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Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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4

CARE MODELS THAT DELIVER

Fictional patient vignette: Raphael was glad that emergency surgery to fix a hip fracture in his 70-year-old mother, Gloria, had gone so well. But he was unsure of what to do afterward. Gloria had steadily advancing dementia, and she wouldn’t be able to take care of herself after surgery, which meant that wound care and other recovery duties would fall on Raphael and his wife, Maria. When Gloria first returned home, Raphael and Maria struggled. Neither had any medical background beyond Maria’s CPR training, and they weren’t sure how to tell if Gloria’s surgery site was healing correctly. Their insurance offered to pay for a visiting home nurse, however, who came twice a day to change Gloria’s bandages and to check on her. When Gloria began to show signs of infection, the nurse recognized it before Raphael even knew something was wrong, and she was able to have it treated quickly. She also taught them about community resources—which their insurance would cover—that would help them handle Gloria’s dementia symptoms. Raphael was incredibly thankful for the service and unsure how they would have managed without it.

For a patient taxonomy to be actionable, it needs to inform the care of high-need patients by identifying key care elements that align with the needs for specific patient populations. At the same time, providing effective and sustainable care for high-need individuals within those populations requires identifying attributes and features of care models shown to improve the experience and outcomes of the patients and reduce the cost for individual patients and the communities in which they live (Berwick et al., 2008). To examine how these two critical components relate, speakers at the first and second workshops discussed the intersection of models of care and taxonomies. Additionally, a review of evidence syntheses and other literature on care models for high-need patients identified promising models, classified areas of convergence, and produced a list of attributes holding the most potential to improve outcomes and to lower costs.

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

CHARACTERIZING SUCCESSFUL MODELS

Defining a successful care model starts with the goals of the stakeholders involved. In general, successful care models foster effectiveness across three domains: health and well-being, care utilization, and costs. The success of even the best care models depends on the particular needs and goals of the patient a model intends to serve, and those will vary even within segments of the high-need population. Dual-eligible patients, for example, are often considered a high-need group or segment as a whole, but as Randall Brown from Mathematica Policy Research explained at the second workshop, nearly 40 percent of this population does not need extensive services (see Figure 4–1). Even among those dual-eligible individuals who have severe chronic illnesses, only some require long-term support services that need to be integrated and coordinated. Each of these different dual-eligible subpopulations benefits from different managed care models or fee-for-service models.

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FIGURE 4–1 | Variations in the needs of dual-eligible individuals.
SOURCE: Adapted from Brown presentation, January 19, 2016

Different high-need segments will require different services and workforce competencies. A patient taxonomy may help define the competencies needed in the workforce, noted David Atkins from the Department of Veterans Affairs during workshop 2, but there are likely to be generalizable aspects that cut across the different segments. “As we look at these segments and map successful programs to the different populations, we may find [that] two segments that look different from a program perspective are actually served by similar looking

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

programs or that there are common elements in each of the programs that address the needs of these segments.”

At the third workshop, Arnold Milstein of Stanford University noted the profound changes that models of care have undergone over time. “It wasn’t that long ago that there were five boxes that defined America’s care models. You could either end up in the office of a surgeon, a medical doctor, or an internist, or you could end up in a hospital general surgical ward or a hospital general medical ward, and maybe an OB ward, but that was it. Over the last 100 years, as medical knowledge and health care delivery science have begun to advance, there has been a lot of evolution and customization, most of it with very good results.”

Milstein’s statement is borne out by the increasing abundance of care models available for high-need patients. As the number of models has grown, researchers have reviewed and classified these models and their attributes to determine how and why different models realize success (Anderson et al., 2015; Berry-Millett and Bodenheimer, 2009; Bleich et al., 2015; Brown et al., 2012; Cohen et al., 2015; Davis et al., 2015; McCarthy et al., 2015; Nelson, 2012; Salzberg et al., 2016; Taylor et al., 2015a; Zurovac et al., 2014). These reviews and syntheses span the heterogeneous populations and settings for which the models are designed.

Synthesizing areas of convergence in the evidence base for the wide variety of models, attributes, and implementation techniques in the third workshop, Milstein outlined four dimensions or areas of focus that constitute a possible analytical framework for identifying successful care models: (1) focus of service setting; (2) care and condition attributes; (3) delivery features; and (4) organizational culture. In the remainder of the chapter, a selection of the supporting research for each dimension of this framework is provided, together with a summary of a conceptual mapping exercise to illustrate how a patient taxonomy may inform care or care model selection. In addition, the chapter presents an example of implementing a population health approach to delivering primary care.

