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Advance Care Planning: Why Patient Education Matters

Advance Care Planning (ACP) adoption has been slow because clinicians don’t have ample time or are uncomfortable with the topic; patients tend to associate ACP with end-of-life. Today, however, ACP has evolved into a reimbursable priority that benefits adults of any age, as well as their families and providers. Certainly, the COVID-19 pandemic demonstrated the value of preparation when patients unexpectedly can’t speak for themselves. Considering that studies show that up to 75% of patients will need someone to make medical decisions for them in the future, now may be the right time to integrate ACP into your standards of care.

ThoroughCare’s 120-Day Playbook: Launching Your Care Management Program

ThoroughCare offers more than a software platform for care delivery. User organizations also receive access to unique clinical support services that enable successful care management programs. This includes tailored training and a comprehensive onboarding process to help launch and scale care coordination services. While working with ThoroughCare, clients can leverage our 120-Day Playbook, a complete guide to starting and growing a new care management program. This resource provides step-by-step support for all the necessary elements key to success.

How Clinicians Use ThoroughCare to Educate Patients

Physicians and clinical teams face a catch-22. They can’t gain patient participation and adherence without increasing health and disease education. Yet, they don’t have the time to engage patients deeply. But what if clinical teams used a focused approach supported by trusted, timely educational resources that maximized teachable moments? With ThoroughCare, physicians and care teams can access evidence-based, targeted, and timely educational content from Healthwise, all within their normal workflow.

Using Care Management as a Patient Engagement Solution

Medicare’s care management programs, such as Principle Care Management (PCM), Chronic Care Management (CCM), and Behavioral Health Integration (BHI), all rely on monthly patient engagement, typically conducted via phone or virtual care. Depending on the program and patient complexity, the monthly minimum billable time for care management activities could be 20, 30, or 40 minutes or more. The purpose of each program is threefold: to improve the patient’s health status, reduce emergency department and hospital utilization, and decrease overall healthcare costs. And monthly touchpoints are critical to making meaningful, long-term changes.

The CMS 2024 Physician Fee Schedule Final Rule

The Centers for Medicare & Medicaid Services (CMS) has released the Final Rule for its 2024 Medicare Physician Fee Schedule (PFS). According to a CMS fact sheet, this update “is one of several Final Rules that reflect a broader administration-wide strategy to create a more equitable health care system that results in better access to care, quality, affordability, and innovation.” While next year’s payment policies introduce notable changes—some good and others not-so-good— the 2024 Final Rule offers significant opportunities for organizations focusing on care coordination or offering care management programs, particularly for rural health clinics (RHCs) and federally qualified health centers (FQHCs).

Assessing the Economic Value of Care Management Programs

There are numerous benefits to launching a care management program. These include measurable results for patients, such as improved healthcare access, efficiency, and health outcomes, as well as cost savings for Medicare, Medicare Advantage, and even commercial payors. But, there is also a substantial economic and value-added benefit to provider organizations, including those in primary and specialty care. Here, we’ll outline the financial and indirect economic benefits of establishing or scaling one of several care management programs. We’ll also provide a rubric for decision-making when designing a program and how best to quantify revenue potential.

Value-based Care Solutions: Team-based Care Coordination

Several factors are driving the adoption of team-based care coordination. Workforce shortages exacerbated by the pandemic, a growing population of adults living longer with chronic disease, and the shift toward value-based care models top the list. The Institute of Medicine (IOM) defines team-based care as being delivered by at least two healthcare providers. This includes coordinated collaboration with patients and their caregivers to accomplish shared goals within and across settings. The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care.” When combined, team-based care coordination can help providers and payors support streamlined, more efficient service delivery. This can lead to consistent patient engagement and help achieve better outcomes in health and cost.

Value-based Care Solutions: Advance Care Planning

Healthcare’s goal is to cure. However, Advance Care Planning (ACP), or end-of-life planning, can address the tension between care at all costs and ensuring an individual’s wishes are met when they can’t speak for themselves. Research shows that people would prefer certain treatments near the end of their lives over those they often receive. This disconnect can lead to burdensome and costly treatments that may increase suffering. While 25% of all Medicare spending occurs during patients’ last years, research shows that about 70% of adults prefer less aggressive treatments at the end of life. Observational studies have highlighted the many benefits of ACP. For instance, patients are less likely to die in the hospital, and they are more likely to receive care that is consistent with their preferences. More than 50% of Americans know the type of medical treatment they want to receive at their end of life, yet only about 22% have formally documented their wishes. Only 17% of patients say they’ve talked about it with their doctor.

Using Care Management as a Patient Engagement Solution

Medicare’s care management programs, such as Principle Care Management (PCM), Chronic Care Management (CCM), and Behavioral Health Integration (BHI), all rely on monthly patient engagement, typically conducted via phone or virtual care. Depending on the program and patient complexity, the monthly minimum billable time for care management activities could be 20, 30, or 40 minutes or more. The purpose of each program is threefold: to improve the patient’s health status, reduce emergency department and hospital utilization, and decrease overall healthcare costs. And monthly touchpoints are critical to making meaningful, long-term changes.

Value-based Care Solutions: Medicare Annual Wellness Visit to Identify Risk

Medicare’s Annual Wellness Visit (AWV) can be instrumental in improving care quality for older adults. This yearly assessment captures information about a patient’s health and functioning to document disease and identify new or worsening risk factors. AWVs ask about lifestyle, social history, mental health and home environment. Documenting these details can help providers risk-stratify patient populations and develop comprehensive, personalized care plans that can close gaps. This can help clinicians better coordinate services, streamline collaborative decision-making and support value-based care delivery. AWVs have been shown to build stronger provider-patient relationships, secure additional revenue and contribute to cost savings.

