GE Healthcare Camden Group Insights Blog

Top 10 Critical Success Factors for Care Model Redesign

Posted by Matthew Smith on Jun 24, 2015 12:33:27 PM
By Bridget Gulotta, MBA, MSN, RN, Senior Consultant, and 
Teresa Koenig, M.D., MBA, Chief Medical Officer, The Camden Group

Care Model Redesign, The Camden Group, Population HealthAs the healthcare landscape shifts from volume-based fee-for-service reimbursement toward value-based risk sharing payments and penalties, organizations must develop new and innovative strategies across all care delivery channels. In order to move to true value-based care, financial models must be aligned, and the quality and overall patient health and outcomes must be addressed. Care model redesign is a necessary solution to achieve success and long-term sustainability.

The process of care redesign entails a systemic shift in the way care is delivered across the continuum with input from leadership, acute and post-acute clinical and administrative staff, and community partners and stakeholders. To ensure effective and efficient integration and strategic alignment, a governing steering committee should be established, and their vision and recommendations implemented by working groups that focus on distinct components. The following represents the top 10 considerations needed to implement transformative care.

1. Use an interdisciplinary care team approach supported by plans of care. Focusing on the accountability and improvement of the care delivered across settings for all dimensions of health and associated costs is a collaborative approach. It includes different disciplines working together to share knowledge and skills to guide and impact patient care. A physician drives the clinical care but collaborates with the entire team, with the ambulatory care manager as the consistent thread who follows the patient throughout the continuum of care. The patient and his/her family or caregiver is an integral part of the care plan development. The developed goals are patient-centric and focused on the patient’s preferences and wishes, taking into account specific cultural and linguistic needs. Each provider and/or discipline contributes to and aligns care with the patient’s plan and goals.

2. Target care from both a medical condition(s) and social determinant perspective. In order to move to true value-based care, the overall health, safety, and well-being of a patient must be addressed. The delivery of coordinated, quality care needs to expand from the acute setting across the continuum, with a focus not only on the clinical aspects of care, but of equal importance, and at times more important, the social determinants of health. This includes access to care, caregiver support, behavioral health, social economic status, health literacy, adequate food and shelter, addiction, etc. Key components of a “whol-istic” approach include: patient/family engagement, tools for effective self-management of chronic conditions, an individualized comprehensive treatment and continuum-based care plan, health education for disease and medication management, primary care, and care management follow up – all supported with appropriate community-based resources.

3. Facilitate new patient identification, and identify high-risk population(s) to address barriers to care (e.g., poverty, behavioral health, health literacy, social support, etc.). The use of risk stratification is necessary to manage patient populations and identify high risk and risk rising patients who need proactive and careful management. The development of interventions to address individual clinical and social needs is recommended to improve the success rate of transitioning the delivery of care across settings. Risk stratification methods enable the prioritization of clinical workflows by cohorting patients for population health and disease and chronic care management programs. Additionally, they help ensure patients receive an assessment and inclusion into the appropriate case management programs. Homegrown and proprietary platforms exist, but all stratification models should include the critical components of comorbidities as well as (but not limited to) age, poor pain control, and low functional status or cognitive deficits to calculate a risk score.

4. Expand utilization management (“UM”) focus from episodic to complex chronic care, post-acute care or community-based care delivery needs. UM is increasingly important to manage healthcare costs and services across the continuum. Traditional UM is episodic and driven by point-of-care medical necessity and appropriateness of ongoing provision of care. As alternative payment and service delivery models are developed and tested by The Centers for Medicare and Medicaid Services and adopted by private payers, the care delivered will need to be considered across the continuum. The delivery of the right care at the right time in the right setting is evolving the role of UM. It requires considering a longitudinal approach to care provided outside of the four walls of the hospital, moving away from acute episodes to proactive delivery of complex, chronic care that maintains a patient’s health in a community-based setting.

5. Align primary care physicians (“PCPs”) incentive compensation to encourage coordination and access to all care team members. As the care delivery model for PCPs continues to move toward patient-centered models by organizing as a medical home or medical neighborhood, compensation models need to promote health outcomes and the coordination of care team members across the continuum. PCPs are tasked with driving care through a proactive, collaborative approach with patients and specialists with a focus on chronic disease management. New models of care delivered by PCPs will improve the health of populations and value for patients and compensation plans need to support the evolution of care delivery.

