Affordable Care - The Real Deal?

Transcription

1 PREPARING FOR ACCOUNTABLE CARE: COORDINATED CARE

2 PREPARING FOR ACCOUNTABLE CARE: COORDINATED CARE Global Institute for Emerging Healthcare Practices Accountable care is more than a new program for Medicare patients. It is a new payment model already being adopted for Medicaid and by commercial health plans. Key Points Accountable care in the United States is much more than the Medicare Shared Savings Program (often referred to as the ACO Program ). States and private health plans are already contracting for healthcare services with ACO-like mechanisms for tying quality and cost to reimbursement. The core elements of accountable care are assuming responsibility for care across the continuum and demonstrating quality care through measured performance against a given set of quality indicators, while reducing overall spending growth. Coordinated care delivery organizations (CCDOs) will engage in multiple accountable care contracts to manage health services for the covered populations. An organized, systematic approach to care coordination is central to successful accountable care. One of the biggest challenges for CCDOs will be building processes that overcome the current fragmentation of care for many patients and lead to gaps in care and poor quality and cost outcomes. Direct care providers will collaborate with care coordinators in these new processes centered around a medical home for each patient. There are many models for organizing care coordination. The considerable experience base suggests that the model is less significant to success than a close working relationship between providers, care coordinators and patients. Much of the work on care coordination to date has focused on patients with one or more chronic conditions, because they can benefit the most from the additional support. In assuming responsibility for a population, CCDOs will need to apply care coordination in less-intensive forms to the population more broadly. Health Information Technology (HIT) will be critical to enabling providers at the point of care and at the point of coordination to do the right things for each patient. With the combined goals of bringing down the escalating costs of healthcare in the United States and addressing the well-documented gaps in care under current fee-for-service reimbursement, health reformers have been experimenting with other models that increase the incentives for providers to deliver better value for the money. Three aims have been identified for healthcare reform by the Institute of Medicine and others: improve patient care, improve population health, and reduce costs. 1 Payment reform is aligning reimbursement with the expectation that providers deliver improvements in each of the areas covered by the triple aims. This new accountability is reflected in the term accountable care used to describe the new environment. 2 Groups of providers assuming the responsibility for delivering accountable care must deliver coordinated care to succeed. This white paper reviews the resulting emergence of coordinated systems of care and the landscape in which they will deliver care, the models that are evolving for delivering care in a more collaborative and coordinated way, and the health information technology needed to do so.

3 Many providers are already finding that a substantial amount of reimbursement is coming from multiple accountable care contracts, and they have a strong incentive to achieve tight clinical integration with new care management and coordination processes over and above traditional encounter-based care. The Landscape of Accountable Care Multiple Contracts Making Providers Accountable for Quality and Efficiency Federal and state policy makers have focused their payment reform efforts primarily on Medicare and Medicaid. By far the most prominent of these is the CMS Medicare Shared Savings Program (MSSP) because of its national scale, as well as its role in the ongoing public debate about approaches to healthcare reform. At the same time, however, states have been moving to new payment models for Medicaid, such as global payments or budgets that have at their core the same type of performance expectations regarding quality and cost, 3 and many private health plans have entered into contracts with similarly structured reimbursement. 4 5 As a result, accountable care is much more than simply a new model for Medicare. It is an emerging payment model, and many providers are already finding that more and more of their reimbursement is coming from multiple accountable care contracts. 6 Under accountable care contracts, a group of providers assumes the responsibility for care across the continuum for a defined population of patients and agrees to reimbursement pegged in some way to measured performance against a given set of quality and cost indicators. 7 There are many models for tying quality and cost performance into the formula that is used to calculate actual reimbursement. (One review of ACO-like models being used by private health plans identified thirty. 8 ) Five general approaches are summarized below. Hospital Participation in ACO Arrangements (operating and planned) Commercial payer contract 56.3% Pioneer ACO 32.0% Medicaid ACO 16.1% Medicare SSP 14.9% More than one category 33.0% HRET National Survey of Hospital Readiness for Population-Based Accountable Care Model Description Financial Risk to Provider Pay for performance Bundled payment (episode payment) Shared savings (one-sided risk) Shared risk (two-sided risk) a nextgeneration risk sharing arrangement Capitation (full or partial), also called global payment or global budget Financial incentive or disincentive tied to measured performance (quality, but not always cost); may involve performance thresholds, improvement thresholds or a relative performance cut-off (e.g., lowest quartile nationally) Provides a single payment for all services for a specified procedure or condition as for pregnancy and birth Performance-based incentive to share cost savings, applied retrospectively based on outcomes and experience Performance-based incentive to share cost savings combined with incentive to share excess cost Payment per patient for specified services Provider receives performance -based adjustment to reimbursement rates (+ or -) May be in the form of preferential rates for high performers and/or incentives structured as bonuses (+) or claw backs (-) Provider(s) covers excess costs of services for procedure or condition Provider financial risk is limited to potential savings Often combined with feefor-service, P4P, bundled payments, global payments or capitation Provider covers some portion of costs if savings targets are not achieved Often combined with other reimbursement models ranging from fee-for-service to capitation Provider covers excess costs (likely to invest in stop-loss insurance) Often combined with other reimbursement models As noted, there are also combination approaches, such as global budget with shared savings or risk on top of traditional fee for service, which is common in ACO contracts of commercial payers Whatever the specific formula used, providers engaged in accountable care contracts have a strong incentive to achieve tight clinical integration with new care management and coordination processes over and above traditional encounter-based care. Preparing for Accountable Care: Coordinated Care 3

