NWX-HHS-AOA-1 

Moderator: Lauren Solkowski

05-15-15/1:00 pm CT

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NWX-HHS-AOA-1 

Moderator: Lauren Solkowski

May 15, 2015

1:00 pm CT

Coordinator: Welcome and thank you for standing by. At this time all participants are in a 

listen only mode until the question and answer session of today's conference.

At that time, if you'd like to ask a question, please press Star then 1 on your 

touchtone phone. Be sure to un-mute your phone and record your first and last 

name clearly when prompted.

Today's conference call is being recorded. If you have any objections, you 

may disconnect at this time.

And now I would like to turn the meeting over to your host for today, Ms. 

Lauren Solkowski, sorry Ms. Solkowski. Thank you and you may begin.

Lauren Solkowski: Great. Thank you so much. And good afternoon and thank you, everyone 

for joining us today, for the Administration's Board community living 

business document Webinar entitled Tools for Building Housing and 

Healthcare Partnerships.
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As the operator mentioned, I am Lauren Solkowski with the ACL and will be 

facilitating our Webinar. First on today's Webinar, we have invited colleagues 

from the LeadingAge Center for Applied Research to present on their housing 

and healthcare partnership toolkit in addition to a return on investment 

calculator which is a component of that toolkit.

The toolkit provides the resources and guidance to help providers of 

affordable senior housing and their healthcare partners to work together to 

improve health, safety and quality of life for housing residents. The ROI 

calculator is a tool that organizations can use to estimate the financial value of 

their housing and health partnership.

So before we learn more about that toolkit, I have a few items that I'd like to 

run though in terms of housekeeping. Starting with, if you have not done so, if 

you could please use the link that was included in your calendar appointment 

to get onto the WebEx so that you can not only follow along with the slides, 

the PowerPoint slides, as we go through them. But also you can ask your 

questions when you have them through the Chat function.

If you do not have access to the link that we emailed to you, you can also go 

onto www.Webex.com. Click on the Attend a Meeting button that is located at

the top of the page. And then there enter the meeting number.

The meeting number for today is 662003987. Again that number is 

662003987. If you have any other problems getting onto the WebEx, please 

call the technical support number. And that number is 1-866-229-3239. That's 

1-866-229-3239.

Next, as the operator mentioned, all of our participants are currently in a 

listen-only mode. However, we do welcome your questions throughout the 
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course of the Webinar. So there's two ways that you can ask your questions.

The first of which is using the Chat function.

You can enter your questions there. It’s located on the right-hand side of the 

screen. And we will sort through them and answer them once we open for the 

Q&A session.

And the second way to ask your question will be after the speakers have 

finished their presentations will be through the audio line as the operator 

mentioned. And when that time comes, she will give instructions as to how to 

ask you question.

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

Webinar, we will be sure to follow-up with you to get them answered. If you 

think of any questions, you can also email them to me. And actually I will, 

once we start the presentations, I'm going to enter my email address in that 

Chat box on the right-hand side for everyone's reference.

So, also as the operator had mentioned, we are recording today's Webinar.

And we will post the recording, the slides, and a transcript of the Webinar on

the ACL Web site as well as for the learning collaborative members that are 

joining us today, it will also be posted on the N4A Mltss network Web site.

And I will also enter that information in that Chat box so that everyone can 

see. You won't have to worry about scribbling that down.

Okay so with that, I think I'll go ahead and introduce and welcome our 

speakers that we have for today. Our first presenter is Robyn Stone. Robyn, is 

a noted researcher and leading international authority on aging and long-term 
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care policies and serves as the Executive Director of the LeadingAge Center 

for Applied Research and is Senior Vice President of Research.

Joining Robyn is Alisha Sanders. Alisha is the Senior Policy Researcher

Associate for the Center for Applied Research at LeadingAge and Managing 

Director for the Center for Housing Plus Services where she works closely 

with Robyn. She developed the LeadingAge Center-for Urban Housing 

Infrastructure.

Also joining us today is Guy D'Andrea. Guy is the Managing Partner for 

Concerned Health. Which is a consulting firm focused on better health system 

performance especially through innovative measurement and payment 

systems that reward providers who patients achieve better overall health at a 

lower cost.

Some of their projects include developing performance measurement models 

for innovative delivery systems and designing shared savings payment 

approaches. So thank you all so much for being with us today.

'

And with that, Robyn, I will turn it over to you.

Robyn Stone: Great, hi, thanks and welcome everybody. We are really happy to be with you 

today to share our toolkit which was wonderfully funded by the AARP 

Foundation. It is really the culmination of about ten years' work that our group 

has done.

For those of you who don’t know LeadingAge, we are an association of about 

6000 nonprofit aging services providers. And we run the gamut of very high 

end continuing care retirement communities to the poorest, low income senior 

housing properties.
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About a third of our membership are actually low-income housing developers 

and managers. And they came to us because of a tremendous interest in 

helping low-income elderly residents age successfully in their communities.

So this has been a real joint effort with real, on the ground housing providers 

who we see as essential, a real essential and perhaps significant part of the 

community based infrastructure that you all work with.

I'm going to give you a little bit of background if we can go to the next slide 

please. We just wanted to give you a sense of why we would even want to pay 

attention to these folks.

They are poor with a median income as you can see of a little over $10,000.

And they are also growing older. And many of you I know probably have 

worked with senior housing residents. And if we remember the origin of 

affordable, publicly subsidized senior housing, they were typically, young-old 

moving into these buildings.

Right now we've got a median age of actually in 2006, the latest data that are 

available, we had a median age of about 74 but almost a third-are over 80.

And even the age move-in has gone up. The median is 70 but again, 14% are 

80 and over. So this is a significantly elderly population also very diverse.

Only a little more-than a half are white. And you can see, there's quite a 

distribution depending on the geography and the region of various - very, very 

diverse populations living in these housing properties.

So if we can go to the next slide. You know, the reason that we got into this --

in addition to the fact that we had a lot of our own housing providers who 
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were really concerned about aging and community -- was with the tremendous 

expansion of home and community based services as well as the heavy focus 

on improving coordination and integration of services both on the healthcare 

side and the LTSS side, and finally an increased focus on dual eligibles which 

I know are many of the drivers for all of you out there, this seemed like a real 

natural fit.

