Affinia Anchor
Table of Contents
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04
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06
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08
22
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24
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Trinity Mission & Values
Introduction
Affinia Anchors
Senior Leadership
Clinical Transformation.
Network Relations
14
Data & Analytics
Transformation & Integration
Care Management
Finance
Pharmacy
Administrative
The Big Picture
02
Our Mission We, Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.
Our Core Values Reverence We honor the sacredness and dignity of every person.
Commitment to Those Who are Poor We stand with and serve those who are poor, especially those most vulnerable.
Justice We foster right relationships to promote the common good, including sustainability of Earth.
Stewardship We honor our heritage and hold ourselves accountable for the human, financial and natural resources entrusted to our care.
Integrity We are faithful to who we say we are.
04 Introduction Our nation’s health care system is rapidly evolving into one that emphasizes value over volume. In the past, hospitals and other providers were reimbursed based on the volume of admissions, procedures, diagnostic tests and other services provided to patients. The higher the volume, the higher the total reimbursement earned by providers of care. In a value-based system, reimbursement is based on patient outcomes. Hospitals that have lower readmission rates will receive better reimbursement than those with higher readmission rates; likewise, providers with higher quality measures will receive better reimbursement than those with lower quality measures. Trinity Health has long been committed to being a transforming, healing presence in our communities. We have a proud history of improving health, by reaching out to those in need including the poor and underserved. We’ve worked to keep people healthy and out of the hospital because it was the right thing to do; as a result, our legacy of outreach to improve the health of communities pre-dates the national shift from volume to value. The shift to emphasizing value is best realized through a focus on population health management … in which Trinity Health ministries will be responsible for a defined population. This is a shift from traditional health care that focuses on sick care. Instead of caring for one patient at a time, we will be held accountable for a defined population of patients throughout the continuum of care. This means that mental, physical, spiritual, and socio-economic needs are taken into consideration whether the individual is actively seeking care or not. Clinically integrated networks (CINs) such as Affinia Health Network are the chosen vehicle to deliver on Trinity Health’s population health strategy.
The Federal Trade Commission (FTC) considers a program to be clinically integrated if it performs the following: 1. Establishes mechanisms to monitor and control utilization of healthcare services that are designed to control costs and ensure quality of care. 2. Selectively chooses network physicians who are likely to further these efficiency objectives. 3. Utilizes investment of significant capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies. At Affinia Health Network, our expertise, experience and resources will be focused on helping to keep people healthy and out of the hospital; if intervention is needed, we will treat them as efficiently and cost-effectively as possible. Our underlying premise, supported by research and experience, is that high quality and well-coordinated care designed around a patient’s individual needs and desires is also the most cost-effective at a population level. Population Health Management is a critical part of all the many things that are done in a people-centered health system. It’s the only part where we consider the entire population, identify specific individuals with particular needs, and then design care systems that are specifically targeted to improve the care they receive. Population health management will better position Trinity Health to fulfill our Mission, meet our nation’s needs, and improve the health of the millions of people and the hundreds of communities we serve.
Enclosed you will find an overview of our team and culture at Affinia Health Network. The Affinia Anchor articulates who we are and why we are here – to be a transforming and healing presence in the communities we serve. *Adopted from www.trinity-health.org
06 Affinia Anchors
Be Adaptable
Failure is the inability to adapt. To be successful, we must be resilient and flexible.
Embrace Diversity
We value unique perspectives and encourage new ideas.
Build Relationships
Individually we are one drop; together we are an ocean.
Challenge the Status Quo
We consistently ask, “how, why, and can it be better?�
Have Relentless Curiosity
We ignite the imagination and foster continuous learning and improvement.
Blaze Trails
We are pioneers and aim to be national leaders in population health.
08 Senior Leadership Influence, motivate and empower others to reach their maximum potential. Create and articulate a clear strategy, vision, and priorities. Foster unity and achieve alignment. Develop strategic relationships to drive execution of goals.
