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Moderator: Marisa Scala Foley

07-16-13/1:30 pm CT

Confirmation # 6023455

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NWX-HHS-AOA-1

Moderator: Marisa Scala Foley

July 16, 2013

1:30 pm CT

Coordinator: Welcome and thank you for standing by.

All participants will be in a listen only mode until the question and answer 

session of today’s call.

At that time to ask your question please press star 1. You’ll be prompted to 

state your name. Please do so, so that we may announce you.

Today’s call is being recorded. If anyone has any objections you may 

disconnect at this time.

Now I would like to turn the call over to your host Lauren Solkowski. You 

may begin.

Lauren Solkowski: Thank you (Diane). And thank you everyone for joining us today for the 

ACL Targeted Technical Assistance webinar, Perspectives from an 

Accountable Care Organization and a Health Plan.
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On today’s webinar we will be hearing from both a health plan and the 

Accountable Care Organization in terms of how they come to some of their 

decisions in partnering with community-based organizations and what also are 

some of their expectations or requirements of CBOs that are part of their 

network.

So before we get started with the actual presentations, there are a few 

housekeeping announcements that I’ll run through so to start if you have not 

done so yet please use the link included in your calendar appointment to get 

onto WebEx so that you cannot only follow along with the slides as we go 

through them but also ask your questions as you have them through the chat 

function.

If you don’t have access to the link that we emailed you, you can also go to 

www.webex.com. Click on the Attend a Meeting button at the top of the page 

and then enter the Meeting Number which is 665887127 so that’s 665887127.

If you have any other problems getting into WebEx you can also call the 

WebEx Tech Support at 1-866-569-3239, that’s 1-866-569-3239.

Now as (Diane) mentioned we are - all the participants are in listen only 

mode. However we do welcome your questions throughout the course of this 

webinar. And there are two ways that you can ask questions.

The first being through using the chat function in WebEx, you can enter your 

questions and we will sort through them and answer them as best we can when 

we take breaks for questions between each speaker.
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And then the second way is that after the speakers wrap up we will offer you a 

chance to ask questions through the audio line. And when that time comes 

(Diane) will provide instructions as to how to queue up to ask your questions.

If there are any questions that we cannot answer during the course of the 

webinar we will be sure to follow-up with you and get them answered. If you 

think of any questions after the webinar you - please feel free to email them to 

me at lauren.solkowski@acl.hhs.gov.

And as (Diane) had mentioned we are recording the webinar. We will post the 

recording, the slides and the transcript during the course of this webinar on the 

ACL web site as soon as possible.

And I will notify everyone once the slides and the recording are available.

So with that I’d like to begin with our speakers. And the first of our speakers 

being - is Merrill Friedman. She is the Assistant Vice President of Advocacy 

for the Amerigroup Corporation.

So with that Merrill you are welcome to begin.

Merrill Friedman: Great, thank you so much Lauren. I appreciate it, thank you guys for allowing 

me the opportunity to speak with you all today.

Being a VP of Advocacy for Amerigroup and WellPoint this conversation is 

so incredibly important to me because I have it almost daily, actually probably 

daily with people around the country and (frame) that we’re really building 

strong dialogue and conversation about the role of AAAs and Centers for 

Independent Living, people with disabilities, seniors, families and that they’re 

really at the table as states look to develop and design managed care systems 
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as they look to implement managed care systems and really as managed care 

organizations look to do the same things within the state.

So I think this is just incredibly important and thank you again.

That being said we can move to the next slide. It’s really just a quick overview 

because Amerigroup was bought by WellPoint and just wanted to make sure 

that, you know, we stated that in here.

And so it’s new and so I am now really on the side of the Government 

Business Division which they’ve called it GBD because it’s what we do. We 

put an acronym to everything.

So it’s now the GBD. We’re learning all the new terminology as well and 

really just the strength that the joining of these two organizations and having a 

larger enterprise and hopefully behind that strength the resources to make sure 

that we can really comprehensively implement Medicaid Managed Care 

presence within the states that are really meaningful to people and their 

families.

When I talk about managed care it’s not everybody’s favorite conversation.

There’s still a lot of fear, a lot of confusion. And rightfully so, I think we’ve 

certainly gone beyond the days of the 1-800 say no managed care.

But I still don’t think that we’re at a time where things are perfect and 

probably far from it.

So and literally, you know, what value can managed care brand bring to 

providers, to service organizations, to AAAs and centers as they fit in that, 
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you know, their service capability as well as the advocacy, systems change 

and other influences.

And really looking at that value along with the risks of design and 

implementation because we really I think all know that managed care is a tool 

or a vehicle. And it’s really only good if it’s done right.

So what does it mean to do it right?