And if we can go to the next slide, I can talk a little bit about that even more.

A large proportion of the folks living in this housing are dual eligibles. And

many of them are elderly, very elderly, and have significant functional as well 

as chronic condition problems.

So it just seemed natural that this might become a platform for actually 

helping to think about more formal coordination and care integration. The 

population trends coming together with the desire to age in community both at 

the resident level but also the housing level because it's very difficult for your 

typical (palser) to actually evict someone.

Fair Housing allows residents to stay and of course there are few alternatives 

for a low-income person. So an eviction is not a simple thing. Not only is it an 

ugly process but also is particularly problematic when there is no other place 

for a senior to go. There are not many affordable assisted options and, you 

know, the one last option, of course, is if functionally eligible, a move to a 

nursing home.

And then finally the sort of drive for the Feds and the states who are really 

looking at enhancing community options, improving the health outcomes of 

people and that includes both health and quality of life. And obviously, a 

heavy focus on efficiencies and lowering costs particularly for the Medicare 

and Medicaid programs.
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And I would argue also that with the focus on social determinants of health 

and population health management that housing where you've got tremendous 

economies of scale and large numbers of folks who are at risk that this is a 

great place to shine a light. So this all sort of boils down together to the 

synergies for advancing new models and strategies.

You can move to the next slide. So the value, I talked a little about that. But 

here, we're really talking about building on existing infrastructure. Where 

we've already got affordable senior housing, where we have health and 

supportive networks many of which you provide in the community. And a 

high concentration of pretty high cost, high risk individuals including many 

duals.

The economies of scale cannot be underestimated. It is wonderful to have a 

community living in such close proximity where you can actually get these 

delivery efficiencies for the providers and make services really more 

affordable for seniors.

Providers also have access to the residents and the residents have easier access 

to services which we believe and there's some at least anecdotal evidence that 

this kind of a platform actually allows for more resident engagement which 

may encourage greater utilization, appropriate utilization and follow-through 

and compliance on the provider side.

There's a regular staff presence particularly given the fact that many of these 

buildings already have a service coordinator on site. So there is staff presence 

that can really help with knowledge of the resident needs and resources that 

are available.
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Building trust with the residents which is really key, I mean these folks 

particularly lower income are vulnerable and sometimes suspicious. And the 

need to really have this trust factor also can't be underestimated and then 

finally, early recognition of potential issues before they become costly crises.

So in essence we're talking about the value of this housing plus services 

strategy that ultimately helps preserve the seniors' autonomy and 

independence.

Next slide. The picture of health, you can see this is data that we actually 

gathered together with the Lewin Group. We have had a federal contract to 

merge HUD data, HUD administrative data, for the years of 2007 to 2009 

with Medicare and Medicaid claims data for low-income subsidized housing 

properties in 12 jurisdictions around the country.

And these data definitely affirm all of the assumptions and the sort of 

rationale for why low-income housing may be a really good platform for this 

type of coordination. You can see that the duals is 70% in HUD assisted 

housing on average. This is a very high percentage and really shows the 

potential for states and for integrated care plans and what have you to think 

about housing as a great place to perhaps partner with.

You can also see that these are very chronically disabled folks. Much more 

disabled, by the way, and chronically ill then even their counterparts who are 

duals who are living in the community not in assisted housing. So this again, 

means that if you want to get the goals, the triple end goals of health, and you 

want to talk about population health management, this may be a really good 

place to start. Next slide.

This is just a more detailed overview of some of the data that we have 

uncovered through our merged database. You can see that the average 
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Medicare PMPM is also higher than unassisted duals. And if you look at the 

utilization patterns you can also see that there is a higher utilization rate for 

many of these services.

So if we move to the next slide, you can also see that the same holds true for 

the Medicaid PMPM and for use of some of the more long-term services and 

supports including personal care services and other home and community 

based services. Next slide please.

I'm going to turn it over to my colleague, Alisha Sanders to talk a little bit 

now about what actually goes on in these properties. But just to summarize, 

we have a high risk, elderly population, large proportion of duals, some 

infrastructure in an environment that provides economies of scale to think 

very formally about making partnerships with the healthcare world as well as 

the social services world.

Many of these relationships, by the way, have already been in existence on an 

ad hoc basis. So the goal of these models is to actually formalize them.

Alisha Sanders: Great. Thank you, Robyn. So I'm happy to jump in here and tell you a little bit 

about the research that we've been doing in this area and looking at the 

potential effectiveness of these kinds of strategies.

And Robyn is still sitting here beside me so I'm sure you're all hear from her

again. So with that dataset that Robyn just discussed, we originally hoped to 

be able to look at the effect that service enrichment in a property could have 

on those residents Medicare-Medicaid utilization costs.

And we weren't able to do that with that dataset because there's no data on the 

services available in housing. But we were lucky to get a grant from the 
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MacArthur Foundation that allowed us to build on that study. And so we 

surveyed those about 2000 properties in 12 jurisdictions, as Robyn said, about 

the services that were available on the properties in 2008.

So we had to go back to the same year that our data was from, our MedicareMedicaid data was from. And we asked them about a range of services, a 

range of service related questions on their property. And I'm just going to 

highlight a few things for you about the kinds of staff and the types of services 

that they had available.

So on this slide you can see that a good portion of the properties surveyed had 

service coordinators available. And just in case there is anybody out there 

that's not familiar with the service coordinator, this is a role that's based on the 

property, onsite, that is there to help residents identify, and access, and to 

connect with services. And they develop very strong and knowledgeable 

relationships with the residents.

So a little over two-thirds have service coordinators and about a quarter of the 

properties had activities, and of course a much smaller portion had nurses.

And then about 25% of the respondents had no services staff. And you can 

also see by that pie chart upfront that some properties had multiple staff in 

different combinations. But still the most common was to have just a service 

coordinator, a little under half of the properties. Next slide, please.

And then we asked people about the type of services that they had available in 

their property. You can see from this chart that we asked about them about 13 

or so different properties -- excuse me -- services. And the most common was 

social and recreational activities.
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We also saw that it was pretty common to have health education and health 

screening services available onsite. And sorry, I should have clarified upfront, 

what we asked about is services that were available onsite purposely to the 

residents. So not services that residents got referred to out in the community 

but were available onsite.