4 A coordinated care delivery organization (CCDO) is an entity that contracts to manage the continuum of care for a population under a reimbursement agreement that ties reimbursement to cost and quality performance. To cover the full spectrum of services, most CCDOs will have contracts and operating agreements with some participating entities that do not share in the performancebased financial risks. Coordinated Care Delivery Organizations A coordinated care delivery organization (CCDO) is an entity that contracts to manage the continuum of care for a given population under a reimbursement agreement that incorporates one or more of the models described above. To avoid confusion, these organizations are called CCDOs in this paper, rather than ACOs because CMS coined the term specifically to apply only to the MSSP. (A CCDO is essentially the same as a medical neighborhood, for each medical home the constellation of other clinicians providing health care services to patients within it, along with community and social service organizations and State and local public health agencies. 11 ) In many cases, CCDOs are pre-existing legal entities under one corporate umbrella (health system, large multi-specialty medical group or either of these possibly including a health plan,) with centralized contracting and varying degrees of clinical integration. Other virtual entities are being formed to function as an organized delivery system, although participating entities sharing in the financial risk do not currently operate under a common corporate umbrella. Some CCDOs are formed including or led by a health plan. 12 For purposes of contracting for accountable care, these new CCDOs will need to create a legal entity recognized and authorized under applicable state and federal law. (Without a history of clinical integration, these new organizations will probably find it more challenging to achieve the collaboration and coordination required for accountable care.) Most accountable care contracts require the CCDO to manage healthcare services for a population across multiple settings of care. To do so across the full continuum, the set of services includes not just primary care, specialty care and urgent/emergency/inpatient care, but also community and home-based services, rehabilitation care, skilled nursing, and long-term care. Although managing care may be more challenging, not all entities comprising the CCDO have to be owned and operated by the corporate parent or any participating entity. As a result, many CCDOs will have contracts and operating agreements with some participating entities that do not share in the performance-based financial risks. The Resulting Accountable Care Landscape In any geography, when multiple CCDOs are engaged in accountable care, the typical landscape of care provider affiliations and accountable care contracts is illustrated in Figure 1. Each of the two CCDOs shown (1 and 2) participates in one CMS MSSP (Medicare ACO contract). Hospital B participates in two, as is allowed under the rules for the program and likely reflects a history of shared patients with CCDO 2. CCDO 1 also has a bundled payment agreement with CMS for inpatient and post-discharge care for Medicare patients requiring a handful of surgical procedures and for patients with congestive heart failure (CHF). It operates a discharge clinic to provide post-discharge, transitional care for some highrisk patients and also works in close collaboration with Primary Care Practice A and Medical Group A on post-discharge care and follow-up to reduce readmissions. CCDO 2, which includes a health plan, has operated as an integrated health system for some time; it has a common board, clinical and financial governance, and contracting. All providers within the health system participate in a private payer ACO contract, and all except Hospital C participate in a state Medicaid global payment contract. A community health center also participates in the Medicaid contract. Preparing for Accountable Care: Coordinated Care 4