Value-based Care Solutions: Health-related Social Needs

Unaddressed health-related social needs (HRSN) can make achieving care plan goals difficult. Provider and payor organizations that assess, identify and work on HRSN can help remove barriers that would otherwise thwart clinical efforts. This can support more comprehensive patient care planning. Care plan requirements of value-based care contracts, Medicare’s Chronic Care Management program, or other care coordination services aim to improve health outcomes, control costs and engage patients.

Value-based Care Solutions: Transitions of Care

Policy and value-based payment models promote the importance of managing transitions of care. Historically, hospitals were the primary focus of Medicare’s Hospital Readmissions Reduction Program (HRRP). However, consider that one in five Medicare beneficiaries is readmitted to the hospital within 30 days, and a high percentage of these readmissions are considered preventable. They cost the US healthcare system about $17 billion annually. Beyond cost, research has shown that 30-day readmissions are an independent risk factor for all-cause mortality that persists for at least two years. Despite hospitals lowering 30-day readmission rates for Medicare patients from 20% to 17.8%, care coordination between the acute setting and primary care providers is an essential next step in quality improvement.

Maximizing the Value of Patient Assessments

Patient assessments are used in various settings by different medical professionals. They can be part of a proactive process (e.g., during an Annual Wellness Visit) or when some symptoms or signals indicate further assessment is necessary. Not only can patient assessments reveal previously undiagnosed illnesses, but they also provide an opportunity for engagement and education to build healthier habits. Let’s explore how care teams, particularly those within a care management or value-based care program, can maximize patient assessments.

Culturally Sensitive Chronic Care Management

An individual’s culture and language play a large part in their health. Healthcare professionals see the impact that culturally sensitive approaches can have on building greater awareness, closing care gaps, and spurring health-driven patient action. These interventions are particularly impactful when embedded in a Chronic Care Management (CCM) program. Why are culture and language influential in healthcare? The US is becoming more diverse. More than 10% of adults living in the US speak a language other than English. Nearly half of those individuals report speaking English less than “very well.” Racial and ethnic minorities are also disproportionately affected by chronic illness.

Selecting the Best Health-related Social Needs Screening Tool

Screening for health-related social needs (HRSN) is evolving into a care standard. Value-based care contracts and accreditation bodies are beginning to require screening for social determinants of health (SDOH) and social needs. The Joint Commission now asks healthcare organizations to assess HRSNs for a representative sample of their patients. Their focus on health-related social needs highlights the needs of individuals versus social determinants of health that describe population characteristics and influences. Health systems, ambulatory settings, and health plans will begin to see more screening requirements for HRSN or SDOH. However, most will leave the choice of which tool or questions to use up to the healthcare organization. While there has been little research into health-related social needs or SDoH assessment tools, several have been validated and reviewed. These options are in alignment with the Institute of Medicine's (IOM) recommendations and other healthcare quality organizations' requirements.

Understanding Social Need, Social Risk, and Social Determinants of Health

Health plans and provider organizations are beginning to wrestle with the non-medical influences that significantly affect patient health. Referred to as social determinants of health (SDOH), they include factors like socioeconomic status, education, neighborhood and physical environment, employment, social supports, and access to healthcare. Assessing these factors can indicate the level of social risk and social need that create barriers for patients to receive timely, adequate care and achieve better health. However, for healthcare leaders who want to support clinical and non-clinical aspects of wellness, identifying the subtle differences among these concepts is critical. This understanding can help create meaningful change.

Engaging Patients is Key to Closing Gaps in Healthcare

In a previous article, we looked at foundational ways that provider organizations can close care gaps: cyclical consistency, workflow integration, and alignment with care priorities. While closing care gaps to improve quality may seem complex, the main objective is to support patient health through the best evidence-based medicine available. Care gap resolution isn’t about checking a box, but helping patients understand the value of prevention and health maintenance throughout every phase of life. Yet, the vast majority of patients aren’t on board. According to the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, only 8% of U.S. adults attain all guideline-recommended services. With that in mind, how can clinicians and their teams engage patients to gain cooperation, commitment, and energy focused on disease prevention and closing care gaps?

Making Care Primary: CMS Now Accepting Applications

The Centers for Medicare & Medicaid Services (CMS) is accepting applications for its new advanced care model, Making Care Primary (MCP). Set to start on July 1, 2024, this initiative will use gradual, population-based payments to support small, independent, and rural organizations as they transition to value-based care contracting. The overall aim of the initiative is to reduce care costs and improve outcomes through more coordinated, whole-person care.

Value-based Care Solutions: Hybrid Payment Models for Primary Care

An aging, chronically ill population has put pressure on healthcare to lower costs and deliver proactive primary medicine. For this reason, healthcare payment models are moving towards value-based contracts, where the provider’s compensation is tied to care quality and patient outcomes. This transition has gained steam throughout the last decade due to federal and state policy initiatives, payor influence, and technological innovation. However, many healthcare organizations are still working to figure out exactly how to implement this new system. Conversations about value-based care tend to emphasize a need to fully switch away from fee-for-service (FFS) payments. The idea is to leave one model behind to adopt the other, putting providers in a position of haste to adjust their businesses, accordingly. Yet, a hybrid payment model, where FFS and value-based contracting co-exist, may offer a more versatile way for healthcare organizations to utilize alternative incentive programs without completely sacrificing their financial stability.
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