6. Develop new provider contracting models to address care across the continuum and engage new physicians and provider networks. As alternative payment models reward and penalize organizations for the quality of care provided, there is a corresponding need to evolve physician compensation models from a production/Relative Value Unit focus to one of value. Contracts need to clearly define the organizational strategy and goals as well as the expectations and accountabilities of the contracted providers. When designing compensation models, key factors to consider include aligning organizational and system goals with physician goals, identifying the appropriate quality benchmarks, and determining the proportions of compensation tied to risk, productivity goals, and quality.

7. Include value-based incentives and key performance metrics to provide appropriate and accountable care. Reporting quality measures is a familiar practice for providers who have participated in pay-for-performance programs such as Physician Quality Reporting System or the Hospital Inpatient and Outpatient Quality Reporting Systems. To promote appropriate and accountable care, existing and new value-based model metrics are now tied to incentives and penalties for providers to prove they are not only decreasing the overall cost of care delivered but are meeting quality standards. As payers continue to expand patient populations required for reporting financial and quality metrics, effective management and alignment of contract incentives is needed to ensure that care is delivered efficiently to lower costs but also improve the quality of the care delivered.

8. Create clinical data analytic functions and integrate relevant data sources (e.g., practice management, claims, financial, pharmacy, etc.) to support clinically data-driven efforts with real-time data. A robust data analytics infrastructure is necessary to integrate varying tools and data sources and to manage the vast amount of data to support real time, point of care decision-making. Health information exchanges or data warehouses are platforms to provide a solution to improve data integration functionality, aggregating data so staff spends its time analyzing data (not integrating data) and meeting organizational performance goals. The capabilities of the system should include all data sources related to clinical and patient experience, financial and cost performance, and quality data.

9. Develop robust communication, feedback, and reporting systems. The development of the most sophisticated data analytics infrastructure and the clinical information derived from the care of the patients is of little use if that knowledge is not communicated in a timely, meaningful way to the appropriate providers or systems across the continuum. If these gaps in communication of healthcare information are not addressed with the same effort as the development of information systems, the gap will continue to grow as networks expand and population panels increase. Greater consideration needs to be placed on communication enhancements to improve the quality and safety of clinical services. It is critical to view the communication needs from multiple directions – within and outside of the organization, with PCPs and community-based organizations, and between providers and their patients.

10. Develop system-wide tracking, reporting and accountability plan(s) to drive to population health-based outcomes and to compare internal and external peer group benchmarks and trends. Long-term success and intervention sustainability cannot be achieved without the continuous performance improvement and continuum based key performance indicators. Data reported in real time dashboards fosters close monitoring and analyzing both the financial and clinical data. Tracking, review, and actionability of the results will target the successes, areas of needed improvement, and the gaps in care for continued care delivery improvements.

Ms. Gulotta is a senior consultant with The Camden Group with more than 10 years of experience in the healthcare industry, including clinical experience. She specializes in clinical integration and patient care management, with a focus in quality and performance improvement, financial analysis and budget administration, as well as regulatory compliance, and strategic planning. She may be reached at bgulotta@thecamdengroup.com or 312-775-1700.



Dr. Koenig is a senior vice president with The Camden Group who specializes in developing and designing clinical integration strategies, medical management programs, and value-based care delivery and payment models. She has worked with a variety of healthcare organizations, from individual physician groups and health systems to academic health systems and Fortune 50 companies, guiding them as they look for solutions to their specific challenges. Dr. Koenig is skilled in utilization and quality management, including setting metrics to help organizations deliver accountable care, as well as in the development of provider networks and incentive systems. She may be reached at tkoenig@thecamdengroup.com or 310-320-3990. 

Topics: Teresa Koenig MD, Care Model, Bridget Gulotta, Care Team, Care Redesign, Transfomative Care

Quality Outcome Achievement and the Impacts to Care Delivery

Posted by Matthew Smith on Apr 30, 2015 2:23:35 PM

By Bridget Gulotta, MBA, MSN, RN, Senior Consultant, and Tina Pike, MBA, MSN, HCM, RN, Senior Manager, The Camden Group

016_healthcare_consultant.ju.jpgThe Affordable Care Act has changed the paradigm of our healthcare system moving from rewarding providers for the quantity of care they provide, to rewarding them for the quality of care provided. Frameworks such as the Triple Aim™ developed by the Institute for Healthcare Improvement and the National Quality Strategy from the Centers for Medicare and Medicaid (“CMS”) are two of the various models aimed at improving health system performance. While these approaches differ, each focuses on the accountability and improvement of care delivery across settings for all dimensions of health along with the associated costs. Through the use of quality measurement, CMS is driving healthcare transformation in collaboration with practitioners and patients.

