How will this module help me adopt a value-based care model?
Details five STEPS to prepare your practice for value-based health care.
Answers common questions about becoming a value-focused organization.
Provides case reports describing how physicians can create value-based practices.
What is value-based care?
Unlike traditional “fee-for-service” care models that link payment to the number and type of services utilized, “value-based healthcare is a health care delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes. Under value-based care agreements, providers are rewarded for helping patients improve their health, reduce the effects and incidence of chronic disease, and live healthier lives in an evidence-based way.
Value-based care differs from a fee-for-service or capitated approach, in which providers are paid based on the amount of healthcare services they deliver. The “value” in value-based healthcare is derived from measuring health outcomes against the cost of delivering the outcomes.”1
Five STEPS to prepare your practice for value-based care:
Identify your patient population and opportunity.
Design the care model.
Partner for success.
Drive appropriate utilization.
Quantify impact and continuously improve.
Step 1 Identify your patient population and opportunity.
Quiz Ref IDKnowing your patients is the foundation of value-based care. Patient populations with the highest risk of hospitalization or high utilization of the emergency department (ED) tend to drive high health care costs and most often receive fragmented care. These populations often include poly-chronic patients — those with chronic and complex conditions with multiple co-morbidities, such as diabetes, hypertension, depression, heart failure, cancer, kidney failure, or chronic obstructive pulmonary disease.
Understanding which patients drive your highest cost of care and those who use the ED frequently will help you to identify your target population and opportunities for improvement. Once you have this information, you can begin to develop your model.
“I have seen patients go from disengaged to self-motivated, from helpless to hopeful, from naïve to empowered by education and knowledge. This clinic has not only saved lives but has changed lives as well. The positive impact has a ripple effect, where we are not only impacting their heart failure but their overall health.”
Ursula Grant, Nurse Practitioner, Cornerstone Cardiology Heart Function Clinic, High Point, NC
Step 2 Design the care model.
Develop care models that are evidence-based and easy to follow.
You can consider the following elements in the development of your value-based care model:
Identify the target patient population(s).
Identify which payers will be involved.
Estimate how the type and volume of services will change. Involve your legal advisors at the outset so you are aware of and design the program in compliance with federal and state laws.
Identify the benefits expected for patients and payers.
Design the workflows required to provide the desired care to the selected patient population.
Discuss details including:
Team members who will support the new model.
Roles and responsibilities of each physician and the care team.
Frequency of patient contact (via phone call, email, or portal messaging).
Frequency of patient visits to the practice or from home health care.
Identify measurable success metrics for each population, and determine your baseline in order to quantify your impact in the future. Your metrics should be easy to capture in the electronic health record (EHR) or population health registry to prevent having to extract them manually.
Identify transition costs (as a note, revenue needs to be addressed as well as risk-stratification).
Depending on the licensure, education, and training of your team, current team members could potentially fill the staffing needs of the new value-based care model with proper education and redistribution of responsibilities.6 Utilizing current staff can be cost effective during the initial transition period, but additional staff may be needed as the model continues to be adopted by the practice, particularly since value-based models rely heavily on effective care coordination and require a greater amount of data capture and analytics.
The care team should be led by a physician7 to identify, engage and elicit from each team member the unique set of training, experience, and qualifications needed to help patients achieve their care goals, and to supervise the application of these skills.8
Quiz Ref IDRoles of other team members who care for patients in the model could include:
Patient outreach coordinators.
Non-clinical team members who can utilize patient registries and analytic tools to reach out to patients who need additional assistance from a variety of care team members.
Nurse educators/navigators.
Registered nurses with specialized training in appreciative inquiry, motivational interviewing, health coaching, and case management can positively impact the health of patients by extending the traditional reach of providers and their clinical care teams. They can intervene with the most vulnerable populations between office visits to educate and assist them in better managing their chronic health conditions. Registered nurses can schedule appointments and cover patient education, as well as provide the hands-on support and partnership that patients need to improve their health.
Care coordinators.
Medical assistants (MAs) with training in population health management, clinical documentation, and quality improvement can work closely with the nurse navigators to provide follow-up communication and care coordination for high-risk patients. MAs can routinely check in with patients to support adoption of healthy behavior changes and work independently or with patient outreach coordinators to identify and close care gaps through patient engagement.
Certified medical assistants (MAs).
Certified MAs (CMAs) can perform medical record reviews for patients scheduled for upcoming clinic visits, coordinate daily huddles, obtain all pertinent vitals and labs, complete medication reconciliation, and set the visit agenda with the patient, in accordance with state law. In this more advanced MA role, the CMA has the opportunity to start identifying gaps in care in preparation for the physician visit and then document the visit while in the room with the physician. After the physician finishes the encounter, the CMA makes sure the patient understands the plan of care and answers any questions. This type of workflow allows the provider to focus more on the patient and ensure that all the patient's needs are met during a single office visit, thereby increasing provider productivity and quality, while reducing clerical burden. While working within his or her scope of practice, the CMA is able to answer patient questions and coordinate patient care after the visit, providing continuity and consistency for patients.
Referral coordinators.