FOCUS OF SERVICE SETTING

The first dimension of the framework categorizes the service setting of models. In general, the most successful programs for managing high-need individuals focus on either a targeted age group with broad combinations of diagnoses or individuals classified as high-utilizers. Models tend to fall into several broad categories related to care settings: enhanced primary care, transitional care, and

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

integrated care. In a synthesis review they conducted in 2009 (Berry-Millett and Bodenheimer, 2009), Berry-Millett and Bodenheimer found a similar categorization of care management by setting. Their categories included primary care, vendor-supported care, integrated multispecialty groups, hospital-to-home systems, and home-based care.

A review of evidence for successful models of comprehensive care for older adults with chronic illness identified 15 types of models, including comprehensive patient care, pharmaceutical care, and preventive home visits (Boult et al., 2009b). Each type of model had different levels of supporting evidence for measures of success such as quality of care, increased functional autonomy, and use or cost of health services. A separate study by Brown and colleagues found the strongest evidence for reductions in hospital use and cost of care from select interdisciplinary primary care models, care coordination programs focused on high-risk patients, chronic disease self-management programs, and transitional care interventions (Brown et al., 2012).

Grounded primarily in the typology of successful care models for older adults with chronic conditions (Boult et al., 2009b) and The Commonwealth Fund’s evidence synthesis of care models for high-need patients (McCarthy et al., 2015), the framework presented lays out nonmutually exclusive categories of promising care models (see Box 4–1).

The primary and transitional care settings are the two key categories because of strength of the evidence base and potential for spread and scale in today’s clinical practices. Additionally, interdisciplinary and enhanced primary care—two care model categories that are often distinct in the literature—are combined because overlapping and indistinguishable definitions suggest a single category for primary care models. The three subcategories of primary care—interdisciplinary primary care, care and case management, and chronic disease self-management—are highlighted but are not mutually exclusive. For example, Care Management Plus is a successful example of an interdisciplinary primary care model, but there is clear overlap with a care management approach (Brown et al., 2012).

Furthermore, there is a specifically emphasized category for models that features the integration of medical, social, and behavioral services because of the importance and impact that engaging factors outside of the medical care system has on improving care for high-need patients. Meaningful care often requires alignment, coordination, and cooperation by the care system with social and behavioral health programs and services. For example, during the first workshop Robert Master, of Commonwealth Care Alliance, explained that a challenge

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

with the One Care population8 is that many within it have never been nor likely ever will be bonded to a primary care practice, given the large number of people in this population with persistent mental illness, intermittent homelessness, and

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8 One Care is a program started in October 2013 by Commonwealth Care Alliance. At the time of the first workshop, 10,300 dual-eligible individuals under age 65 with disabilities were enrolled. Some 42 percent, most of whom enrolled voluntarily, have serious physical, developmental, or mental-illness-related disabilities. Additional information about this program is available at: http://www.commonwealthfund.org/publications/case-studies/2016/dec/commonwealth-care-alliance.

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

concurrent substance abuse. For many segments of high-need patients, these highly integrated models can be the most effective, especially for populations with high levels of social or behavioral health needs.

CARE AND CONDITION ATTRIBUTES

While the details of any given model will be guided by specific conditions, successful care models share many common care attributes—the second dimension of the framework. Research has identified attributes that lead to successful models. For example, in their evidence synthesis McCarthy and colleagues (McCarthy et al., 2015) found several attributes to be widespread in successful models, including targeting patients likely to benefit from the intervention; coordinating care and communication among patients and providers; promoting patient and family engagement in self-care; comprehensively assessing patients’ risks and needs; providing appropriate care in accordance with patients’ preferences; relying on evidence-based care planning and patient monitoring; and facilitating transitions from the hospital and referrals to community resources.

Targeting patients who are most likely to benefit from an intervention, based on a comprehensive patient assessment and subsequent segmentation, is a key common attribute of successful programs (Boult et al., 2009b). Reviews of existing care models have indicated that comprehensive assessments should include multiple dimensions such as medical diagnoses, physical functioning, social risk factors, and behavioral health concerns (Boult and Wieland, 2010; Hong et al., 2014b). The factors that determine who is most likely to benefit include both the conditions that cause them to need a high level of care (Brown et al., 2012) and the patient’s amenability to complying with treatment protocols and change behaviors (Hibbard et al., 2016; Hibbard et al., 2015). With a more complete understanding of the full spectrum of needs of the patient, care providers can select a suitable care plan.

