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.