Chase Lists & Care at Home
I spent the last week at HIMSS24, talking to tech companies and healthcare providers using tech to solve problems, and I listened to several presentations on this topic. I noticed a lot of ketchup salesmen there selling their condiment to a lot of ketchup users. There were some standouts, though, too. (Tune into BoPC’s soon to be released HIMSS Highlights podcast to hear more on that.)
A big area of interest in both the Exhibition Hall and the presentations was Care at Home. Given this newsletter’s recent focus on Care at Home, I attended as many of those talks as possible.
For the talks focused on Hospital at Home, no one really mentioned the fact that the CMS waiver allowing for reimbursement of this service ends on 12/31 this year. However, there is a nationwide push to get Congress to extend the waiver for 5 years. This will aid in building out the needed tech and human infrastructure to scale the current successes.
SNF at Home, the focus of this month’s edition, is paid differently from Hospital at Home, so that’s not as much of a worry.
At HIMSS, I heard David Collins from VCU repeat an often-used phrase from BoPC’s Season 2 Podcast series – “It’s not just about a tool. It’s about having people to monitor the flow of information and act accordingly.” In that presentation, he also showed that about 45% of all Medicare patients are discharged from the hospital with post-acute services, with almost half of those going to a skilled nursing facility.
Obviously, the need for appropriate home alternatives to institutional skilled care is huge.
My favorite quote from the conference came from the CEO of Zipline, Keller Rinaudo Cliffton. (Check out what they do at https://www.flyzipline.com/ - VERY cool and helpful.) Mr. Cliffton said, “At the end of the day, no one in healthcare cares about technology; they care about impact.”
I heard one presentation where the health system was doing Care at Home as a proof of concept for patient acceptance and determining whether they could collect the data they needed. They had no measurements of clinical outcomes. My opinion – they were looking for wheels (or ketchup) that had already been invented. I was a bit disappointed in that presentation.
This month’s newsletter hears from a couple of different organizations not only engaged in SNF at Home, but who are showing improved clinical outcomes and decreased cost with their efforts.
It’s not about the tech; it’s about the impact.
Tried & True
This month, our VBC foundation article is brought to you by Andrea Hurteau, Value-Based Care Executive and Chief Operating Officer at Winston Healthcare Advisors.
Andrea Hurteau,
Winston Healthcare Advisors
Value-based care executive focused on the delivery of exceptional clinical, economic and membership growth outcomes.
As we continue to look at foundational work of Value-based care (VBC), effective Population Health Management strategy and supporting tactics should always be at the forefront. Whether you are a smaller PCP practice or part of a larger multispecialty group, the fundamentals remain the same.
Activities that drive both quality and cost performance outcomes and are aligned with the payor contract incentives are where PCPs should initially focus their VBC efforts.
Knowing which patients need what and when they need it is essential in effectively completing Annual Wellness Visits, Transitional Care Management services, closing HEDIS measures, etc. A “chase list” can facilitate that work.
In entry level VBC models, such as pay for performance (P4P) and pay for quality (P4Q) contracts, PCPs generally take no financial risk for total cost of care. P4P/P4Q contracts align financial incentives with activities and quality program outcomes based on HEDIS and Medicare Advantage Star metrics.
In shared-savings or risk-based VBC models, Payors incent PCPs to effectively manage the total cost of care of an attributed population. However, these total cost of care focused contracts usually include a quality performance “gateway” or “multiplier” to earned shared savings requiring a level of clinical quality performance to be achieved prior to the PCP earning either partial shared or full shared savings.
Regardless of the degree of risk-taking a PCP takes, optimized VBC contract performance rewards PCPs for Population Health Management (PHM) activities that improve the overall health outcomes of their patient panels through care coordination and patient engagement strategies.
HEDIS and Stars Measures are used as the basis for most VBC contract performance measurement although Payors often select a unique subset of these measures for their quality incentive programs which can add even more complexity to a PCP’s PHM efforts.
Data analytics and reporting that inform actionable insights to guide both patient engagement efforts and clinical interventions form the foundation for any successful PHM program.
