Thank you. Can you hear me . Thank you very much. Im going to start off with a disclosure, which i is on my front slide. I want everyone to know i will talk about home based primary care, a house call clinical model for elders and how that led to the independence at home. My disclosure is, my presentation does not involve cms sponsored analyses. Its my responsibility and no review or verification by them. Hopefully, patrick will be okay with it. Next slide. Im going to talk first about the patients that we serve. I would like to do a brief survey of the room. How many people in this room have an elder in their life who is sick and has trouble getting to the Doctors Office . Raise your hand. Looks like more than half the room. Independence at home and homebased primary care is the model of care for those people. 17 years ago, dr. George toller and i came to d. C. And decided to set up a clinical model for care for those who are frail and have trouble getting to the office. A House Call Program but more than that. A homebased primary care program that would follow them across all settings. Well talk more about the details. We wanted to look at the effect of that kind of model, a mobile teambased approach to care in the home on quality of care, the Patients Experience and ultimately the costs of care. Which is i would say a secondary outcome. Most importantly, what is the impact on the patient and the family . We will talk about some of those results. Then i want to close with talking about whats next. How can allies and policy makers both here in this room and across the city help us expand this program . So who are the patients . Its actually a highly targeted clinical service. In contrast to some of the other demos, it targets less than 5 of the medicare population. Roughly 2 million of the medicare population could be eligible if it was expanded nationwide. Our practice, they age 66 to 110. The 110yearold just recently passed away. She was born on january 1, 1900. At the beginning of the century. So this is the kind of folks that we talk care of. This service, the intervention is really simple to describe. Hard to execute. Its interdisciplinary mobile primary care teams. 24 7 availability across all clinical settings. Its not just about making house calls. You take care of the patients wherever they are. You coordinate all services that they need, medical services, social services, subspecialty, transportation, whatever they need. The goal ultimately is to enhance the health and dignity, bring peace of mind to the caregivers and families. Those are the two primary goals. Happy side effect of this kind of care is that it has a dramatic impact on per capita medicare costs which we will talk about. In a positive way. The independence at home model, which was based on homebase primary care systems across the country, allows Home Based Primary Care Teams to be scaleable. Thats the major take home point for the day. The independence at home both demo and payment model allows it to be scaleable. The reason for that is we will talk about more. These are the main points. Theres strict criteria for eligible patients. You have to be frail, disabled, have had high costs in the past year. Theres a high bar for Service Quality in the program. You need to have all the researchers in play to take good care of these very complex patients. You only receive savings only after you have achieved 5 reduction in per capita medicare costs. Theres no upfront payment to the programs. Theres no payment until you have exceeded statistically a greater than 5 reduction. You have to link the savings to six relevant Quality Metrics that providers would get 80 of savings if they immediate all six Quality Metrics. This highlights it highlights the focus on the top 5 . Why that has super a big impact. The orange on the top on left is is the number of beneficiaries. But they expend nearly 50 of the budget. This is similar now in the current Medicare Medicaid population as well as commercial payers. This is the population you focus on to have the greatest impact on costs. Im going to talk about a patient. A 69yearold who had liver and falls and care given burden. The year before she moved to d. C. , she had six admissions to the hospital. Thats six admissions per patient year. The daughter moved her mom to d. C. In order to gain entry to a program. For last four years, shes received over 150 house calls, many social services, coordination of aid, home xrays, ekgs, wound care, many urgent visits by our team. Had a terminal diagnosis reversed. Had a radiology procedure where she was hemorrhage and we thought she was going to die. We used the hospital high level high tech care to do kind of a last minute procedure that worked. She has been home for the last 18 months. In the last 4 1 2 years now, shes had two admissions. Shes been four years orlando older and four seeks sicker. She had one e. R. Visit in four years. I have to change this. Two days ago she had another e. R. Visit. I want to say its two in two years. How does this work . This is say busy slide. I wont read it all other than to say, Home Based Primary Care Team has to coordinate everything. Over time, until the last day of life. We coordinate routine and urgent visits. Today from the weekend, we had ten unstable patients. Nurse practitioners around d. C. Making house calls to prevent emergency room visits and keep people at home. We coordinate e. R. Care, subspecialty. We direct hospital care so we can manage the discharge to home. Were available 24 7, as are all of the programs have to have a 24 7 availability. We manage rehab, hospice. The next six are the things you can do at home. What is possible . The hospital really is only for intensive care, surgery, procedures, complex level of things. You can do almost Everything Else at home. From radiology to blood draws to ekgs to echos to