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

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.

For many patients, they will be.  That’s because many health systems engaging in accountable care contracts are transforming physician practices into PCMHs.  This separate, but complementary healthcare reform initiative shares many of the same goals as accountable care. Although transforming practices into PCMHs is a big investment, the PCMH design builds the extra resources and processes for care coordination right into the team, fosters a tight collaboration, and aims to accomplish patient-centered care so it hits many of the hot buttons for accountable care.  Other approaches include embedding additional care coordination resources in local, more traditional practices, special care coordination programs operated outside of the medical home (by the community or a health plan), and specialized high-intensity clinics that provide temporary or ongoing care management for high-risk patients.  In practice, organizations that have been at this for a while, typically evolve a combination of these approaches—a hybrid model.

You mention that some organizations have more experience than others.  For those for whom a systematic approach to care coordination is new, what are likely to be the biggest challenges?

Every hospital has been working on readmissions and most practices/clinics have been doing some care coordination for referrals to certain specialists or for patients with diabetes.  The big challenge will be organizing that and taking it to the next level so that it works seamlessly and systematically for large numbers of patients. Meanwhile, it is today’s challenge, because most health systems (or virtual health systems organized for the purpose of engaging in accountable care) already have several accountable care contracts in place or will have them soon—global payment for Medicaid patients, an ACO-like arrangement with one or more private payer, a Medicare Shared Savings Program pilot or actual contract.  We believe every organization needs to treat care coordination as a new enterprise-wide process and develop a near-term, mid-term, and long-term strategy for putting it in place.  Accountable care brings with it other complexities to tackle, but this is one requiring a home run.

Per the IT foundations for all of this, you address extensively how the meaningful use requirements under HITECH do not compel the creation of the full data set needed for clinical care and care coordination. Given that, how can provider leaders create the population management, clinical quality reporting, and patient tracking tools and systems they need to implement, to support coordinated, accountable care, while also meeting the requirements of meaningful use?

Meaningful use is a good start, but only if the goal is all of the required data for every patient, captured in a meaningful way rather than the thresholds set for HITECH.  But even that is insufficient. Coming up with the full minimum data set is complicated by the fact that patient-unique health challenges, the current care management context (e.g., post-discharge care, watchful waiting for changes in status), and the specific role of the participant (e.g., developing or implementing the care or coordination plan) determine what is needed in practice.  In the paper, we suggest focusing on the contents of the care coordination plan, electronic screening for gaps in care or changes in patient status, and data needs for population management, clinical quality reporting, and patient tracking as a good starting point.

You have a great section on health information exchange. Where are the biggest gaps right now? And has anyone created a model that works for all the purposes discussed in your document?

As I understand it, most organizations  aren’t doing much routine HIE yet, even things as basic as transmitting discharge summaries and patient discharge instructions to a patient’s medical home. HIE will be critical to enabling providers at both the point of care and the point of coordination to do the right things for each patient.  Large-scale HIE is based on the premise that participating entities have systems in place that can send and/or receive the needed information; we’re so far from that today that I think it is more realistic to work incrementally toward broader and deeper HIE, but at the same time to provide paper-based or other mechanisms to fill gaps in electronic opportunities.  Most of the activity and planning for HIE so far has involved medical record information for the direct care team, not the overlapping but also somewhat different information for care coordination.  In my snooping, I only found one organization today that I thought had this covered.