Another common attribute among successful models is that a dedicated care coordinator—usually a social worker or registered nurse—located in the physician’s office coordinates care for patients. One important role for the care coordinator is to develop an ongoing working relationship with the patient, family members, and other informal caregivers, as well as with the physicians caring for that patient (Berry-Millett and Bodenheimer, 2009; Bodenheimer and Berry-Millett, 2009; Brown et al., 2012; Hong et al., 2014b). An analysis of program design in Medicare’s demonstration projects on disease management, care coordination, and value-based payment found that the nature of interactions among care managers, patients, and physicians was the strongest predictor of success in

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

reducing hospital use (Nelson, 2012). These interactions occurred in a variety of ways, such as meeting patients in the hospital or occasionally accompanying patients on visits to their physician.

Effective care communication, through coaching and education, can play an important role in engaging the patient and family in sharing decision making, actively managing care, and developing a care plan that best reflects a given patient’s goals and desires—all common attributes of successful care models. When describing Minnesota’s Health Care Home (HCH) program at the first workshop, Bonnie LaPlante, HCH interim director and capacity building and certification supervisor in the Health Policy Division at the Minnesota Department of Health, explained that care coordinators develop relationships with the patients while physicians identify their panel of patients and commit to helping each one understand that better care results from choosing a primary care provider.

Patient monitoring, strategic use of data to provide timely feedback to the care team, and facilitating transitions between inpatient and outpatient or nursing home care are other important attributes of successful programs. Transitional care interventions have been shown, for example, to reduce hospital readmissions by as much as one-third (Englander et al., 2014; Feltner et al., 2014; Kansagara et al., 2015).

On the whole, there is convergence in the literature around many common care attributes. The eight attributes highlighted in the framework (see Box 4–2) are based on McCarthy and colleagues’ (2015) synthesis, as well as other pertinent literature.

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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DELIVERY FEATURES

The third dimension of the framework addresses delivery features. As with the evidence supporting common care attributes, there is substantial overlap in the indications supporting specific features. In the second workshop, for example, Brown highlighted two managed care plan models that show some evidence for improvement and that share many of the same features. The first model, Geisinger Health System’s Patient-Centered Medical Home (ProvenHealth Navigator) (Maeng et al., 2015), embeds care managers with primary care providers to identify and work with the truly high-risk cases that are identified on a list the case managers receive. The care managers have links to physicians at other care sites and serve as the communication hub. The second model Brown discussed, the Comprehensive Care Physician model (Meltzer and Ruhnke, 2014), has eliminated hospitalists to improve the continuity of care for all of its high-risk patients and instead allocates these patients to specific physicians who have limits to their panel size to increase their interaction with their patients. This model uses interdisciplinary teams and data-driven meetings to improve care and care coordination. Both of these programs achieve meaningful shared savings.

Brown and colleagues’ analysis of the Medicare Care Coordination Demonstration identified six practices of care coordinators that were common among the more successful programs for high-need individuals (Brown et al., 2012): Care coordinators had monthly face-to-face contact with patients; they built a strong rapport with physicians through face-to-face contact at the hospital or the office; and they acted as a communications hub for the many providers involved in the care of these patients and between the patient and those providers. In addition, the care coordinators used behavior-change techniques, not just patient education, to help patients adhere to medication and self-care plans; they also had reliable information about patients’ prescriptions and access to pharmacists or medical directors. Finally, the care coordinators knew when patients were hospitalized and provided support for the transition home.

In his presentation at the second workshop, Rahul Rajkumar, deputy director at the Center for Medicare & Medicaid Innovation (CMMI), noted that after 5 years of studying various approaches for change, CMMI has developed an abstract understanding of some of the common delivery features of successful models. Among those features are using team-based approaches, providing enhanced access to providers, proactively using continuous data to improve care, working across the medical neighborhood with a very select group of medical subspecialists, engaging patients in shared decision making, and stratifying patients based on risk.

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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The common delivery features highlighted in the framework (see Box 4–3) represent these more granular activities that are required to realize the common attributes.

