What Do We Know About Care Models That Work for - PowerPoint Presentation

1. What Do We Know About Care Models That Work for High-Need, High-Cost Patients? Douglas McCarthy, Senior Research DirectorThe Commonwealth FundDelivery System Reform Advisory Board MeetingJune 13, 2014With acknowledgments to my coauthors Sarah Klein and Jamie Ryan1

2. Purpose and MethodsInform the development of principles for a high-performance health system for high-needs, high-cost patients by describing: A typology of care models and evidence of their impactCommon attributes of successful care modelsChallenges and barriers to sustainability and spreadSynthesized expert reports, literature reviews, evaluations of: Comprehensive care for older adults with chronic conditions (IOM)Care coordination for high-need Medicare beneficiaries (CBO, MPR)Care management of patients with complex needs (RWJF, CMWF)Advanced illness care programs (C-TAC)See bibliography for citations.2

3. Framing the Opportunity: Targeting Interventions Along the Population Health ContinuumSource: Coalition to Transform Advanced Care, Advanced Care: A Model for Person-Centered, Integrated Care for Late Stage Chronic Illness, http://advancedcarecoalition.org. 3

4. Comprehensive Care Models: Typology and Evidence of ImpactCATEGORIESEXAMPLESEVIDENCE OF POSITIVE IMPACT*1. Interdisciplinary Primary CarePACE, GRACE, IMPACT, Guided Care, CHF teamsQoC, QoL, FA, Survival, Use, Costs (mixed)2. Enhancements to Primary CareCare and case managementQoC, QoL, Use (mixed)Disease managementQoL, UsePreventive home visitsFA, Survival, UseComprehensive Geriatric Assessment (CGA)Geriatric Evaluation and Management (GEM)QoC, QoL, FA, Use (mixed)Pharmaceutical careQoC, UseChronic disease self-management QoL, FA, UseProactive rehabilitationQoL, FACaregiver education and supportQoL, Use3. Transitional Care Hospital to home (Naylor, Coleman)QoL, Use, Costs4. Acute Care in Patients’ HomesSubstitutive hospital-at-homeQoL, Length of Stay, CostsEarly-discharge hospital-at-homeUse5. Team Care in Nursing HomesMinnesota Senior Health Options, EvercareQoC, Use (mixed)6. Comprehensive Care in HospitalsPrevention/management of deliriumQoL, Length of StayComprehensive inpatient careQoL, FA, SurvivalSource: adapted from C. Boult et al., “Successful Models of Comprehensive Care for Older Adults with Chronic Conditions,” JAGS 2009;57:2328-37.Note: QoC = quality of care; QoL = quality of life; FA = functional autonomy. *Impact indicated only when true for a majority of studies or meta-analysis. 4

5. Medicare Demonstrations Show Mixed Results But Offer Important Lessons for Program Design5Source: L. Nelson, Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment, Issue Brief (Congressional Budget Office, Jan. 2012).

6. Context Matters: What Works May Vary by Care Site, Subpopulation, and Payment TypeSUBPOPULATIONExample models that work in managed care arrangementsExample models that work in fee-for-service arrangementsIn nursing homesEvercareINTERACT IIUsing long-term services and supports in the communityPACECommonwealth Care AllianceGRACE (Geriatric Resources for the Assessment and Care of Elders)With severe chronic illness, but no long-term services/supportsCareMoreMCCD, e.g., Health Quality PartnersCMHCB, e.g., Mass General HospitalWith less severe chronic illnessPhysician Group Practice Demo (ACO)Source: adapted from R. Brown, Care Coordination Programs for Improving Outcomes for High-Need Beneficiaries: What’s the Evidence? Presentation to the Commission on Long-Term Care, July 17, 2013. MCCD = Medicare Care Coordination Demonstration; CMHCB = Medicare Care Management for High-Cost Beneficiaries.SITE OF CARE MANAGEMENTImpact on Quality Impact on Hospital Use and/or CostsPrimary careImprovedSome reduced useTelephonic (vendor supported)Some improvementInconclusiveIntegrated multispecialty groupImprovedSome reduced costHospital-to-home transitionImprovedReduced use and costHome-basedNo clear evidenceNo evidenceSource: adapted from T. Bodenheimer and R. Berry-Millett, Care Management of Patients with Complex Health Care Needs, Robert Wood Johnson Foundation, 2009.6

