Coordinating Care under Accountable Care: A Complex Web of Strategic, Tactical, and IT Challenges

April 10, 2013
Earlier this month, Jane Metzger, principal researcher in the Waltham, Mass.-based Global Institute for Emerging Healthcare Practices within the Falls Church, Va.-based CSC, authored a new white paper, "Preparing for Accountable Care: Coordinated Care." With the healthcare delivery system facing unprecedented foundational challenges moving into the new environment of accountable, coordinated care, Metzger spoke recently with Mark Hagland about the reality of what providers face going forward.

Earlier this month, Jane Metzger, principal researcher in the Waltham, Mass.-based Global Institute for Emerging Healthcare Practices within the Falls Church, Va.-based CSC, authored a new white paper, “Preparing for Accountable Care: Coordinated Care.”

As Metzger articulates in “Preparing for Accountable Care,” the reality of accountable or coordinated care is exceptionally complex, and encompasses numerous concepts and organizing principles, including the accountable care organization (ACO), whether of the Medicare Shared Savings Program variety, or of the private type; the patient-centered medical home; bundled-payment contracts; and organized transitions of care. Not surprisingly, the information technology foundations for the organizations being created to provide such care, which Metzger refers to as coordinated care delivery organizations (CCDOs), are correspondingly equally complex.

As Metzger notes, “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.”

What’s more, she writes of health information technology, “HIT can’t enable any process discussed without considerable patient-specific information. For HIT to make secondary use of that information (i.e., for quality reporting, electronic patient tracking to detect exceptions, clinical decision support), each element must also be available for computer analysis (i.e. structured, coded).” Happily, she notes, “Stage 1 meaningful use for HITECH [the Health Information Technology for Economic and Clinical Health Act] builds a strong data foundation, not just for the care teams  using the local EHR [electronic health record], but also for communicating critical information to other provider teams for continuity of care, and Stage 2 adds somewhat foundations.”

All that said, she adds, “However, the definitions of how much is enough and who is to be the documenter set low expectations. For example, for a patient with multiple chronic health problems and relevant past history (resolved problems), a problem list containing one entry, as allowed by the Stage 1 measure is not meaningful for care.”

Clearly, there are many levels of complexity here, levels that even the most advanced patient care organizations moving forward on some version of accountable care are only beginning to address. With regard both to the care delivery and organization issues, and the multifaceted IT issues, Jane Metzger sat down recently with HCI Mark Hagland to discuss the broad range of challenges facing healthcare and healthcare IT leaders in this emerging area. Below are excerpts from that interview.

Let’s start at the care delivery and care coordination level. Why is coordinating care so critical for accountable care?

Because it overcomes the fragmentation in care and provides support to high-risk patients.  Accountable care ties reimbursement to performance, and fragmentation of care results in lots of dropped balls that lead to poor outcomes—both in quality and in cost.  The discharged patient who doesn’t receive timely post-discharge care, the ill patient referred to a cardiologist who can’t get an appointment, are both examples that can have bad outcomes. And don’t forget that the measures for the CMS Medicare Shared Savings Program include the patient’s feedback about the experience of receiving care—a fragmented care system with patients bouncing around will never get good ratings from patients.

Also, we know that 10 percent of patients incur 80 percent of healthcare costs. Care coordination provides a process and resources (usually nurses) to track these patients more intensively, coach them in self-management, and ensure that barriers to receiving care are reduced.  Doing a better job with and for these high-risk patients is critical to success. One could say that care coordination has to be excellent for accountable care to work for patients and the provider organizations now at financial risk of achieving good outcomes.

Jane Metzger

You looked at many models for organizing care coordination, so there doesn’t seem to be just one way to do this.

Care coordination isn’t new.  The experience base is quite extensive, including in HMOs and integrated systems of care receiving capitated reimbursement, demonstration projects sponsored by CMS or other groups, new ACO-like partnerships between health plans and providers,  demonstration projects to strengthen the effectiveness of the medical home, and work in the safety net, including large-scale Medicaid programs.  When you look at all of models in these examples, there are two common themes. The first theme is that added resources are needed to do care coordination (not added work for the primary care physician); and the second is that direct care providers can perform some coordination activities, but also that there is a need for dedicated care coordinators and/or case managers.