And then you see a good portion of properties also have exercise and fitness 

activities and transportation related assistance. And a smaller portion have 

there's more functional and health related services available onsite. So next 

slide please.

So what we did was we merged those two datasets together to see if we could 

see an association between having a services available onsite and the 

resident's Medicare-Medicaid utilization outcomes, certain outcomes, in their 

Medicare-Medicaid costs. And this is preliminary data. We're just wrapping 

up this analysis right now.

But I want to clarify that what we are looking at here is just the association 

with services. We don't actually have utilization data. So this is kind of a 

higher level look. Which we think is even more significant is that we're seeing 

association when we don't know who in the property or what portion in the 

property are using the services.

So we looked at some primary, some high level outcomes areas. We looked at 

ER visits a couple of different ways, acute care stays, office visits and then 

Medicare-Medicaid expenditures. And you can see, I won't go through each 

one of these for you but you can see where the availability of those services 

onsite increased or decreased those particular outcomes we looked at.
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So we saw quite a bit of services that decreased some of the areas that we 

would be helping to affect. So you can see that the presence of a service 

coordinator helps decrease the odds of having at least one ER visit during the 

year. And then several of the services helped to decrease having a hospital 

stay over the course of the year.

And then of course there are a few that we do see increase either of these. You 

know, this is just associations and unfortunately we don't necessarily know a 

lot about why this might increase or decrease. We can speculate some things 

but some interesting and new data that we haven't had before. Anything to add 

to that Robyn?

Robyn Stone: No. I would just say, again, reiterate that I think because it's just availability of 

the service, we don't know. And for example, it may be that on the mental 

health side, why does it increase the odds of at least one acute stay? Well one 

could argue that if you add mental health services onsite that you're going to 

have more appropriate moves to the hospital of people with high needs.

Or that you might have a population with high needs and so you have these

services available. I think the most important piece of this is that we are 

seeing some relationships. And that it underscores the need for us to 

understand a lot more what happens when people actually use these services.

The other thing is the strength of the exercise variable for us was quite 

interesting. That in at least three categories, the availability of exercise onsite 

had a strong relationship with decreasing hospital stays, decreasing the odds 

of at least one hospital stay, and also decreasing Medicare expenditures 

PMPM.
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So, you know, I think this is a lot of food for thought as well as the role, the 

potential role, of the service coordinator as a strong association. These are 

only the significant statistical results that we put on this chart.

Alisha Sanders: Thanks. So Lauren, if we could go to the next slide. So we want to tell you 

about another evaluation we're currently working on. And this is an exciting 

evaluation for us because we are looking specifically at utilization. And this is 

a very rigorous evaluation where we have comparison groups.

This is an evaluation of the supports and services of at home program. Which 

is a care coordination model anchored in senior housing that was started by a 

housing organization and a group of their colleagues in Vermont. The basic 

model is that there is a housing based SASH onsite staff coordinator which is 

an enhanced service coordinator teamed with a part time wellness nurse.

And they are formally connected with a network of community based service 

providers that include the home health agencies, the Triple As, mental health 

providers. So they create this sort of interdisciplinary team.

SASH has been fortunate to link in with Vermont's statewide health reform 

efforts. And so they are formally functioning as extenders to the medical 

homes. And it is currently being supported through a larger Medicare 

demonstration. Next slide please.

So we are doing a three-year evaluation with our partner, RTI International, 

on this. And as I mentioned, we are comparing SASH participants to two 

groups. One that is in state and one that is outside of the state and not 

participating in the Medicare demonstration.
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And we have done our first year analysis. And the first year results show that 

SASH is bending the Medicare cost curve. So we found that the growth in 

annual total Medicare expenditures was about between $1800 and $2200 

lower for the SASH participants than the two comparison groups.

And we have another couple of years of data coming out. And actually we'll 

continue to look at the evolution and the impact that the program is having.

Next slide please.

And then I just want to tell you about one other model quickly that we have 

some data on. This is a partnership between an affordable housing provider 

and a health system in Harrisburg, Pennsylvania. What they have established 

is a weekly onsite clinic.

Where Pinnacle Health, the health system, sends a physician and a nurse 

navigator, a medical social worker to operate the clinic and then the nurse 

navigator is really working with the residents all throughout the week. It's 

really basically a care navigation program.

That they're focusing on those high utilizers to help them identify the barriers 

to care and help them get through and use the healthcare system appropriately.

But they will help any resident in the building. And they identify people 

through the health system's HIE to allow them to know who to connect with 

and who to follow up on. So next slide, please.

So I just wanted to show you the drop in the number of ER visits and inpatient 

visits they have seen through this program. So when they started at the address 

for the property they had, in the past year, they had 81 ER visits and 57 

inpatients stays.
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And in their most recent look at the last six months, they dropped down to 11 

ER visits and five hospital stays so pretty significant drops in both of those 

areas. Next slide please; are you doing this part?

Robyn Stone: Oh, I don't know. We hadn't decided who is doing this part. I guess I could say 

why now.

Well we've already talked about this really which is that this is really about 

thinking how we link long-term care reform and health reform efforts at the 

national and state level with affordable housing. And think about looking at 

the triple aim particularly for vulnerable populations.

And as important as the high risk piece and the super utilizers, we actually 

believe that the value of affordable senior housing is around the population 

management perspective which is in senior housing, yes, you have high risk 

people but you also have mid risk and lower risk people.

And so you can be managing the entire population. Which, you know, if 

there's large enough volume, is actually very appealing to a local, accountable 

care organization, managed care plans potentially, other types of integrated 

models. And we have a fledging group of housers who are working with 

healthcare in a number of different ways across the country.

So there are quite a few examples. The question for us can the business case 

be made in different parts of the country? And then what's the replicability 

process and the sustainability process? And next slide.

So the population health piece is really both the high risk, low risk and we say 

mid risk, particularly around timely preventive care. Most of these housers 

that are working with healthcare are also doing a lot of group health 
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education. A lot of evidence based practices around things like chronic disease 

self management, exercise, fall prevention, depression screening and 

intervention.

So again, it's the economies of scale that allow you to get access to a lot more 

people than you would just having needles in the haystack in the community.

And then improved care coordination and finally reduction in the over 

utilization of expensive services. And I would say appropriate use of other

services.