Core Responsibilities • Develop and favorably execute contracts based on the Quadruple Aim • Drive positive transformation by facilitating clinical integration and care coordination infrastructure development • Colleague, provider, and board engagement • Distribution of responsibility • Build a culture of innovation by making it safe to fail • Accountable for organizational health including financial sustainability, employee retention, and strategic alignment • Prioritize organizational efforts
Key Deliverables • Board, colleague, and provider education • Contracting/contract performance oversight • Growth of attributed lives • Assess/monitor organizational ability to assume risk • Ensure appropriate funding/resources for APM contracting work and other key initiatives
Team Measurements • Colleague engagement scores • TCOC in APMs (including CM engagement, CCR, and RAF metrics) • Membership numbers • APM attributed lives • Pass through dollars • Operating margin
10 Clinical Transformation Facilitation of clinical transformation to ensure elite performance in value based contracts.
Core Responsibilities • Implementation/Facilitation of Affinia Clinical Transformation strategy • Incentive Education/Interpretation • To train managers, providers and staff to develop the capacity for sustained change and improvement • Identification and facilitation of practice level opportunities for improvement
Key Deliverables • CIN clinical guidelines current calendar program strategy • Establish and maintain the relationship with Community Linkages • Refine and advocate for the integration of clinical transformation tools • Develop and execute actionable performance scorecards at the network, practice and provider level • Responsibility for supporting, assessing and advocating advanced payment model adoption
Team Measurements • Metrics as defined by the performance scorecard • Alignment of Provider to CIN Standards • Dollars left on the table • Effective Communication/Engagement– survey responses, number of touches with practices • Clinical Transformation Advancement
12 Network Relations Designers of the Affinia value proposition which is used to manage network relationships through communication, advocacy and connectivity with the goal of improving population health. Core Responsibilities • AHN Salesforce • Relationship Management • Payer Escalation • Stakeholder Advocate • Membership communication • Strategic Network Growth • Attribution Education • Leadership Communication
Key Deliverables • Manager Meetings – Quarterly • Communication – Affinia Advisor/Alerts • Payer Escalation Dashboard • Payer Scorecard • Membership Outreach
Team Measurements • Payer Escalation • Relationship Evaluation/Participation Agreement • Membership Retention • Manager Meeting Attendance
14 Data & Analytics The AHN analytics department exists to support Affinia members on issues related to acquiring, warehousing, processing, analyzing and reporting, with a particular focus on population health. The department supports contract and population management within the framework of the quadruple aim. Core Responsibilities • Data Consultation and Acquisition
• Payer Contract Data Evaluation
• Data Aggregation
• Application Development
• Data Integration
• Application Support
• Data Validation
• Support of Audit Processes
• Data Visualization
• Supportive Presence on Stakeholder Committees
• Data Analysis • Data Submission
Key Deliverables • Population Health Tools • Data Application Platforms • Reports, Dashboards, and Scorecards • Application, Data, and Analytics Education • Standard Supplemental Quality Data Files
Team Measurements • Colleague Development and Goals • Timely updates of PHM tool with quality measures • Timely completion of monthly data load to PHM tool
16 Transformation & Integration Creating efficiencies, feeding, protecting and maintaining value for our stakeholders. Core Responsibilities • Business strategy • Payer liaison for contract alignment • Development of business plans and project plans • Project management • Colleague Development • Measurement Analysis • Validation: Membership, ACO, Contract • Communication
Key Deliverables • Executive level dashboards • Affinia Institute– quarterly • Intentionally connecting mission and strategy • Developing measurements of key initiatives • Business and project plan development
Team Measurements • CCV Metrics • Network Integrity • Network Adequacy • Employee Satisfaction
18 Care Management Care Management is the collaborative process of assessment, evaluation, planning, coordination, and advocacy to assist patients and their support systems in managing complex medical and psychosocial conditions with the aims of improving health status, enhancing the coordination of care, and eliminating the duplication of services to improve quality, increase patient satisfaction, and reduce health care costs. Core Responsibilities • Identify patients with complex chronic conditions who are at high-risk for negative health outcomes, care fragmentation, and/or high-cost of care that are likely to benefit from care management services • Monitoring hospital admission, discharge, and transfer reports to identify patients with transitions of care needs • Comprehensive health assessments to identify the risk and needs of patients and develop patient-centered plans of care