Beyond that, yes, there are many models.  What seems to matter more than the model is the close collaboration between care coordinators and the clinical team in the medical home and, at least for patients requiring intensive care coordination, frequent contact between coordinators and the patient.

Where does the patient-centered medical home (PCMH)  fit into this?  To many people, accountable care and the PCMH appear to be the same thing.

For many patients, they will be.  That’s because many health systems engaging in accountable care contracts are transforming physician practices into PCMHs.  This separate, but complementary healthcare reform initiative shares many of the same goals as accountable care. Although transforming practices into PCMHs is a big investment, the PCMH design builds the extra resources and processes for care coordination right into the team, fosters a tight collaboration, and aims to accomplish patient-centered care so it hits many of the hot buttons for accountable care.  Other approaches include embedding additional care coordination resources in local, more traditional practices, special care coordination programs operated outside of the medical home (by the community or a health plan), and specialized high-intensity clinics that provide temporary or ongoing care management for high-risk patients.  In practice, organizations that have been at this for a while, typically evolve a combination of these approaches—a hybrid model.

You mention that some organizations have more experience than others.  For those for whom a systematic approach to care coordination is new, what are likely to be the biggest challenges?

Every hospital has been working on readmissions and most practices/clinics have been doing some care coordination for referrals to certain specialists or for patients with diabetes.  The big challenge will be organizing that and taking it to the next level so that it works seamlessly and systematically for large numbers of patients. Meanwhile, it is today’s challenge, because most health systems (or virtual health systems organized for the purpose of engaging in accountable care) already have several accountable care contracts in place or will have them soon—global payment for Medicaid patients, an ACO-like arrangement with one or more private payer, a Medicare Shared Savings Program pilot or actual contract.  We believe every organization needs to treat care coordination as a new enterprise-wide process and develop a near-term, mid-term, and long-term strategy for putting it in place.  Accountable care brings with it other complexities to tackle, but this is one requiring a home run.

Per the IT foundations for all of this, you address extensively how the meaningful use requirements under HITECH do not compel the creation of the full data set needed for clinical care and care coordination. Given that, how can provider leaders create the population management, clinical quality reporting, and patient tracking tools and systems they need to implement, to support coordinated, accountable care, while also meeting the requirements of meaningful use?

Meaningful use is a good start, but only if the goal is all of the required data for every patient, captured in a meaningful way rather than the thresholds set for HITECH.  But even that is insufficient. Coming up with the full minimum data set is complicated by the fact that patient-unique health challenges, the current care management context (e.g., post-discharge care, watchful waiting for changes in status), and the specific role of the participant (e.g., developing or implementing the care or coordination plan) determine what is needed in practice.  In the paper, we suggest focusing on the contents of the care coordination plan, electronic screening for gaps in care or changes in patient status, and data needs for population management, clinical quality reporting, and patient tracking as a good starting point.

You have a great section on health information exchange. Where are the biggest gaps right now? And has anyone created a model that works for all the purposes discussed in your document?

As I understand it, most organizations  aren’t doing much routine HIE yet, even things as basic as transmitting discharge summaries and patient discharge instructions to a patient’s medical home. HIE will be critical to enabling providers at both the point of care and the point of coordination to do the right things for each patient.  Large-scale HIE is based on the premise that participating entities have systems in place that can send and/or receive the needed information; we’re so far from that today that I think it is more realistic to work incrementally toward broader and deeper HIE, but at the same time to provide paper-based or other mechanisms to fill gaps in electronic opportunities.  Most of the activity and planning for HIE so far has involved medical record information for the direct care team, not the overlapping but also somewhat different information for care coordination.  In my snooping, I only found one organization today that I thought had this covered.

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