Home Health (RFI) Request For Information


About (PCM) Prime Care Managers ACO
In January 2017, PCM was designated as an Accountable Care Organization. As an independent primary care ACO, our primary care providers were assigned 7,500 Medicare Beneficiaries in our initial year. These Beneficiaries are scattered across the northeast Texas and southern Arkansas region. Approximately 50 primary care providers represented by 13 unique taxable entities participated in our initial filing.

Since then, we have grown to include additional independent entities adding another 60 primary care providers and some specialists. Our total independent physician participation now exceeds 150 with 15 unique entities. Our expected assigned Medicare Beneficiaries is expected to exceed 15,000 in 2018. As an ACO, our primary care providers are delegated the responsibility, by CMS, to manage the total cost of care for our assigned Beneficiaries regardless of where and by whom it is provided. We believe an independent and unaffiliated physician organization provides the greatest hope for accountability and value to our beneficiaries.

CLAIMS & RISK DATA
As an Accountable Care Organization we receive monthly updates of detailed claims information from the Centers for Medicare and Medicaid Services (CMS) for assigned beneficiaries. The cost and utilization data is specific by data of service for each claim encounter submitted to CMS. The claim data is comprehensive to all information provided on a submitted claim including, provider, facility, procedure, diagnosis, and supplies for all Part A, B and D claims.

The purpose for receiving claims information is to give an ACO insight into the cost and utilization practices of area providers. To some degree we are able to compare specific providers and measure their performance to local, regional and national benchmarks. We are also supplied a means to measure relative risk of a specific beneficiary. In addition to CMS supplying us a Hierarchical Condition Category risk score (HCC) for each beneficiary, we are able, based on diagnostic codes and historical use patterns, to predict risk. Our ability to predict risk allows us to adjust care plans and interventional activity to prevent and better manage future treatment options.

BUILDING A NETWORK
We realize, claims data relative to risk is not the only source for evaluating quality, outcomes and cost of providers. There are many other factors that drive the ability to align providers into high value networks of healthcare delivery. To form an accountable high value network, our ACO will evaluate self-reported data from area providers. The self reported data includes information regarding ownership structure, physician alignment, patient engagement, coverage area, service levels, staffing, clinical pathways, specific clinical performance, risk management and ability to clinically integrate into a value oriented network.

It is our goal as an ACO to work with multiple provider options in the marketplace. It is not our intent to exclude providers who can meet our objectives. Rather, it is our desire to build accountable long-term relationships with providers who continually demonstrate integrated capabilities that add value to Beneficiaries. Our goal is to build sustainable partnerships and grow our capabilities over time. Attached is a Request for Information (RFI) detailing questions which will provide us with additional insights to your organization. We appreciate your complete response. Any supportive documents are welcome.
Please forward information to:
Prime Care Managers, LLC ACO • 4002 Technology Center • Longview, TX 75605


We appreciate your participation in this important endeavor in our community. If you have any questions, please contact:
Dan Duffee / ACO Network Development
(903) 247-0484 x238 • dduffee@primecaremanagers.com


NOTE: All fields mandatory with: (*) // If not applicable insert: N/A

Primary Contact / Entity

Name of Owner (Legal Entity)(*)
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NPI(*)
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DBA Name(*)
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Organizational Type(*)
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Year of Formation(*)
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Ownership & Control

Name(*)
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Ownership %(*)
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Name(*)
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Name(*)
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Contact Info.

Administrator Name
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Facility Name
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Accreditation Status (List All)

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Contracts with State Agencies

If Applicable
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Offices

(In NE Texas)
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Med. Director(s) / NPI(s)(*)
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Category of Service(s)
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Other Owned or Affiliated Entities

(Include: SNF, Hospice, Rehabilitation, Etc.)
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Specialized Programs

(Please check if you have any of the below programs. Attach supporting documents, see 'Upload Supporting Docs.' at end of this form.)
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Clinical KPI

(Provide patient data for the last 4 months)

Skilled Services

Patient Volume Census
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Skilled Nurse Visits
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Physical Therapy Visits
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Provider Service Encounters
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Length of Stay

Average Length of Service for Skilled Nursing
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Number of Start-of-Cares
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Number of Recertifications
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Number of Deceased
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Case Load

Average Case Load / RN
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Average Case Load / LVN
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Average Case Load / HHA
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Recertification Rates

Average Number of Recertifications 1 to 2
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Average Number of Recertifications 3 to 4
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Average Number of Recertifications 5+
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Quality

Number of Missed Visits - Nursing
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Number of Missed Visits - Physical Therapy
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Number of Patients Sent to ER
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Number of Patients Admitted
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Number of Patients Re-Admitted to Hospital
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Compliance

Please describe policy and procedure for certifying patients for home health services. In your response please include:
a. What steps you take to identify the patients primary care provider.
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b. How you prevent services from being authorized without the knowledge of the patient’s primary care provider.
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c. How you assure that the primary care provider is duly notified and is involved in the qualification process for home care services.
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d. Who do you allow to sign orders. Specifically, in what situations do you accept orders from other than the patients primary care provider (verbal or written) from 1) a hospitalist, 2) a surgeon 3) a medical director 4) a specialist
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e. Describe your feedback process to the patient’s primary care provider in the event of a significant change in health status. What constitutes a qualifying event. In what manner or form do you notify the primary care provider.
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f. Describe your mid-term review process.
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Clinical Interoperability

There has been a growing need for interoperability in the health care industry, as despirate organizations come together forming new partnerships.
g. How do you suggest providers work together in harmony?
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h. How do you promote administrative efficiency and streamline processes and workflows. An ACO demands enhanced care coordination and collaboration in response to value-based reimbursement, population health, patient engagement, integration and an expanding continuum of care. To accomplish these things, healthcare partners must invest in inter-professional care, clinical integration and evidence-based practice.
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i. How do you promote and integrate the perspectives and practices of every healthcare professional – physicians, nurses, allied health professionals and non-healthcare providers engaged in prevention and care management.
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j. Describe your implementation of evidence-based care planning.
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k. How do you deliver customized and timely clinical reference content that empowers patients to more effectively engage with their providers.
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l. How have you integrated mobile health devices during an episode of care.
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m. Please describe your participation in information exchange, HIE and other initiatives that allow free flow of information to move from provider to provider and provider to patient.
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n. Describe the extent to which your information systems and devices can exchange data, interpret shared data and, use the information that has been exchanged.
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o. What processes do you employ to assure the data in your system is accurate and reportable. Describe your ability to translate medical charts into a discreet reportable format.
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Risk Management

ACOs require management infrastructure to define populations and mitigate risk by identifying potential health problems before they occur and preventing or planning for ways to reduce unfavorable outcomes. Measured and coordinated processes are centered on reducing hospital and ED utilization, avoiding readmissions, promoting wellness and managing chronic disease.
p. Please provide meaningful processes and metrics for your organization that would assist the ACO in meeting these objectives.
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q. What processes, technologies, capabilities and tools have you put in the hands of providers to help mitigate risk and promote best outcomes in an efficient manner.
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r. Describe how you have created or stratified your patient base into risk subpopulations. What criteria is involved as you perform your cohort analysis.
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s.Describe your actionable strategies you have employed to reduce over utilization and improve clinical quality.
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Upload Supporting Documents
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