We did see an increase, for example, in the potential for increase in some 

long-term services and supports for example. And it may be that those are 

appropriate usage. And I think we're going to need to have policymakers who 

understand this isn't always just a total reduction in everything. That it's more 

appropriate use for the right reasons. And next slide.

The benefits, concentrated population, I think we've already gone through this.

The other thing that I would add is that the physical and personnel 

infrastructure is important. Not just that you've already got service 

coordinators in about 70% of these properties but you have physical space.

You always have some common space. You have the ability of folks living in 

apartments next to each other to look out for each other. To be peer mentors as 

well as to have oversight. And, you know, that physical aspect cannot be 

overestimated.

And then finally, the next slide is the challenges here are managing chronic 

illness, really looking at the smooth transitions, minimizing the rehospitalizations. Addressing medication complications, this was a big one for 

us.
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What we have found both in the data as well as our case studies is that there 

are tremendous poly pharmacology issues in these buildings, particularly 

because this is a lower income population. There are also behavioral health 

issues here.

And so the real ability to actually manage medications better is a very positive 

attribute of housing as a platform. And then again the patient engagement 

which we think can be increased because of the economies of scale as well as 

the potential for really addressing the nonmedical social determinates of 

health and targeting super utilizers while still recognizing that there is room 

for intervention with lower risk populations.

So in conclusion, this is in the toolkit. So most of what we've gone through is 

laid out in the toolkit. And what we really are highlighting in this toolkit -- it's 

a pretty hands-on tool -- is understanding healthcare reform. Why housing and 

healthcare should work together.

How do they actually collaborate? What are the tools? How do you identify 

and cultivate a partner? And how do you actually structure the partnership.

And so you're going to hear about the ROI calculator. We also have a series of 

videos that talk about the value of this.

We have some really nice videos of some healthcare providers who are 

working with housing. And also there's a whole set of resources that can be 

available to you.

So if you are a houser, this is fabulous. If you're not a houser, we believe this 

toolkit is just as relevant to your needs. And it may also help you to think 
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about how you might bring housing as partners into your plans for serving as a 

CBO in a particular community.

And all of this is on our Web site. So thank you. And now I think we are 

going to turn it over to Guy.

Guy D'Andrea: Thank you. So hi everybody, this is Guy D'Andrea. And I'm going to pick on 

the conversation that Robyn and Alisha have started. They've described from 

the housing provider perspective some of the opportunities and some of the 

innovative practices that are emerging around how to drive a better population 

health, better health outcomes, lower total cost.

And what I'm going to do in my presentation is spend a little bit of time 

addressing similar topics but really from the health system, healthcare 

provider perspective and some of the things that are going on in terms of 

overall health system improvement.

And then I'll try to connect the dots between what housing providers can do 

and what health systems needs. And illustrate how the ROI calculator we've 

developed with LeadingAge connects the dots and shows how these different 

entities can work together to drive overall system value and also results that 

are meaningful to the individual participants.

So next slide, just a brief background about Discern, we are a consulting firm 

as Lauren mentioned earlier. And we work with healthcare systems, and 

healthcare providers, and purchasers to try to define how we measure and then 

reward health system improvement through, you know, payment systems, 

through quality reporting, and scoring and so on. So next slide.
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So I think the next few slides summarize some of the main trends in the 

healthcare space that we've been now, I guess, engaged in over the last 15 

years or so. But that really have begun to accelerate in the last half decade.

You know, starting in the late 1990s there was a lot of research that was 

starting to emerge around the performance of the healthcare system.

And we started to understand that in many ways the healthcare system not 

only -- the US healthcare system -- was not only very expensive relative to 

other countries. But also did not produce the health outcomes that we wanted.

And that in many cases there were quality lapses where patients with chronic 

illness either don't receive necessary services or they don't get managed as 

they navigate through the healthcare system from one provider to another.

There were patient safety issues that were identified in hospitals with infection 

rates and so on. And so over the last 15 years, there's been a multilevel public 

and private effort to really to try to define and address some of these 

challenges in the healthcare system. And really take advantage of the 

connection between the quality of care and the cost of care.

And the recognition that by focusing on quality and focusing on getting 

patients the services that they need in the most efficient setting, hopefully 

before they have an acute exacerbation or other complication, we can improve 

quality and we can also reduce costs. And so, you know, now we're really 

starting to see those effects propagate through the healthcare system.

And so for example, we've gone from basically no NCQA recognized medical 

homes, patient-centered medical homes, to, you know, well into the 

thousands. And that is a number that continues to grow.
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So if you're not familiar with this concept, the medical home is a primary care 

physician practice that takes a much more proactive role in managing overall 

patient health and tracking and reaching out to patients who might need more 

support and management. Especially for patients who are either high risk or 

who have chronic disease.

We've also now over the last several years largely because of the influence of 

federal purchasing programs like Medicare, we've seen rapid increase in the 

number of accountable care organizations. Which are integrated healthcare 

systems that include primary care, specialty care, and inpatient care that are 

focused on managing population health. And I'll talk a little bit more about 

ACOs as we get farther through the presentation. Next slide.

So if you think about this journey that we've been on for the last 15 years or 

so, there's been quite a lot of evolution and innovation during that time. And 

in this slide I summarize that in terms of three generations of value based 

healthcare systems.

So the first generation which really started to gain momentum in the early 

2000s was around trying to measure and drive improvements in health 

delivery processes. To a large degree, these programs were focused on the 

existing silos or structure of the healthcare system.

So we asked physician practices to report and get rewarded on, you know, 

measures of what they were doing. We asked hospitals to measure the care 

that they provided within their four walls.

But in that first generation, the focus is not really on the interconnections of

healthcare. It's really focusing on each provider as a stand alone entity and 
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what they're doing when patients are receiving care, you know, directly from 

them.

The second generation of value based healthcare systems which, you know, 

really started to gain momentum about five years ago is one where we're 

starting to be more focused on healthcare outcomes. You know, are patients 

healthier? Are they avoiding complications? Are they enjoying better health 

status rather than only process measures.

But we're especially starting to see programs that are trying to focus on the 

interaction of different parts of the healthcare system. So that's asking primary 

care providers, for example, to be more externally focused and not just 

worrying about what a patient is experiencing when they're in the primary 

care physician's office.

