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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

10 Key Indicators of Clinical Integration Success

Posted by Matthew Smith on Jun 23, 2015 10:14:10 AM

By Megan Calhoun, MS, MSW and Teresa Koenig, M.D., MBA, The Camden Group

ci_2-resized-600.jpgAs healthcare organizations are looking for strategic initiatives to transport them into the future, clinical integration is often the plan. Clinical integration is the answer for provider practices and/or systems that are ready to move into the “new normal.” However, clinical integration requires more than organizational realignment and a commitment to the Triple Aim. Developing an effective clinically integrated network demands commitment and investment in a complete clinical care model redesign focused on team-based, patient-centric care along with the necessary infrastructure to enable this change. Clinical integration requires several key components for success. When is an organization ready to take this next step toward clinical integration? Below are ten key indicators that an organization’s efforts are poised for success.

1.  Primary Care Geographic Coverage of the Target Market

When considering a clinically integrated network, the expansiveness of the primary care network is a critical component. In a clinical integration model, primary care is a pivotal access point to the system, and the primary care physician works alongside the patient to drive the care plan. Geographic coverage not only refers to an adequate number of primary care physicians, but also to the presence of extended hours sites, urgent care clinics, or telephonic triage services.  All of these access sites can assist in directing patients, who may otherwise access the emergency room inappropriately or not access care at all, to the right care at the right place at the right time. 

2.  Affiliation or Ownership of Services Along the Continuum

A fully integrated care model with services across the continuum is a central tenet for success. Gaps in coverage along the continuum can lead to insufficient knowledge transfer among physicians, poor hand-offs, and a high risk for complications during transitions in care. The delivery network must include ambulatory, acute care, and post-acute services through ownership or affiliation. Additionally, the network should be linked with community agencies that can provide psychosocial supports, preventive care, and education, as well as integrating these services into the care planning when necessary.

3.  Scalable Care Models and Information Technology (“IT”) Systems

A clinically integrated network must maintain an infrastructure that can adapt as the network grows. Patient workflows, care models, and staffing models must be developed such that they are scalable as the network continues to grow. Similarly, the IT systems in place to enable these work flows should be able to mirror the growth of the delivery network. Interoperability, cost, and ease of implementation should all be considered. The IT should support the needed care models across the continuum.

4.  Established Quality Improvement and Process Improvement

Clinical outcomes, patient satisfaction, and patient safety are critical to the success of the clinically integrated network. Value-based payment models utilize process and outcomes-based metrics to determine reimbursement. To continuously improve in these areas, a clinically integrated network relies on ongoing quality improvement initiatives with an established framework for process improvement. 

5.  Population-Based Reporting On Clinical Quality and Financial Outcomes

In order to educate members of the network on their performance, the network should have the capability to conduct analytics and reporting for both patient and population management. Clinical integration relies on clinical model transformation; clinical transformation can only occur with enough data to produce information that will drive this change. Physicians need information on their clinical outcomes, adherence to protocols, and value-based metrics. Transparency in these reports (including the financial results) is critical to physician behavior change. 

6.  Providers and Facilities Across the Continuum With Aligned Incentives and the Same Strategic Goal

In the past, physician and hospital incentives have not always aligned. Clinical integration requires a re-wiring of these incentives. Trust must exist between providers and facilities. In a clinically integrated network, all providers are working towards the same organizational goals. Providers must work together towards the Triple Aim and develop mutual respect – and rewards – for everyone’s involvement and input in this effort. 

7.  Established Evidence-Based Guidelines

Evidence-based guidelines are key to reducing variability among physician practice patterns. Established guidelines and protocols ensure that providers are following standards that result in the high-quality care – consistently across the network. Additionally, these guidelines eliminate unnecessary utilization of healthcare services. Evidence-based guidelines should be embedded in the technology tools that physicians utilize. Physicians must lead the charge in developing, utilizing, and monitoring adherence for the use of guidelines and protocols. Reports of non-adherence should be made available to the clinically integrated network’s leadership, and processes for remedial action need to be established for providers who routinely vary from the established protocols. 

