Still seeking best practices

After frequent visits to his doctor, Alfonzo Pansza often struggled to make sense of the written information and instructions he was given before he was sent home.

Pansza, a diabetic with other chronic diseases, could not read the jargon-heavy documents from his physician. “I never even knew whether I had diabetes one, two or 10,” he says. He did not fully grasp the importance of his medications, he admits. The 82-year-old would “wait too long” to seek help for worsening symptoms. “I can take pain pretty good,” he says. “I would just tough it out.”

Not anymore. Pansza now works with a care manager and social worker to help recognize his symptoms and identify who and when to call for help. He more closely follows his prescriptions and better understands why to do so.

The change came after his son, Jamie Pansza, arranged for his father to receive care through the Heartland Regional Medical Center in St. Joseph. Mo. The hospital is working to better coordinate care for the most costly and complex patients through its accountable care organization. The ACO participates in Medicare's Shared Savings Program.

Doctors and hospital officials routinely cite care coordination as key to the potential success of accountable care, a still unproven payment model that seeks to more tightly integrate providers and establish joint financial incentives for them to deliver better-quality and lower-cost healthcare.

That interest is underscored by results of Modern Healthcare's third annual survey of ACOs. Most of the 37 ACOs that responded to the survey reported that efforts to track their performance included care-coordination measures. Under accountable care, performance on quality measures and healthcare spending targets is tied to potential bonuses or financial penalties for hospitals and medical groups. Medicare is testing the concept with a growing number of ACOs, as are private insurers.

And as accountable care continues to expand and evolve, organizations seeking to embrace the payment model are experimenting with how best to measure the impact of critical strategies to improve patient care, including better care coordination. Examples varied widely when respondents listed their top care-coordination measures, which highlights an observation made repeatedly by ACO executives interviewed about the results: There's still much to learn about the best approaches to managing medical care.

“This is a very nascent science,” says Dr. Namita Mohta, medical director of Partners HealthCare's department of population health management. “And we have a lot to learn about how to improve care coordination overall for our patients, as well as how to measure it effectively, so then we can improve our performance.”

The fledgling nature of the effort is illustrated by Partners HealthCare's response to Modern Healthcare's ACO survey. The Boston-based system was one of five surveyed that reported its ACO did not measure care coordination. Yet such measures are included as the ACO tracks hospital readmissions, care for medical complex patients and care for terminally ill patients, Mohta says.

Nonetheless, officials do not explicitly track coordination separately. Instead, embedded in all their efforts is “a relentless focus on coordination of care and reduced fragmentation,” she says.

Modern Healthcare added two questions about care coordination to its survey of ACOs for the first time this year. Is care coordination measured? And if so, name the ACO's top five measures.

This year's respondents included ACOs with and without hospitals, ranging in size from those that manage care for 553,000 covered lives to those with 5,600. The majority of the organizations were in contracts without potential financial penalties if they don't meet quality and financial benchmarks. Even the most ambitious test of accountable care, the Center for Medicare and Medicaid Innovation's Pioneer program, saw some ACOs exit in the second year, when an optional one-year exemption from financial risk ended.

Roughly one-third of ACOs surveyed by Modern Healthcare were in contracts that included the risk of financial loss should the ACO fail to meet spending and quality targets. Some organizations included fewer than 100 doctors; one had 2,000 physicians.

Heartland Regional's ACO keeps tabs on hospital readmission rates, one commonly reported care-coordination measure among respondents. The ACO also tracks the percentage of patients who rank among the most costly and receive screenings from a care manager. The most costly patients are those with costs in the top 5% of patients. Jill Tracy, the Heartland care manager working with Alfonzo Pansza, says she coordinates among the patient's doctors to create a care plan. Pansza will meet with Heartland care managers when he visits a doctor or the emergency room.

Care managers typically are registered nurses with clinical and care management experience.

“It's been a good experience for me,” Pansza says. “I'm the kind of person you have to give me a reason to pay more attention to my treatment,” he says. Without it, “I have a tendency to forget.” Pansza says he now feels better, and his son notices the change. “You can tell he's got more pep in his step,” says Jamie Pansza, a firefighter and paramedic. “I honestly and truly believe if it weren't for them, I don't think my father would be here right now.”

Heartland's ACO also monitors patients who leave the hospital for a nursing home and receive care management during the transition. That includes a visit to the nursing home within 48 hours by a Heartland care manager to discuss treatment and medications with the facility's nurses, the patient and family of the patient, says Linda Bahrke, administrator of Heartland's community health improvement solutions plan.

