CMS has, for years, suggested to healthcare providers across the care continuum that they must refine old and create new methods of providing care. Providers are expected to collaborate and coordinate to minimize the fragmentation in healthcare. They need to work together to improve care delivery, efficiency, and effectiveness. Home health care providers should be aware of the new Chronic Care Management Models that include Accountable Care Organizations (ACOs) (see Select Data ezine, January, 2012 ) and Patient Centered Medical Homes (PCMH).

Through collaboration amongst stakeholders, with coordination of expensive chronic care, and with partnership developments, strategic alliances are being encouraged. Is your home health agency ready? What specific programs do you have in operation? Are they evidenced-based? What have been the outcomes? Do you have reliable statistics?

As stated in the January, 2012 ezine:

“Home health agencies should be paying VERY close attention to the latest requirement for home health found in the Affordable Care Act. The Act encourages development of Accountable Care Organizations (ACOs) and provides for “incentives to enhance quality, improve beneficiary outcomes and increase value of care.” (CMS Q&As Section 1899 of Title XVIII)  The ACO becomes a type of managed care organization that may use fee-for- service or capitation payment, and is accountable to patients and the third party payor for the quality, appropriateness, and efficiency of the care provided. Because of the Affordable Care Act, CMS must have an ACO in place by January, 1, 2012.

Some home health agencies have begun aligning with physician offices, hospitals, rehabilitation facilities, and long term care providers to coordinate care across the health care continuum. Home health agencies are becoming members of hospital teams in both general and specialty areas. Agencies which cannot seem to form the alliances may find themselves with declining referrals in the near future. Home health needs to demonstrate their personalized approach to care so they may be appealing to the PCMH team.

Home health agencies should be encouraging discussions among provider leaders of all levels of the care continuum. Patient ultimate outcomes should be shared by all providers. Establishing those mutual patient outcomes is a primary step in a strategic alliance between ACOs and PCMHs.

Hospitals know that the bundled payment pilot begins January, 2013. It is expected that hospitals will be responsible for the patient three days prior to hospitalization, during hospitalization, and 30 days after hospitalization. They will more likely want to work with agencies with proven hospital reduction programs, quality care clinical programs, and positive patient outcomes. Agencies with those types of programs are already aligning to form care transition models to be ready to bill the new CMS ACO.” (Select Data ezine, 1/2012)

Hospitals are also expected to be working closely with primary care practices which have the PPC- Patient Centered Medical Home Recognition. Many practices approved using the 2008 Standards have now applied to meet the 2011 National Committee for Quality Assurance (NCQA) Standards.

The PCMH is defined by NCQA as an innovative program for improving primary care using clear and specific criteria centered around patients and their care needs, working in teams coordinating and tracking care over time. The PCMH program is for practices that “provide first contact, continuous, comprehensive, whole-person care for patients across the practice.” (NCQA, 2011)

Per the NCQA:

“The Patient Centered Medical Home is a health care setting that facilitates partnerships between

individual patients and their personal physicians, and when appropriate, the patient’s family. Care is

facilitated by registries, information technology, health information exchange and other means to assure

that patients get the indicated care when and where they need and want it in a culturally and linguistically

appropriate manner.”

The PCMH is being touted as an excellent way to improve healthcare in this country by “transforming how primary care is organized and delivered. The Agency for Healthcare Research and Quality (AHRQ) defines the PCMH as a model of the organization of primary care that delivers the core functions of primary health care.”

The Patient Centered Medical Home must encompass five core functions and attributes:

1. Comprehensive Care: The PCMH is accountable for meeting “the large majority of each patient’s physical and mental health needs, including prevention and wellness, acute care, and chronic care.” To meet required standards, comprehensive care must include a patient-centered team that may include physicians, nurses, PAs, pharmacists, social workers, and care coordinators. Large primary practices may have large teams while smaller practices may “link themselves and their patients to providers and services in the community” (NCQA, 2008).
2. Patient Centered: The PCMH must provide “primary care that is relationship-based with an orientation toward the whole person.”  The standards require a partnering with patients and families that demonstrates an understanding of their unique needs, values, and preferences. The PCMH primary physician and team are expected to assist patients to manage and organize their own care.
3. Coordinated Care: Care is required to be coordinated across “all elements of the health care system.” This care is considered critical during transition between levels of care with clear and open communication.
4. Accessible Services: The PCMH is expected to deliver care in shorter timelines with individualized hours of care and 24/7 phone or electronic access to a member of the PCMH team demonstrating responsiveness to patient needs.
5. Quality and Safety: The PCMH is committed to quality and quality improvement with ongoing evidence-based medicine and “clinical decision-support tools to guide shared decision making with patients and families.

CMS believes that for too long patients have been provided care by disparate systems; a hospital here, a home health agency there, and yet long term care over there. An ACO (created by health care reform law) is expected to include a broad network that will share responsibility for providing care. The ACO must be able to show they can provide care better than the singular services. Home health agencies should consider establishing patient populations of mutual interest and present evidence-based practice interventions that are likely to improve quality, diminish decline, and improve patient satisfaction not merely in one level of care but across that continuum.  NCQA released its ACO Accreditation Standards in 2011.The NCQA approach to ACOs emphasize patient-centered primary care; use of measurement techniques that improve health care, and high standards for care coordination.

The CMS ACO initiatives were launched January 1, 2012, but ACOs were already being explored not only for Medicare but for other payor sources as well.  ACOs, theoretically, would make the providers jointly responsible for care and offer incentives to achieve quality outcomes yet, make a profit. There would need to be a seamless way to share information.  They would encourage standardizing care to reduce variable clinical practices. It is expected that those who would achieve the quality and financial goals would retain a portion of the savings.  The amount or percentage is yet to be determined.

To work together with agencies with like values, goals, and evidenced-based processes could challenge present regulation. Would this mean the regulation regarding the hospitals discharge policy involving a referral list of local agencies would be changed? It would seem that would be needed since the hospital would be working with agencies that were a part of their ACO. Also, under a hospital led bundled payment, hospitals it would seem, would want to transition patients to agencies with specific programs in place to prevent readmissions. Agencies should be developing programs NOW that can significantly reduce emergent and inpatient care. Outcomes will play a larger role as to which agencies will be chosen as ACO members.

NCQA views primary care as the foundation of the health care system. The primary care physician/team is frequently the first point of contact. The NCQA new standards require a patient survey to help drive quality improvement. It also requires involvement of patients and family in quality improvement. In addition, tracking care over time is necessary. Reducing fragmentation, involving patients and families actively, while transitioning through levels of care is a primary goal of the PCMH and the ACOs.

Home health agencies should be prepared to statistically present outcomes and be ready to participate actively in devising a plan for sharing information. The need to dramatically alter home health care delivery is upon us. Agencies need to be prepared for this change. Be open and receptive to collaborative practices. Be prepared to assist in standardizing teaching and discharge planning instruction. And one other point: CMS is subtly suggesting that discharge planning will soon evolve into transitional planning as the patient moves from one level of the care continuum to another. Be prepared for that transition or face the potential consequences.

Before and after home health care could well be the PCMH. Home health agencies may need to blend into that model. No matter what, data, statistics, and analytical analysis will be vital and an integral part of any Chronic Care Management Model. Are you prepared…or preparing?