8.  Regular Education for Providers and Staff

The healthcare environment is changing at a rapid pace. Clinically integrated networks must continually educate their physicians and staff on these changes. Rigorous training programs focused on standards of practice should occur regularly. Changes in reimbursement, care models, coding requirements, IT systems and capabilities, and organization-wide goals should be regularly distributed with timely education sessions. Care management staffs need significant training to ensure they are providing adequate support to providers and are working to the top of their license.

9.  Interdisciplinary Care Teams

To continuously improve quality and patient satisfaction, clinically integrated networks require interdisciplinary teams to provide care to their highest risk patients. The use of an interdisciplinary team could include the involvement of primary care physicians, specialists, care managers, social workers, pharmacists, dieticians, or any other ancillary provider. The team works together towards a single care plan for the patient. 

10.  Aligned Vision that Focuses On the “We” Not the “Me” 

Clinical integration requires significant cultural change. It is a mindset based on accountable care, where the entire care team is responsible for providing high-quality care. The vision for clinical integration must be ingrained in all physicians and staff as they work to achieve a common goal. No longer can physicians be worried only about their individual performance but rather the care of their patients across the continuum. The clinically integrated network needs to concern itself with its population of patients and how appropriate interventions and utilization of care can improve the health of the population. 


Megan.png

Ms. Calhoun is a senior consultant with The Camden Group and specializes in the areas of care management strategy and design, strategic and business planning analysis, accountable care organization applications, development and implementation, and the development of clinically integrated organizations. Ms. Calhoun has supported numerous clients with the completion of Medicare Shared Savings Program (“MSSP”) applications and implementation strategy and planning. Her experience includes care model design and implementation that spans the continuum. She may be reached at mcalhoun@thecamdengroup.com or 310-320-3990.   

 

koenig_headshot.pngDr. 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: Clinical Integration, Population Health, HealthIT, Care Continuum, Teresa Koenig MD, Megan Calhoun

Top 10 Survival Tips for Physicians Straddling Fee-for-Service and Fee-for-Value

Posted by Matthew Smith on Feb 19, 2015 2:45:00 PM
By Teresa Koenig, M.D., MBA, Senior Vice President and Chief Medical Officer and Tawnya Bosko, MHA, MSHL, MS, Senior Manager, The Camden Group

Volume-to-value, The Camden Group, Tawnya BoskoTransitioning payment systems from volume to value is a recurring theme in healthcare delivery. With this increased focus on payment based on value (“PFV”) as opposed to volume (fee-for-service or “FFS”), physician practices, or those involved with physician practices need to plan for how to transition to new reimbursement models. While challenges exist around every aspect, one reality is physicians have the largest impact in driving changes in cost and quality (i.e., value). The additional reality is that physicians must deliver care in both the fee-for-service and payment based on value worlds – a difficult actuality for those trained and living in a FFS system. Here are the top considerations for physicians that will allow success in both fee-for-service and payment for value systems as they begin to understand and transition to a value-based world.

1. Accurate coding. As electronic medical records become the norm, coding accuracies become more critical for both payment and population health data tracking. Busy practitioners often miscode, mistype, and use incorrect templates. This can result in incorrect documentation and/or insufficient documentation. These inaccuracies can lead to delayed billing and incorrect data for quality driven reimbursement and health plan audits. Educate and assist physicians in accurate and appropriate coding practices. This will be increasingly important with the transition to ICD-10.

2. Patient engagement. A physician’s understanding of the patient engagement process, strategy, and how it affects their daily practice is crucial for engaging patients and improving patient satisfaction. Whether the strategy has multiple IT facets (i.e., open access scheduling, patient portals, etc.) or paper-based educational materials and other tools, it is necessary for the physician to understand the goals and their role in the strategy. Engaging patients in their care will result in clinical and financial success in either payment model.

3. Care management. Faced with a plethora of programs, physicians may not be aware of how the numerous care management, disease management, or transitional programs impact their patients or the care they deliver. Programs need to include physician leadership and buy-in for success. Make the programs easy to access and support physicians – again these programs can drive clinical and financial success in both payment worlds.

