Who, What and Why: The Basics of Integrated Care Organizations

New patient care models are emerging in waves, each with their own acronym: accountable care organizations, patient-centered medical homes and consumer operated and oriented plans are just a few of the most well-known innovations. Another model more providers are considering is the integrated care organization, designed for patients who are dually-eligible for Medicare and Medicaid.

In a Care Team Connect Webinar, John Loughnane, MD, medical director for Boston's Community Medical Group, said ICOs are designed to help patients who traditionally fall out of the care continuum or rely on emergency departments for healthcare services. These are the patients that have generally encountered the most splintered healthcare, and require more coordination for cost-savings.

Who are ICO patients and what services do they need?

ICO patients generally fall in the age range of 21 to 64 and come from all living situations, including independent living with and without certain healthcare services, long-term care settings and group homes. Their medical issues include developmental disabilities, serious mental illnesses, substance abuse disorders, chronic physical conditions and/or three or more acute-care admissions per year.

ICOs provide a network of providers that tailor care plans for these patients' individual needs, which can range drastically. Dr. Loughnane said the patient-centered medical home is the best analogy for ICOs. Rather than focusing on primary care, however, the ICO includes behavioral health services, pharmacy benefits, adult foster care, adult day health, durable medical equipment and transportation to and from appointments.

"When you see these services, you see this is not just about a medical team taking care of a patient and handing them off," Dr. Loughnane said in the webinar. Dual-eligible patients represent a diverse population that may require vastly different services. Sometimes, behavioral health teams may need to take the lead in a patient's care, whereas medical teams may need to take the reigns at other times. These complex and correlated demands mean providers need to carefully integrate their care partners in an ICO.

Questions to ask, strategies to determine
Hospitals seeking partners for an ICO should ask a few questions. What does the hospital do well, and in what areas does it need help? What organizations has the hospital worked well with in the past? How well do organizations communicate throughout the care continuum?

Hospitals will also have to determine whether they will wrap the ICO around primary care providers or build their own primary care model for the ICO. "Do you go out and find primary care physicians who are already taking care of these [dual-eligible] patients and say, 'These are your patients, now we're going to be an ICO taking care of them. How should we wrap behavioral specialists around your primary care?'" Dr. Loughnane said. This is known as the "wrapping" technique, since PCPs are still responsible for those patients but are supported by an ICO team that is integrated into the PCP practice.

If hospitals choose to build their own PCP model for the ICO, Dr. Loughnane said there should be clear benefits to that approach. Hospitals also need to consider the ratio of care providers, such as home-based vs. office-based care, employed vs. community physicians and hospitalists vs. end-of-life care. Patients will transition in and out of these settings and may need intensive care one day, but not the next.

What's making ICOs relevant today?
ICOs are a relevant patient care model since 9 million Americans fall under the dual-eligible category and cost about $300 billion per year, according to Dr. Loughnane. In his state of Massachusetts, Dr. Loughnane said there were roughly 96,522 dual eligibles that cost $3.85 billion in 2008. Across the country, 20 percent of dual-eligibles account for more than 60 percent of Medicare and Medicaid spending, according to Dr. Loughnane.

"Go to the Medicaid office in your state and ask where they stand in terms of ICO demonstration projects," said Dr. Loughnane. "Thirty-five states have an interest in this, but find out where your state is and if it's something you can be a part of. Ask the question to yourself about how you're taking care of these patients and if there's room for improvement. Thirdly, analyze what potential partners you have."

More Articles on ICOs:

Study: Little Experience Coordinating Care for Dual Eligibles Warrants Caution
Study: High Rate of Avoidable Hospitalizations Among Medicaid Home and Community-Based Services Users
Moving Dual Eligibles to Managed Care Involves Careful Reform

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