5 Figure 1. Accountable Care: Landscape of Organized Care Systems and Accountable Care Contracts Long-Term Care Nursing Home CMS ACO Contract 1 Community Health Center Medicaid Global Payment Hospital A Medicare Bundled Payment Medical Group C Health System Coordinated Care Delivery Organization 1 Discharge Clinic Hospital B Medical Center Hospital C Coordinated Care Delivery Organization 2 MD Practice Primary Care A Medical Group B Private Payer Risk Contract Medical Group A MD Practice Primary Care B Health Plan CMS ACO Contract 2 Elder Service Center Nursing Home Visiting Nurses Community Service Center Rehab Hospital In the fictitious community shown, the CCDOs include only the participating medical centers, hospitals, and physician practices or medical groups. All other service providers help to cover the continuum of care to community members covered under accountable care contracts through negotiated financial and operating agreements; they receive fees and do not share in any potential financial gains or risks. One of the biggest challenges for CCDOs is building processes that overcome the fragmentation of the healthcare system and the risks of subsequent gaps in care. Collaborative Care for Accountable Care Coordination Across the Continuum Some of the biggest challenges for CCDOs lie in building processes to address events outside of the local provider site and face-to-face patient interactions that are at risk for uncoordinated care leading to poor health outcomes and/or increased cost (e.g., referral not completed, lack of patient compliance). Another way of saying this is that care coordination is a set of activities to overcome the fragmentation of the healthcare system and the risks of consequent gaps in care. Definition of care coordination: the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient s care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care. 13 Terminology applied to this process is highly varied. Terms often used as synonyms or in conjunction with care coordination include collaboration, teamwork, continuity of care, disease management, case management, care management, Chronic Care Model, and care or patient navigator. 14 In this discussion, care coordination applies to any care-related activities not covered by direct care assessing, planning, ordering and delivering medical care. Individuals playing the care coordinator role may not be focused exclusively on this task; in fact many Preparing for Accountable Care: Coordinated Care 5

6 Hospital Participation in ACO Arrangements (operating and planned) Adopt care coordination across the continuum 69% Improve process efficiencies 57% Automate systems and processes 47% 2012 survey of executives, senior leaders clinical and operational. 15 direct care providers will be engaged in coordination tasks of some types, depending upon how the collaboration for care management is outlined in the accountable care contracts under which they are working. Care coordination is hardly new; it has been common practice at health plans for decades (though usually called care management ) and in provider organizations such as Health Maintenance Organizations (HMOs) reimbursed via full or partial capitation, seeking to limit hospital readmissions or addressing other high-risk transitions. Because extra efforts invested in care coordination are labor-intensive, the investment has always been focused on situations in which the lack of coordination presents the biggest risk to the patient. When accountable care is in place for more patients, systematic care coordination will be necessary more broadly, and many provider organizations will be more involved with care coordination than in the past. Once again, more intensive efforts will be focused on patients and situations at the greatest risk of a poor outcome. Accordingly, it is no surprise that building coordinated care has become a strategic priority in many health systems. The Landscape of Collaboration Accountable care will only be successful perform well against performance expectations for quality and do so efficiently when there is tight collaboration between direct care providers and care coordinators within and across sites and settings of care. Accountable care will only be successful when there is tight collaboration between direct care providers and care coordinators within and across sites and settings of care. Direct care teams will continue to provide medical care of different levels at individual sites of care for most patients. (See subsequent discussion for other possible models for some complex, high-risk patients.) Especially during transitions, they will collaborate with direct care providers in other sites as well. Each provider site within a CCDO will also be engaged in care coordination, a role that may be played by dedicated care coordinators or others, including members of the direct care team, who perform some coordination functions for some patients. A centralized care coordination function will also be in place in most CCDOs serving at least complex patients. Depending upon the capacity of individual provider sites, care coordination may be centralized more broadly. In one that is a clinically integrated health system, this will likely be operated under the aegis of the health system (and may have also pre-existed), but will have acquired a bigger scope of responsibility. In a more virtual CCDO, centralized care coordinators may be provided by a health plan participating in one or more accountable care contracts or a department of the medical group or other entity that manages the CCDO. (Under some accountable care contracts, care coordination roles may also be played by state health departments and Medicaid agencies, regional networks of care coordinators and communitybased organizations. 16 ) Figure 2 depicts this typical configuration of patient-facing roles in the same community shown in Figure 1, but without the overlay of the individual accountable care contracts in place. A centralized care coordination function, located at Hospital A, is charged with providing care coordination for patients with transitions to providers outside of CCDO1 and for very complex high-risk patients such as those with cancer and kidney failure. (This scope is illustrative only and would be determined by the collaboration agreements in accountable care contracts and how executives at CCDO1 decided to organize care coordination.) Preparing for Accountable Care: Coordinated Care 6

