How ACOs can optimize post-acute care to succeed in value-based care: 5 Qs with naviHealth's senior medical director

As of 2017, more than 32 million patients were covered by an ACO amid CMS' efforts to spur practice innovation and care redesign within the healthcare industry, according to a survey from the National Association of ACOs and Leavitt Partners.

When health systems, health plans and physician groups first launched ACOs eight years ago, most stakeholders focused on revamping primary care to improve quality and reduce costs. Now provider groups are largely focused on post-acute care, which contains variability in quality and care costs and presents ample room for improvement to effectively manage patients across the care continuum.

However, many ACOs are struggling to coordinate care and share information between hospitals and post-acute settings. To address fragmentation in the post-acute landscape, ACOs can use a high-tech, high-touch clinical model to create a patient-centered clinical perspective and manage patient care at each step of their care journey, according to Thomas Mathew, MD, senior medical director for naviHealth, a Cardinal Health company.

Dr. Mathew is no stranger to post-acute care, serving more than a decade as a hospitalist, palliative care physician and medical director of a skilled nursing facility. He spoke with Becker's Hospital Review about how ACOs can take advantage of post-acute care coordination opportunities to drive quality outcomes and cost savings.

Editor's note: This article has been lightly edited for length and clarity.

Question: Why is a post-acute care strategy critical for an ACO's success?

Dr. Thomas Mathew: It's really important from the standpoint of where ACOs have come from and where they are going next. A lot of ACOs' opportunities, at least initially, focused on remodeling primary care. However, CMS' most recent benchmarking data revealed a large percentage of ACO savings were attributable to a post-acute care strategy. Identifying a uniform strategy around partnering with institutional post-acute care providers, determining which patients need what care environment — and for how long — contributes to variation in use. Hospitals also need to factor in readmissions linked to post-acute care, which present a huge opportunity to reduce variation in how healthcare dollars and care quality align. Understanding the different stakeholders involved in an ACO and having a strong post-acute care strategy really embodies the idea of providing the right care, at the right place, at the right time, which CMS has laid out as the next step for these entities to achieve.

Q: What key performance levers should an ACO focus on based on current strategies and initiatives?

TM: Care coordination is an important lever. But it's not just about passing information through the care continuum. It's about recognizing high-risk patients and the variables putting them in harm's way. A patient's level of debility surrounding his or her medical diagnosis is a true harbinger of what challenges lie ahead. So the idea of risk-stratifying patients — collecting health information and being proactive to recognize downstream implications — is important. The more you activate a patient and family with information about the care journey, the more they'll be able to participate in their care and anticipate challenges.

The next lever is identifying quality post-acute care partners in your ecosystem. The challenge is that for every hospital, there are probably 30-plus home health agencies, skilled nursing facilities, etc. Some of the objective quality measures, such as Star ratings, often do not reflect true quality or value. To partner with providers that meet this definition within their existing ecosystem, hospitals need improved data around actual patient outcomes in as real time as possible.

Even when you put all these things together, you still need to be able to engage with your post-acute ecosystem. One of the biggest challenges with reviewing claims data is the difficulty of talking about events that happened 10 to 18 months ago. The ability to take information, follow it as concurrently as you can and effectively communicate it to all your stakeholders is an important part of managing your care continuum.

Q: How has technology changed the way a patient moves from one healthcare setting to another?

TM: We're in the age where EHRs, transfer summaries and medication reconciliation are all part of the workflow. One thing that's missing is assigning a general manager of care as patients move from one setting to another, since a lot of questions can emerge. ACOs must be sure they're capturing the right care down the line, which involves recognizing high-risk patients. A patient's functional barriers need to be highlighted earlier in the care process for a successful transition. ACOs can use technology to identify patients with a specific medical comorbidity via a functional assessment, compare them to a larger cohort of patients with similar circumstances and map out their journey based on best outcomes. It's also important to recognize potential pitfalls for these patients, like higher readmission rates. The more upstream we're able to identify that information, the more we can activate the care team and patient during the care journey.

Population health data also helps hospitals identify their largest post-acute partners. A lot of existing technology and quality ratings capture bland data, or data that doesn't move. By following live patient outcomes, health systems and ACOs can better identify which partners take on the most clinically complex patients or which discharge patients in the most successful way with the least readmissions.

Q: How has CMS continued to drive a universal definition of function to inform the post-acute care journey? How will technology play a part in this?

TM: One of the reasons for so much variation in post-acute healthcare utilization is because care settings have different definitions of function, which need to talk to each other. CMS sought to provide standardization around how quality measures are reported in the Improving Medicare Post-Acute Care Transformation Act of 2014, with one of the main focuses on function. However, we are still very early in this journey. We still need to make it easier for post-acute stakeholders to input the right information and start talking to each other.  

Navihealth has 15 to 18 years of outcome data around function for patients across the care continuum. We've been able to study the outcomes of more than 2 million lives. By creating a cohort of patients with a similar functional assessment and matching their medical comorbidities, we can drill down individual patients and begin to chart their journey. You can learn so much about the right post-acute care location for patients and the right amount of time they need to be there to prevent readmission by understanding a patient's functional journey through post-acute care.

Q: How does the new Bundled Payments for Care Improvement Advanced model play a role in ACO strategy?

TM: A lot of ACOs initially took on more upside risk moving from fee-for-service to value-based care. As we see CMS offer more risk tracks — which feature greater upside risk, but also potential downside risk — a natural corollary is understanding the post-acute ecosystem managing care around episodes, rather than primary intervention. It's important to recognize BPCI Advanced is an alternative payment model, as well. This is just another card ACOs can hold to start dipping their toes farther into value-based care.

This model allows ACOs to better partner with hospitalists and specialists in charge of care episodes in the hospital. The advanced payment model also improves alignment with physicians participating in the Medicare Access and CHIP Reauthorization Act and Merit-based Incentive Payment System. Physicians who have a relatively large volume of their care provided with BPCI Advanced could meet criteria to receive a 5 percent increase for their fee services and schedules under Medicare Part B. An ACO should be using this model because it helps drive their goal to provide the best quality of care across the continuum and align many different stakeholders.

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