equipment to i. V. As long as you coordinate, you can have a dramatic reduction in costs. This is a quote from sylvia, the daughter of the patient, about how the Program Saved her moms life. It restored her faith in the system. The good days, hours and moments she has are a result of the passion and commitment of those who created the program. She gave us permission to give this quote. I will close with some of the results. This is the v. A. Study that came out in 2014. The highest rated program in the v. A. , 12 lower costs. A study of our program showed similar mortality, high mortality of both controls and cases, but a 17 reduction. The independence at home year one results, ours had a 20 per capita cost reduction. That was 1,000 per patient month. Close to 12,000 per patient year. Nine of the 17 programs were paid savings ranging from six to 31 savings. In year one, 25 million was saved in 12 million was returned to the providers. I will close with just what are the challenges going forward. Finding the skilled work force is probably the number one goal. Its very doable. The people are out there. You have to have a Financial Model that will support them. You have to build a lot of practice capacity to support these teams. All the other service partners. Then you have to have a Health System that will commit to really doing valuebased care. Unfortunately, med star is building a new team in baltimore based on the independence at home results. Both the quality and the cost savings, because they have faith that cms and other payers will row ward this kind of care. Finally, how can you all in this room help . I would we are working with Senate Finance house ways and their sugar level doesnt matter that much when they just have a year or two left of life. It has to be within parameters. Make sure its relevant for population. Cms have been working hard on independence at home to target the right patients who have persistent high costs, use fair and very rigorous criteria for new practices as we roll this out across the country that will preserve the quality and the impact. Use really good fully risk adjusted methods when you do the outcomes of the analysis so its fair to the government and provider. Here is a picture of our team. This is a team of 20 people here in d. C. That do the work. Finding the right people is the key to success. Thank you. [ applause ] i just have to say that i had the privilege of sitting in on a team meeting and shadowing George Toller who is your partner in crime. This is the work you kind of hear about. This is teambased approach. Its collaborative. Its using people to do what they do best in different capacities. And if i had someone who was old and sick and impaired in d. C. , i would be thrilled to give you a call. Thank you. Great. Were going to move now to jim garnham who will give us his own perspective from the university of Rochester Medical Center where they are trying out bundled payments. Jim. Great. Thank you. I appreciate the time to be here this morning or this afternoon. I do want to just level set understandings of what bundle payments are. Its a single budget for an episode of care. We have a little bit of a definition around that. It starts with in our case an inpatient admission. What we call the anchor admission. It goes out beyond discharge out to again in our case 90 days. There are options for less time than that. It includes if you think about everything that happens to the patient after they are discharged from the hospital, inpatient, outpatient, physician, nursing home. There was a term used earlier today about patient centricity. And what marilyn said is the patient comes first. If you think about a patientcentered approach to care, i think first and foremost about bundles. If you think about somebody has Knee Replacement surgery, how have i conceived it, if i need Knee Replacement, think bundle starts at the episode or the episode starts when i go to my doctor and say, you know what, the injections arent working, the medication isnt working and it ends when i go back to golfing and now i have a better excuse for how bad i golf. Thats the totality for me, the concept of what Knee Replacement is. Thats how patients think about. Its not how we finance it. Its now hot we pay for it. Im excited to be part of this program because i think it very much is a much more Patient Centered viewpoint. As you can understand, if were at risk for that care, then theres a huge incentive for us to reduce unnecessary care and reduce unwarranted variation. Thats what we started with. We started with do we have volumes here that would indicate that we its worth doing and do we have variations that would say that there is something that we can do to reduce that variation standardized care and improve care and reduce cost. But while this is a financial arrange mntd ant contracting arrangement and thats why im involved, ultimately, first and foremost, this is a clinical practice. Its a clinical program. So we had to go to them. We took the data which is great and we went to the leads of our Service Lines and said, here is some opportunities. Here some potential opportunities for us to improve care, reduce cost and really dip our toe into valuebased payment. What would you do differently . What would you do to go after this opportunity . What resources would you need . How much would it cost . How quickly could you get there . What kind of outcomes do you think you could achieve . Do we have the Clinical Knowledge to get this done . Ultimately, do we have the clinical leadership that can actually get it there . This brought us then down to the major joint replacement as one opportunity. Then congestive Heart Failure as the other. These are very different programs. So this is just a little bit of the data that we started with. This is our baseline data, some of it. Each vertical line is an