In caring for our communities, a carefully designed Care Continuum Blueprint becomes the roadmap to enhanced population health outcomes—a testament to the profound impact of integrated care and strategic coordination.  There has never been a more compelling time to adopt a system of care based on population health management. The COVID-19 pandemic revealed substantial health disparities and compels us to take action. The population is aging, and the Medicare insolvency crisis is looming. Now is the time to move away from fee-for-service care and toward an approach that prioritizes quality, outcomes, and affordability for all populations.

In this week’s episode, we interview Dr. Mark Angelo, a senior administrator of a large accountable care organization and a leader in population health and palliative medicine.  He is the author of the new book Caring for Our Communities: A Blueprint for Better Outcomes in Population Health, that provides tactical guidance for developing effective population health programs and explores value-based care models. Dr. Angelo is an inspirational leader to the health value movement, providing a road map for creating an equitable, outcomes-focused system, using the right resources to nurture the health of our communities.

Dr. Mark Angelo currently serves as CEO and President for the Delaware Valley ACO (DVACO). In this role, he oversees clinical strategy and operations, including quality, population health pharmacy, clinical integration, care coordination, post-acute networks and practice transformation. In addition to serving patient communities as an executive with the ACO, he is a practicing palliative care doctor who continues to see patients.  DVACO has participated in the MSSP since 2014 and also works with commercial and Medicare Advantage payers in an effort to grow and expand the mission of value-based care in the Greater Philadelphia area.

Episode Bookmarks:

01:30 Introduction to Delaware Valley ACO and Mark Angelo, MD, MHA, FACP.

04:30 Referencing Dr. Angelo’s new book Caring for Our Communities:  A Blueprint for Better Outcomes in Population Health.

05:00 “Never doubt that a small group of thoughtful committed citizens can change the world; indeed, it is the only thing that ever has.”  — Margaret Mead

06:00 Dr. Angelo provides his perspective on population health underpinned by his clinical practice of palliative care.

07:30 A care continuum strategy that ensures care continuity, collaborative planning, and case management for complex patients.

09:30 The post-acute care journey at DVACO that began in 2014.

10:30 The Skilled Nursing component of DVACO’s post-acute care strategy.

11:30 Using claims data and real-time readmission tracing to monitor performance of SNF partners.

12:30 Graduating from a post-acute care focus to an overall care continuum strategy.

13:45 Optimizing home health to prevent avoidable hospitalizations.

14:30 How to identify suboptimal hospice care (e.g. length of stay greater than 180 days).

16:30 Home-based therapy as part of the care continuum to reduce TCOC in a frail elderly population.

18:00 An optimal zone of therapy between 12 and 32 therapy units over the course of a year.

19:00 Medicare reimbursement differentials across the different settings in a post-acute care continuum.

20:30 Building a population health playbook in post-acute care begins with SNFs.

22:00 Assessing performance data in developing a small SNF network to guide steerage decisions.

23:30 Applying the SNF assessment strategy in the vetting of preferred providers in home health and hospice.

26:00 Are partnering PAC facilities communicating with you in a meaningful way?

26:45 “Discharge planning shouldn’t happen in the last 24 hours of discharge. It should be happening all along. This is an important factor when it comes to creating partnerships across the care continuum.”

28:00 DVACO (in partnership with Main Line Health) developed a palliative care program that reduced hospitalizations by 50%!

28:45 “If you are an ACO and you are not focusing on your seriously illness population, you are missing a big opportunity.”

29:30 Developing an analytics methodology to identify patients with serious illness.

31:00 Guidance from Dr. Diane Meier, a nationally-recognized geriatrician and palliative care expert.

31:30 Improving lives of patients while decreasing costs at end-of-life through a home-based palliative care program.

34:00 Population health data that confirms the superiority of home-based palliative care (e.g. decreased hospitalizations and ED visits, increased hospice utilization).

37:30 Dr. Angelo provides leadership insights on how best to engage providers in population health approaches to care.

38:45 An example of supporting providers in VBC (a dedicated call center that connects resources to patients most in need).

41:00 SDOH and behavioral health resources for patients (e.g. addressing food insecurity to improve population health).

42:00 Another example in supporting providers in VBC (a successful aging program).

43:00 In-home wellness assessments for patient (e.g. medication reconciliation, dietician and care coordinator consults).

44:45 “We help our providers to better care for patients at the point of care. That is a great way to get providers to want to be part of your ACO.”

46:00 Health equity as a societal flashpoint and the challenges of inequality in the Greater Philadelphia area.

47:30 How DVACO provides a health equity lens in the design and implementation of all population health programs.

48:45 The need to compare QM results between population segments (e.g. an overall mammogram completion rate of 88%).

49:30 How the pandemic highlighted health inequities and reframed opportunities for improving population health.

50:00 “In an Accountable Care Organization, you’re responsible for managing the care of your community, not the care of a fraction of your community.”

52:00 The impact of social isolation on frail and elderly populations.

52:45 People experiencing social isolation have a higher risk of heart disease, stroke, depression, and anxiety.

53:45 Surgeon General Dr. Vivek Murthy’s call to action to address “the epidemic of loneliness” as a public health crisis.

54:00 The correlation between excess utilization of healthcare services and social isolation.

55:00 Building bridges with Community Benefit Organizations to address social isolation.

57:00 The emerging “payvider” trend and how Humana became a valued partner in Delaware Valley ACO.

58:45 The benefits of a strong payer relationship within an ACO.

60:00 “Payvider relationships say to the market that we are laser-focused on the success in value-based programs.”

61:00 The Infinite Game: “Infinite-minded leaders don’t ask their people to fixate on finite goals; they ask their people to help them figure out a way to advance toward a more infinite vision of the future that benefits everyone.”

63:00 Parting thoughts on balancing fee-for-service with the “infinite game” of value-based care.