I would say it really means engaging a community in the process which is you 

all as well as consumers and their families. And I don’t mean, you know, 

getting started down the road and then, you know, calling upon you guys. I 

think this is something that you all should be involved with early before the 

process begins. I think you should be involved constant (often) at the forefront 

of this dialogue.

It also means that ensuring that the services are really robust enough so that 

people who are living independently in the community, in the settings of their 

choices really can access the services that they want and that they need.

And I don’t think managed care is ever going to work without that level of 

participation and home and community-based services and having you guys at 

the table really helping to figure out what those are and how they should be 

networked then within a managed care environment.

So requires making sure, you know, that’s the case is building that 

collaboration with you all. There is nobody better at providing services to 

seniors and people with disabilities than AAAs and centers so to me it always 

seems to make sort of this very good fundamental sense. And I probably say 
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that because I’m a simple person. I just think this is the best way to start and 

finish it with you guys.

States really are looking, you know, in designing their Managed Care 

Programs beyond those typically required services for prevention, primary 

care, specialty and acute and really now looking at de-medicalizing the system 

and the processes.

So that, you know, that’s where - when I, you know, happen to say mutual, 

you know, goals for Medicaid Managed Care. I mean this is such an 

incredible place for you all to be and to leverage your experience.

So if we start talking then about what that, you know, is, its transportation, 

housing, employment, habilitation. I’m starting to wear out. All family 

support, caregiver support and training, meaningful community inclusion and 

participation, in-house services and support, personal incentive services; it’s 

the list of things that really help people to live independently and live lives, 

you know, that they can choose, that they can direct, that their families are a 

part of but have access to services and support.

So when you look at, you know, those goals and you’re looking at improving 

quality of care and services, lowering overall program costs, supporting 

families and caregivers, fostering independence, coordination and that concept 

of enhancing home and community-based services, utilizing centers and 

AAAs, it’s those (mutual) goals then that seemed again to be so clear that you 

guys are getting engaged and driving these conversations with the MCOs and 

with the state.

So what are some of the steps that, you know, we can possibly lay out for 

getting involved in the managed care dialogue?
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I started on pretty much the very beginning and we can move forward and 

during conversation, you have questions, we can, you know, tap into some of 

these further as you wish.

But really it starts with knowing what the state plans are doing around 

managed care because none of us like surprises.

So we do know that many, many states, I think we’re looking at up to 28 to 30 

now getting engaged, you know, in long-term services and support. Many 

more are engaged in the Medicaid Managed Care.

So it’s asking and proposing a question, you know, to the state. If it’s not 

already in your state, you know, what’s coming down the pike. If there’s 

Medicaid Managed Care already implemented in your state clearly where, you 

know, you guys are looking and collaborated already it’s what’s next because 

many states are adding on.

So it’s staying ahead of that conversation and getting involved really with 

your state administrators, knowing which waivers are going to be included 

and what, you know, what those plans are because you can then start to 

predict from a business sense, you know, what your sustainability is.

So if they’re going to design around conflict pre-case management, do you 

need to pick and choose where you’re going to be on providers, you know, 

providing assessment or possibly service delivery?

And they’re really difficult, you know, conversations around what the designs 

will look like that go beyond rates and evaluating their services. I talked to a 
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lot of folks really who struggle with evaluating services because they’ve not 

had to put a price to them.

But so that’s one level of the conversation. And the other is then service 

coordination and case management being such a significant part of what 

centers and AAAs do but it’s also such a core part in the heartbeat of what 

managed care bases their assessments on as well.

So similar conversations are pretty difficult but if we can plan ahead for those 

and get together on those early with the state it makes it easier I think for you 

guys to build-out, you know, your sustainability, how to resource staff, how to 

enhance your capabilities and where you’d want to diversify both in your 

funding and your service capability.

Getting involved early and sharing, know there’s transparency and input in the 

design and composition of the plan, the approval processes, oversight 

mechanisms, I think that, you know, managed care organizations see more 

oversight now than ever before. And I think it’s really built-out some of those 

safeguards and outcomes that people really want to see that will make it easier 

to continue to move forward.

Other things would be you know the rule of the ombudsperson, of course 

stakeholder engagement. Building allies, there’s so much about a health 

insurance plan that’s really very technical. So let’s say in the support of 

healthcare advocates, legal service, attorneys and weaving these (stay to the) 

rules and regulations by building alliances with various disability and aging 

groups like you all have already done really provides a way through 

collaborating to have better brainstorming and sharing of the resources to do 

that.
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As far as really engaging folks who are actually going to be served by the 

plan, you guys are working with people every day advocating for people, 

advocating for the services and people utilizing the services themselves.

But really building out that consumer voice and speaking out on basic 

principles in the design and in the contracting as well around consumer 

direction, choice and services and providers, protection such as the (PO) rights 

and ombudsperson, having end-of-life conversations and planning for that, 

ensuring that services are accessible compliant with (ADA). What a great role, 

you know, for you guys in terms of being that trainer and working with the 

managed care plans to ensure that.