7 Figure 2. Accountable Care: Landscape of Patient-Facing Roles in Providing Care and Care Coordination Long-Term Care Coordinated Care Delivery Organization 1 Nursing Home Coordinated Care Delivery Organization 2 Hospital A Centralized Care Coordinators Hospital B Care Teams and Care Coordinators in Accountable Care Delivery Organization 2 Care Team Care Coordinator Care Team Care Coordinator Discharge Clinic Health Plan Centralized Care Coordinators Care Team Care Coordinator MD Practice Primary Care A Medical Group A Care Team Care Coordinator Care Team Care Coordinator Elder Service Center Community Service Center Visiting Nurses Rehab Hospital For some Medicare patients, Hospital B will also be collaborating with care teams and care coordinators in CCDO2 because it participates in a second CMS ACO contract. This collaboration can potentially include any care delivery organization in CCDO2, as well as the centralized care coordinators at the health plan. Not shown in Figure 2 are care teams and care coordinators in the participating entities operated separately from CCDO1, but participating in one or more accountable care contracts to provide a broader continuum of services. For many patients, care teams and care coordinators will also need to collaborate with their counterparts in these entities. Within this rather complex landscape, the collaboration for any given patient will be defined by: The next steps in care and support for the patient and The operating agreement (roles, responsibilities, process and procedures) negotiated among participants in the accountable care contract the covers the patient. The remainder of this paper discusses models for the necessary collaboration across sites and settings of care and the HIT that will be required to manage care in this way for large numbers of patients. Models for Collaboration Experience Base 17 Although accountable care as an approach to healthcare reform is fairly new, the experience base with care coordination in the United States is quite extensive, and current efforts to build systematic care coordination in CCDOs can benefit from this experience. Preparing for Accountable Care: Coordinated Care 7

8 Many health plans have engaged in care management, which involves monitoring and support of high-risk populations, for decades. Arguably, the practice fits the definition of care coordination used in this paper. More recently, private health plans have created and/or participated in a number of ACO-like ventures with provider organizations, and evaluations and descriptions of the collaboration models are emerging. CMS has been testing different models through demonstration projects relevant to accountable care for more than a decade, and the pace of experimentation grew with the establishment of the Center for Medicare and Medicaid Innovation. Many demonstration projects have explored ways of integrating disparate healthcare sites and teams to improve outcomes and not all have yielded the desired improvements; however, some of the models have been promising enough that organizations are continuing development There have also been a number of demonstration projects and industry collaboratives working to improve the effectiveness of medical home-centered care and/or ACO-model comprehensive, organized care. Other sources of experience with tested models for collaboration and care coordination include numerous evaluations of approaches to making transitions in care safe and effective, especially work on reducing hospital readmissions, but also on post ED 31 care and closing the loop on referrals Another important source of experience is the safety net, which operates under conditions that parallel accountable care in multiple ways. The following discussion draws upon models for collaboration and care coordination from this experience base. A medical home for each patient is at the center of how care is organized for each patient. Providing Direct Care From the beginning of discussions about and experimentation with accountable care, a medical home has been at the center of how care is organized for each patient. The model is rooted in the belief that patient needs are met more successfully and efficiently when there is an ongoing, supportive ( patientcentered ) relationship between the patient and a provider (usually a team) delivering the full range of prevention and wellness care, acute outpatient care, and chronic care (if needed). In some models, the medical home also arranges for or facilitates receipt of mental healthcare and inpatient care. Definitions and working models employed in experiments and demonstration projects concerning the medical home have varied, and positive results have not always been obtained, but success stories are promising For most patients in a CCDO, a primary care practice will serve as the medical home. In fact, the CMS MSSP is primarily care-centric, assigning patients to an ACO based on a history of receiving primary care services from a physician with a primary specialty designation of internal medicine, general practice, family practice, or geriatric services. 40 (Primary care physicians can participate in only one ACO.) Many existing CCDOs and those that are still forming CCDOs are adopting the model of the Patient-Centered Medical Home (PCMH), a complementary health reform initiative that seeks to strengthen primary care and is being encouraged through demonstration projects, payment reform (including additional patient management fees), practice support and recognition programs Although the transformation requires considerable investment, the model adds team-based roles and resources and new processes capable of more proactive care management, with objectives overlapping those of accountable care. Not every CCDO will transform primary care in this way, but those that do not will have to rely upon other collaborations to provide comparable care management services for at least some patients. Preparing for Accountable Care: Coordinated Care 8

