Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions

Key takeaways/implications

• There are many barriers to transforming primary care to serve patients with complex needs. These barriers include 1) The current payment mechanisms for primary care; 2) Assuring clinical competence; 3) Managing the urgent and acute concerns (this may distract from other important activities for providers like updating needs assessments in nonmedical domains, talking with family caregivers, and coordinating long-term support and community-based services; 4) Fragmented financing and administration of health and social services (this can cause confusion in determining patient eligibility for services and an agencies’ ability to interact effectively and efficiently with primary care clinicians); and 5) The special issues of smaller practices (smaller practices may have less capacity and flexibility to devote extra time to new complex need patients or to a new set of comprehensive care challenges for current patients, suggesting a need for additional resources and expertise to effectively coordinate and integrate care for complex needs patients)
• There are 4 essential elements of care coordination for populations with complex needs:
  1) Comprehensive needs assessments – In addition to evaluation of medical diagnoses and the traditional family and social history, a comprehensive assessment should note how individuals function in their daily lives and with their family and other social supports. This assessment should also clarify the patient’s preferences regarding community participation and goals for care. The purpose of this comprehensive assessment is to identify all care needs and preferences of both the patient and the caregivers that can be used to formulate the individualized care plan. Primary care clinicians and other providers involved in the patient’s care, should periodically update this information, including when new medical problems or other changes in health or functional status arise. This will likely require a multidisciplinary team of providers
  2) Individualized care planning – Patients, their families, and the care team should jointly create an individualized care plan. Ideally, it should reflect current and long-term needs and goals for care; specify the types and frequency of all planned health, rehabilitation, and mental health treatments, medications, home care services and supports, and other services; identify who is responsible for providing each service; and flag any critical issues that trigger a need to revise the plan. In addition, the process of developing the care plan should involve the individual and family members to ensure that it reflects their values and preferences. Additionally all members of the care team, including the patient, should have easy access to the plan. To develop an adequate care plan, the medical home for these patients would need to devote the time and expertise to include family caregiving, reflecting cultural issues and family dynamics at play for each patient. Furthermore, a realistic care plan for complex-needs patients should reflect the physical setting of the patient’s home as well as that individual’s ability to access needed services
  3) Facilitating access to needed services – Care coordination requires attention to a broader set of services than is typically offered by most PCPs (e.g., motorized wheelchairs). Thus, someone must arrange and facilitate receipt of these services. This is especially difficult for small practices with fewer resources and flexibility for increased coordination. Additionally, patients with very complex are more likely to have frequent life-threatening complications, expanding the necessary range of services
  4) Regular communication and monitoring – Effective care coordination can be accomplished only through regular monitoring of the patient’s health status, needs, and services, and through frequent communication and the free exchange of information. It often requires multiple modes of communication (in person, by phone, or in writing) and increasingly depends on the effective use of electronic tools (e.g., remote physiologic monitoring, networked electronic health records (EHRs), patient education modules, and informed decision-making tools). While the frequency of communication depends on a variety of factors, it must occur at several levels: 1) Between healthcare professionals and patients and their families to ensure they understand the care plan and their responsibility for self care, and any help, such as respite care, that is available; 2) Within teams of health and social service professionals; and 3) Across the entire care spectrum, particularly when individuals transfer between care settings. Timing is important as well and communication must include the information that each team member must know in order to provide care that is congruent with a patient’s preferences. Another key element involves monitoring and support for patient adherence to therapy and other elements of self care