• Assist patients and caregivers in managing complex chronic conditions through self-management support • Provide resource support, education, and care coordination during transitions between health care settings • Assessment of psychosocial needs to connect patients with resources in the community
Key Deliverables • Standardized work protocols to drive efficient and effective care management services • Hiring, training, and embedment of care management staff in to practice teams • Payer and Government care management program tracking to ensure service alignment and compliance • Population Health tools for the risk stratification of patient populations to identify patients appropriate for care management services • Care Management billing support and ongoing claims and documentation monitoring to ensure compliance and revenue optimization • Care management data and analytics tracking to ensure program productivity and alignment with standards
Team Measurements • Care Management Productivity, Caseload, and Payer Mix • Care Management Quality and Utilization Outcomes • Incentive Program Performance
20 Finance Prepares and oversees Financial Analysis in support of physician or other ambulatory partner strategies, managed care activities and population health activities on behalf of Affinia Health Network (CIN, ACO & APN). Core Responsibilities • Attributed Lives Analysis • Establishing, Maintaining, and Refining AHN Capital and Operating Budget • Supporting and Administering Financial Projects as Needed • Monthly Financial Variance Reporting and Analysis • APM Contract, Payment and Gainshare Analysis • Contract Settlement Analysis • Develops and Calculates Financial Models for new Payment Methodologies • Administrative Tasks – Generate Invoices, Data Entry, Check Process, etc. • FTE Approval Process • Attribution and Distribution of Payments • Payer & Incentive Payment Reconciliation • Financial Forecasting
Key Deliverables • Maintaining Financial Stewardship • Trending Financial Analysis • Maintaining Attributed Lives Dashboard • MTD & YTD Financial Reporting & Forecasting • Provides Tax and Insurance Documentation Support and Maintenance • Month End and Year End Adjustments, Reporting and Analysis • Attribution, Reconciliation and Distribution of Incentive Payments
Team Measurements • Producing Attributed Lives Dashboard, Financial Reports, Analysis and Forecasting by Defined Deadlines
22 Pharmacy Address Triple Aim goals with specific attention to pharmacy cost and utilization patterns in addition to providing insight and guidance on leveraging the unique skillset of pharmacy across the continuum of care for Affinia patients while supporting Affinia leadership on pharmacy strategy.
Core Responsibilities • Support quality initiatives with pharmacy focus • Engage with providers and deliver education and feedback on medication utilization and cost at a network and individualized level • Enhance communication and coordination between Grand Rapids and Muskegon pharmacy teams • Develop relationships with payers and vendors to support beneficial pharmacy initiatives • Develop pharmacy clinical support standard work for alternative payment model (APM) care managers • Assist leadership in development of pharmacy strategy around APMs, initiatives and talent procurement • Support ongoing education for students and residents on issues surrounding APMs and population health from a pharmacy perspective
Key Deliverables • Monthly Affinia Advisor article • Pharmacy cost of care dashboard • Direct collaboration with care management leaders to identify and support need for pharmacy services • Standard work and creation of pharmacy practice model for support of APM care managers
Team Measurements • Pharmacy cost of care • Pay for performance measures specific to pharmacy • Care manager satisfaction and utilization of clinical support services
24 Administrative Organizational Administrative support for all teams, and the directors of first impressions.
Core Responsibilities • Colleague development • Communication/Outreach • Supply purchasing • Payroll/Time and Attendance • New employee onboarding • Payer committee coordination/liaison • Maintenance of confidential documentation • Organizational integrity
Key Deliverables • Affinia Boards & Committees • Affinia Institute • Feel Good Friday • Financial stewardship • Organization wide coordination • Affinia culture • Time Management
Team Measurements • Employee engagement/satisfaction
26 The Big Picture
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Anchor = Mission Anchor Chain = Core Values Captain = Leadership Foundation = Clinical Transformation Lookout = Network Relations
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Mast = Data & Analytics Rudder = Transformation & Integration Lines to Sail = Care Management Keel = Finance
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Port Holes = Admin Island = Quadruple Aim Goals Sun = Quality/Value Clouds = Fee for Service Water = Trinity system
15 16 17 18 19
Lifesaver = Social Detriments of Health Wake = Competition Sail = Practitioners & Physician Partners Helm = Strategy Wind = External Factors