9 Core Functions of the PCMH 45 Patient-Centered provides primary healthcare that is relationship-based with an orientation toward the whole person Comprehensive a team is accountable for meeting the large majority of patient s physical and mental healthcare needs Coordinated coordinates care across all elements of the broader healthcare system Highly Accessible responsive to patient needs and preferences, including shorter waits for urgent care, 24 x 7 access to care and advice, and alternative methods of communication Committed to quality and safety ongoing engagement in performance measurement and improvement, responsive to patient experiences and satisfaction, and engaging in population management A regular primary care practice or clinic may not be equipped to provide the additional services and support (i.e., close monitoring, education/coaching, health system navigation) for patients with higher risks for poor outcomes, either temporarily for the duration of a particular health condition or event or on an ongoing basis because of sociodemographic and/or health-related risks. Models for the Medical Home Primary Care Practice Specialized High- Intensity Practice or Clinic Hybrid May be Patient-Centered Medical Home (PCMH) or more traditional primary care practice or clinic May include in-house programs for high-risk patients or refer some or all such patients to externally hosted programs May serve patients temporarily during resolution of a condition or event (Discharge Clinic, special program managing cancer patients in treatment or newly diagnosed diabetics) May be ongoing (Program of All-Inclusive Care for the Elderly or PACE Care Center; Diabetes, CHF or Kidney Failure Clinic for high-risk patients with a particular condition; Elders Care Program for at-risk populations with complex care needs and/or socio-demographic risks; intensive primary care for at-risk populations) For some patients, responsibility for primary care shared by a primary care practice and a specialized high-intensity practice or clinic for designated aspects of care (Coumadin Clinic for medication monitoring and PCMH for all other health services; any combination of the two models above) There are many models for providing more intensive support to at-risk patients from the experience to date. Common typical elements are a separate, dedicated care team, a multi-disciplinary team that may include specialists (e.g., diabetes nurse educators, specialist physicians, geriatric nurse practitioners), and sometimes a different, dedicated primary care site. Some programs even bring care teams to patient residences on a temporary or ongoing basis. These types of alternative medical homes are found most commonly today in health systems receiving capitated reimbursement (e.g., HMOs), special programs created by public or private insurers for specific patient populations, or demonstration projects. However, ensuring that care delivery is structured to meet the needs of patients for whom routine care is insufficient is a wellestablished part of population management. (In CCDOs based on the patientcentered medical home, fewer alternative medical homes can be anticipated because of interdisciplinary resources available within the practice.) An important element of negotiating the partnerships and operating agreements among participants in any CCDO will be sorting out, for each accountable care contract, the specific definitions of at risk to be used in identifying patients needing an alternative medical home, clarifying how risk assessment will occur and collaborating to create the programs. Preparing for Accountable Care: Coordinated Care 9

10 Work on transitions in care especially following hospital discharge provides an initial experience base for broader work on care coordination. Ensuring Safe Transitions in Care Transitions in care from one level or site of care to another present many opportunities for things to go awry. Although monitoring and support to ensure safe transitions are actually care coordination activities, transitions are discussed separately here because many CCDOs have been focused on the post-discharge transition for some time. In fact, one can argue that this provides a useful experience base for broader work on care coordination. 46 In addition, some models for transition management incorporate care management infrastructure separate from that in the patient s medical home. The public policy focus on avoidable readmissions has led to not just public reporting about hospital performance, but also increasing financial stakes, as both public and private insurers have linked reimbursement with readmissions performance in some way. Despite considerable research on risk factors and interventions to reduce risks, there is no magic bullet indicating what mix of interventions will minimize the risk for each patient. One thing that is clear is that both comprehensive discharge planning and post-discharge care and support improve outcomes for high-risk patients. Successful models for comprehensive discharge planning and post-discharge care and support have employed some mix of the interventions listed below, though not necessarily the full set listed for each element. 47 In practice, interventions are particularized to the unique set of sociodemographic and medical risks of each patient, and an assessment of transition risks has become standard practice for every patient admitted. For patients deemed to be low-risk, fewer interventions are put in place. Promising Components and Interventions to Reduce Readmissions Comprehensive Discharge Planning 48 Element Assess Transition Risks Prepare the Patient Develop Post- Discharge Plan of Care Interventions Screen patient for medical and social readmission risks Standardize risk assessment Query patient about prior post-discharge period Initiate planning to mitigate transition risks immediately Obtain information from primary and community care providers as needed Identify the primary learner (may be family or other third party) Personalize education Teach patient regarding condition and recovery (selfmonitoring, warning signs) Use teach-back to assess comprehension Provide patient-centered information to patient/family at discharge for reference (discharge instructions including plan of care, medications, appointments, contact information, etc.) Involve clinical pharmacist in pre-discharge education Utilize transition coaches/advocates Assess patient understanding of discharge plan of care Involve all disciplines (nursing, social work, clinical pharmacist, etc.) Involve patient/family members Reconcile medications Incorporate care events and recovery milestones Council re: palliative and end-of-life care as appropriate Electronically prescribe discharge medications directly to community pharmacy Preparing for Accountable Care: Coordinated Care 10