But what happens to that patient when they are in getting treatment or getting 

advice from a specialist physician or as they navigate through the healthcare 

system? How can we reach out to those patients and engage them more fully 

in their healthcare?

And so there are a few different kinds of organizations that meet that 

description. The most important ones right now are accountable care 

organizations of which there are many varieties. And I describe them briefly.

And then I already touched on patient-centered medical homes.

And then the third generation is where we move from medical care to really 

thinking about population health. And how do we integrate medical care 

delivery with all the other factors that influence the outcomes the patients 

achieve, the overall population healthcare costs and results.
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There was a study or a report that just came out from the Institute of Medicine 

in the last couple of weeks that described our objectives for measuring health 

system performance. And it was very focused on broad aspects of the social 

outcomes of the healthcare process not just whether a patient in a physician 

office gets the right care in that moment.

But really, how do we measure whether the healthcare system is actually 

supporting better overall results in a broad, broad sense. So, we're just now 

starting to see organizations start to align themselves with this. And that's why 

I have those question marks in that example.

We hear terms like community integrated medical home. We're starting to see 

programs like the ones that Robyn and Alisha mentioned where medical care 

providers are aligning themselves with housing providers and other 

community resources to try to really manage overall population health.

So the way I would summarize these different generations of value based care, 

the first generation is really just asking providers, healthcare providers, to do 

what they do better. In the second generation, we're asking healthcare 

providers to transform how they deliver medical services to patients.

And then in the third generation that I think is starting to emerge and will start 

to gain momentum in the next several years, we're really asking providers to 

work with all of the other resources that affect patient health to transform 

population health management.

You can see in the slide that the dates that I've given for these generations, 

you know, different people would give you different dates, but you can 

certainly note that they overlap. And that's certainly true today. There are a lot 
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of medical care and a lot of healthcare that's still managed in a not even in a 

value based setting, right.

It's still in a traditional fee for service care delivery setting. We still have a 

number of organizations that are in that, you know, first generation 

description. And then a smaller number that are moving ahead to the second.

And then a very small number but hopefully a growing number that are 

looking at the third generation, population health management approach. And 

of course that's where housing providers do have an opportunity to really 

make a contribution. Next slide.

So as we think about value based care, we have to think about how to define 

value and how to establish expectations of the healthcare system. One of the 

reasons that this concept is starting to gain so much momentum is that large 

purchasers, private health plans, state Medicaid programs, but most especially 

the Federal government, have begun to move a larger portion of their payment 

to health systems to value based systems.

These are systems that tie payment to quality performance. They put providers 

at risk through various mechanisms for the results that they achieve. And the 

Department of Health and Human Resources have stated a goal to move most 

healthcare payment to alternative arrangements just in the next few years.

So, you know, all this change I've been describing that has taken place over 

the last 15 years is only going to accelerate in the next five to ten years. And 

again that creates an opportunity to create and form new partnerships between 

entities in the healthcare system.
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Most of the alternative payment arrangements define value by creating some 

set of benchmarks, some set of quality measures that they expect healthcare 

entities to meet. Those might be adherence to evidence based guidelines for 

care.

They might measure patient satisfaction with care processes. They might look 

at reducing complication rates and reducing ER use, unwanted utilization.

Typically the newer programs would combine a number of different measures 

across these different domains.

And then they would link that to the total cost of care for patients. And 

provide some incentives for a healthcare provider to reduce that total cost of 

care relative to a benchmark. And the specifics of how those benchmarks are 

set and how those financial mechanisms work, do vary from one arrangement 

to another. But these are the common themes.

And health systems that meet these goals can earn these payment incentives.

So the overall goal here is to create a market mechanism that rewards 

improvement. That rewards quality and thereby will drive improvement, and 

quality and better outcomes in the system. Next slide.

So what we've done for LeadingAge is to develop a calculator that helps to 

quantify this definition of value. And connect that to what housing providers 

can offer specifically around the Medicare accountable care organization 

program. And I'll talk a little bit more about that momentarily.

But this calculator, as I'll demonstrate in a few minutes, is a tool that you can 

use first of all for ACO quality measures, right. So what are ACOs being held 

accountable for? To understand the potential cost impact of interventions that 
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might be based in a housing setting, to understand the implications of those on 

the overall cost of care.

And then how housing can impact both the cost of care and the results on 

those quality measures. Which we hope provides a foundation to engage with 

ACOs in a conversation about working together, helping to manage patient

health, helping to improve results.

The calculator as I'll demonstrate it today is focused on Medicare ACOs.

Because that's one of the more well defined and more common structures that 

we see in the marketplace right now. But the concepts that we'll discuss really 

could apply to a range of other accountable or value based healthcare 

arrangements. Next slide.

So just a brief summary, when we talk about Medicare ACOs, what we're 

talking about is typically an integrated network of hospitals, doctors, and 

providers that are in their delivery systems that have come together and agreed 

to share risks around delivery of care to Medicare patients.

These networks enter into a contract with Medicare to serve a defined 

population that has to include at least 5000 Medicare beneficiaries. The 

minimum is there because below that number, it's hard to manage risks 

because there's a lot of volatility with smaller numbers.

The population is defined through an attribution model where the patients that 

receive most of their healthcare that are in the ACOs would be attributed to 

that ACO. The ACO is then evaluated on a range of quality measures. And 

we'll get into the details on those momentarily. But they include domains 

around patient satisfaction, preventative care, care coordination, and so on.
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ACOs in the Medicare program continue to get paid to submit claims and 

receive reimbursement from Medicare in exactly the same method as they 

have previously. But then, at the end of each year, they're eligible to earn a 

shared savings payment if their total population costs have gone up at a lower 

rate than the benchmark which Medicare sets looking at national trends in 

healthcare expenditures.

So if an ACO is able to take the population that it serves and over time, 

reduce, relative to trend, reduce the costs of that population, they can earn a 

shared savings payment. The shared saving eligibility though is also tied to 

their quality performance.

They have to achieve certain minimum quality results in order to be eligible to 

receive any shared savings. And then the actual shared savings is adjusted 

above that level based on how they do so the higher their quality scores, the 

higher their shared savings eligibility. So next slide.

