Advance care plans/advance directives, Community health workers, Interventions to address social determinants of health, Protocols/agreements with care partners, Risk stratification, CRISP tools (e.g., Encounter Notification Service)
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What types of organizations participate in the program?
Physicians office (primary care), Hospital/health system, Skilled nursing facility, Home health care, Rehabilitation center, Hospice, Behavioral health provider (e.g., mental health and/or substance abuse), Non-clinical setting
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Which population(s) does the program target?
Medicare/older adults
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How many patients have participated in the program to date?
10500
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In what Maryland jurisdictions do participating patients reside?
Carroll, Frederick, Montgomery
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Briefly describe the staffing resources required to operate the program:
8.5 FTE care managers, 2 IT Analysts, 1 practice transformation specialist, 1 Director of Operations, many other resources shared with the health system, 2 part time co-Medical Directors.
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Briefly describe the key initial steps to implementation:
Board and physician education regarding transformation in healthcare reimbursement and national trends, engagement of key physician and community stakeholders, collaborating with experienced organizations, recruitment of strong leadership, making the case for participation based upon stakeholder needs and demonstration of community health metrics and opportunities, creating a vision for the future, contracting providers, applying to CMS.
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Are incentive payments to health care providers part of the program?
False
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Which incentive type(s)?
Shared savings, Shared resources (e.g., IT infrastructure)
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Does the innovation program qualify as a CMS Advanced Alternative Payment Model (APM)?
No
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What are/were the expected results in improved outcomes, population health, and cost savings?
Our goal was to achieve at least 3.5% cost savings and improve quality and customer service scores year over year. We have 19 different electronic medical record systems to abstract from for quality reporting.
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Have expected results for improving outcomes and population health been met?
Yes, expected results were achieved
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Please briefly explain your answer to Question 25, and describe any results for improved population health achieved to date:
By virtue of achieving a 95% quality score we improved the quality of care for patients with chronic conditions. This was evidenced by the improvement in scores for 17 HEDIS measures and outcome measures showing we reduced readmissions by 18%, admissions 10% and ER visits leading to hospitalization by 13%., Yes, expected results were achieved
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Please briefly explain your answer to Question 27, and describe any cost savings results achieved to date:
We achieved 9% savings of $11 million in savings that the network shared with CMS. Incentive payments were made to network physicians based upon criteria established by the network.
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Please provide URLs to any published evidence (e.g., peer-reviewed literature, white papers, etc.)
http://www.fihnaco.org/; http://www.fihn.org/ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/