And, you know, looking at we know still people who use wheelchairs that are 

going to feed and grain stores in rural areas to get weighed. And we can be 

implementing and incentivizing providers to ensure that they have the 

accessible (GMA) and (MDE), accessible tables for GYNs.

And when I look at accessibility I look at, you know people with mental 

health condition. It’s like actually disabilities that are sitting in packed waiting 

rooms for two hours to see a doctor. You know if you have an anxiety 

disorder of any kind you’re really not going to stick around for that so it’s 

really educating that provider and being engaged in what those provider 

training’s need to be.

Looking at the services that are being embedded in these Benefit Design 

Programs like sleep cycle support, you know, we saw one state where sleep 

cycle support, you know, was removed as a covered benefit.
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But that’s really another proponent of what ensures people, you know, to be 

able to stay at home. So that should be included by advocate, everybody 

advocating together, you know, add it back in.

Financing mechanisms, incentivizing for long-term services and support, 

incentivizing for home and community-based services and not 

institutionalization; again, you know, places, you know, really to be engaged.

Not cutting services for short term savings so really helping to build-out what 

these models are, to invest in the prevention, really everyday needs that people 

have.

I know one story where a young man needed - he’s in his 20s and needed 

adult briefs. But the benefit was changed so that they limited to the number of 

adult briefs. He really ended up at that point with a stem (brake) on because of 

that. It doesn’t make sense.

So really, you know, to have you guys at the table and engaged with the 

managed care organization to make sure that we’re not running into situations 

like that. Those are very preventable situations that you all deal with every 

day but really helping to influence that with the state.

Not to be - I would say, don’t be intimidated by the technical nature of health 

insurance plans because consumer direction, choice and adequate caring 

services really shouldn’t be complicated. Clearly the nuances are. We’re all in 

this together in enough states to know that it is very difficult to get through it.

But we really should be educating each other on what the language is on all 

sides, what the service needs are on all sides so that we’re really moving the 

ball on this and not getting hung up in variation.
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Laruen Solkowski: Merrill?

Merrill Friedman: Yes.

Lauren Solkowski: This is Lauren. If I could just - I’m just going to interrupt for one second.

Merrill Friedman: Thank you.

Lauren Solkowski: Apparently we’re having a problem here with the slides, everyone seeing 

the slides being advanced. I’m advancing them but they’re not changing.

So I wanted to let everyone know we are going to be sending the slides 

around, you know, through an attachment to everyone so that you can look, 

you know, view them that way.

And we apologize for this problem. We’re not sure what the problem is. But 

so just so you know Merrill the slides aren’t advancing for people to see so 

but you can - we will get through it.

So and now...

Merrill Friedman: I will.

Lauren Solkowski: ...I’m showing the third or the key steps for getting involved.

Merrill Friedman: Yes, it’s not even showing on mine so but I mean I have them (out there) so 

I’m happy to revisit anything.
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Lauren Solkowski: Okay. Well I think we’re okay. And but, you know, if you could just say -

maybe pull up your slides and say Slide 4 and/or whatever slide number 

you’re on and we can - so folks will know what slide you’re referencing.

Merrill Friedman: Happy to.

Lauren Solkowski: Okay.

Merrill Friedman: I think, see that’s how good I am at the slides. We’re on Slide - well for the 

key steps to getting involved so I believe its Slide 3.

Lauren Solkowski: Okay, great. That’s the one I was on but.

Merrill Friedman: So sure.

Lauren Solkowski: Okay, thank you Merrill.

Merrill Friedman: Sure. So there it goes. Working with some of these (ADHD), I just completely 

lost my track too.

Lauren Solkowski: I apologize for that.

Merrill Friedman: Oh please don’t. I jump around so much.

So, you know, we can talk - I know there are questions related to look at 

engaging managed care organizations.

And looking at the requirements I mean that MCOs are held accountable to.

Because the thing is you all have such a significant influence on that and the 
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space in there to leverage your services and your history and your experiences 

and the talent.

So there are requirements that managed care organizations, you know, work 

directly with beneficiaries so individuals and their families. Having 

Stakeholder Advisory Boards, having influence directly by members on 

consumer direction.

So I think that there are really great places to come together. There are ways 

that you can actually help at the beginning but even throughout. Because, you 

know, you can change it on ongoing training’s and oversight, input on 

program design, elements of care and services, working on assessment 

processes and outcome measures that really consider an individual’s ability to 

live either independently in the community, with their family, in the 

community setting of their choice, using transportation, live in accessible and 

integrated housing, all of those areas.

There are also measures attached to them and performance measures. And 

that’s where again you all really influence the success of a managed care or 

health plan.