Practice registries of patient subgroups can be created within a PCP’s VBC population that have a common chronic disease or qualify for certain screenings, and these can be valuable tools in focusing population health management activities including the closure of care gaps. Registries hardwired into the PCPs EMR and PHM tool are optimal because they can trigger workflows at the point of care; however, many PCPs simply utilize patient lists or spreadsheets.
While patient registries help inform workflows, the more targeted PHM efforts of the team are directed at a much smaller subset list of the registry. These are patients with outstanding care gaps and the basis for the care gap “chase” list.
Patients identified on the care gap chase list require more extensive outreach efforts and individualized patient engagement strategies to manage their health, close their care gaps, and optimize VBC program performance.
Care gap chase lists require attention year-round, and efforts tend to increase as the contract performance year progresses and care gaps still remain. This is a good reason to front-load the year’s efforts or take a balanced approach to the year, focusing both on when patients have scheduled appointments and on those patients without scheduled appointments.
Chase lists usually include patients with a mixed level of engagement. Reasonably engaged patients eventually close their care gaps and are usually just busy or perhaps procrastinating. With the help of a nudge from the care team, they usually get the required service and close the care gap.
However, truly unengaged patients can be incredibly challenging to get care gaps closed and are often still on the chase lists in Q4 each year.
Annual Wellness Visit (AWV) completion should always be part of a Chase list. AWVs are the primary opportunity for the PCP to engage the patient, close outstanding care & HCC coding gaps, accurately document and maintain patient attribution in the PCP’s VBC panel. Many PCPs underestimate the importance of a rigorous attribution management program, and AWV completion is an invaluable tool to ensure you are getting credit for the patients you are managing.
There are many care gaps that seem out of the PCPs control because they require the patient to do something to close the gap. Yet PCPs are the ones held accountable for the care gap closure in VBC models. For this reason, PCPs and their practices need to feel responsible for completion of the care gap measure and design workflows to accomplish that.
Often patients who have completed their AWV still remain on chase lists because they have AWV follow up orders left undone such as getting a lab test, having a colonoscopy or mammogram, obtaining an eye exam etc. As we all know, just because the PCP sees the patients and puts in the order does not mean the patient will follow through and obtain the recommended service. Followup built into the workflow is essential to optimize completion rates.
Chase lists are also critical in managing total cost of care. These utilization-related chase lists generally focus on patients who have had an acute admission or ED visit (eg., CMS’s Transitional Care Management program). Unlike preventative screenings eligibility where the list is more static and can be worked throughout the year, utilization chase lists are very fluid since patient eligibility is triggered by an event. They are more time sensitive for outreach and PCP intervention.
Utilization-related patient engagement can be easier to achieve if PHM outreach occurs close to the utilization event. Post discharge PCP follow up visits are a key KPI that should be monitored. ADT alerts and payor authorization data can be leveraged to add patients to the utilization chase lists since waiting for paid claims data is often too late to make meaningful impact.
Getting patients in for a post discharge follow-up PCP visit can reduce readmission risk, avoid subsequent ED utilization, provide an opportunity to close care gaps, and improve patient engagement and HEDIS performance.
Here are a few suggestions on how PCPs can optimize their PHM strategy by effectively managing care gap chase lists and other best practices:
Maintain a master patient centric chase list that contains all the quality measures the patient is eligible for and be sure to continuously track care gap closure progress. Remember to always keep PHI secure.
Include the data source for the gap closure and be sure to document any relevant information obtained from all sources including the patient, EMR data, paid claims data, population health manager inputs etc.
Ensure accurate documentation in discrete reportable fields in your EMR for easy reporting.
Automate data sharing with payors whenever possible.
Start outreach efforts and appointment scheduling early in the year with a broader outreach approach via letter, text and targeted patient telephonic outreach for those patients you don’t see in the office regularly
Schedule AWVs and other required services at the point of care whenever possible and ensure you comply with the 365 AWV rule for Traditional Medicare VBC programs
Take a well-coordinated, patient-centric and personalized approach to your patient outreach efforts focused on closing ALL outstanding care gaps to avoid multiple outreaches from different team members which often leads to both patient confusion and frustration
Assign and hold team members accountable for certain tasks, it takes a village and be sure to celebrate successes!
