Rural critical access hospitals face plenty of resource challenges in the shift to value-based care. The expansion of the care coordination function in ambulatory medicine at independent Eaton Rapids Medical Center (ERMC) in rural Michigan has been critical to its early work in accountable care.
Beth Charles, M.A., a care coordinator and ACO champion, said she had recently joined ERMC a few years ago when it partnered with Caravan Health, now a Signify Health subsidiary, on an accountable care organization program. Previously she had worked at a different ambulatory care medicine clinic that worked primarily with the CPC Plus program. In her previous work she developed an understanding of the people and resources you need in place to make this work. “We've always said it's the right people at the right time, and it's all about the quality, not the quantity anymore,” she said. “Value-based care is about how that quality is going to be delivered to patients in a way that is sustainable, and helps them and the providers in the clinic, so that we can deliver the care that the patients need. It's all about what we can do to help them stay safe and healthy in their homes.”
The care coordination group has grown to three employees supporting seven primary care providers. Many of their patients are elderly and dealing with diabetes, chronic heart disease or COPD. “It really starts from the top down. The providers identify patients via ER visits or hospital visits,” explained Deb Smith, R.M.A., another of the care coordinators. “That's how we get started with getting them in the CCM [chronic care management] program. We have different tracking mechanisms, but the key is having that communication with the provider. Our office is centrally located, and all three of us share the same office. That allows for good work flow, because it's easy access to be sure we're following up on something and we're taking care of what they need.”
Caravan offers some technology tools that allow the care coordinators to download lists of current patients that are attributed to ERMC. It helps them identify patients who need to come in for appointments or could use annual wellness visits. They look closely at patients who have two or more disease issues and who might need more attention to make sure that they're coming in for appointments, Charles said. The Caravan tools helps the care coordinators get reports to the physicians a week before an appointment. “They understand and see where those diagnosis gaps are,” Charles said. “If they haven't been in for an annual wellness visit, we get them scheduled for one. If there's somebody who has a higher risk score, maybe the provider is going to spend more time to try to get them associated with a care coordination program.”
In addition to the Caravan tools and team support, Charles said, they also have registries available in their Meditech EHR to help track patients with chronic conditions.
The care coordinators room all the patients for annual wellness visits, and go through all the preventive care screenings and current medication lists and vaccines. “If they see cardiology or nephrology, we make sure we have the most current office visit from that provider,” Smith explained. “If they need a mammogram or colonoscopy or bone density to be ordered, that's already ordered before the provider comes in. By the time we finish, we have spent 30 to 45 minutes with the patient first, and we have all that ready for the provider. Then they can have their full appointment time addressing each of these bullet points with the patient. We spend a lot of time making sure we establish a rapport with the patient, and dive into their social determinants of health also. If something comes up — they lack a source of healthy food or are between homes, we're able to help connect them with a community resource. Sometimes you are surprised at the annual wellness visit. It's almost like an ‘A-ha’ moment. You recognize that there are some other things going on with this patient than just preventative medicine.”
Smith said they have been really focusing on those social determinant issues for the past two years, especially with the impact of COVID on their patients. “When we were asking them questions about food insecurities or inability to pay for their medications, initially we didn't have all the resources in place. Now we have a binder available in each exam room, so the minute the patient answers yes to one of those problems — transportation, food, medications, domestic issues, anything like that — we've got instant resources to discuss with them and to give to them.” They also are starting to build tools into the EHR to track those social issues as well.
The pandemic complicated the care managers’ role significantly. When the pandemic first started, they switched all of their appointments to telehealth. “Initially, we were doing the wellness visit via telehealth, for two or three months. It wasn't a very good or feasible way to stay in contact with the patient for preventative visits,” Charles said, “so we held off on doing those.” Also, some rural patients don’t have broadband access to do video visits. They worked to stay in touch with patients by phone so they had somebody they could talk to in the office when they're at home in fear. “We do have a large elderly population in the care coordination program, and for some we were their only contact,” Smith said. They also worked to arrange appointments for vaccines once they became available.
Another component of what they do involves transitions of care — patients who are going home or to a skilled nursing facility from a hospital inpatient stay. “We want to make sure we're following their timeline and making sure they have a follow-up here with their PCP in a timely manner within seven to 14 days,” Smith said. “Also, if they have had significant hospital stay and they're going to need some more assistance at home, it is an opportunity for us to sign them up for that care coordination.”
Looking back now, Charles said, it is interesting to think about what the primary care providers had to do alone before their department was created. “Now they establish a care plan and we can help follow through,” she said. “They can be really busy in their clinic. We don't always have to see them and talk verbally to update them. We send it straight through the patient's chart electronically and message them, so they're always up to speed, and it has helped lighten their loads, which is really important to all of us.”