And then my last - this one slide on key steps for getting involved in, I think, 

you know, we’ll continue. I’ll continue to go through some others. Is really is 

not to say no to the managed care conversation. It’s incredible the number of 

times that we reached out to people and organizations just don’t want to talk 

to us.

And I can understand that, you know, to some extent. But we’re really - if 

states are going to go forward with this as much as managed care is difficult to 

embrace, if you’re there and you’re talking with the managed care entity you 
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can really help to break down some of those barriers that managed care 

organizations may put up even unintentionally.

So if you’re sitting there at a table and looking at services, I know in one state 

where we did letters of intent with all of the AAAs and all of the Centers for 

Independent Living there was one entity that didn’t want, you know, to 

provide services, didn’t want to meet with the managed care organizations or 

anything. So the other AAAs and the other centers really took over that 

region.

But it’s really hard then for individuals to have choice if the organizations are 

not enrolling in managed care because they’re not going to have as many 

choices of providers in that area.

So it’d be great, you know, to really ensure that we had everybody talking at 

those tables and everybody really enrolling as providers and working through 

that so that there’s as much choice for people and their families.

When states look at the outcomes and performance incentives that they set in 

place for managed care entities they look at improving coordination and 

integration of physical healthcare and behavioral healthcare, supporting 

members successfully in their communities, promoting wellness and healthy 

lifestyles, reporting on money as well as the person, improving health status 

by increasing or decreasing hospitalization, appropriate use of psychotropic, 

preventing pressure sores and (UTI). These are areas we’re contracting with 

AAAs and centers. You guys are the ones that really make that happen for 

people and also for the managed care organization.

So there’s a great spot obviously where you are the center of, you know, that

service delivery.
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And now when you look at some of the newer outcomes, performance 

incentives that are out there some of the states are seeing incentives around 

employment for people with disabilities, people with mental health condition.

Managed care organizations are having incentives around increasing life 

expectancy, decreasing utilization of any inpatient services, (NRS). Follow 

with management, decrease hospital admissions post-nursing facility 

discharge and increased community inclusion post-transition to the

community.

So really it’s no longer just ensuring that we’re transitioning people to the 

community, but really that they are engaged in meaningful activities within 

their community whether it be work, social, family.

And so you guys really are the core, you know, to seeing that happen. Some of 

the NOMs that are out there, those National, you know, Outcome Measures 

support those. And so you can really see. And you can go on that federal web 

site. You can look at in contract.

And that’s where your services are, you know, with those outcomes. And so it 

really shows you exactly your influence in that (sphere).

I’m not sure if I’ve gone beyond my time or not Lauren so I’m happy to quit 

talking for a while and...

Lauren Solkowski: Okay. I mean I think you’re fine. I think we will move to Emily’s 

presentation.

But before we do that we did have a question come in on chat. Who should be 

the first contact, Medical Director, Community Relations or etcetera?
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Merrill Friedman: So depending on when the - when that conversation, you know, when you’re 

going to start contacting. If the health plans are already there in the area you 

can call directly to the executive, the CEO or the health plan President and 

engage there. You may already know who their outreach people are and if you 

know those people enter that way. Because I have heard from several 

organizations that they’ve had trouble connecting with the health plans.

They’re not getting returned calls or they’re not calling the right person.

So you can escalate up to that, you know, health plan Director or you can just 

start there.

If it’s a state where it’s new, and let’s take Kansas for example just because 

there was literally no managed care there before they implemented KanCare 

so there wouldn’t have been a Medical Director to call. There wouldn’t have 

been a CEO or health plan President to call.

And then you really are working with advocacy people like myself who are on 

the ground or whoever their government relations people are that are on the 

ground first.

And you can, I mean can - if you reach out to those folks, you know, early on 

they’re going to connect you as well.

Lauren Solkowski: Great, thank you Merrill. Okay with that so our next presenter we have is 

Emily Brower. She is the Executive Director of Accountable Care Programs at 

Atrius Health.

And Emily I’m going to pull your slides up. I think we’ve figured out what the 

problem is, should come up in one second here.
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Emily Brower: Okay, well thanks for having me and thanks everyone on the call who’s 

listening.

I could say this has been one of my favorite projects within the work we’re 

doing on accountable care so glad to speak with you all today.

And I see my slides so I’ll start.

So what I’ll just cover today in our time is a little bit about Atrius Health, a 

little bit about our Pioneer ACO strategy because that’s really the context 

within which we started to ramp up and do some new work with our AAAs 

which in Massachusetts are called ASAPs or Aging Services Access Points, a 

little bit about the work that we’re doing in that area with - which includes our 

work with Merrimack Valley which is one of your participants. And then 

some lessons learned and next steps.

So you can advance that. So Atrius Health, so Atrius Health is a group of six 

multispecialty physician group practices and one home health agency, VNA.

And together we care for - provide primary and specialty care for about 1 

million patients in that geography that you can see there so Eastern and 

Central Massachusetts.