4. New care delivery models. Patient-centered medical homes, chronic care service lines, accountable care organizations…each of these “new” delivery models has, at its core, the same goal: improving the overall value of healthcare and improving patient health. Identifying high risk patients and providing appropriate and early interventions to keep the patients healthier is integral to success and promotes improved quality, whether in a value-based or volume-based system. Engaging in more effective care coordination not only supports more effective referral networks but assures satisfied patients.

5. Price transparency. As patients become more engaged in their healthcare and responsible for larger shares of the financial responsibility of their healthcare, they want and need to know what their portion of the cost for services will be. This is good in a value-based system because it allows patients to make educated decisions regarding their healthcare. This is also effective in a volume-based system because if a provider is able to provide accurate cost estimates to patients, it then also enables them to collect the patient payment responsibility at the time of service. Increasing cash collections and decreasing resources needed to collect on the back end improves the revenue cycle while decreasing operational expense. Providers should use tools to manage insurance eligibility and estimate patient responsibility at the time of service to become more transparent.

6. Clinical transparency. Physicians are unaccustomed to having their notes in the patient medical record shared with patients. Ultimately, the medical record is the patient’s information, and they have a right to access it. Patient portals and other tools have eased the burden of access. Physicians should embrace this process, while following policies for disclosure. Providing patients with access to their information will ultimately help engage them in their healthcare and lead to improved outcomes. Providing patients with access to their information also has been shown to reduce medical malpractice risk, which is beneficial under either structure.

7. Preventive medicine. Embrace preventive medicine services. Healthcare reform has promoted access and coverage to preventive medicine services such as physical exams, health risk assessments, annual wellness exams, and other visits that focus on the overall well-being and health status of the individual. Again, this is necessary to improve healthcare outcomes and value but also generates additional appropriate visits in the volume-based world.

8. Timely completion of records. Whether for paper-based medical records or the electronic medical record, physicians should strive on getting their notes done in a timely manner. Completing notes as soon as possible after the patient visit is a good practice for many reasons:

  • The physician has a sharper memory of the visit and can more accurately convey information to the record;
  • It allows the practice to bill more timely for services, thereby increasing cash flow;
  • It allows crucial medical information to be accessed, if necessary, by other members of the healthcare team;
  • It enables information that recaps the information from their visit to be given to the patient at the time of service or shortly thereafter, thus allowing immediate engagement.

Timely completion of records not only improves overall value, but it is also best practice in a volume driven system.

9. Flexible access and appointments. Many people have very busy schedules and limited flexibility for routine healthcare visits. Providing non-traditional appointment hours (early mornings, evenings, and weekends) promotes patient compliance with follow-up visits and is less disruptive to both the schedules of working adults and a typical school day for children and adolescents. More convenient appointment times generate additional appointment volume for providers and improve patient satisfaction. Additionally, flexible access such as an after-hours answering service that is also able to triage calls and schedule appointments not only improves the quality of service provided to the patient but also helps fill providers’ schedules.

10. Patient satisfaction measurement and ratings. Measurement of patient satisfaction continues to be tied to reimbursement. Embracing patient satisfaction measurement in a practice is a positive, proactive step to take in transitioning to payment for value. Using a reputable survey tool to query the practice, results can then be compared across practices and regions. Pay attention to online ratings of physicians in the practice. While patient satisfaction and online ratings are becoming a large component of value-based care, they also have an impact on volume as patients begin to use online ratings to select their physician.

Teresa KoenigDr. Koenig is a senior vice president and chief medical officer 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. She may be reached at tkoenig@thecamdengroup.com or 310-320-3990.

 

 

Tawnya Bosko, The Camden Group, Ms. Bosko is senior manager with The Camden Group and specializes in designing and implementing clinical integration, high growth medical service operations (“MSO”) and finance, physician hospital organization (“PHO”) and MSO development, managed care strategy, and physician alignment. She may be reached at tbosko@thecamdengroup.com or 310-320-3990.

 

Topics: Payment Models, Tawnya Bosko, PFV, Payment-for-Value, Teresa Koenig MD

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