Hold regular collaborative cross-functional team meetings to review PHM performance metrics, progress towards goals and opportunities for process improvement
Assist the patient in scheduling follow up items at the time of check out, best opportunity for engagement is when the patient is in front of you
Utilize a patient engagement platform that can provide proactive and personalized omnichannel communication to outreach to patients
Capitalize on other point of care opportunities to engage patients to close care gaps at various patient touchpoints in the system including key specialists who are co-managing your patients’ chronic conditions and can help in closing related care gaps
Leverage population health specialists or care coordinators in patient outreach efforts whenever possible, allowing clinical staff to focus on managing care and working to the top of their license
Ensure telephonic outreach team members have an PCP office-identifiable caller ID, otherwise odds are patients won’t answer the call
Provide flexible appointment access for your VBC patients including same day appointments, video visits or if possible in-home visits via your practice or a vendor partner for patients that cannot come into the office
Manage panel attribution with rigor, PCPs are primarily accountable for the health, clinical outcomes and costs associated with their attributed panel so make sure the patients your are managing are assigned to your panel
Success in VBC requires continuous collaboration and engagement of all key stakeholders including physicians, population health teams, patients and payors who jointly contribute and impact the overall quality and cost outcomes for the patient population under their care and management.
Innovation
For this month’s innovation article, let’s pick back up on the theme of Care at Home. We’ve looked at augmenting care and coordination through EMT/Paramedic Home Visits (MedArrive) and through the utilization of Hospital at Home (SENA Health). Last month we touched on palliative and hospice care and how it can augment care while a patient is at home. Let’s look at the concept of Skilled Care at Home, commonly called SNF @ Home.
A difference, though, is it doesn’t necessarily need all the tech bells and whistles required for safe and effective Hospital at Home. It’s likely that this is the reason Jordan claims SNF at Home, though initiated after the Hospital at Home movement started, has leapfrogged Hospital at Home in the number of patients it’s serving.
One could liken SNF at Home to turbocharged home health services without the homebound restrictions on the patient. The primary use case is for a patient who has been hospitalized and, either through a surgical procedure or through deconditioning, needs PT, OT, ST, or wound care services that would otherwise qualify them for a short stay in a SNF.
But most people would rather go home than to a facility if possible.
As Jordan puts it, “They've been in the hospital for five days, for seven days. All they want to do is go home.” After screening the patient and their needs, the team lets the hospital Care Management team know that care at home is an option. They then educate the patient and family and move the next steps of care into the home.
There are at least four great reasons to pursue this type of care.
First and foremost, the experience of the patient. They want to go home, and by facilitating that choice we have improved the odds of their engagement in their care. Engaged patients (and families), as we know, have better outcomes. Jordan ranks the patient’s response of joy to this option as the most satisfying part for him. He says, “To be able go to that patient and their family and say, you don't have to go to a facility, you can go home now, is just such a rewarding experience.”
Second is cost. This especially true for organizations engaged in value-based care and contracting, like Robert’s Independent Physician Association (IPA) in Rhode Island that is in global capitation models with all its Medicare Advantage (MA) plans.
Robert told me, “We cover everything under the sun in the global cap. We're given a percentage of revenue and then we have to pay the medical expenses and away we go.” This includes any post-acute services like stays in SNFs. Robert’s team has put a stake in the ground with the goal being to eliminate as many stays in skilled facilities as possible.
Why? Because caring for the patient in their home carries a cost of sometimes less than a third of a facility stay. Robert notes, “There can be a thin line between, ‘we've got to send a patient to a SNF’ for an average of a 13 to 25 day stay (for at least $400 per day) versus getting them home with a few hours of PT in the home, a little extra support, and then a few days later, they're ready to go to the outpatient PT center.”
The patient’s happier, the cost is cheaper, and the outcomes (readmissions to the hospital, return trips to the ED) are comparable or better than a SNF according to Prospect Medical’s results.. Remember, an engaged patient does better.