VNA Care Network and Hospice is the newest Atrius Health member. And 

it’s very different for us to have a home health agency as part of the Atrius 

Health System so we’re doing a lot of work, new work around that.

But that gives you a sense of who we are and what area we cover.
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Next slide, so some of the foundations or what we think of as the core 

competencies of Atrius Health that have supported much of the work that I’ve 

been leading and some of the work that we’re doing with our ASAP partners 

is the fact that we do a lot of our population management, patient care under 

global payment. We have a lot of tools to be able to do that including a very 

rich corporate data warehouse, rosters, lots of population management tools.

And we’ve been doing - historically have been a leader in quality and 

performance measurements as well as and global payment.

So for us this is a strong foundation to go into the Pioneer ACO and other 

risk-based global payment like contracts within which - wherein which we 

have the opportunity to work in new ways with our elder services or AAA 

partners.

Next slide, so a little bit about the Pioneer ACO so as most of you know 

Medicare has two ACO Programs, the Shared Savings Program and the 

Pioneer ACO. And we participate in Pioneer.

The reason that we decided to be part of that program is that we wanted to 

take - get out of a payer-based approach to managing care for Medicare 

patients into a population-based approach. So rather than having different 

programs and services depending on the payer, if we can take a populationbased focus and say it doesn’t really matter if it’s a fee-for-service patient, a 

patient in the Pioneer Program or a patient in Medicare Advantage. We are 

going to look for the best opportunity to manage the care of that population.

And it gives us a chance to treat all of the patients in the kind of payment 

model as close as we can towards global payment that we think best aligns 

with meeting our goals around quality.
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Next slide, so some of the key features of the Pioneer model which are helpful 

to understand as we talk about some of the new work we’re doing with our 

ASAP partners. So it’s a three to five year program and we’re taking the five 

year or long term view. The first term is three years and then there are two 

additional years.

And we are hopeful that we will be participating in the full five years. Unlike 

the Shared Savings Program ACO the Pioneer Program goes through the 

Center for Medicare and Medicaid innovation. They are sort of CMS partners 

in this.

And we can - we feel like we can be responsible or accountable for this 

population because we’re getting claims data. So we can understand what 

services they’re using, what care they’re getting. Put that together with the 

electronic health record information and really have a much fuller picture of 

this population that we - than we had under fee-for-service.

Even though people refer to this as a Shared Savings or Shared Savings and 

Loss Program, we really do think of it as global payment because you have a 

population-based budget that your performance is measured against.

We chose a model that has both up and downside risk sharing so some 

pioneers have upside only. In the first year we have both up and downside.

And then there’s a lot of incentive and really an important feature of the 

program is around meeting the quality measures.

So unlike a typical pay-for-performance or managed care performance 

bonuses kinds of arrangements, with Medicare Pioneer ACO performance on 
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quality is the gate through which you receive any savings or losses that you’re 

responsible for.

So your performance on the quality measures, determine your actual financial 

performance. So that’s very different and the quality measures really are front 

and center and so are very important to the program.

Next slide, so some of these quality measures because we are working with 

our ASAP partners to collect some of these so give you a sense of that.

So there are 33 measures, many are new. Not measures that - not metrics that 

we have been measuring before. We have patient experience which Medicare 

actually does a survey and brings that data back. There’s a measure around 

participation and meaningful use so with our electronic health record, a 

meaningful use record and are reusing it that - using it that way.

And then there’s a set of measures meant to reflect our efforts around 

coordinating care. Are we doing a good job preventing avoidable admissions?

That’s the ambulatory sensitive condition admissions. And how are we doing 

at managing readmissions?

And then there’s a whole set of measures around preventative health as you 

see there.

And it’s not highlighted here that I wish was, was a measure around falls risk, 

but you can see that - which is a new measure for most plans to be looking at 

capturing falls risk. So those are some of the quality measures.

Next slide, so this is our - what Medicare calls our Driver Diagram. So every 

Pioneer ACO had to produce a diagram like this that talks about what your -
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what outcome you’re trying to achieve, your primary drivers for achieving it 

and then what are the particular tactics or secondary drivers.

And you can see there the one I circled is that integration of home and 

community-based support we see as integral to achieving our goal of high 

value care for Medicare patients.

And that’s sort of the strategy under which we started to do more and new 

work with our ASAP partners.

Next slide, so in particular when we looked at home-based care we understood 

that there’s sort of two pieces to that. One is are patients getting skilled care at 

home when they can, in other words are we really using home health and 

VNA in the most effective way?

And then what’s the primary care at home since we have part of our model 

includes home-based primary care?

And what are we doing to connect with our ASAP partners in supporting 

patients to both get the care they need at home and also get the support they 

need to avoid unnecessary hospital stays, ED visits, the kinds of things that we 

all care about. Not having our Medicare patients have to go through those 

transition visits at all possible to avoid them.

