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Coordinating Care under Accountable Care: A Complex Web of Strategic, Tactical, and IT Challenges

December 18, 2012
by Mark Hagland
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CSC’s Jane Metzger offers her insights into the massive IT foundational challenges embedded in care coordination under accountable care

Earlier this month, Jane Metzger, principal researcher in the Waltham, Mass.-based Global Institute for Emerging Healthcare Practices within the Falls Church, Va.-based CSC, authored a new white paper, “Preparing for Accountable Care: Coordinated Care.”

As Metzger articulates in “Preparing for Accountable Care,” the reality of accountable or coordinated care is exceptionally complex, and encompasses numerous concepts and organizing principles, including the accountable care organization (ACO), whether of the Medicare Shared Savings Program variety, or of the private type; the patient-centered medical home; bundled-payment contracts; and organized transitions of care. Not surprisingly, the information technology foundations for the organizations being created to provide such care, which Metzger refers to as coordinated care delivery organizations (CCDOs), are correspondingly equally complex.

As Metzger notes, “Accountable care will only be successful—perform well against performance expectations for quality and do so efficiently—when there is tight collaboration between direct care providers and care coordinators within and across sites and settings of care.”

What’s more, she writes of health information technology, “HIT can’t enable any process discussed without considerable patient-specific information. For HIT to make secondary use of that information (i.e., for quality reporting, electronic patient tracking to detect exceptions, clinical decision support), each element must also be available for computer analysis (i.e. structured, coded).” Happily, she notes, “Stage 1 meaningful use for HITECH [the Health Information Technology for Economic and Clinical Health Act] builds a strong data foundation, not just for the care teams  using the local EHR [electronic health record], but also for communicating critical information to other provider teams for continuity of care, and Stage 2 adds somewhat foundations.”

All that said, she adds, “However, the definitions of how much is enough and who is to be the documenter set low expectations. For example, for a patient with multiple chronic health problems and relevant past history (resolved problems), a problem list containing one entry, as allowed by the Stage 1 measure is not meaningful for care.”

Clearly, there are many levels of complexity here, levels that even the most advanced patient care organizations moving forward on some version of accountable care are only beginning to address. With regard both to the care delivery and organization issues, and the multifaceted IT issues, Jane Metzger sat down recently with HCI Mark Hagland to discuss the broad range of challenges facing healthcare and healthcare IT leaders in this emerging area. Below are excerpts from that interview.

Let’s start at the care delivery and care coordination level. Why is coordinating care so critical for accountable care?

Because it overcomes the fragmentation in care and provides support to high-risk patients.  Accountable care ties reimbursement to performance, and fragmentation of care results in lots of dropped balls that lead to poor outcomes—both in quality and in cost.  The discharged patient who doesn’t receive timely post-discharge care, the ill patient referred to a cardiologist who can’t get an appointment, are both examples that can have bad outcomes. And don’t forget that the measures for the CMS Medicare Shared Savings Program include the patient’s feedback about the experience of receiving care—a fragmented care system with patients bouncing around will never get good ratings from patients.

Also, we know that 10 percent of patients incur 80 percent of healthcare costs. Care coordination provides a process and resources (usually nurses) to track these patients more intensively, coach them in self-management, and ensure that barriers to receiving care are reduced.  Doing a better job with and for these high-risk patients is critical to success. One could say that care coordination has to be excellent for accountable care to work for patients and the provider organizations now at financial risk of achieving good outcomes.

Jane Metzger

You looked at many models for organizing care coordination, so there doesn’t seem to be just one way to do this.

Care coordination isn’t new.  The experience base is quite extensive, including in HMOs and integrated systems of care receiving capitated reimbursement, demonstration projects sponsored by CMS or other groups, new ACO-like partnerships between health plans and providers,  demonstration projects to strengthen the effectiveness of the medical home, and work in the safety net, including large-scale Medicaid programs.  When you look at all of models in these examples, there are two common themes. The first theme is that added resources are needed to do care coordination (not added work for the primary care physician); and the second is that direct care providers can perform some coordination activities, but also that there is a need for dedicated care coordinators and/or case managers.

Beyond that, yes, there are many models.  What seems to matter more than the model is the close collaboration between care coordinators and the clinical team in the medical home and, at least for patients requiring intensive care coordination, frequent contact between coordinators and the patient.

Where does the patient-centered medical home (PCMH)  fit into this?  To many people, accountable care and the PCMH appear to be the same thing.