• The report uses 5 examples to present the multiple approaches to care management. The 5 programs are sponsored by different types of organizations: 1) Community Care of North Carolina – a nonprofit, physician-led practice support organization with regional branches; 2) Minnesota healthcare Homes – a state health or Medicaid agency; 3) Summa Health System in Ohio – a large integrated health system and their Center for Senior Health, a geriatrics program that provides many services and program to frail elderly patients; 4) Commonwealth Care Alliance – a nonprofit health plan; and 5) Community Health Partnership in Wisconsin – a nonprofit health plan. All 5 serve patients who are disabled and have multiple chronic conditions and/or behavioral health program. 3 of the 5 programs serve people who are dual eligible. The other 2 programs—Minnesota healthcare Homes and Summa Health System—serve people with any type of health insurance, and finance program operations and pay physicians for care coordination using either State funds and payments by all health plans (as in Minnesota), or State Medicaid and grant funds (as Summa Health System does)
• The identified approaches to care coordination and case management are as follows:
  1) Case manager arrangements – In all 5 programs, a variety of professionals with different types and levels of training serve as care coordinators or case managers, including physicians, advanced practice nurses, registered nurses, licensed mental health counselors, and social workers. Many programs also use nonprofessional community health workers in case management teams. 3 of the 5 programs—Commonwealth Care Alliance (CCA) in Massachusetts, Community Care Q100of North Carolina (CCNC), and Community Health Partnership (CHP) of Wisconsin—provide or
  contract for case management staff to work in or with PCPs to coordinate care for patients
  2) Case management resource and caseloads – There is significant variation in how case managers are shared with PCPs across and within each program, and in average case manager caseloads. For example, primary care nurse practitioners or nurse case managers in the CCA program typically have caseloads of 40 to 65 patients, a smaller ratio than the others, because most patients in its Senior Care Options (SCO) program are dually eligible for Medicare and Medicaid, as well as nursing home eligible, so their health and social support needs are relatively high. By contrast, North Carolina Community Care Network case managers have much higher caseloads (one to 4,000)
  3) Allocation of case managers to PCPs – The number of case managers and whether they are shared among several PCPs or dedicated to just one PCP depends on the size of the practice, and the number of complex patients in the PCP panel. For example, CCA develops a staffing plan based on assessment of the patient mix, including the number of nursing-home-certifiable patients, ambulatory patients, and other characteristics
  4) Teams – Case managers in all 5 programs strive to work with at least some local PCP leadership and staff in teams to share all relevant information about patient needs, preferences, and circumstances when developing care plans. Several program leaders said they judge the success of their case managers or care coordinators by the degree to which they are accepted and integrated into the PCP. For example, CCA creates multidisciplinary teams, using its own clinical staff and that of the PCP to perform comprehensive health and social assessments, provide enhanced primary care, and develop individualized care plans. For patients who are eligible for nursing home care, a nurse practitioner often heads the team and has responsibility for first response and home visits
• However, several programs noted the challenges of bringing disparate providers together. For example, in Minnesota, community agencies that have long been providing case management to older adults and people with disabilities expressed concern that if the primary care practices participating in HCH are paid for care coordination, the community agencies will lose the funding they receive to coordinate care for these individuals
• Other support to PCPs in managing care for complex populations is also an important consideration. The range of additional supports to PCPs included 24/7 call lines for patients to complement or substitute for the practice’s after-hours coverage; recommendations on (or provision of) EHR systems, Web-based health information technology (IT) registries, and referral tracking systems; and support in review and analysis of service utilization and quality indicators for the PCP patient panel.