So as you start to think about as a housing provider, how you can create value 

in a partnership with an ACO, and these are themes that Robyn and Alisha 

spoke to earlier, you need to ask yourself two interconnected questions.

First of all, how can you impact the ACO's results on its quality measures?

Can you help them to engage with patients or get patients engaged with their 

care process in managing their health? Can you help to facilitate access to care 

by helping to schedule appointments or providing transportation? Or making 

sure that patients have a designated primary care physician?

Can you help to screen for health risks by, you know, observing patient health 

status by hosting screening events and, you know, other mechanisms? And
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certainly in addition to these strategies, there might be other strategies that 

you could employ to impact quality measures.

And then you would also want to ask how can you impact costs by, you know, 

improving overall health status? Can you generate better health outcomes and 

therefore fewer complications of chronic illness, fewer hospitalizations, fewer 

unneeded ER visits?

Can you help to manage the social determinates of health? Again these are all 

themes that Robyn and Alisha spoke to earlier. And cited some research that's 

already out there that suggests in fact housing providers can have an impact 

on these kinds of results.

So at this point, if I could ask Lauren to turn the controls over to me, I'll pull 

up the ROI calculator and share a demonstration of that.

Lauren Solkowski: Okay I'm going to pull up the spreadsheet here; one second. And then I 

will email a link to try to turn the controller over to you. Okay, one second 

again.

Guy D'Andrea: While we're working on transferring the control, Lauren, could you click on 

the tab in the spreadsheet that says ACO measures and benefits?

Lauren Solkowski: Yes, one second. Okay.

Guy D'Andrea: So as we work on the controls, basically where I would really start in using 

the ROI calculator is on this tab that lists all of the various measures that a 

Medicare ACO has to report and has to be accountable for which then affects 

their performance under the Medicare Shared Savings program.
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Okay and I think I've got...

Lauren Solkowski: And Guy before you start, just really quickly, for the participants, if the 

Excel you are seeing is, you know, small, there is that toolbar that's on the 

right-hand side of your screen that you may be seeing that says Participants, 

Recorder, there's a couple of other options there.

If you click on Participants, it will minimize that toolbar screen. And you 

should be able to see the three Excel spreadsheets in a larger view. Okay, 

thanks Guy.

Guy D'Andrea: Thanks Lauren. So this tab and this spreadsheet lists the different measures 

that Medicare has included in the ACO program. And you can see that for 

each measure there is the domain that that measure is in. There's some 

information about how the measure is collected, the type of measure. And 

then a description about what that measure is focused on.

And really what I think you will want to do to begin is to ask this question of 

yourself, what can your housing do to provide better results on this measure?

As Alisha was describing earlier, there's a lot of variation in the various 

services that housing providers have available onsite.

So each housing provider has to do an assessment of what they provide onsite, 

what they could provide. And ask this question, can we help an ACO do a 

better job of, for example, helping their patients get timely care? And if the 

answer to that is yes, what specifically could you do to help them achieve 

that?

Because as you go through the questions and, of course, some of them are 

more focused, as we mentioned care coordination, on preventative health. So, 
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you know, getting flu vaccinations for your residents is a way that you can 

help them be healthier but also help the ACO meet its quality expectations.

You know, going through this list and really think about qualitatively what 

can you do to help the ACO be successful, I think is the starting point for that 

conversation and for building a partnership with them. So that's really where I 

would begin your own self-assessment.

Then in terms of using the calculator, what you could do is look at the 

measure scoring tab. And so here, what you're basically going to quantify on 

this tab and I'll shrink it down here for a minute is what the ACO's 

performance would be without you, without your support. And then what it 

could be with your support.

So it's really taking that qualitative analysis which I just described earlier 

where you're looking at the list of measures and you're thinking about which 

of those measures you can impact and how you would impact them. And then 

in this spreadsheet or this worksheet, you're starting to take that information 

and try to put it in a quantifiable framework so that you could start to calculate 

the impact of your collaboration with an ACO.

So in terms of the steps for this sheet, you would first of all want to look at 

which performance year the ACO is being measured for. And this is 

something you'll have to get from the ACO. So ACOs for Medicare enter into 

a three-year agreement with the program.

Depending on the performance year, the actual requirements and the quality 

benchmarks do change. So depending on which you select, which 

performance year they're in, that will influence the scoring and therefore the 

outputs of the calculator.
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You'd also want to find out from the ACO which shared savings tract that 

were on. There's basically a one-sided model in which the ACO can only get 

savings but can't have losses. And then a two-sided model which is less 

common where they're at risk, they have more upside but then take on some 

downside risk. Most of the current ACOs are in the one-sided model.

So then in terms of the quality measure results, that's the summary. But the 

next step to use the spreadsheet is to basically input the ACO's actual or 

expected performance on each of the quality measures.

For Medicare ACOs this is actually publicly available information. Medicare 

does post the results of the various quality measures for ACOs. Here, we've 

put in placeholder data. And it's important to observe for some measures, a 

higher score is better. And then for some measures, like readmissions, a lower 

score is better.

But you would put in the ACO's current performance. And then perhaps most 

importantly, you would estimate your projected impact of housing provider 

interventions on those scores. So, you know, for those measures where you 

don’t actually think you could have an impact because of the kinds of services 

you provide, you might, you know, you could zero out the impact.

But in other areas where you think you can have a substantial impact, you 

could quantify that. You can also test different values and see, okay well if we 

are able to have a large impact, the results would be X. If we have a smaller 

impact the results would be some fraction of X. So this is a way to test 

different scenarios as well.
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So if you have the ACO's current performance and then estimate your impact 

on that performance then the calculator looks at that result. And then 

summarizes that on the performance with and without housing.

Now in the performance, Year One, you can see that without housing the 

score is actually higher because in Performance Year One, it's all about 

reporting.

But in Performance Year Two, with these values that we entered into the 

calculator as default values, you can see what the quality score would be 

without housing and then with housing and how it goes up and most 

importantly in this example, that it would actually make a difference in terms 

of the eligibility of the ACO to receive shared savings payments.

And for the ACO, of course, that is a very important result. Because if they're 

not eligible for shared savings payments then it doesn't matter what financial 

result they achieve, they wouldn't receive that payment.

