Primarily, ACOs are charged with keeping patients healthy rather than treating them when sick. As soon as a hospital or health system becomes an ACO, they accept responsibility to care for patients regardless of where they are, meaning they need to care for patients who are not even in the hospital in many cases. By accepting payment from the federal Centers for Medicare & Medicaid Services (CMS), Baltimore, to care for each patient regardless of cost, the health system becomes accountable for the outcomes of all of patients in the ACO. In this way, the health system serves as a health insurer for patients who become members of a health plan.
Providing proactive care often means keeping those members out of the hospital when appropriate. In the past, fee-for-service health system income was built on patient volume. More patients and more procedures meant more income. Today, ACOs must deliver care at lower cost while improving quality and access. Here are five ways one ACO in Maine meets the challenges of proactive access to care.
Improving patient satisfaction
One organization that knows how to succeed as an ACO is EMHS Beacon Health, an eight-hospital system in, Maine, and one of the original 32 Pioneer ACOs designated by CMS in 2012. In September, CMS recognized EMHS Beacon Health for delivering the fifth highest quality scores of any of the 19 remaining Pioneer ACOs and getting high marks in patient satisfaction and engagement. EMHS Beacon Health improved in 13 of 17 clinical scores.
Yet, as a measure of how difficult it is to convert from a traditional health system to an ACO under CMS’ shared-savings and shared-risk program, EMHS spent more to deliver care to its 22,000 patients than it did in the previous year. As a result, it returned $2.9 million to Medicare under the CMS shared-risk payment arrangement.
Accepting new responsibilities
In all health systems, physicians ensure patients get the best, most appropriate care. But ACOs strive to keep patients healthy whether or not they’re inpatients. At EMHS Beacon Health, nurse case managers take on the responsibility of serving as care coordinators under the ACO model, a role they did not play when the health system operated as a traditional care model, explains Tori Gaetani, RN, EMHS Beacon Health’s director of care coordination. Earlier this year, the National Committee for Quality Assurance (NCQA) accredited the ACO’s nurse care coordination program.
“We use an embedded care coordinator model. These are registered nurses who are embedded in many of our 74 physician practices that are part of the EMHS Beacon Health ACO,” she says.
Reaching outside the walls
As the job title implies, 55 nurse care coordinators support 60,000 patients, and next year (2015) we will have 65 nurse care coordinators supporting 100,000 patients in a statewide network serving some of the most rural areas in the nation in northern and eastern Maine. Care coordinators meet with patients, call patients at home and work with physicians and other care providers.
“Care coordination is a challenge because the majority of our care is in rural communities, which makes the training we give them in patient engagement critical to helping them do their job effectively,” says Gaetani. “For each patient, care coordinators have to determine if they get better engagement with that individual face to face or over the telephone. Given the rural nature of the area we serve, we also have a challenge getting patients in to see their providers or, if needed, getting care coordinators out to see the patients,” she adds.
Caring for patients outside the hospital, particularly in remote areas, poses challenges for health systems. “We are developing creative ways to address that challenge by collaborating with care teams who are out in the communities and who can help us to serve patients who need care in their homes,” notes Gaetani.
Engaging patients in care
“Part of their job is to educate patients, which requires engaging them to make sure they are fully involved in their care plan,” she adds. “To help them engage patients, we provide them with training in motivational interviewing. It’s critical to their success that our care coordinators have a thorough understanding about how to engage patients in their care.”
Serving such a large number of patients in many different settings requires care coordinators to master a variety of skills. “In a sense, all of our coordinators are specialists in care management and some are certified in care management. We also have certified health coaches and many of our nurses specialize in certain aspects of care coordination. We have one nurse, for example, who is certified as an asthma educator. All are very skilled in the art of care coordination,” comments Gaetani.
Identifying gaps in care
In addition, care coordinators analyze data to identify gaps in care—services patients should get—to identify high-risk patients, including those with chronic conditions and complex medical needs.
“To make sure we use our data most effectively, we are continually sharing it with our care coordinators and educating them about how to use it to help improve our efforts,” Gaetani comments.
Improving care transitions
Care coordinators also ensure patients move from one site to another appropriately. “We have a care-transition program that automatically triggers our care coordinators to work closely with these patients and monitor them as they move from one level of care to another,” explains Gaetani.
ACOs need all of these strategies to be successful, explains Iyad Sabbagh, MD, EMHS Beacon Health’s senior medical director. “We have to find a way to balance the need to deliver high-quality care with the need to deliver cost-effective care,” he says. “The data we have shows when we are achieving the proper balance between the two and when we are not.
“Having data available that reflects the performance of the organization and of our individual providers is useful because we’re holding the team responsible for our results, not just the physician or the care manager,” he adds.
Using data to improve processes
“Just this year we started reporting data to each provider organization about where they stand on quality and cost so that they can evaluate their success and begin moving care slowly to a lower cost, even higher-quality domain,” says Sabbagh. “Anyone can deliver low quality high cost care. We want to ensure our patients are getting the highest quality most cost efficient care and that requires us to engage all those providing care, including the physicians and care coordinators.
“The care coordinators are the cornerstone of our strategy of making sure that each patient gets the right care at the right time in right place. Traditionally, most care has been delivered in the inpatient setting and not all care has to be delivered there. Some care may be delivered more appropriately at home, in a physician’s practice, or in a skilled nursing facility,” he adds.
“We’re trying to drive care at the most appropriate level. To do that, we have care coordinators assess their patient needs carefully and then work with physicians to identify the most cost- effective way to deliver high-quality care,” Sabbagh concludes. “In most cases, the care coordinators know the patients and their families better than any other provider on the care team.”
Central Role of Care Coordinators Demands Workforce Development Tools
In an evolving healthcare system where case managers often function as extensions of physicians and other providers, workforce educational tools can help hospitals and health systems improve patient care while also keeping staff abreast of changes in the healthcare system.
That’s the word from Tori Gaetani, RN, EMHS director of care coordination at Beacon Health, a Pioneer ACO Maine. Gaetani—who says, “Our workforce management strategy involves providing continuing education to our care coordinators. To do that, we give our care coordinators an educational service called Athena Forum. When they feel they have the information they need to do their job properly, they are empowered to be more effective and efficient.”
Iyad Sabbagh, MD, EMHS Beacon Health’s senior medical director, says care managers have a vital role in ensuring that the ACO delivers appropriate and timely care to all patients. “The physician serves as the coach while the care manager serves as the quarterback of the care team,” Sabbagh explains.
As a result of working with patients, their families, and with physicians and other providers, care managers have an unusual and important role in the health system. “Care managers interact with all others who are involved in delivering care. That places them at the center of what happens with each patient,” Sabbagh says.
Gaetani agrees, saying, “They (case managers) have established relationships with physicians and other providers. They are the ones who often have the closest relationship with the patients. In that way, they are at the hub of care for each patient.”
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker’s Hospital Review/Becker’s Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.
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