Leaders of two large health systems recently described how their experience with clinically integrated networks, value-based care, and population health programs allowed them to be nimble and shift resources to the COVID response, prompting them to accelerate these efforts.
Emily Brower, M.B.A., senior vice president, clinical integration at Michigan-headquartered Trinity Health, and Arshad Rahim, M.D., M.B.A., vice president of clinical integration and network development at Mount Sinai Health System in New York City, spoke recently on a panel at the NAACOS fall meeting.
Brower said that fairly early in the pandemic, the national data was showing that providers that had invested and developed experience in value-based care and the basic blocking and tackling of population health — being able to identify and stratify populations, putting together outreach programs, developing comprehensive plans of care, bringing care into the community —were able to bring all of those capabilities to their response to COVID. Brower said the conclusion from the CMS administrator at that time was that we need to go faster and move more providers into these models, and we need to advance the level of both clinical and financial accountability. “That was very consistent with our insights at Trinity health as well,” she said. “We felt very called to accelerate our strategy.”
Trinity Health has 16 clinically integrated networks across 22 states and two national ACOs. “Every opportunity that we have to move into more advanced models — more accountability for clinical outcomes, more accountability for financial outcomes — we are doing that across all segments, Medicare, commercial and Medicaid,” she said. “Within those 16 clinically integrated networks, we put together the full continuum of care so that we can provide that connective tissue around a patient's journey, and make sure that they're getting the right care at the right time, and so we can intervene appropriately to prevent exacerbation of chronic disease or whatever that individual’s issues are.”
Trinity made a public commitment in the middle of the pandemic to say it would go faster into value-based care and move more of its contracts into alternative payment models. “We made a very specific, measurable commitment to move half of our Medicare business into two-sided risk models by 2025,” Brower said, “and at Trinity Health, Medicare is half our business, so that's a pretty significant commitment for us.”
Rahim also spoke about the importance of proactive condition management and patient engagement and outreach. “Of course, we know this is important, but I think just seeing the importance of it in action through this COVID experience really propelled us and maybe gave us even further focus that this needs to be exactly how we deliver care,” he said. “I also give huge kudos to our pharmacy team that was already planning to stand up a remote patient monitoring program, but really COVID was a great propeller, and this was a must-do in terms of managing patients with hypertension. We have moved very recently into managing patients with heart failure with a clinical pharmacist-driven program. It was fortuitously timed that we were already planning to move seriously in this into type of program.”
There were revised priorities during COVID, Rahim added, “but you really saw that ability to be nimble, and that focus on managing complex patients — this was a perfect time for that. So of course, you had all the outreach dealing with COVID-19 related issues, as well as all the chronic disease needs.” That proactive work involves the ability to use predictive analytics, he said.
Brower said teams within Trinity’s clinically integrated networks — the nurse case managers, social workers, and community health workers — “all of the folks who we had organized to be able to take accountability for an attributed population, we just said this is your new attributed population” — people who were at higher risk for COVID. “So instead of our usual math behind the number of ED visits, frequent admissions, we said, this is now our new high-risk population. And those teams have the same approach that they had developed to manage a population, whether it was a Medicare, ACO, Medicare Advantage, Medicaid, those same approaches, that same muscle that we had built, we flexed it to respond to patients with COVID.”
Among other changes, the pandemic has highlighted the role of the community health workers, Brower said. ‘Previously, we had some of our 16 networks deploying community health workers in some fashion, but there was no consistency and it wasn't a requirement. Now it is it's part of our staffing model. So just like we say you need R.N. care managers for this kind of population, social workers for this kind of population, you need this many community health workers, and they are delivering this standardized package of services.”
She noted that there is still lots of uncertainty involving traditional hospital and ambulatory service pattern disruptions brought on by the pandemic as well as how it might impact patient attribution and benchmarks in value-based care models. “In terms of CMS models, what is going to happen with Direct Contracting? Is that going to be opened up? For those already in that model, it is really undergoing a lot of change,” Brower said. “That feels like additional uncertainty on top of the uncertainty from COVID.”
Rahim said another lesson coming out of the pandemic is that care must reach out into the community. Academic health centers are naturally designed with an “if you build it, they will come” approach, he added. “Mount Sinai has taken the approach that that's not the future of care. It's got to be proactive; it's got to involve outreach in the community. It has got to be 24/7/365, and not just the episode when the provider and patient are in the clinical setting. We have to meet patients where they are.”