So in the first tab, we look at the measures and we started to think 

qualitatively where can housing have an impact. And again, for each 

individual housing provider, that will be an answer that depends on the 

services that they offer.

Then we try to quantify that impact by looking at the scores on measures and 

the potential impact on the score impacts due to the housing provider 

collaboration and intervention with the ACO. And then finally that all rolls up 

to the ROI calculator.

And this ROI calculator is focused on the perspective of the ACO. So what's 

the ROI to the ACO of working with a housing provider to achieve these 
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results? So one of the things you need to think about is for the significant 

drivers of cost, hospitalizations, readmissions, and ER visits, what are the 

current rates that the ACO is experiencing, and what impact can you have for

your population on those rates; right?

So if you can, you know, generate a 2% reduction in hospitalization for 

example. And think back to the slide that Alisha shared earlier about the 

results from the Presbyterian health program in Harrisburg where they were 

able to achieve very significant decreases in both hospitalizations and in ER 

visits.

So here you're looking at those possible reductions and then quantifying the 

costs before and after those interventions. So that then can then propagate 

through the calculator.

The calculator also looks at the impact on the shared savings eligibility for the 

ACO based on the change in the improvement in the quality scores that you 

can help to generate. So in this case, in this example, given the data that are 

entered into the calculator, as we saw earlier, the shared savings eligibility 

without housing was 0%. And then with housing was almost 2 1/2%.

So then clearly that then flows through to the shared savings payment that the 

ACO could receive. That's money that they wouldn't have gotten otherwise.

And then that flows through to the ROI calculation.

So the overall results look at the costs that you're asking the ACO to invest in 

the intervention, right. So this program investment is essentially your costs 

that you're asking the ACO to support. And then by looking at your 

population, the ACO's total population, the average cost of care, the possible 
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impact on utilization through the care improvements that you would help the 

ACO to implement, we can estimate an ROI for the ACO.

Now in this case, the direct savings are actually because the ACO is not 

eligible for shared savings without improving their quality scores, there would 

be no shared savings directly. But then when you factor in the impact of the 

improvement in their quality score and their shared savings ability, there is a 

positive ROI.

And, of course, where the programs are already eligible for direct savings that 

number increases and I can show an example there. So where the shared 

savings eligibility was already there without housing then the ROI with 

housing actually increases pretty substantially because there's that much more 

payment available to the ACO.

So just to summarize, the way that we use this calculator, it's to think about 

which measures you can impact to try to quantify the potential impact on 

those measures. And then to connect that impact to the financial outcomes for 

the ACO both in terms of their direct savings through reduced utilization as 

well as their increased shared savings eligibility through improved quality 

performance.

And while again, this is built around the Medicare shared savings program 

that basic concept could apply to any accountable care arrangement or any 

other health system that is subject to value based purchasing incentives that 

you might be seeking to form a partnership with.

If we go could go back to the slides. There's one more slide which I think just 

summarizes what I described. Thanks.
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So in terms of using the calculator, I think the first use is really about just 

developing a framework so you can help understand from the ACO's 

perspective what is going to drive their results in a shared savings program.

And so that you can frame the value proposition to them and think about the 

services that you might want to offer to them in the context of the incentives 

that apply to them.

If you have the necessary data or if you can make some assumptions about 

those data or test different assumptions, you can use the calculator as a way to 

look at possible quantitative results. And then going forward, you could use 

the results of the calculator and the framework as an evaluation model.

So if you said to the ACO you think you can impact a certain set of measures, 

then that is a set of measures you might work with the ACO to track over time 

to connect to the interventions that you've implemented to continue to refine 

and improve your model.

So at this point, that's the demonstration and sort of the overview of the 

calculator. I'll turn it back over to Lauren to facilitate the Q&A.

Lauren Solkowski: Excellent. Thank you so much Guy and thank you to Robyn and Alisha for 

excellent presentations.

So yes, now we would like to open up the lines for Q&A. Operator, if you 

could please provide instructions again for asking a question through the 

audio lines?

Coordinator: Absolutely. At this time, if you would like to ask a question from the phone 

line, please press Star then 1 on your touchtone phone. Be sure to un-mute 

your phone and record your first and last name clearly when prompted.
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If at any time you decide that you would like to withdraw your question, you 

may do so by pressing Star 2. Again if you would like to ask a question, 

please press Star 1.

Lauren Solkowski: Thank you. So while we're waiting for some questions to come in through 

the phone, I will ask a question that came through the Chat. And Robyn and 

Alisha I think this is directed towards you.

So the question is that the Oasis Institute works with many affordable senior 

housing organizations to deliver their evidence based programs. One of the 

large challenges is getting enough participants to come to the group 

workshops or to have the group workshops.

Are there any thoughts in terms of motivating and/or recruiting participants 

for those deprived from working with the service coordinators?

Robyn Stone: You know, I don't think there is any magic in engagement. You know, I think 

we have a couple of providers that are trying to work through -- and this is 

actually more not empirically based at this point -- but have been looking at 

the PAM, the patient activation measure, and both that tool as well as its 

coaching mechanism.

And I think what it adds to some of the folks that are doing evidence based 

practice is it starts with a screen around level of engagement. So that, again, 

you have to get people engaged to even do the PAM. But I think, you know, if 

you can get enough people to get engaged with a process. And we have found 

in many of our housing properties where folks are actually doing standardized 

assessments that elders really like that.
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So it may be starting to engage people around an assessment process where 

you use the PAM as part of that to then identify sort of the levels of 

engagement that you're starting with. And maybe that's where you begin to, 

you know, sort of target.

You know, I don't think there is any real answer to this. But we do think that 

one of the problems that housing properties have and in their partnerships with

evidence based practice is that they don't really know their residents. They 

may think they know their residents because their service coordinators see a 

few of them.

But the models of housing with services that we are working with have 

standardized assessments and so they are getting their residents engaged as 

part of developing healthy aging plans, working on their specific needs and 

goals. And, you know, this begins to build more of a trust and an engagement 

then you would if you just came into a property that really didn't have any 

clue about their residents.

It is a much more intentional process. I wish I could tell you that we've done 

evaluations of this so that we know it's working. We don't. But I think 

anecdotally and Alisha can speak to this as well, in the case studies that we've 

done, the more that there is standardized assessment, and buy-in, and working 

with residents to think about their healthy - their plans for a healthy aging, the 

opportunities may be there to engage.