ORGANIZATIONAL CULTURE

McCarthy and colleagues’ (2015) synthesis of common attributes, in which they separate the feature content (i.e., the what) and the method (i.e., the how), inspired the fourth dimension of the framework: the incorporation of organizational culture.

A study of 18 successful complex care management programs for high-need, high-cost patients with multiple or complex conditions—often combined with behavioral health problems or socioeconomic challenges—recommended a number of operational approaches (Hong et al., 2014b). In particular, this study highlighted the success of programs that adapted and customized their approaches and teams to the local context and caseload. Success often involved structuring the size of the program to better facilitate communication and adapting the program as local circumstances changed or evolved (Anderson et al., 2015).

During the first workshop, LaPlante described an example of a clinic in Minnesota’s HCH that might start with a care plan in which a registered nurse

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

serves as the care coordinator, but over time the plan adapts to changing circumstances and adds a social worker or a community health worker as a care coordinator and involves other health care team members to contribute their talents to care coordination. She noted that some of the state’s small, rural, solo-practice clinics do not have the resources to hire a care coordinator and have just started assessing their population and identifying what would be best for that population.

In addition, because care management programs are highly specialized, customized training for team members enhances success. This may involve offering specialized education and training for providers and team members (American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity, 2012; Hong et al., 2014b) or using care managers who have already received specialized training (Bodenheimer and Berry-Millett, 2009; McCarthy et al., 2015).

The Health Resilience Program (HRP) in Oregon, which was a 4-year-old program at the time of the first workshop, is a care program for high-need, high-cost patients that marries a nontraditional workforce with a safety net of primary care practices. The program’s primary workforce, explained Rebecca Ramsay, director of community care at CareOregon, consists of master’s degree–level community outreach specialists paired with culturally specific peer-support specialists and addiction recovery mentors to work intensively with CareOregon’s highest-risk and highest-need patients. These specialists focus primarily on the social determinants of health, but they are embedded in practices and function as part of a primary care team. “We have hired skilled behaviorists and peers with community outreach capacity and excellent engagement skills who spend 60 to 70 percent of their time in the community going to shelters, hospitals, park benches, and single-room occupancy housing, the places where our clients are living their lives,” said Ramsay during the first workshop. She continued, “They are trained in trauma-informed care, and they are learning evidence-based trauma-recovery interventions.” Those interventions include seeking-safety methods (Najavits, 2001) and eye-movement desensitization and reprocessing (EMDR), both of which have proven effective in treating posttraumatic stress disorder (PTSD) and substance abuse. Behavioral health clinicians provide clinical supervision, with dotted-line supervision provided by a primary care champion.

Ramsay also discussed the strong operational relationships that have developed among HRP program staff, and McCarthy and colleagues’ (2015) synthesis of care models cites effective interdisciplinary teamwork as of one of the execution methods of successful models. Boult and Wieland, however, noted that, for many primary doctors, the inability to effectively treat complex chronic patients was

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

exacerbated by not having the proper training or experience to work in a team setting (Boult and Wieland, 2010). Molly Coye, social entrepreneur in residence at the Network for Excellence in Health Innovation, explained in the second workshop that some programs have seen substantial changes in workforce roles, highlighted by the inclusion of social workers, licensed professional counselors, behavioral health specialists, and pastoral professionals as principal members of the integrative care teams who serve to coordinate a broad range of behavioral health and social services, including help with housing and financing. Embedding case managers in the practice to facilitate access and build trusting relationships with both patients and primary care providers can help solidify complex networks (Hong et al., 2014b; Nelson, 2012).

The workforce is not the only adaptive feature of successful care models. Effective use of data access, sources, and application can vary considerably and have a significant impact on the construction and responsiveness of a program (Hong et al., 2014b; McCarthy et al., 2015). Data sources themselves range from qualitative in-person assessments to such sophisticated health information technologies as interoperative electronic health records and patient-generated outcomes data from wearables and trackers—all of which care programs could use to assess outcomes or attribute value. Health systems can also use metrics gathered by the care team to evaluate and improve care models and their performance (American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity, 2012; McCarthy et al., 2015).