So when we took a look and said okay so where are the gaps in that model of 

improving care for patients at home, we had some individual practice-based 

good work between a practice and a local AAA or ASAP. But we nothing 

system wide that looked at how to work more closely with our ASAP partners 

so that’s what we decided our work was, is sort of to bring it to the level of 

trying to create a system wide strategy.
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And then roll that down to what’s the actual standard work around how we 

communicate referrals, information and close the loop back to the practice.

When we have an ASAP providing care to our patients how do we really 

make them an authentic member of the Care Team? That’s our overriding 

goal.

Next slide, and so we would expect that by partnering better with our ASAP 

partners we could better - we could improve care for the populations. If you 

think about the triple aim of better care, better health and lower cost we think 

that our ASAP strategy should be able to deliver on all of those.

So we should be able to have better costs by taking some of the waste out of 

the system. Unnecessary care particularly unnecessary hospitalizations or ED 

visits that are very disruptive.

We should improve health outcomes by improving the care for the population.

And the patient experience should improve because it would really be a wow 

for the patients to be able to get what they needed at home and live 

independently for as long as possible.

Next slide, so as I mentioned our sort of overriding theme was how do we 

work with our ASAP partners so they’re an authentic member of the Care 

Team.

So when we have our Multidisciplinary Care Team Meetings we’re thinking 

about how do we include our ASAP partners in that. When we are doing 

individual patient support and we’re calling up an ASAP to refer that we 

know the information they need to be able to connect with the patient, they 
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have the information they need and then we have the information back about 

what’s the results of the assessment and what are the services.

So again we have a more holistic care plan that includes the view of the 

patient at home, a unique view that the ASAP partners can give us.

So we started our collaboration through some practice-based pilots that I’ll 

talk a little bit about. And then also looking across the population and saying 

what are the kinds of - what’s the value that an ASAP brings particularly 

around say falls risk where we may be able to assess falls risk in a practice but 

there’s a population who really needs to have falls risk assessed in the home.

So how do we leverage the good work that the ASAPs do around those kinds 

of population-based interventions?

Next page, so this shows you where the Atrius Health practices are that are 

involved in some of this pilot work.

So Harvard Vanguard which is the largest of the Atrius Health practices. Its 

Chelmsford, Massachusetts site and Elder Services of Merrimack Valley; 

that’s one pilot that’s - and pretty far along, also Southboro Medical Group 

out to the west a little bit and Bay Path as the other ASAP out in that area.

And then we have sort of in development, three and four. And there are more 

beyond that. But that gives you a visual.

Next slide, so what we’re - how we’re approaching this work that we’re doing 

between the individual practice and its local ASAP is sort of starting with how 

do we improve communication between the two entities, build on what good 

relationships there might be between say a social worker or a nurse in a 
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practice and a case manager at the ASAPs. How do we take the good 

relationship there and turn it into some standards around communication.

We set up a secure email so that we can exchange information in a way that is 

HIPAA compliant.

And then we build on top of that the sort of what we think of as one-to-one 

communication. So contracting with the local ASAP to provide a - an 

individual in the ASAP who can work with an individual in the practice to 

really be able to close the loop on the care that patients are receiving.

And the pilot with Elder Services and Merrimack Valley we have sort of a 

part of a social worker that we’re working very closely with, part of FTE.

And with Southboro Medical Group it’s somebody who’s onsite in the 

practice so a slightly different model. But again making sure that we’ve got 

good communication, coordination and we’re closing the loop to make sure 

that we have a comprehensive care plan for each patient.

Next slide, so what we - so having done a couple of these pilots where we see 

the opportunity is moving from a good relationship between one social worker 

and one social worker and trying to build a system that says it shouldn’t be 

dependent on an individual relationship. We should have systems that work 

well together.

I think we’re both seeing that because we’re involved in new programs where 

it makes a lot of sense to have the ASAP be part of the Care Team and our 

local ASAPs in Massachusetts are also looking for ways to partner differently 

with medical groups and with health plans. So there’s very good collaboration 

on how we can do things differently together.
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And then what we are tracking, sort of what we are calling, you know, the 

performance that we’re trying to measure is, are we seeing clinical and 

financial results? So are we hitting goals around that triple aim?

And we’re starting to see some good results there.

The challenges is that we’ve sort of - we’re building it as we go. So we’re 

figuring out what it means to work more closely together as we work more 

closely together which makes it hard to scale because we haven’t really built 

the model yet that we can scale and spread although we’re trying to do that.

We’ve got - it takes a while to get enough data to know whether or not we’re 

having an impact. And we are trying to leverage the work. When the ASAP is 

in the home if there’s certain pieces of information they sort of can collect on 

our behalf that demonstrates the quality and captures some of those quality 

measures. It’s taken us a little bit of time to build that but we’re doing that 

now.

