Accountable Care Organizations and Emerging Delivery Models for Spiritual Care

Transcription

1 Accountable Care Organizations and Emerging Delivery Models for Spiritual Care Rev. Cathy Chang, MDiv, BCC Chaplain, MissionPoint Health Partners, Nashville, TN Jan C. Heller, PhD System Director, Ethics, PeaceHealth, Vancouver, WA

2 Presentation Outline Introduction (JCH) A deluge of new acronyms ACA, ACO Our aim: Identify and consider some implications of ACOs for the delivery of spiritual care services A high-level overview of the ACA and ACOs (JCH) Some implications for Spiritual Care (CC) Structure (vs. acute care and hospice) Goals of spiritual care in an ACO (life goals vs. treatment issues?) Delivery of services Triggers to a spiritual care consult Distinctive issues encountered (vs. acute care and hospice) Questions and discussion (CC leads, JCH if needed)

3 Overview of the Affordable Care Act Actually titled the Patient Protection and Affordable Care Act Signed into law by President Obama on 23 March 2010 Focuses on three broad areas Provisions to expand health insurance coverage Control of rising health care costs Improvements to the health care delivery system Principal Sources: Kaiser Family Foundation modified on 23 April

4 ACA and Provisions to Expand Coverage Requires most US citizens and legal residents to have health insurance Creates state-based exchanges for individuals to purchase insurance, with premium and cost-sharing credits for individuals and families with incomes between % of federal poverty level (FPL, $19,530 for family of three in 2013) Separate exchanges for small businesses Expands Medicaid eligibility to 133% of FPL Graduated (increasing) penalties for those choosing not to purchase insurance

5 ACA and Provisions to Expand Coverage Changes to health insurance Basic essential health benefits package for all, with four tiers and reduced out-of-pocket limits Guaranteed issue and renewability Rating variation allowed only on age, rating area, family composition, and tobacco use No lifetime limits Note Unauthorized immigrants not eligible for health insurance

6 ACA, Cost Containment, Health Improvement Simplifies certain health insurance administration rules and claims management processes Extensive changes to Medicare, e.g., Incentives to providers to accept patients in Medicare Advantage (vs. patients with higher fee for service rates) Reduce premium subsidies to higher income individuals and couples Creation of Innovation Center within CMS Demonstration projects for bundled payments preparatory to implementing Accountable Care Organizations (ACOs) Note: ACOs originated largely as part of cost containment efforts, but also have implications for improving population health

7 ACA and Accountable Care Organizations ACOs: Three key elements Provider-run organizations at base Collectively accountable for health outcomes of an enrolled patient population Potential to share in financial savings (and, possibly, risk) associated with improvements in quality and efficiency of the care provided Aim: Incentives to providers to work across continuum, high quality and effective care, improved health outcomes, and lower costs First used in 2007 for Medicare, quickly moved to commercial (private) insurance sector, and now some states are developing ACOs for Medicaid enrollees

8 ACA and Accountable Care Organizations Some statistics as of Q4 of ACOs nationwide in all sectors, including 260 based in physician groups 238 based in hospital systems 55 based in an insurance company 53 based in some other category Covered lives: ~18.2 million Take away ACOs are likely hear to stay Experimentation will continue, leading to diversity Their success will depend not only on outcomes, but also on patient satisfaction and adoption

9 ACOs and Spiritual Care

10 Who does MissionPoint serve? Clinical populations with whom we have a contract with an employer or insurance provider ex. Medicare, BCBS members under certain plans, Kohl s, etc. Only certain pts. are actively managed Mostly outpatient and long-term. Across all age, income, and ethnic demographics. One of the primary pastoral care issues is isolation.

11 MissionPoint Clinical Structure Actively managed patients are assigned a health partner. Three teams of health partners: Ambulatory, Transition and Integrated Care. Focus is on behavioral change and population health: a way of providing holistic health.

12 Referral and Screening Ambulatory and Transition: Life-threatening illnesses or death Clear spiritual need (rituals, angry at God all the time, etc.) Integrated Care (IC) Everything else usually assessing anger, grief, loss, etc. Looking for spiritual and/or existential crisis. We have internal software send a referral and create a to-do for me.

13 Pastoral Care at an ACO Cross between hospital chaplaincy and pastoral care in a religious community. A combination of doing and being. Resources are more like pastoral care in a church, mosque, synagogue, etc. than hospital chaplaincy. Primary spiritual issues of the patients are sometimes health issues, but often not.

14 Pastoral Care Goals at MP Spiritual Wellness how spiritual health affects physical health and vice versa For each patient to have and/or develop healthy spiritual support systems and practices Pastoral care at an ACO is a spiritual waystation

15 Assessment After referrals, spiritual assessment by chaplain to identify and address needs. Always looking for resources: faith communities and their resources, pastoral counseling, etc. Patient is placed on pastoral care path. Try to keep visits to maximum three and then refer. Mostly phone calls with some home visits. Try to avoid overlap in pastoral care.

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17 Coordinating care In-patient Hospital: coordinating with chaplains In-patient facility: Faith community support Coordination with chaplain Outpatient: Faith community support Hospice: resign the patient

18 A Case Study A evangelical Christian man in his late 60s who had end stage renal disease, and was going to dialysis 3 times a week. Wheelchair bound. He did not tolerate dialysis well, and would regularly be admitted to the hospital for fainting at dialysis. He was hospice eligible, but was not on a hospice service. He was married, and also had a stepson, daughter-in-law, and 2 grandchildren living with him.

19 Issues around comfort care, end of life choices, DNR/DNI status. Psychosocial issues: finances, housing, etc. all dependent on him. Coordination between ACO and hospital pastoral care staff, to provide continuous and seamless spiritual care. And also with his inpatient and outpatient medical team. Coordination with their church to provide spiritual and physical services. Burnout issues with the church.

20 Pt. was outpatient palliative care eligible, so eventually with the help they were to keep him at home instead of constant hospital admissions. Home visits to discuss end of life choices, quality of life choices, and views of suffering. A lot of pastoral care for the staff, because of the stress and distress the case was causing them. Pt. was on our service for about 1 year and a half before passing away at the hospital.

21 Summing Up Ultimately, pastoral care at MissionPoint is about helping our patients develop their own spiritual health and find their own spiritual home. We can t be their sole spiritual support forever, but we can be a helpful waystation on their journey to spiritual wellness.

22 Questions and Discussion