Employees responsible for both scheduling referrals and obtaining any precertification required by the patient's insurance company are referral coordinators. Referral coordinators also communicate with the patient to confirm that the next appointment is kept. Referral results are obtained by the referral coordinator and scanned into the patient's medical record or sent electronically for the physician to review, if needed. If any follow-up care is needed, the coordinator can connect with the patient and schedule the proper appointment. Referral coordinators must be mindful of applicable federal and state laws including those that prevent patient steering and protect patient choice.
Transition of care nurses.
Nurses can provide support and care coordination services to patients undergoing a transition between different levels or venues of care. This function requires meticulous attention to the details of a patient's care, including, but not limited to: medication reconciliation, discharge instructions, resource availability for outpatient or community-based care, and provider follow-up within a defined time frame. In your practice, these nurses could make sure that patients who are seen in the hospital or ED receive the follow-up care they need in the practice by scheduling those appointments.
Extensivists and hospitalists.
The extensivist team works alongside the hospitalists, ensuring that patients receive the appropriate follow-up care and care coordination after they are discharged. Hospitalists and extensivists work hand-in-hand with care transition teams to ensure that proper follow-up care is received and understood by the patient and care team.
Some practices also use nurse practitioners, care managers, and others to assist with care transitions and patient care management. Again, referrals must be handled in accordance with federal and state law requirements.
Step 3 Partner for success
Depending on the size of your practice or organization, you may need the additional resources that a collaboration can offer to help you successfully shift to a value-based care model. Quiz Ref IDCoordination with local hospitals, practices, urgent care centers, insurers, or other organizations may enhance your ability to offer better transitional care and outpatient care management to your patients. Multi-provider arrangements should be considered with legal advisors to avoid running afoul of fraud and abuse and other laws applicable to the health care space.
Care fragmentation poses a major safety risk and can lead to patient dissatisfaction and disengagement. The hospital-practice collaboration is a great example of an opportunity to decrease care fragmentation through coordination and communication. A hospital collaborator may be able to provide discharge lists and ED visit reports that can help your practice follow up with patients and ensure continuity of care.
“By partnering and establishing trusting relationships with patients, caregivers, providers and community partners, [we] are able to improve quality of life, satisfaction with care, and reduce unnecessary spending.”
Edgar Maldonado, MD, Cornerstone Personalized Life Care Clinic, High Point, NC
Step 4 Drive appropriate utilization
As the new model is adopted, look for ways to reduce unnecessary costs or variances, and drive utilization toward a lower-cost, highest-quality approach. Often, when patients stay within an integrated provider network, it enhances quality and reduces cost. However, patient choice and clinical needs ultimately govern where a patient receives care.
As your team is increasingly empowered to help your patients manage and improve their chronic or poly-chronic conditions, collaborators may increasingly rely on your practice as the new model is adopted and refined. Through a more effective, team-based approach to care, outcomes should improve, and physician time can be spent on new appointments, annual visits, and critical patients. Intermediate care, follow-ups, and education can be provided by other members of the team if deemed appropriate by the physician team leader, and/or in accordance with each physician's practice preferences.
Quiz Ref IDBy working with your practice's financial expert or using analytic software to determine your high-cost spending patterns you can identify if there are any unnecessary costs associated with your practice. Note that there may be some start-up costs associated with purchasing these programs.
For instance, analysis may reveal that an imaging center used by your practice is more expensive than others in the area. After comparing the quality of services and ensuring value, it may be prudent to start referring patients to high-quality, lower cost centers. Discuss referral practices or proposed changes with legal counsel to ensure compliance with applicable federal and state laws.
Other STEPS Forward™ modules may be useful in your quest to identify and eliminate unnecessary costs and improve efficiency in your practice. For example, pre-visit planning, team documentation, and implementing team-based care are time-saving approaches that have helped other practices reduce costs.
Step 5 Quantify impact and continuously improve
Continuously monitoring your progress will help you determine the impact you have on your target patient population. To achieve positive outcomes, reassess how well your practice is accomplishing the predetermined goals monthly or quarterly, and adjust your efforts as needed. You may want to consider using the Plan-Do-Study-Act (PDSA) method to track your success. Reevaluate your care model annually to ensure it is providing the desired impact. Regularly measure your patient, provider, and team member satisfaction as these are key to your model's success.
Keep an eye out for other value-based contracting options with payers and partners. Check your negotiated contracts on an annual basis to ensure you use the latest evidence-based metrics and receive appropriate financial compensation.
Each step on your journey to value-based care is a learning experience. Some decisions will work well, and some ideas will not work as planned. As these experiences provide your practice with more knowledge about what works best, the practice can make the changes that will better meet patient needs. Transparently and routinely informing your practice of the results of the value-based care model implementation, either in scheduled team meetings or with brief recaps during huddles, can help encourage the team to stay positive so they can continue to deliver value to patients.
Value-based care metrics (39 KB)
Value-based care models are the future of sustainable health care. This module is designed to help your practice make the shift towards this model so that your patients and team can reap the benefits of this outcomes-focused approach that incentivizes high quality, patient-focused care, and reduces overall health care costs.