Ep 195 – A Care Continuum Blueprint for Better Outcomes in Population Health, with Dr. Mark Angelo

What this episode covers

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 partn...