Success under that strategy has prompted Heartland to consider expanding the effort to all Medicare patients, not merely the most costly. “We anticipated there would be value, but there was more than we realized,” Bahrke says. By Heartland's estimates, care-coordination efforts have reduced spending per Medicare ACO patient per month by 0.93%, though the CMS may calculate the figure differently, officials caution.

The ACO will expand its coordination efforts to the top 15% most expensive patients, an effort to try and improve the health and lower the cost of the costliest patients by targeting those who may eventually rank among the top 5%. Improvement efforts won't succeed “if you wait for people to become high-risk,” Bahrke says. “We want to engage with those people sooner.” Heartland will track the monthly expense per patient in the top 5% over time to see if earlier intervention can reduce the total.

In Akron, Ohio, care managers with Summa Health System's ACO spend 45 minutes with a patient before a clinic visit discussing a possible care plan. After meeting with a doctor, the patient, care manager and physician together discuss the plan. The percentage of patients with a complete care plan is one care-coordination measure that the system monitors. Summa doctors did not use care plans before launching the ACO, according to the health system.

Harder to track is the degree to which the plan of care is followed, an example of how some measures are more “fuzzy” than others, says Dr. James Dom Dera, medical director of patient-centered medical homes for Summa's joint ACO with Northeast Ohio physicians.

Doctors might refer patients to a specialist and the patient might visit the specialist—and then decide never to return for follow-up care. Records indicate the patient stuck to the plan, but the patient also abandoned the course of treatment. “This is all new to everybody,” Dera says.

But measurement also might have a less direct influence on quality by changing physicians' perspective. “Doctors are really good at taking care of the patient in front of us,” he says, but traditionally, not so great at managing the broader health of a population. Performance measures reveal gaps in care that force doctors to think about patients before they arrive for an appointment.

Summa also tracks measures of medication management, where patients received care, such as the emergency room, the level of care required, and health promotion and education to monitor care coordination.

Medication reconciliation is one of a dozen care-coordination measures endorsed by the National Quality Forum. The NQF first endorsed care coordination measures in 2008, but more development is needed, says Dr. Helen Burstin, senior vice president for performance measures at the NQF. “It's not as advanced as we'd like it to be,” she says.

During the 2011 routine review of NQF-endorsed care-coordination measures, no new measures were submitted for review. Instead, quality experts identified major priorities for development, including measures of patient-reported outcomes and identification of adverse events that signal a lapse in care coordination.

Burstin says patients are best able to speak to the degree of coordination, and more measures are needed to capture patients' voices. Limited—but growing—ability to transfer medical records from one location to another has hindered efforts to identify quality gaps as patients transition from hospital to nursing home to home, she says. That's already beginning to change with broad efforts to expand installation and implementation of electronic health records.

Meanwhile, health professionals who are most likely to use health IT for care-coordination have little chance to report on such technology-enabled measures, according to research published this year in the journal Health Services Research.

More than half of the coordination instruments identified by the researchers—which fell into 17 categories such as teamwork, communication, care plan development and mediation management—were developed for primary care. Another 25% were useful within hospitals. Only 3% were applicable to home care and 5% to long-term care facilities.

Ellen Schultz, an author of the article and a project coordinator at the Stanford University Center for Health Policy and Center for Primary Care and Outcomes Research, says primary-care providers who work “day in and day out” with patients and technology are key sources of information.

Another gap identified by the research, which surveyed previously published work on care coordination measures, was limited measures to track performance as patients' needs change, not only as patients change locations.

Changing needs occur when an oncology patient goes into remission, for example. Of the 96 identified instruments of care coordination, only 11% tracked patients' changing needs, the study found.

A portfolio of coordination measures is needed to track immediate progress and also capture quality improvement that occurs over time, Schultz says.

Advocate Health Care in Oak Brook, Ill., is making some changes to its care-coordination measures. Advocate has sought to identify emergency room patients who visit frequently or seek care that could be treated in less-acute primary-care settings, says Sharon Rudnick, the health system's vice president of outpatient care management.

Care managers may work with those patients to help connect them with primary-care doctors and other resources to manage conditions and avoid the ER, Rudnick says. “Patients do want to learn how to use the healthcare system more efficiently,” she says.

Advocate reported two measures of care coordination in Modern Healthcare's survey: in-network coordination of care and patient engagement in care management.

It's no longer enough to exclusively monitor patients after they leave the hospital to prevent their swift return, Rudnick says. Advocate historically tracked hospital readmissions, but patients may receive care across multiple network locations without ever being admitted to the hospital. Now, officials are searching for ways to track coordination from home to clinic to nursing home, she says. “That's our new focus.”

Follow Melanie Evans on Twitter: @MHmevans

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