Atrius Health and AAAs: 

Partners in Accountable Care: 

ACL Learning Collaborative 

July 16, 2013 

Community Care Linkages SM

Mass Home Care
Today’s Discussion 

• Atrius Health: Who We Are 

• Atrius Health’s Pioneer ACO Strategy

• Atrius Health - ASAP Partnership 

• Lessons Learned and Next Steps

2 
Atrius Health Core Competencies 

• Corporate Data Warehouse integrates single 

platform, electronic health record data with 

multi-payer claims data to manage quality and 

cost 

• Long history with and majority of revenue under 

Global Payment across commercial and public 

payers 

• Widespread Population Management tools 

including disease-based and risk-based rosters 

• Sophisticated development and reporting of 

Quality and Performance Measures

• Patient-Centered Medical Home foundation, 

achieving level 3 NCQA 

• Newest Addition to Atrius Health: home health 

care, private duty nursing and hospice care 

through VNA Care Network & Hospice 

4 
Why Participate in Pioneer ACO? 

“Reason for Action”

5 
Key Features of Pioneer & Performance 

Measures 

• Three year contract 

effective January 2012; 

accountable for all 

Medicare A and B 

benefits 

• Partnership with Center 

for Medicare and 

Medicaid Innovation 

• Medicare FFS 

beneficiaries aligned 

with ACO based on their 

historical claims data 

• Global budget and 

performance measured 

against national 

benchmark 

• Upside and downside 

risk sharing with CMS 

• Incentives rewards to 

achieve high quality 

performance 

measurements 

• Accountable to Pioneer 

ACO obligations 

6 
Quality Measures: Key Features 

7 
Atrius Approach to Pioneer 

Secondary 

Drivers 

Tight coordination of 5% highest risk 

patients

Integration of home-based care and 

community supports

Longitudinal management of chronic 

conditions

Population-based outreach and 

preventative care 

Discharge process that includes standard 

Atrius Health elements

Bi-directional access to medical records

Concurrent reporting of admissions, 

discharges, ER visits

Collaborative care improvement and 

performance incentives

Effective network of facilities and providers

Consistent and appropriate documentation 

and information exchange

Shared SNF coverage with other Boston 

Pioneers

Primary 

Drivers 

Stratified, populationbased, geriatric 

model of care 

Aligned hospital 

relationships 

Coordination of postacute care and care 

transitions 

Outcome 

High Value 

Care for 

Medicare 

Patients 

8 
Addressing the Gaps in Home-Based Care 

Accountable for managing 

care, cost and quality of 

Medicare services in the 

home setting. 

• Costs are substantial across 

dozens of post-acute providers. 

• Patients have choice and are 

geographically distributed. 

• Poor transitions result in 

unnecessary readmissions and 

other wasteful costs, harm, and 

errors. 

• No standard model of homebased care across Atrius Health, 

no standard measurement 

ASAPs, while not 

currently 

Medicare 

providers, 

can be an 

important 

resource 

in closing these gaps. 

9 
ASAP Strategy: Link Primary Care to 

Community Home Care Services 

Achieve triple aim objectives by linking primary 

care practices to community resources 

– Reduce costs through prevention and/or reduction of 

unnecessary utilization of health care services 

– Improve health outcomes through better care coordination 

and patient education 

– Improve patient experience and satisfaction by aligning 

with goal of remaining functionally active at home 

Community Care Linkages SM

A Division of Mass Home Care

10
Atrius Health – ASAP Collaboration 

 Expansion of the “Care Team” to include the patient’s 

home and community-based networks 

 Requires: effective communication for timely and efficient 

referrals, hand offs, and “closing the loop”

 Results in: patient centered care plans with realistic goals 

and resources for implementation 

 Collaboration through: 

 Practice-based Pilots 

 Population-based Interventions 

Community Care Linkages SM

A Division of Mass Home Care

11
Atrius Health/ASAPs Practice-Based Pilots 

1. HVMA Chelmsford & Elder 

Services of Merrimack 

Valley 

2. Southboro & BayPath 

3. HVMA West Roxbury & 

Ethos 

4. HVMA 

Wellesley/Watertown & 

Springwell 

Currently expanding to new 

sites 

Community Care Linkages SM

Mass Home Care

12
OUR PARTNERSHIPS 

 Practice-based pilots and population-based interventions of varied intensity 

 Creation of patient centered care plans with resources for implementation 

 Development of standard work processes for optimal care coordination 

Harvard 

Vanguard 

Medical 

AssociatesWellesley and 

Watertown with 

Direct communication between practices and ASAPs 

with secure e-mail

Harvard Vanguard 

Medical AssociatesChelmsford 

with 

On-site ASAP Social Worker integrated into the 

practices 

Southboro Medical 

Group 

with 

Enhanced care 

coordination to “close 

the loop” on services 

provided 

PROGRESSION OF SERVICE DELIVERY 

Community Care Linkages SM

Mass Home Care
Opportunities & Challenges 

• Opportunities 

• Build sustainable 

relationships beyond 

individuals 

• Continuous learning 

together => innovation 

• Demonstrate Value => 

Clinical and Financial 

Commitment 

• Challenges 

• Slow Start Up 

– Hard to scale 

– Building as we go 

• Data timing 

– Utilization & costs 

– Quality measures 

• Integration into primary 

care protocols 

– Work flow changes 

– Education 
Value Proposition for Southboro Medical 

ASAP as Authentic Member of Care Team 

• Quicker and "more economically feasible" to buy 

• Better access to ASAP services through embedded 

staff in practice (vs. standard I&R) 

• Improved care management that reduced 

duplication of handoffs 

• More patients access ASAP network services 

through relationship 

• Opportunity to focus on prevention, develop 

innovative model for best practice 

• Align with ACO measures 

• Reduces burden on MD practices 

“wish she was 

here 5 days per 

week”

“Our staff can 

focus more on 

care 

management and 

less on the 

details or making 

arrangements”

Community Care Linkages SM

Mass Home Care

15
Lessons Learned 

ASAP Collaboration 

• Build relationship with one point of contact and spread 

• Allow time for MD practice staff to experience value of ASAP, one 

patient at a time 

• Participation in case “roster” review is powerful

Internal Atrius Health 

• MD engagement drives change 

• Care Managers are key to everything 

• New opportunity to spread pilots across Atrius Health 

External 

• Potential conflicts AND/OR opportunities with other initiatives 

– CCTP, MSSP ACOs, Bundled Payment Pilot 

16
What’s Next?

• For Pioneer and ASAP work 

– Spread the good work 

– Track the results 

• For Atrius, More “O”s....

– SCO – Existing MA duals plan, 65+ 

– ICO – New MA plans, < 65 

Community Care Linkages SM

Mass Home Care

17
Questions? 

Emily Brower 

Executive Director, Accountable Care Programs 

Atrius Health 

Emily_Brower@AtriusHealth.org

Amy S. MacNulty 

Project Director 

Community Care Linkages

amy@macnultyconsulting.com

Community Care Linkages SM

Mass Home Care