  Some also facilitated ready access to geriatrics or mental health consultation. In exchange for these supports, most programs have corresponding requirements for participating PCPs, such as expectations regarding PCMH certification, health IT infrastructure, and participation in quality reviews. More specifically, the following were identified as common supports:
  1) EHRs/health IT – EHRs and other health IT are important tools for case management and care coordination. They enable teams to record and share information on many different aspects of patient needs and service use including: 1) Results from needs assessments for different domains (health, medications, home environment, social support, and family caregiver); 2) Referrals and results from lab and radiologic tests, specialty consults, and home health and other community-based care; 3) Real-time monitoring of such critical events as hospital admissions and ER visits that trigger a need for follow-up; 4) Prompts and reminders regarding visits and preventive care; 5) Decision-support tools for complex patient care, such as clinical care paths and guidelines; and 6) Community resources lists. Though each of the 5 programs report that they and their providers use EHRs, three programs (CCA, Minnesota HCH, and CCNC) require PCPs to use an EHR system that feeds information to the overarching program as a term of participation. The other programs reported that their providers and care coordinators used separate electronic systems but consider information-sharing an essential part of each program
  2) Quality measurement and improvement – All of the programs emphasize quality improvement, and many use the EHR and data capabilities described above to report cost, quality, and utilization outcome measures to PCPs, program management, and patients. Although there is some variation in certification standards, 3 of the 5 programs use National Committee for Quality Assurance (NCQA) or State-specific NCQA-like standards to determine whether practices are using PCMH processes. 3 of the programs sponsored team-based quality improvement through peer-to-peer learning and in person meetings, though their breadth and intensity varies
• Payment to PCPs for care coordination can take many approaches. In most cases, programs serving patients with complex needs pay physicians to participate in care coordination activities. Payment approaches used in the 5 programs include pay per member per month and risk-adjusted capitation rates
• Important lessons learned for providing care coordination support to PCPs include:
  1) Clinician and practice engagement – Many program representatives stressed the importance of directly engaging the primary care professionals and office staff in the practice, and providing sufficient flexibility to allow clinic teams to design the care coordination approach that works best for them. Both PCP engagement and flexibility appear to be critical for providing initial motivation to contemplate participating, as well as subsequent commitment to implement, care coordination programs
  2) Clinician leadership – It is so important that CCA sometimes asks the practice to identify a clinical “champion” and then reimburses the practice for that person’s time to develop the program. It might be more productive, at least initially, to target programs for complex populations to primary care practices that are already PCMHs, trying to meet PCMH standards, or otherwise have physician leaders actively engaged in PCP transformation
  3) Direct payment to PCPs – 3 of the programs make payments directly to the practice. A fourth program found that its payment method, which asked practices to bill for program services on a FFS basis, were administratively burdensome because it required too much work to adapt standard clinic billing systems. The fifth program found that providing access to external case managers to assist with these complex-needs patients was enough to achieve physician engagement, but only after offering a one-time fee that opened the door. Thus, the way payment to PCPs is structured must take into account the way practices currently bill, and whether changes are acceptable and feasible
  4) Practice size and share of complex-needs patients in total practice panel – There are different views on whether a certain threshold of complex patients in the practice is needed to make it feasible for PCPs to participate in these types of programs. From the practice support perspective, a minimum number of complex patients in the practice may be necessary to justify the investment of time in a given practice. The CCA, for example, says a critical mass of around 100 to 150 complex patients must be in the practice panel to make it worthwhile for CCA to invest its “wrap-around” services, such as intensive primary care enhancement clinical services and case management support
  5) Rural practices – In the North Carolina program, case managers are responsible for serving patients across several practices, but they say that their job is more challenging in rural communities, because of shortages of other health and social service providers, and also when they have to cover a greater geographical area
  6) Community partners in primary care – Large health systems that already engage or own smaller PCPs and have experience providing community-based care to complex-needs patients may be more equipped to provide the support required. Partners for small PCPs may also be found among community-based organizations with experience and expertise serving complex-needs populations, such as Area Agencies on Aging, independent living centers, and hospice agencies
• Policies and strategies to surmount barriers to serving complex-needs patients in small PCPs are as follows:
  1) PCP payment reform – Fundamental changes in the payment model are likely needed beyond the current per member per month care coordination fees and other payments. PCMH payment strategies must address the substantial additional costs related to currently uncompensated activities involved in coordinating the care of patients with complex needs to ensure this model will successfully serve them
  2) Augmenting clinical competence – Resources like employing advanced practice nurses with specialized expertise to conduct in-home assessments, and employing teams that offer geriatric consultation to PCPs are helpful
  3) Systematic quality improvement – There are much untapped potential within quality improvement, including integrated clinical information, computerized reminders, and other computer-based clinical decision support
  4) Extra resources to manage acute/urgent care – These include after-hours coverage, providing 24/7 call service staffed by program nurses, and home assessments
  5) Care coordination – Provision of services and resources that extend outside of the “medical neighborhood” (e.g., home visit)
• Research moving forward may want to consider among of payment to PCPs, impact of multi-payer strategies, organizational models and features, and professional competencies required by populations, practices and programs