As an example of how metrics can inform care, John O’Brien, vice president of public policy at CareFirst BlueCross BlueShield, explained how CareFirst gives providers access to a suite of data and analytic reports, called SearchLight, that uses clinical claims and other information to help them hot-spot across their population. If these analytic tools identify a patient who needs additional services, SearchLight provides a link to the iCentric service request hub for referrals or requests for additional services, such as a medication consult with a pharmacist. To help the providers use and make sense of the SearchLight data, CareFirst employs 22 program consultants. In addition, CareFirst uses 300 nurse care coordinators as the interface between the patient, the provider, the care plan, and the community at large. O’Brien said a care coordinator who senses something is missing from someone’s care can request a consult from a registered nurse, who will go into the home to look for fall risks, gaps in care, lack of medication adherence, and lack of a caregiver. The information from that consult then feeds back to the care team.

Informed by these practices, and with grounding in recommendations from Hong et al., 2014, Anderson et al., 2015, and others, the six elements of

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

organizational culture included in the framework reflect the strong convergence of common operational approaches to successful care models (see Box 4–4).

CARE MODELS THAT DELIVER AND THE PATIENT TAXONOMY

A Conceptual “Crosswalk” Exercise

Examples of health care systems that use validated care models to successfully address the high-need and high-cost patients abound (see Appendix A for examples). Indeed, the lack of models is not a significant barrier for any delivery system that truly wants to improve care delivery for this population (Anderson et al., 2015; Boult et al., 2009; Brown et al., 2012; McCarthy et al., 2015). Specific characteristics of a given system’s patient population will influence the requirements, as Brown discussed during the second workshop: a patient in the community is going to have different care delivery requirements than is a patient in an institution, while individuals with a fee-for-service Medicare plan may have different needs than are individuals who are in a managed care plan.

To demonstrate the utility of the starter taxonomy described in Chapter 3 for selecting appropriate care models, the committee performed the following conceptual mapping exercise on a sample of 14 successful care models that highlight many of the attributes, delivery features, and operational practices described in the framework Milstein proposed. Selected programs span the range of potential models, including interdisciplinary primary care (e.g., Guided Care, Centers for Medicare & Medicaid Services’ Program of All-Inclusive Care for the Elderly [PACE]); care and case management (e.g., Integrated Care Management Program at Massachusetts General Hospital); transitional care (e.g., Naylor Transitional Care Model); and programs with strong integration of medical, social, and behavioral services (e.g., Improving Mood: Promoting Access to Collaborative

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

Treatment [IMPACT]). The sample programs were chosen in part due to the available evidence to support effectiveness across three domains: health and well-being, care utilization, and costs.9

Using the targeted populations described by the selected models, the committee determined which segment or segments proposed in the taxonomy would be served by that care model. The committee also determined whether the selected models were designed to specifically target individuals with complex behavioral or social factors.

An illustration of the resulting “crosswalk” is shown in Figure 4–2. This diagram shows that there are successful care models that apply to each of the

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FIGURE 4–2 | A sample of 14 care models which have evidence of success, matched to the six population segments identified in the taxonomy showing that each segment has been matched to at least one program. A subset of these care models also targets social and/or behavioral risk factors faced by high-need patients and is marked with an (*).
NOTE: Many of these programs could be matched and/or adapted to other patient segments.
SOURCE: Models of Care for High-Need Patients Planning Committee, National Academy of Medicine

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9 An exception was made for pediatric-specific programs because of a dearth of evidence.

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

different segments defined by the taxonomy. Additionally, the diagram shows that there are areas of overlap, with some programs being applicable to multiple segments in the taxonomy and some segments being served by multiple programs. Even with this limited selection of care models, the range of available options enables targeting of individual care models to specific patient groups based on characteristics and needs. Consequently, this crosswalk demonstrates that, with a patient taxonomy and “menu” of evidence-based care models that incorporate many of the care attributes, delivery features, and operational practices identified in the framework laid out in this chapter, health systems would be better equipped to plan for and deliver targeted care based on patient characteristics, needs, and challenges.

This crosswalk was performed solely as a conceptual mapping exercise to illustrate how a patient taxonomy can inform care: it is not an exhaustive crosswalk of all evidence-based care models. The intent of this exercise was to demonstrate the practicality of matching specific care models (e.g., GRACE or Hospital at Home) to identified patient groups (major complex chronic with social risk and/or behavioral health factors or advancing illness, respectively) to guide practical translation of this knowledge. In addition, many models could be matched or adapted to multiple patient groups, which Figure 4–2 suggests but may not fully reflect. Similar to the taxonomy, this is one approach—a starting approach—and is intended only to be illustrative. Theoretically, such a mapping exercise could also identify programs that are needed to meet the needs of specific segments otherwise lacking in targeted care models.