11 Promising Components and Interventions for Reducing Readmissions Post-Discharge Support and Care 49 Element Prepare the Next Provider of Care Ensure Post- Discharge Follow-up Ensure Post- Discharge Support Intervention Identify next provider of care Standardize format and content of communication to next provider of care Include post-discharge plan of care and medication reconciliation Assign responsibility for communication Communicate discharge summary to physician responsible for follow-up care Use patient as conduit of information to next provider (paper communication, patient-managed personal health record) Confirm receipt by next provider of care Verify common understanding with telephone call to next provider of care Involve the patient s physician in developing the discharge plan of care and home care Utilize a checklist for visits following discharge Arrange care for patients lacking a regular source of care Schedule appointments pre-discharge for follow-up clinician care and testing Arrange home care/visiting nurse Implement home-care protocols for high-risk patients Front-load PCP/clinic visits Front-load home care Utilize APN with special training in population (CHF) Provide transportation, free follow-up care (for uninsured) Provide home visit(s) by nurse practitioner (NP), physician or multidisciplinary team Verify visit and/or dispensing of discharge meds Provider continuity during the transition Post-discharge telephone outreach (NP or clinical pharmacist) Multiple telephone contacts Provide patient hotline Utilize transition coaches/advocates Engage community services Use telemonitoring with electronic link to case manager/ provider to monitor status and compliance Work on readmissions has evolved from an initial focus on patient education to a formal process that begins at admission and involves the direct care team, but is managed by dedicated staff such as nurse discharge planners and/or social workers. Most of the work on discharge planning has been the sole responsibility of this in-hospital team. The local team has also typically conducted telephone outreach post-discharge and made arrangements for follow-up care. For many patients, this pattern is likely to continue. For high-risk populations, some hospitals and health systems have assembled dedicated teams to provide additional post-discharge care and support, even sometimes in patient homes. These teams have often included physicians and/or nurse practitioners, as well as pharmacists. 50 For many patients, these processes will not change substantially. However, as more patients are covered under accountable care contracts, discharge planning is likely to involve a clinician in a care coordination role from the PCMH, alternative medical home or care coordination entity. Notifying the appropriate external contact upon admission will become a standard practice. For some high-risk patients, discharge planning will be collaboration, sometimes even involving a provider from the program interacting with the patient, as well as the care team during the hospital stay. Care coordination protocols for some accountable care contracts will also decrease the role of hospital teams in postdischarge care and support. Preparing for Accountable Care: Coordinated Care 11

12 One snapshot of how this may work is provided by an evaluation of Medicare Coordinated Care Demonstration Programs. 51 Care coordinators in the ones that cut hospital readmissions of high-risk patients conducted the following routine activities when patients were hospitalized: Had face-to-face patient contact post-discharge >0.9 per month Collaborated with physicians (visits, hospital rounds) Served as communication hub (including during hospital stays) Received discharge instructions Monitored transition protocol Successful care coordination programs also focused on patient education, including behavior change model and medication management. As accountable care takes hold, additional transitions will warrant the same type of systematic approach that is being applied to post-hospital discharge care, though likely less intensive post-emergency department discharge and referrals to a specialist. Coordinating Care What s Involved The activities involved in care coordination centered around a medical home are distinct from those for direct care, but require close collaboration with the direct care team. Care Coordination Activity Determine and update care coordination needs Create and update a proactive plan of care and coordination Communicate Facilitate transitions Connect with community resources Align resources with population needs Description Inputs include: Treatment plan, treatment goals, and physical, psychological, social and environmental factors that may put plan at risk Patient preferences and goals Updated if gaps in treatment or attainment of goals or change in health or functional status Content includes: Current and long-term care goals and needs Coordination needs and plans to avoid gaps Who does what (patient, physician, coordinator) Updated if gaps in treatment or attainment of goals or change in health or functional status Exchange information, preferences, goals, experiences: Patients and families Among direct care providers across sites and settings Other care coordinators Ensure transfer of both accountability and information Arrange, coordinate, and/or provide services and support to ensure safe transition Arrange, coordinate, and/or provide services or programs outside of the healthcare system: Financial, social, educational Support groups or programs Inputs include: Historical coordination needs of population Feedback from providers and patients Data on wait times for services The level of care coordination and intensity with which each of these activities is performed for each patient is based on an assessment of the risks of attaining the health management goals set by the care team. Preparing for Accountable Care: Coordinated Care 12

