This blog is part 2 of a discussion of value-based care—the new paradigm in which care is no longer delivered only by doctors and nurses, but by an entire community of providers that treat the “whole” patient rather than just treating the disease. The focus is on treating the entirety of a patient’s needs to bring about better health outcomes—which means that communication and care plans no long reside solely within a doctor’s office. To achieve this objective, the industry is migrating to a de facto set of standards that it is believed will take us down the right path.
Standard #1: Collaboration
Collaboration is not just an event—it is an ongoing process in which joint communication and decision making is the norm, and interdisciplinary team members work together to care for the whole patient and whole population based on medical, behavioral, and social needs. But, value-based care also comes with a new level of collaboration that includes an alliance among those that have historically been competitors—an arrangement that is not without friction. The idea of opening oneself up to collaborate with business competitors to decrease risk is difficult for providers to embrace, and therefore will need to overcome some inertia to take hold. As the community-based team model becomes the standard, organizations will no longer fight each other for the churn of patients.
Standard #2: Care Management
Care management now extends beyond direct delivery of care, into requiring a greater level of project and workflow management to ensure care is delivered in the way it is intended across the continuum of disparate care providers and life circumstances. Care managers manage care in new ways, making sure resources are allocated, assignments are known and understood, and each individual care provider is doing his or her part of a coordinated set of actions that lead to a care outcome. No longer can individual, autonomous efforts remain unreconciled with the bigger picture of care.
In this world, it’s not just transparency that matters—it is the proactive identification of what the care teams SHOULD be doing TOGETHER to achieve the outcome.
Standard #3: Population Identification, Stratification, and Intervention
Identifying the highest utilizers of care is not a new concept—health homes strive to manage high-risk patients in a special way to achieve better outcomes. But, where do you draw the line? And what about people who are below—but close—to that threshold?
For these “rising risk” patients, a little intervention can go a long way in preventing them from moving to the high-risk category—but these additional interventions cannot extend to the entire population. Some programs, such as New York’s DSRIP initiative, are going beyond simply cherry-picking the patients to be managed, and instead allowing the providers in charge of their care decide what level of effort is required to treat each at-risk patient. Care providers are empowered not only to deliver care, but to determine who needs what level of intervention. This program is just one example of the change that is taking hold across the country.
To keep patients “out of the red,” healthcare providers are increasingly required to perform a statistical analysis of their populations to identify how actively each patient needs to be managed. This type of analysis, though, is difficult—not only do many providers not have access to a central repository of information, but statistical analysis is not a core competency of these organizations. They deliver care, not patient stratification. So what are their options?
To stratify a population within a geography means that providers first need to know who their patients are so they can divide the population and distribute accountability for individual patients. Many performing provider systems (PPSs) don’t have a way to get data, but are still responsible for managing the patients. Without integrated records, these providers are working in a silo, unaware of what’s going on outside their four walls—and seeing only part of the information about a patient. The challenge is to get the information they need to treat a patient in a holistic way, and to reconcile and get credit for the patients they do see so that they receive the appropriate compensation.
Standard #4: Secure Data Aggregation
In today’s environment, care teams need information from disparate sources—but organizations are afraid of handing out big chunks of data due to privacy considerations. It’s a healthy fear, as organizations that have a core competency of healthcare rather than IT are not necessarily equipped to keep a deluge of data secure so that patients aren’t put in jeopardy. States are establishing requirements to make sure data is protected, but this erects barriers that keep providers from accessing and processing the data. To add to the problem, rules on data exchange are still being hashed out.
Many organizations turn to other sources as aggregators of data, such as payers that administer Medicaid plans or clinical systems. These systems can be leveraged for basic stratification, outreach, and treatment activities, but don’t provide a complete picture. In New York, for example, the state-sponsored [LJ1] Medicaid Analytics Performance Portal (MAPP) can serve as a system of last resort for care coordination activities, providing basic access to data, collection, and entry run reports. This is great in theory, but how do these care organizations tie in their own systems, or interface with emerging partner organizations and other information sources within the care ecosystem?
The Solution—Integrated Care Coordination and Robust Analytics
Just delivering care to individuals isn’t enough—you need to do it in an informed way, and with measurable outcomes. You need tools that allow a team to be a team, not just a collection of people using a system to document facts and actions. Having a centralized planning activity with data from different settings brings together all providers regardless of the type, enabling all to contribute in a uniform fashion to care. Differences are negated by providing one central tool and unified plan of care that carry across all settings.
A complete solution requires a number of features:
- Care coordination that enables providers to organize as a team and act as a team, interacting with one another and with the patient in a secure way that complies with privacy laws
- Transparency that enables all team members to be organized and efficient and to coordinate interdependencies so that their efforts complement what everybody else is doing
- Care plan that contains the collective intelligence of the entire group, including contributions from all team members
- Support for different types of providers, including behavioral, social, and human services—who don’t use the same types of tools
- Extensive patient classification and stratification to help providers strategically manage at-risk patients and proactively address gaps and care
- Messages, alerts, and reporting that enable team members to understand what’s happening in real time plus dig deeper when required
- Robust analytics with quality measures and outcomes and operational reporting and compliance requirements
- Assessments and managed consents that enable patients to be appropriately allocated and enrolled into programs
We believe that care coordination and analytics need to be together—just one in isolation isn’t enough to get the job done. By bringing both into a single platform, you maximize synergies—you can share information and how it relates to activities within a unified framework. By establishing this close linkage, care coordination and analytics reinforce one another, delivering a total package of functionality that helps you achieve your goals in a more effective way.
Our GSIHealthCoordinator solution does just that, integrating care coordination and robust analytics and making it accessible to the entire care team so you can collaborate, manage, and analyze your data, and use it to improve the health of your population.