And then just making sure that we’re always thinking about when we’re 

making changes in the primary care practice how do we include the ASAP in 

that. So how do we make sure that this good work that we’re building stays 

integrated as we continue to transform care in the practice?

Next slide, so one of these pilots the one that is probably furthest along is the 

one between Southboro Medical Group and Bay Path. And they have pulled 

together some slides around their work so I’m sharing one of those here.

So in that practice besides a contract with Bay Path, their local ASAP, for one 

of their staff social workers to really and have that person be onsite in the 
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practice part of the Primary Care Team and to integrate them as much as they 

possibly can into the multidisciplinary case reviews, ongoing longitudinal 

management, making that sure patients who are at home are getting all of the 

services that they need and collecting some of those quality measures.

And you can see some of the comments from that practice which is that they 

love it. The Primary Care Team thinks it’s great. The care management staff 

wish that they had even more of this person’s time because it’s so helpful to 

them in managing their high risk patients in particular.

Next slide, so some of the lessons learned, some of this I’ve already touched 

on, is that first of all you need to have an existing good relationship between 

the practice and the ASAP. So you need to have folks who feel like on both 

ends of it we’re doing a good job to support each other.

And once you - when you have that then you can build something on top of 

that or around that to make that more systematic and less independent on 

individual relationships. But you need that good relationship to start.

And then you need time for the practice to really experience the value. So 

seeing how much the ASAP services can help support the care plan for the 

patient.

And then this piece around (Loss) Review, that’s that Multidisciplinary Care 

Team Meeting so it’s really important to integrate the ASAP into that work.

So internal to Atrius Health, some of the things that we’ve seen that helps us 

to make this successful is making sure that we’ve got physician engagement 

that physicians can experience. It doesn’t just stay within the sort of Care 
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Management Nurse Social Work Team but that the physicians are seeing how 

this helps to improve the care for their patients.

That said the really day-to-day work is done by the care management staff 

whether those are nurses or social workers and then always making sure that 

we’re looking for those opportunities to spread.

On external side what we’re seeing is that our work within Pioneer ACO is 

bumping up against other Medicare demonstrations which could be an 

opportunity but could conflict. And a lot of that we’re just starting to work out 

right now. You can see them there. The Community-based Care Transitions 

Program, the other ACOs in our neighborhood and the bundled payment pilots

and I’d be happy to talk about questions around that.

Next slide, so what’s next?

What’s next is trying to take the best of the pilots that we’ve got going and 

spread that across Atrius Health. Making sure that whatever we do we’re 

tracking our performance against our triple aim goals because this is an 

investment for the practice. So like any other investment they want to make 

they want to see that they’re getting results.

Also Pioneer is just one of the programs where we are trying to work more 

closely with our ASAP partners. We’re also in both of the dual plans in 

Massachusetts. These happen to be the acronyms for them. So the Senior Care 

Options is what Massachusetts called the program for the duals who are 65 

and older. And the Integrated Care Organizations are now called One Care 

Plan for the duals under the age of 65 so more of the disabled population.
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So a lot of the work that we’re doing in Pioneer should spill over into success 

with those other programs.

Next slide, so I put here my contact information. Also the contact information 

for Amy MacNulty who’s the Project Director for what is called Community 

Care Linkages, the effort that the Massachusetts ASAPS are doing to work 

together to figure out how to be part of healthcare reform, work with 

practices, groups like Atrius Health more directly.

So Amy’s been very involved in the projects and pilots and you can see the 

logos on a bunch of the slides because she and I have presented some of this 

work before. So she’s helped developed these slide decks. So I want to give 

her credit there.

I did get some questions and I hope that I’ve talked a little bit about the value 

that community-based organizations, ASAPs, AAAs bring to any - really any 

population-based approach to managing patients whether it’s through 

managed care, global payment, shared savings like the ACO. We definitely 

believe that the AAAs bring a lot of value there particularly around avoiding 

preventable admissions, readmissions, ER visits, some things that are very 

important for this population as well as supporting patients to age and place 

and be independent for as long as they can.

Thanks.

Lauren Solkowski: Thank you so much Emily. That was really great.

I think - so with that I will now open it up for Q&A. So (Diane) if you could 

please provide instructions for our participants for asking a question through 

the audio line.
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Coordinator: Thank you. If you would like to ask a question from the audio line please 

press star 1. You’ll be prompted to state your name. And we ask that you do 

that so that we may announce you. Be sure that your line is unmuted so that 

the system can pick up your name. If you’d like to withdraw your question 

please press star 2.

Once again to ask your question, please press star 1. One moment please.

Lauren Solkowski: Thank you (Diane), and as - while we’re waiting for questions to come in 

I’ll go through some that have come in through the chat.