13 Models for Organizing Care Coordination There are many models for organizing care coordination, and no one model appears uniquely positioned to deliver the best outcomes. 55 MedPac has identified four categories of models for organizing care coordination for patients with one or more chronic conditions. 56 Model 57 Organizing Principle Examples Practice Transformation Integrating Care Coordination Embedded Care Manager Transition Models External Care Manager Primary care as major point of contact for health services Medical home as major source of care coordination Care coordination staff integrated into care teams Dedicated staffing for care management/coordination funded by health plan, public program, or other entity in practice site Care coordinator collaborates with direct care team and patients in the medical home Formal collaboration to ensure safe transitions from hospital discharge to next provider of care Requires collaboration between hospital, patient/ family, and next provider of care Includes comprehensive discharge planning and post-discharge care and support Care management/care coordination program for high-risk patients operated outside of medical home Community-based program with community health teams for patient support and care coordination Chronic Care Model Patient-Centered Medical Home Intensive Primary Care Many ACO-like partnerships between health plans and provider organizations ACO-like partnerships between hospitals or health systems and independent physician practices Transition coach involved in planning and patient support Transition care team performs post-discharge monitoring and care, including in the patient s home Discharge clinic as core element of transtion management Disease management program operated by health plan or employer PACE (Program of All- Inclusive Care for the Elderly) Preparing for Accountable Care: Coordinated Care 13

14 However, there are many examples of operating programs incorporating two or more of these models, as illustrated below. Setting State partnership with nonprofit community care networks to care for Medicaid and indigent patients Large medical group and IPA Health plan accountable care collaborative with medical practices Medical Home Care Coordination Embedded case manager in large-volume practices function as part of primary care physician (PCP) team Some case managers work with patients across small practices Provide high-touch coordination for patients referred by PCP or identified by network data mining: Patient assessment and education Arrange referral care and community services Monitor status and compliance (including home visits) PCMH Integrated case managers and social workers function as part of medical home teams Refer patients to teambased disease management and other programs for high-risk patients Refer patients to wellness programs and resources Coordinate referrals Requirement that practices meet care coordination standards for PCMH Registered nurse care coordinators hired by practice: Contact patients with care gaps/non-compliance Coordinate care for high-risk patients upon hospital discharge Engage patients in health advocacy programs of health plan Role of External Care Coordination Program support to regional networks Program- and network-level disease management initiatives Some network disease management centers Some networks also manage behavioral health Embedded case manager in larger hospitals to manage transitions Network-level coordinators: Link to community programs Special programs for complex patients Provide lists of high-risk patients Provide notification of admissions Hospitalist Program: Manage care in partner hospitals Notify and communicate with PCP Complex Care Management Coordinate care for patients with complex care needs (cancer, renal failure, multiple chronic conditions) Disease and Case Management Programs (also post-discharge) Case managers coordinate care and monitor treatments Home Care Team: Provides in-home medical management by specialized teams for patients with limited access to outpatient care Shared coordinated care information system and clinical data warehouse Care coordination programs for complex case management (behavioral, disease, polypharmacy) Provide reporting to practice care coordinators: Predictive modeling to identify high-risk patients Lists of patients with care gaps/non-compliance Preparing for Accountable Care: Coordinated Care 14