As an aside, the payers know this, too. They know that if they can delay a hospital’s prior approval of a SNF for a couple of days while a patient gets therapy in the hospital, the patient’s needs will likely change enough to no longer need a SNF. This delay irritates hospitals (more on that below) and frustrates patients who just want out of the hospital.
Robert mentioned the thin line that often exists between needing SNF care and being able to get care at home. But it's an extremely important line. You don't want to send somebody home without support and have them fall through the cracks or crash and burn. But in some cases, if you can just give them a little bit of support, you can avoid that SNF stay altogether.
A third reason might not be as apparent to readers not familiar with the acute care hospital space, but it’s a big deal to hospitals – delayed discharge due to SNF availability or prior authorization issues. Jordan and Robert both pointed out the assistance their care at home programs give to health systems and their Care Management services.
Jordan shared, “Case Management teams struggle with patient placement in the post-acute setting. Skilled nursing facilities have limited capacity, and to be able to get the patients into that next site of care in a timely fashion is where we’ve found the biggest opportunity overall, especially when it’s where the patient wants it to be delivered – in the home.”
Patients and hospitals both win. Hospital administrators constantly complain about the cost to them that arises from discharge delays, and they point to SNF placement as the biggest culprit. SNF at Home can help alleviate some of that backlog and extended stay due to delays, including the prior authorization delays previously mentioned.
Along the same lines, Robert spoke to how his team finds the patients and helps the hospitals rethink the discharge plans.
“Because we’re at full risk for the medical expenses, we are delegated for care management and utilization management with those MA plans. We’ve developed the criteria for finding patients in the hospital who would be appropriate for this program. Our UM team flags them, so when we get a request from the hospital for that patient to go to a SNF, we put the brakes on and see if the patient can get into our care at home program.” They then work with the patient, the family, and the hospital CM team to make the arrangements.
That’s where the coordination begins. Getting the right services into the home at the right time – PT, OT, ST, meal prep, Nursing, Nursing Aides – that’s where the heavy lifting is. Jordan’s company (Compassus) handles that. Robert’s IPA relies on a vendor to do the work for them, High Bar (https://www.highbarhealth.com/).
There’s a fourth benefit to care at home – a positive impact on social risks.
Jordan reminded me that folks engaged in care at home, from home health to hospital at home to hospice, have always “lived and breathed finding and addressing social needs.” It’s not a new thing for them, even though the rest of the world seems to think addressing social risks is a recent phenomenon.
“We're in a patient's home, so we see everything. We see if their fridge is empty. We see if they can't get access to their medication. We see if they desperately need pest control. And we see what level of dependence they have on their family and what level of access they have to other caregivers that can provide them support. And so, you know, I think we've always been in a world in the home-based care side of where we're having to triage and manage social determinants all the time.”
He goes on to say that addressing social needs for patients is a core tenet of their program, since successful recovery at home is otherwise not possible. “Do they have access to meals or even food? If not, we can deliver those right to the home. Transportation issues to get to and from follow-up appointments, whether it's with their PCP or a specialist or dialysis? We’ll address those needs, too.” If the patient doesn't have good caregiver or family support, they get someone to be with that patient, cook the meals, do their laundry, etc.
It's not just about therapy. It’s about people, their needs, finding those needs, and appropriately addressing those needs to facilitate the best recovery and optimize health and well-being. Eyes and ears and hands and feet in the home can make a huge difference for your patients.
Robert Millette,
Prospect Medical Group
Healthcare Executive focused on Population Health, Primary Care and Specialty Services, Health Care Strategy, and Payor Contracting.
In my conversations with Robert Millette from Prospect Medical Group and Jordan Holland of Compassus, I received a refined image of what SNF at Home is. Like Hospital at Home, SNF at Home requires a higher level of coordination across the care team and a greater level of participation from patient and family than the conventional Skilled Nursing Facility (SNF) model of care.
Jordan Holland,
Compassus
Strategically expanding access to quality post-acute care for patients through innovation.