An Example from the Crosswalk

As a specific example of a well-served segment, Milstein highlighted two populations during his presentation at the second workshop: the frail elderly, and the frail elderly with social risk and/or behavioral health. He then discussed those programs that he and his colleagues identified as favorably impacting health and well-being, measures of utilization, or cost (net of the cost of the program itself). He noted that although a range of interventions improved the health and well-being and cost domains, much of the research used to evaluate the programs was completed before the field recognized the growing importance of patient experience. He expressed confidence, however, that “some of these programs would have also moved the needle on patient experience.”

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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For the frail elderly population,10 Milstein described two potential programs as appropriate matches. The two programs were the Transitional Care Model, developed by Naylor and colleagues at the University of Pennsylvania (Bradway et al., 2012; Hirschman et al., 2015; Naylor, 2000), and CMS’s PACE (Boult and Wieland, 2010; Hirth et al., 2009; Lynch et al., 2008), which was developed to serve elderly in San Francisco’s Chinatown-North Beach neighborhood (Ansak and Zawadski, 1983; Zawadski and Ansak, 1983). In reviewing the two programs, Milstein explained that the Transitional Care Model has a target population of hospitalized, high-risk older adults with chronic conditions. Key components of this intervention include multidisciplinary provider teams, led by advanced practice nurses that engage in comprehensive discharge planning; 3-month postdischarge follow-up that includes frequent home visits and telephone availability; and active involvement of patients and family members in identifying patient and family goals and building self-management skills. Research has demonstrated that this program is effective at reducing rehospitalizations and patient health care expenditures (Coalition for Evidence-Based Policy, 2017).

The target population for PACE includes adults age 55 and older who are publicly insured, have chronic conditions and functional and/or cognitive impairments, and live in the service area of a local PACE organization. Many PACE participants are dual-eligible individuals. Each PACE site provides comprehensive preventive, primary, acute, and long-term care and social services, including adult day care, meals, and transportation. An interdisciplinary team of health professionals provides PACE participants with coordinated care that for most participants enables them to remain in the community rather than receive care in a nursing home. Patients receive all covered Medicare and Medicaid services through the local PACE organization and at a local PACE center, thereby enhancing care coordination. Clinical staff are employed or contracted by the local PACE organization, which is paid on a per-capita basis and not based on volume of services provided.

Several research groups have evaluated PACE programs around the country (Boult et al., 2009b; Eleazer, 2000; Gross et al., 2004; Hirth et al., 2009; Lynch et al., 2008; Meret-Hanke, 2011; Pacala et al., 2000; Weaver et al., 2008). These evaluations have found that participants in PACE programs are hospitalized less frequently but make more frequent use of nursing homes; Milstein noted, however, there is also evidence that PACE programs may be more effective than

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10 Frail elderly is defined as over 65 and with two or more frailty indicators, as defined in (Joynt et al., 2016) (gait abnormality, malnutrition, failure to thrive, cachexia, debility, difficulty walking, history of fall, muscle wasting, muscle weakness, decubitus ulcer, senility, or durable medical equipment use). For more information, see Chapter 3.

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

home- and community-based waiver programs in reducing long-term nursing home use, especially for those individuals with cognitive impairments. PACE program enrollees have lower mortality rates and experience better quality care on some measures, such as pain management. The program appears to be cost neutral to Medicare and may have increased costs for Medicaid, though Milstein said more research is needed on this facet of the program.

Another subcategory, frail elderly with social risk and/or behavioral health problems,11 benefited from a different set of programs, including the IMPACT program developed at the University of Washington (Callahan et al., 2005; Lin et al., 2003; Unutzer et al., 2002; Unutzer et al., 2008; Van Leeuwen Williams et al., 2009), and the Maximizing Independence at Home (MIND at Home) program developed at Johns Hopkins University (Black et al., 2013; Johnston et al., 2011). The IMPACT program targets older adults with depression and includes collaborative care and a care manager. Each individual’s primary care physician works with a consulting psychiatrist and a depression care manager—who can be a nurse, social worker, or psychologist supported by a medical assistant or some other paraprofessional—to develop and implement a treatment plan, including antidepressant medication and/or short-term counseling. The care manager also educates the patient about depression and coaches the patient on self-care techniques. Providers use ongoing measurement and track outcomes validated through use of a depression screening tool, such as the Patient Health Questionnaire-9, and adapt care to changing symptoms. Once a patient improves, the care manager and patient jointly develop a plan to prevent relapse.