So one of the first ones Emily I think this is for you. You were speaking of the 

up versus the down risk.

Could you elaborate on what you meant by that?

Emily Brower: Sure. So up and down risk meaning risk for savings and loss so taking both, if 

you - people talk about upside only models; that means if there are savings 

you share in savings but if they’re losses you’re protected against any losses. 

You don’t share in losses. So that would be upside only.

Up and down would be that you’re sharing in both savings and losses so you 

have what we would consider full financial risk. And that’s the model that 

we’re in both financial risk, both up and down sharing.

Lauren Solkowski: Great, thank you. Another question that came in I think would be for 

either one.
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Will you share some of your quality measures for the caregiver experience 

assuming that this is for family caregivers?

Emily Brower: Sure. And you can actually go to the cms.gov web site and look on the - you 

can get all - you know lots of information about the quality measures which 

are for both Pioneer and the ACO. Pioneer and shared savings ACO are the 

same.

But I can tell you. I actually have those in front of me. So the patient 

experience measures are around access so being able to get appointments, 

information from the practice when they need it.

How well they feel that their Clinical Team communicates with them. How 

they rate their doctor. How they’re able to access specialty care.

What kind of a job does the practice do around health promotion and 

education?

And do patients feel like they’re part of their healthcare decisions?

So those are the, one, two, three, four, five, six domains and under that there 

are specific questions.

There’s also as part of the Patient Experience Survey there’s a question 

around patient self-reported health status and functional status which is very 

new. That’s not something that’s ever been measured in this survey before.

And the survey mostly asks about their experience in the practice. So it’s 

really asking about the care that’s being delivered in the medical group.
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Lauren Solkowski: Thank you. And before we go to the audio one final question on chat, is

there a payment made to the AAAs and ASAPs for their support to the 

practices?

Emily Brower: Yes. So as I said already (unintelligible) for two of the pilots, we do actually 

have a contract where there is, you know, it’s a professional services contract 

where we are making payments to the ASAP. Yes.

Lauren Solkowski: Thank you so much. And (Diane) I think we’ll - we can turn it over and 

check to see if there’s any questions through the audio line.

Coordinator: We have one question at this time from the audio portion. Earle your line is 

open.

Tom Earle: Hi Merrill. This is Tom Earle from Liberty Resources in Philadelphia. And 

together with the Statewide Independent Living Council here and our AAA 

we’re very excited about getting to the table in Pennsylvania to design a 

system that really maintains consumer’s choice and consumer self-direction.

And we’re wondering if there are any particular MCOs that we should focus 

on in Pennsylvania and what advice you might have on that.

Merrill Friedman: Hey Tom. Good to hear your voice. So I can’t call out, you know, any MCOs 

that are there. I don’t know who all is interested or has been having 

conversations with the state. You can find that out though from your state.

And then, you know, my advice really would be to if they have not reached 

out to you yet for you to go ahead and reach out to them. And contact kind of 

like, you know, we talked about earlier but get in touch with whoever their 
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government relations person. Often they’re going to have a lobbyist there first 

as you well know.

So get in touch with them and start getting, you know, your way into building 

relationships within that health plan, explaining to them really the services 

that centers provide. And if you’re partner again, you know, is yourself and 

any of the AAAs in your area are really the strength in capabilities that you all 

have for supporting people in the community. Because really that helps, you 

know, on multiple levels, you know, of course one, with diverting any nursing 

home or institutional placement; and two, it will really help when the 

managed care organization gets up and running that they immediately start 

looking at people who wish to transition to the community as well.

So you can really help them from both ends. And then also there are going to 

be readiness reviews and other things where they have to have a network and 

network capabilities up and going, you know, before going live.

And you all are a part of that. So your services really should be covered. All 

the centers that you can get to the table there, you know, should be there and 

contracting them with - for those services that you - so you are part of the 

initial network.

Tom Earle: Great, thank you.

Coordinator: I’m showing no further questions from the audio portion.

Lauren Solkowski: Okay, thank you (Diane). And actually I’m not showing any other 

questions through chat.
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So if no one has any other questions I’d like to thank our speakers again for 

presenting and thank all of our participants for great questions.

We are planning another webinar for August so please watch your email for 

more information about the topic, date, time and registration information for 

that webinar.

Also if you do have any - if you think of any additional questions once the 

webinar - once we get off the phone, as I mentioned before please email me at 

lauren.solkowski@acl.hhs.gov.

And I also wanted to - before we hang up, to give a quick update on our 

August Learning Collaborative Meeting. Per a meeting that we had today with 

senior staff a decision has been made to move this meeting back to the fall.

And we will provide more information on that very soon.

So I think with that we are done. So thank you again to Emily and Merrill for 

presenting today.

Coordinator: Thank you for your participation. Your call has concluded. You may 

disconnect at this time.

END