Lauren Solkowski: Great. Thank you, Robyn. Okay. So I'll switch back with the operator.

Have we had questions come in through requests?

Coordinator: At this time, I'm showing no questions on the phone line.
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Lauren Solkowski: Okay thank you. We haven't had other questions comes in the Chat. In the 

meantime, we'll give it a few more minutes

I wanted to let the participants that are with us in the learning collaborative

know that in terms of the next, our next upcoming Webinars that based on 

some of the information that we're learning from email as well as the 

information that, you know, is shared during the recent April in-person 

meeting, we are working on scheduling the topical Webinars on some of those 

things that we've heard for the summer, for June, July and August.

And we'll have more information on that very soon. So I know I'm switching 

around the topics. But in a little while we will be sharing, you know, more 

specifically what those topics are. I just wanted to mention that your thoughts 

to be (unintelligible).

And also again, just as a reminder that, earlier, Guy did an excellent 

presentation on the calculator and it was a lot of information. But then again 

this presentation is being recorded. So we will have the transcript as well as 

the audio companion of that available as well as these slides, again on our 

Web site and on the N4A Web site, if you have rights. Any of those materials 

(unintelligible) just send me an email and I am happy to share them with you.

Can we check back, I don't think we have...

Coordinator: Excuse me, we do have a question on the phone line.

Lauren Solkowski: Okay. Go ahead.

Coordinator: That question comes from (Mike Collier), your line is now open.
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(Mike Collier): Hi this question is directed to Guy. And here in Vermont, a lot of the 

discussions and the meetings that I've been attending have already started to 

shift attention towards the next gen ACO application process that CMS has 

announced.

So even though we haven't finished Year Three of the current ACO, two 

things are going on. Both the state and the ACOs are really looking ahead to 

what the design of the next version would look like if they were to be selected.

And for some of the same reasons I think, the biggest of the three ACOs that 

we have in this state, is not actively courting network participants or partners.

At least partly I think because they are trying to figure out sort of strategically 

what partnership relationships they want to have in sort of ACO 2.0. You 

know, on the one hand, I think the ROI calculator is just a really excellent 

presentation and something that even as I was watching Guy go through it, we 

probably want to do some follow-up and ask some more questions.

On the other hand, I'm wondering whether some of the assumptions are likely 

to change as CMS moves in the direction of next gen?

Lauren Solkowski: Guy, I don't know if you're responding. You might be on mute.

Guy D'Andrea: I think I was on mute.

Lauren Solkowski: Okay. I was on too, it looks like.

Guy D'Andrea: Well what I was saying is that you're right that as the different programs get 

implemented and updated over time including the next gen program, that the 

underlying calculations that are illustrated in the calculator, as I demonstrated 

it will change.
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But I think that the basic framework for thinking about value will still pertain.

And well as an exercise in trying to define value, I think the calculator is still 

useful. Looking at that list of measures, Thinking about how as a housing 

provider, you can impact those results. I mean all of that will be relevant 

under any accountable care arrangement.

Thinking about how those innovations that you can implement would flow 

through the utilization and cost results for an ACO all that still is going to be 

very relevant.

And if you're in a mode that you described where the ACOs are waiting until 

the next set of rules come out, I think you can still engage in some of the 

evidence collection and assessment that you would need to do around these 

broader themes of value based care and population health that would position 

you to have those conversations when they're ready.

(Mike Collier): Thank you. Those points are well taken.

Robyn Stone: Can I just say one other thing; this is Robyn. And this may be for other folks 

on the phone who don't have an ACO in their area. And that is that this

framework, you can think about those indicators as ways to have a discussion 

with your healthcare potential partners in terms of what they may be looking 

for.

So you may be talking to a health plan that is managing duals for example.

Where, you know, they have a set of indicators. Some of them may be similar.

Some of them may be different. But I think we thought about this and Guy can 

add on or whatever. But not just as an actual numbers cruncher.
NWX-HHS-AOA-1 

Moderator: Lauren Solkowski

05-15-15/1:00 pm CT

Confirmation # 3640388

Page 40

But as a way of framing your thought processes around value and also then 

having discussions with survey partners. Who may have, you know, may have 

some of the same indicators but there may be different goals. And those goals 

could be plugged in.

And then, you know, you need to figure out either empirically or through what 

evidence base there may be in the literature. We have worked with Guy 

around making the case for example for housers from some of the literature 

that is already out there. That is demonstrated outcomes for certain kinds of 

practices. And so really this is a tool. It's a tool to use regardless of whether 

you're working with an ACO.

Lauren Solkowski: Okay thank you. Oh, go ahead.

Coordinator: I'm sorry; at this time there are no additional questions on the phone line.

Lauren Solkowski: Okay thank you. And I just wanted to - someone had let me know that it 

was difficult to hear what I was saying earlier. So hopefully this will come 

more clearly.

I essentially was just saying that if, you know, I know that we have had a lot 

of excellent information shared today. But, you know, that just a reminder that 

the Webinar is being recorded. And that we will have a transcript as well as 

the audio recording available online at the ACL Web site and the N4A Web 

site that I posted links to those in the Chat box on the WebEx.

But if you would like access to those as well as the PowerPoint slides before 

they are posted live, just send me a quick email and I'm happy to share those 

with you in advance before they're posted.
NWX-HHS-AOA-1 

Moderator: Lauren Solkowski

05-15-15/1:00 pm CT

Confirmation # 3640388

Page 41

So I'm checking one more time to see if we have other questions in the Chat.

I'm not showing any other questions. I'll check one more time with the 

operator for audio questions.

Coordinator: There are currently no questions from the phone line.

Lauren Solkowski: Okay thank you. Well with that, I just wanted to thank our speakers again 

for presenting and joining us today. And thank you, our participants, for your 

questions.

Again, if you think of any other additional questions after we hang-up, please 

feel free to email them to me. And I think with that we will conclude today's 

Webinar. Thank you so much again for joining us today on a Friday 

afternoon.

And I hope everyone has a nice rest of the afternoon and also enjoy the rest of 

your weekend.

Coordinator: Thank you very much for your participation in today's conference call.

Participant lines may disconnect at this time.

END