A randomized, controlled trial of 1,801 adults over age 60 with depression or dysthmic disorder or both revealed that half of patients had a greater than 50 percent reduction in depressive symptoms compared to 19 percent of patients in the control group (Unutzer et al., 2002). Net of intervention costs, the total cost of health care was $3,363 less per patient than for patients in the control group (Unutzer et al., 2008).

The MIND at Home program targets elderly patients with memory disorders. It is a home-based program that links individuals with dementia and their caregivers to community-based agencies, medical and mental health care providers, and community resources. An interdisciplinary team, comprising trained nonclinical community workers and mental health clinicians, delivers individualized care planning, implementation, and monitoring for both patient and caregiver based on comprehensive in-home dementia-related needs assessments the clinicians

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11 High-impact social risk variables are low socioeconomic status, social isolation, community deprivation, and housing insecurity. High-impact behavioral health variables are substance abuse, serious mental illness, cognitive decline, and chronic toxic stress. For more information, see Chapter 3.

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

conduct. In addition to ongoing monitoring, assessment, and planning for emergent needs, the team uses six basic care strategies: resource referrals, attention to environmental safety, dementia care education, behavior management skills training, informal counseling, and problem solving. Each component of the intervention is based on best practice recommendations and evidence from prior research, and the components are combined for maximum impact. The team also provides education, skills training, and self-management support for patients and families.

An 18-month trial of MIND at Home, involving 303 people age 70 and older with memory disorders—primarily dementia—and mild cognitive impairment, found that those individuals in the MIND at Home program were able to stay in their homes an average of 288 extra days over the subsequent 2 years compared to individuals who received no special care. Participants who met regularly with care coordinators were less likely to leave their homes or die than were those in the control group, and they had fewer unmet care needs, particularly with regard to safety and legal and advance care issues (Samus et al., 2014). The researchers reported that the caregivers of individuals in the MIND at Home program also seemed to benefit in terms of reducing the amount of time they needed to spend with the individuals in their care (Tanner et al., 2015).

While these care models share many of the care attributes, delivery features, and organizational characteristics outlined in the framework presented in this chapter and include a variety of different service settings, in order to be successful, they need to be tailored to the health system, the community, and the unique patient characteristics that drive health care need. For example, in the case of the frail elderly segment, the characteristics that drive the need for health care relate to the frailty indicators that must be managed by interdisciplinary teams, often with social supports including family members and community social services, where available. When these individuals also have mental health issues, specialized coordination with appropriate mental health care providers becomes important.

DENVER HEALTH: A “REAL-WORLD” APPLICATION

Denver Health represents one example that pulls together the use of whole population risk stratification, the practical use of a patient taxonomy, targeted care, and many of the care attribute and delivery features of successful care models. Simon Hambidge, chief ambulatory officer at Denver Health and professor of pediatrics at the University of Colorado, spoke about the program at the second workshop. Referring to Denver Health as “unusual,” Hambidge explained

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

that it combines a safety net hospital, a large federally qualified health center (FQHC), a public health department, an emergency 9-1-1 call center, and several school-based health centers. Though the work he discussed in his presentation took place in Denver Health’s FQHC, it impacted the rest of the organization. The goal of this CMMI-funded project was to improve the experience of care, improve the health of populations, and reduce per capita costs of health care. To meet that goal, however, a fourth goal should be added: improving provider engagement and creating healthier and happier providers. Some $9 million of the $19.8 million CMMI award was spent on redesigning health teams; another $9 million was spent on health information technology to enable population segmentation and patient risk stratification; and the remaining funds were spent on rapid-cycle evaluation to enable design iteration.