7. PRINCIPLES(What they aim for)CONTENT(What they do)EXECUTION (How they do it)Population management targeting individuals at risk for poor outcomes and high costs Person-driven values and shared decision-making to define and meet patients’ goals and needsHealth system integration across the care continuum to minimize unwanted care and maximize support for patients and caregiversHealth workforce efficiency through interdisciplinary team-based care including non-physician providersFlexibility to interface with other care models to meet population needsOutcomes measurement to assess and improve performanceIdentification of those most likely to benefit from the interventionComprehensive assessment of patients’ risks and needsEvidence-based care planning and patient monitoringPromotion of patients’ and family caregivers’ engagement in self-careCoordination of care and communica-tion among the patient and care teamFacilitation of transitions from hospital to post-acute care and access to community resourcesProvision of appropriate care in accordance with patients’ goals and prioritiesCalibrated patient selection and enrollment techniquesEffective interdisciplinary teamwork, e.g., meetings, scope of work, trusting relationships Specially trained care manager builds rapport through frequent face-to-face contact with patients and physiciansUse of coaching and behavior-change techniques to teach self-care skillsStandardized processes, e.g., medication reconciliation, advanced care planning, timely and reliable information on hospital use, etc.Effective use of health IT to enable care management, communication, remote monitoring, etc.Source: authors’ synthesis (see bibliography). *Not all attributes/features may apply to all care models. Principles inferred from those articulated in C-TAC and other expert reports. 7Attributes and Features of Successful Models*

8. What Impedes Sustainability and Spread?SOME BARRIERS AND CHALLENGESPOSSIBLE SOLUTIONSFinancial IncentivesLack of incentives to provide care coordination and supportive services under FFS payment; difficulty of prevailing against FFS “headwinds” even when such services are providedUse statutory authority to extend and expand on successful aspects of Medicare and Medicaid demonstrations; move to alternative payment and organized delivery arrangementsCapacity to ChangeStresses on primary care and limited capacity to implement care management models, despite the logic of doing so in this settingTechnical assistance and shared resources to boost primary care capacity and uptakeCulture & WorkforceProfessional uncertainty and lack of training and skills to take on new roles, adopt patient- centered paradigm, and change the cultureBuild champions within professional societies and communities; partner with medical and allied health schools to develop curriculumInfra-structureInadequate EHR systems and software to support integrated care managementSponsor design challenges to develop new apps; share open-source EHR customizationsEvidence & Translation Difficult to translate general principles and specific experiences to other contexts; need for holistic metrics/data to measure what works (e.g., people with multiple chronic conditions)Learn from planned experiments to deepen knowledge of contextual factors associated with success; expand measurement toolbox and develop more practice-based evidence8Source: author’s analysis of synthesis reports and case studies.

9. Questions for ConsiderationBased on your knowledge, role, and experience:What are the most important attributes of successful care models for high-needs, high-cost patients? What are the key barriers and challenges that impede sustainability and spread of successful models?What’s needed to help health systems, payers and providers adopt and adapt effective approaches to successfully manage populations of high-needs, high-cost patients?9

10. T. Bodenheimer and R. Berry-Millett, Care Management of Patients with Complex Health Care Needs, Research Synthesis Report No. 19 (Robert Wood Johnson Foundation, Dec. 2009).C. Boult, A. F. Green, L. B. Boult, et al., “Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine's ‘retooling for an aging America’ report,” Journal of the American Geriatrics Society, Dec. 2009; 57(12):2328-37; C. Boult and G. D. Wieland, “Comprehensive primary care for older patients with multiple chronic conditions,” JAMA, Nov. 3, 2010; 304(17):1936-43.R. S. Brown, A. Ghosh, C. Schraeder, et al., “Promising Practices in Acute/Primary Care,” in: C. Schraeder and P. Shelton, eds., Comprehensive Care Coordination for Chronically III Adults (Wiley, 2011); R. S. Brown, D. Peikes, G. Peterson, et al., “Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients,” Health Affairs, June 2012; 31(6):1156-66.Coalition to Transform Advanced Care (C-TAC), Advanced Care: A Model for Person-Centered, Integrated Care for Late Stage Chronic Illness, http://advancedcarecoalition.org; R. Krakauer and J. Broyles, Final Report to the Commonwealth Fund: Strategies to Promulgate Advanced Illness Models that Work (Commonwealth Fund, internal document).C. S. Hong, A. L. Siegel, T. G. Ferris, Treating High-Need, High-Cost Patients: What Makes for a Successful Care Management Program? (Commonwealth Fund, forthcoming).L. Nelson, Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment, Issue Brief (Congressional Budget Office, Jan. 2012); L. Nelson, Lessons from Medicare’s Demonstration Projects on Disease Management and Care Coordination, Working Paper 2012-01 (Congressional Budget Office, Jan. 2012).Patient-Centered Outcomes Research Institute and The Hartford Foundation, CaRe-Align Collaboration Meeting Summary, Dallas, Tex., April 22-23, 2014; C. Boult, Challenges to CaRe-Align, Presentation to CaRe-Align Collaboration Meeting, Dallas, Tex., April 23, 2014.Select Bibliography10