Develop Patient-Centric Goals

As CMS and private payer reimbursement models move from volume-to-value payments and penalties, organizational leaders are recognizing the need to develop strategies which incorporate quality into all care delivery channels. First steps to approaching this landscape shift are through the development and implementation of proactive patient-centric goals. For example, engage patients as the stewards of their own care. This is a change from the “do as I say” approach of past generations. Truly listen to patients and their goals for their health. Discuss multiple options and assess the social determinants of health in terms of barriers to goal achievement. This is an approach which brings all disciplines together in the patient’s vision. Incorporate quality improvement strategies to support the long-term sustainability of an integrated care delivery model linked to outcome metrics. This will help drive a care delivery strategy and inform care redesign.

These organizational changes are of vital importance given the recent announcement by the Department of Health and Human Services (“HHS”) regarding the timeline for shifting Medicare payments toward alternative payment models such as Accountable Care Organizations or Bundled Payment Initiatives. Starting in 2016, the target for alternative payment model reimbursement is 30 percent—increasing to 50 percent in 2018. Private payers, such as Humana and United Health Group, are following the lead of HHS and tying reimbursement to value-based arrangements. Humana aims to align 75 percent of its Medicare Advantage membership to quality of care reimbursements and UnitedHealth Group will tie $65 billion of its reimbursement to value-based arrangements, each by 2017. The landscape is continuing to shift under our feet.

Reduce Readmissions

Strides continue to be made in the overall quality of care delivered in the U.S. New research released by the CMS 2015 National Impact Assessment of Quality Measures Report, finds that between 2006 and 2012 there was significant improvement in reported performance rates across seven quality reporting programs. Performance on over a one-third of the measures was considered “high performing,” exceeding 90 percent in the most recent three years of collected data. Additionally, health disparities across racial and ethnic groups have narrowed.

Hospital_Readmissions_Blog_Table-1.pngWhile the overall delivery of quality of care is improving, the Hospital Readmissions Reduction Program outcomes measures (see table) have shown limited improvements in readmission rates since 2013, the first program year. Outcome measures reported in the 2014 CMS Medicare Hospital Quality Chartbook (reporting period between July 2010 and June 2013), show variation in hospital performance continues along with the persistence of geographic variation by hospital referral region. Only two regions performed better than the national average on four or more of the condition-specific readmission measures.

Impact Quality and Care Delivery

In order to move to true value-based care, the overall health, safety, and well-being of a patient must be addressed. The delivery of coordinated, quality care needs to expand from the acute setting across the continuum with an equal focus on the social determinants of health—including access to care, caregiver support, behavioral health, socioeconomic status, and health literacy.

The identification of high-risk patients along with the development of strategies to address individual patient needs and barriers to achieving them will improve the success rate of transitioning care to the post-acute setting. Key components of a “wholeistic” approach include:

  • Patient/family engagement
  • Tools for effective self-management of chronic conditions,
  • An individualized comprehensive treatment and continuum-based care plan
  • Health education for disease and medication management
  • Primary care and care management follow-up
  • Improved clinician-to-clinician communication/handoffs--all supported with appropriate community-based resources.

Long-term sustainable success cannot be achieved without continuous performance improvement and continuum-based key performance indicators. Delivering quality care across the continuum with a multidisciplinary methodology will impact the usual way care is delivered. Real-time dashboards will foster the analysis of both financial and clinical data allowing for comprehensive, gap in care interventions and strategy development. Staffing skillsets will continue to change and new positions will continue to be created to meet the needs of the population. We are truly in the midst of the new age of healthcare.

The Camden Group, Hospital Readmissions, Readmissions Reduction

Gulotta_headshot.pngMs. Gulotta is a senior consultant with The Camden Group with more than 10 years of experience in the healthcare industry, including clinical experience. She specializes in clinical integration and patient care management, with a focus in quality and performance improvement, financial analysis and budget administration, as well as regulatory compliance, and strategic planning. She may be reached at bgulotta@thecamdengroup.com or 312-775-1700.



pike_headshot.pngMs. Pike is a senior manager with The Camden Group with over 25 years of clinical, business, and management experience in the healthcare industry. Her areas of expertise include business development, strategic planning, operations management, Lean strategies, and performance and process improvement. She has a strong clinical background and has assisted organizations with patient throughput, physician and patient engagement strategies, transformational culture change, as well as, the development of care models which span across the continuum of care to help healthcare organizations transition to value-based care and population health. She may be reached at tpike@thecamdengroup.com or 585-512-3900.

Topics: Readmissions, Readmissions Reduction, Tina Pike, Quality Outcomes, Bridget Gulotta, Care Delivery

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