episode. The colors indicate where the dollars are being spent. It doesnt take a Rocket Scientist to figure out, green is probably where we need to focus. For major joint replacement, its Skilled Nursing facilitybased rehab. We started out at 74 of our patients were going home with Skilled Nursing to a skilled nurse facility. We can probably do better than that. We can get it down to 25 within a year. Congestive Heart Failure, different story. There is some Skilled Nursing facility. But i look at that and i go, what is red . How can we eliminate it . Red is readmission. The whole thing about congestive Heart Failure is keeping people from coming back. If any of you have anybody in your life that has congestive Heart Failure, you know the revolving door. So we have nailed down what the objectives are. Now we have to have a plan to get there. So we start obviously with the inpatient side. The hospital is the one at risk. We have the right folks in the room. This is not just about improving care in the hospital and handing it over to the postacute side. We brought the postacute folks into the facility and said, work with us. Help us understand these patients. Help us figure out not only what we do here but also what you do on the postacute side. Lets coordinate and lets have a unified plan of care across this continuum. Then we need once we figure out that, we need a way to keep track of those folks. We have a couple of resources. One is a dashboard, which is just a way to a place to put people. Its a software package. We can keep track of people. The real key is the care naf gator. One person who has specific focus and responsibility to watch these folks across the continuum of care. Not just in, okay, here we are done at the hospital, here you go. Its continuing that process all the way through the end so they are there a single point of contact for patients and for providers. Then the other major resource we applied was enhanced home care. For joint replacement, clearly it was getting rehab done in the home with home care and not in a sniff. For congestive Heart Failure, different approach. Its all about applying those home care resources in a rapid environment so that instead of picking up the phone and calling for an ambulance and going to the ed and back up to the hospital, its you call the care the nurse navigator or the nurse visiting Nurse Service and say, come out and do an ceasement. They can bring telemedicine resources so we can do a consult with cardiology. On site and even administer iv medications if thats whats necessary to keep folks from coming back into the hospital. So results. We all care about results, right . This is major joint replacement. Green line is rehab. You see there were 74 at baseline. We set a target for 25 . We have already blown through that. But thats not enough. We want to make sure were not doing that and then people are coming back into the e. D. Or back into the hospital because instead of being in a snf where they are getting good care, they are home and not getting the care they need. Our e. D. Visit rate actually went down. Not only did it not go up, it went down. We are very encouraged by that. And we did then the cost curve. We did achieve what we were looking for. We think we can do better. Congestive Heart Failure, completely different population. We have not yet really solved the readmission problem but theres one shining star in this. Remember, we said we had this clinical pathway and part of that was home care, enhanced Home Care Services to this population. So if we look at just the population that went home, didnt go to a snf, the people that went home with no home care which means they were offered and refused it, they came back at least 40 of the time, 47 of the time, they came back at least once. If they went home with a Home Care Agency that was not one of our partners, they came back 43 of the time. If they went home with our partner Home Care Agency that was committed to applying those rapid resources and doing telemedicine and iv lasix administration, the medication we use to control fluid retention, 17 of the time they came back. So theres a glimmer of hope here and i think if we just keep focusing on that model i think we will do better. So i just want to, in the 30 seconds i have left, i want to just say theres one piece of this that im really excited about, and sort of the spillover effects and the Lessons Learned, and that is you would expect the clinical leaders would all be about hey, lets apply these resources, great resources to more than just the medicare bundled payment folks. So we have had that. We expect that. What i didnt expect is i have just as much attention from the administration of the hospital saying how can we leverage this to other patients, we have a unique opportunity here to really improve the quality of care that were delivering, reduce the costs that were delivering. How can we figure out a way to afford this to broaden it out to other populations. Thats a really exciting place for a policy wonk like me to be, because usually youre trying to drag along the culture and instead, im seeing the culture change before our eyes. So i will end with that. And we will take questions. Great. Thank you for that very, very specific information about these on the ground programs. Its incredibly helpful. We are now open for questions. I invite folks in the room to come up to the microphone. I invite anybody who would prefer to write a question on the green card and our staff will be around to pick up your questions and bring them to us. If you are at home watching this live on cspan, please tweet a question. Anybody in the room can also tweet a question. Again, the hash tag is medicare demos. While we are getting folks set, i will turn it over to trisha to kick us off. I think i have this is a question for patrick. We did some work a few years ago that