Patient Risk Stratification

Denver Health’s risk stratification approach uses clinical risk groups (CRGs), a clinically based classification system originally developed by 3M to measure a population’s burden of illness (Hughes et al., 2004). This approach uses input from clinicians and data analysts to assign every CRG-classified patient to one of four tiers of increasing complexity and risk (see Figure 4–3), with additional criteria used to override a CRG designation.12 As an example, Hambidge explained that a child on Denver Health’s special health needs registry or individuals with certain mental health diagnoses would receive increased care coordination regardless of what their CRGs would normally warrant. Similarly, a family history of premature birth would result in a pregnant woman being targeted for more intensive interventions no matter where she fell on the CRG stratification scale. He also noted that different stratification algorithms are used for adults and children.

Matching Care Delivery to Tier Level

For healthy adults (i.e., those assigned to Tier 1), standard panel management techniques, including a heavy reliance on Denver Health’s eTouch text messaging program, have produced good clinical outcomes, Hambidge said. These outcomes include decreased no-show rates, higher immunization rates, and higher well-child appointment rates. Individuals in Tier 2 start to get increased care management for chronic diseases. For children, Tier 2 care management involves lay patient navigators, some nurse care coordination, and some home visits and environmental scans for children with asthma. For adults, Tier 2 care

__________________

12 NOTE: This risk stratification does not directly map on to the taxonomy described in Chapter 3. However, it is an example of a system that could be used to assist in care delivery.

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

includes more pharmacotherapy management and emphasizes transitions of care to reduce readmissions.

Image
FIGURE 4–3 | Denver Health’s use of Clinical Risk Groups to assign patients to care programs.
NOTE: This is an example of risk stratification. It does not map directly on to the taxonomy proposed in Chapter 3.
SOURCE: Hambidge presentation, January 19, 2016.

Complex case management strategies using enhanced care teams come into play for Tier 3 and Tier 4 patients. Integrated behavioral health assessments and care are standard for patients in these two tiers, as is the involvement of nurse care coordinators, clinical pharmacists, and clinical social workers. For Tier 4 patients, which Hambidge said is where the biggest cost savings and clinical benefits are realized, Denver Health relies on specialized intensive outpatient clinics for adults and multidisciplinary special needs clinics, similar to those prevalent in children’s hospitals, for its highest-risk pediatric patients. The intensive outpatient clinic is targeted to adults with multiple, potentially avoidable, inpatient admissions within 1 year, and it serves as the patient’s medical home. Panel sizes in this clinic are smaller, and the care teams include a dedicated social worker and navigator. This clinic also works closely with the Mental Health Center of Denver.

Outcomes

Hambidge said the total number of “super-utilizers” is stable, but individual turnover is high, which creates a dynamic population (Johnson et al., 2015b). A population- and individual-level analysis of Denver Health’s data showed that over a 2-year period only a small number of superutilizers continuously met the criteria to be considered a superutilizer, and a slightly larger number went

Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

back and forth between meeting and not meeting those criteria. This analysis, he said, shows the importance of developing a population-based stratification system even though individuals are getting care. “You have to step back and look across the population to see who is coming into and going out of your system.” These data also show the importance of taking a population-based, actuarial approach when conducting financial analyses. As Hambidge explained, the natural tendency for high-utilizing patients to become less so over time would lead to an overestimation of cost savings based on individual results. Denver Health’s data at the individual patient level, for example, showed that charges were reduced by 44 percent and admissions fell by 53 percent without any clinical intervention simply because of this natural tendency for individuals to move out of the high-utilization group. When the financial analysis was conducted using population-based cost avoidance as the metric, however, the true savings were approximately 2 percent, or $6.7 million, over a 1-year period, which Hambidge characterized as significant and important. “Even though programs such as this have significant clinical impact and significant impact on family and provider satisfaction, they are going to be sustainable based on financial performance.” Most of the savings, he added, came from Denver Health’s adult population, but some 15 to 20 percent of the savings were realized from its Tier 4 pediatric population.

The demonstrated success of models of care such as those being implemented by Denver Health and other forward-thinking health systems to improve the care of high-need patients and perhaps reduce the cost of care raises an obvious question: why are more health systems not adopting these models of care? Chapter 5 discusses some of the barriers to the wider spread and scale of successful models of care and raises some possible policy solutions to address those barriers.

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Suggested Citation:"4 Care Models That Deliver." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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To advance insights and perspectives on how to better manage the care of the high-need patient population, the National Academy of Medicine, with guidance from an expert planning committee, was tasked with convening three workshops held between July 2015 and October 2016. The resulting special publication, Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health, summarizes the presentations, discussions, and relevant literature.

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