15 Making any model work requires a design that spells out responsibilities, processes and tasks for care coordination and clear accountability and delineated next steps for care coordination for each patient at any point in time. Common Characteristics of Effective Care Coordination Programs Additional resources to perform care coordination tasks Close collaboration between care coordinator and clinicians in medical home Regular contact between care coordinator and patient Patient-centered approach and individualized coordination plan to address risks Adjust plan when interventions not completed or patient status changes Proactive role in transition management 24/7 access to medical advice Focus on medication management Characteristics of Effective Care Coordination Sufficient experience has been gained with care coordination centered around the medical home, including evaluations of impacts on quality and cost of care, that distinguishing features of successful programs have been identified. A systematic approach to care coordination, even just focused on high-risk patients, requires additional staffing; adding to the work of physicians and others in the primary care practice is impracticable. (Care management fees available in some health reform initiatives and the financial incentives of capitation and other ACO-type contracts provide the opportunity to invest in additional capacity for care coordination.) Formal titles, as well as scope of coordination activities, of additional staff vary considerably. Members of the clinical team often perform some care coordination tasks, and formal teams in designs such as the PCMH may include a care coordinator in each team. Typically staff dedicating a substantial part of their time to care coordination are nurses, social workers or certified case managers, although there are some models employing medical assistants in this role. Effective care coordination requires a close working relationship with the direct care team. In some models, an external entity such as a health plan provides care coordinators that spend time in the medical home, sometimes attending patient appointments, as well as meeting with the care team (the embedded care coordinator) and interacting with patients on their own. If not working side-by-side with the patient s care team, a good working relationship is required, with frequent opportunities for communication. Close proximity and a good working relationship contribute to having a common understanding of patient needs and goals and when and how the patient will achieve them. Having physicians work primarily with one coordinator and rely on that individual to facilitate communication with other participants in the patient s care appear to contribute to physician willingness to collaborate. At least patients in need of a high level of care coordination appear to benefit from direct contact with the care coordinator to foster the relationship, be assisted in navigating the healthcare system and connect with community services, and to receive education and coaching in self-management to supplement and reinforce education provided by the direct care team. (Some programs also employ specialists such as diabetes nurse educators or a disease management team, rather than rely upon dedicated care coordination staff to play this role.) Some programs have care coordinators (or clinicians) from the medical home interact with patients during hospitalization and/or make home visits in some circumstances. One rationale for medical-home-based care coordination is that close interaction around a range of health issues allows care coordinators and the care team to develop a relationship with patients, allowing both to understand and address unique needs and patient preferences. Proximity also makes it easier to achieve a common understanding of each patient s status and needs. Effective care coordination takes these into account, as well as the full range of health goals and the treatment plan, in coming up with a practical, individualized plan for care coordination. Monitoring progress against goals and completion of planned interventions is accomplished for high-risk patients by a combination of personal contact with the patient and information gained from participating providers. Because this is labor-intensive, for other patients requiring less intense monitoring, care coordinators ideally rely on reports of gaps in care or unplanned events (e.g., from claims history and eligibility checks when a health plan is involved or direct notification of admission to the hospital or emergency department) to identify issues requiring follow-up. (Discussion with the patient s clinical team and Preparing for Accountable Care: Coordinated Care 15

16 collaboration to adjust the care coordination plan is easier to accomplish when the care coordinator is co-located.) Transitions trigger care coordination for some or all patients, although the intensity varies by patient. How tasks are allocated between individuals in the hospital and the medical home or other subsequent providers of care (skilled nursing facility, long-term care) depends upon program design. Discharge planners in the hospital are always involved in developing the discharge plan, sometimes in collaboration with coordinator and/or clinical team from the medical home. Post-discharge care and support can be provided either by the hospital, the medical home, or other institutional provider, although some programs utilize special transition care teams to deliver and coordinate care for some period of time. Referrals to specialists are another transition that can invoke care coordination. Possible interventions to ensure that planned care interventions happen range from scheduling the appointment and ensuring that appropriate patient information is received by the specialist provider to arranging patient transportation as needed. To manage a high volume of referrals, some medical homes have a dedicated referral coordinator. Other designs facilitate close collaboration with specialists by collocating them in the primary care site or creating a formal network of a small number of good neighbor specialists to whom most patients are referred. Providing access to medical advice 24 hours a day, seven days a week is a common feature of successful care coordination programs (as well as a frequent feature of the PCMH). Some programs establish call-in numbers that are always staffed by care coordinators and/or clinicians or designated call-in times; others provide complex or high-risk patients with direct telephone access to their care coordinator. (In line with providing easy access to care and advice, some programs especially those based on the PCMH model offer extended hours, same-day appointments or walk-in urgent care.) The importance of close attention and support to medication management is reflected in increasing use of clinical pharmacists to supplement care coordinator efforts, both in the medical home and in transitions from hospital care. In addition to medication reconciliation at discharge, specific interventions can include review with patient/family to ensure the treatment plan is understood, verifying that patients have obtained needed medications, and post-discharge medication reconciliation. For complex patients on many medications, this can include faceto-face interaction with a clinical pharmacist in a care site or in the home. Coordinated care delivery organizations will apply the principles of population management to care coordination, with the intensity of interventions for monitoring and support based on sociodemographic and medical risks. Population-Based Care Coordination Much of the recent experience with care coordination has selected patients with one or more chronic conditions, a pattern of high use of healthcare services, or a combination of sociodemographic and medical characteristics indicating a complex situation. Under accountable care, this group of patients will continue to be targeted with intensive care coordination, but in assuming responsibility for a population, a CCDO will need to apply care coordination more broadly to the population. Consistent with the principles of population health, some level of care coordination will be assigned to every patient based on an assessment of risks. Methods for assessing risk range from formal assessments performed by clinicians (including in some cases a risk score or rating) and predictive modeling (as performed by many health plans based on claims history to patient-completed health risk assessments and referral by a member of the patient s direct care team). The intensity of care coordination for each patient will be designed to address the identified risks. Many patients will receive low-intensity care coordination, others medium or high-density 63 as illustrated in very simplified form below. Preparing for Accountable Care: Coordinated Care 16