Tailoring Complex-Care Management, Coordination, and Integration for High-Need, High-Cost Patients

Blumenthal D, Anderson G, Burke S, Fulmer T, Jham A, Long P
Publication Year: 2016
Patient Need Addressed: Care Coordination/Management, Chronic Conditions
Population Focus: Complex care
Intervention Type: Service redesign
Type of Literature: Grey

The increasingly complex healthcare needs of the US population require a new vision and a new paradigm for the organization, financing, and delivery of healthcare services. Some 5% of adults (12 million people) have three or more chronic conditions and a functional limitation that makes it hard for them to perform basic daily tasks, such as feeding themselves or talking on the phone. This group, “high-need, high-cost” (HNHC) people, makes up our nation’s sickest and most complex patient population. HNHC adults are a heterogeneous population that consists of adults who are under 65 years old and disabled, those who have advanced illnesses, the frail elderly, and people who have multiple chronic conditions.

Insights Results

Overview of article

  • This article explores key issues, spending implications and existing barriers to meeting the needs of high-need high-cost (HNHC) patients and suggest policy options for a new federal administration to improve complex care management, care coordination, and integration of services for this population. Health-systems leaders, payers, and providers will need to look beyond the regular slate of medical services to coordinate, integrate, and effectively manage care for behavioral-health conditions and social-service needs for functional impairments to improve outcomes and lower spending

Key takeaways/implications

  • A critical first step to match interventions to patients’ needs is population segmentation, dividing patients into groups that have common needs so that specific complex care-management interventions can be targeted to the people who are most likely to benefit (e.g., Denver Health stratifies all patients according to risk by using a combination of risk-prediction software, medication data, functional status and clinical indicators to identify patients who may need the help of nurse care managers, patients navigators, or clinical pharmacists). Accordingly, higher-need patients receive more follow care following appointments and more social and behavioral health support. However, there are challenges with population segmentation such as cost of development, and inherent tension between integration and specialization or services
  • Improvement in the HNHC population has been difficult at times, however, there are models that target the patients and get favorable results in their ability to reduce unnecessary hospital use or reduce costs of care. After examining successful models, common features emerged and include: 1) Closely targeting patients who are most likely to benefit from the intervention; 2) Use of specially trained care managers who facilitate coordination and communication between patient and care team; 3) Effective interdisciplinary teamwork; and 4) Ability to manage patients in multiple settings
  • Challenges to spread and scale these interventions include: 1) Misalignment of financial incentives, especially for payers and providers; 2) Professional uncertainty and lack of training and skill to take on new roles; 3) Lack of interoperability for EHR systems, potentially impeding integration and coordination throughout the care continuum; and 4) Lack of rigorous evidence from multisite interventions, potentially making it difficult to determine the generalizability and sustainability of different models or program features in multiple contexts. A shared evaluation framework or common set of outcome measures could help to accelerate testing in both the private and public sectors, which is an important strategy for building a robust evidence base
  • There are 7 recommended directions that could improve complex care management for people who are at risk of poor outcomes and unnecessary use of healthcare and high expenditures for it: 1) Promote value-based payment: This payment approach incentives provides to focus on quality of care and efficiency of services for their patient population without worrying about volume to increase revenue; 2) Improve the design and implementation of value-based payment: There is a need for greater alignment between value based payments to risk-bearing organizations and value based payments to individual providers that are part of those organizations. If the individual providers or practice sites do not feel the shift toward accountability, population health, and value, the diffusion of promising practices or models of care will be slow. Additionally, Medicare and Medicaid could work more closely with private provider organizations to achieve greater symmetry between organizational and provider payment approaches. Additionally, value-based payments to providers must account for the different risks that HNHC patients bring to their care and appropriately pay the entities that accept the risks. Another concern is the misalignment between investment and savings. Supplemental payments to providers to support transformational and capital expenditures could help to defray the cost and speed of adoption or a partial capitated fee to the site that offers the care management program could cover part of the investment of the transition to value-base conception. Finally, the discrepancy between payment and savings has serious consequences for dual-eligible patients and must be considered; 3) Increase flexibility of accountable providers to pay for nonmedical services (e.g., home meal delivery); 4) Provide intensive technical assistance to providers regarding care for HNHC patients; 5) Give high priority to health-information exchange. This is critical for screening and identifying eligible patients. It’s also important for enabling patients, caregivers and providers in different settings and sectors to share behavioral, social, and medical information about patients to improve care management; 6) Continue active experimentation and support the spread and scale of evidence-based practices. For this recommendation, stakeholders need a consensus on the criteria that should be met to declare a model “evidence based” or successful. Then, payers and delivery-system leaders need to understand how core metrics can be applied to improve care delivery and health outcomes; and 7) Healthcare practitioners need more support to learn how to translate the successful features of evidence-based models and the administration. Congress should continue to support CMMI and PCORI and their directions to test the effectiveness of care approaches for HNHC patients and should continue to encourage private-sector engagement
  • The Program of All-Inclusive Care for the Elderly (PACE) is an example of a successful care-management model for HNHC adults. The model targets adults age 55 years and older with insurance through Medicare or Medicaid, with chronic conditions and functional or cognitive impairments, and living in the service area of a local PACE organization. Patients must be certified by Medicaid as eligible for nursing-home level of care and be able to live safely at home with help from PACE. Each PACE site provides comprehensive preventive, primary, acute, and long-term care and social services, including adult day care, meals, and transportation, to allow patients to live independently in the community. An interdisciplinary team meets regularly to design individualized care plans; clinical staff are employed or contracted by the local PACE organization, which is paid on a per-capita basis and not on the basis of volume of services provided. PACE enrollees experienced fewer hospitalizations but more nursing home admissions, better quality of some aspects of care (such as pain management), and lower mortality than comparison groups. PACE appeared cost-neutral with respect to Medicare and may have increased costs for Medicaid although more research is needed to reflect current payment arrangements. A later study found that PACE may be more effective than home- and community-based waiver programs in reducing long-term nursing-home use. Higher self-rated PACE team performance and other program characteristics were associated with better enrollee functional health outcomes
  • Another example of a successful care-management model for HNHC adults is the Naylor Transitional Care model, which targets hospitalized, high-risk older adults with chronic conditions. With this model, a multidisciplinary provider team led by advanced practice nurses engages in comprehensive discharge planning, including 3-month post discharge follow ups with frequent home visits and telephone calls. The program involves patients and family members in identifying goals and building self-management skills. A randomized controlled trial found the following 1 year after discharge: 36% fewer readmissions; 38% reduction in total costs; and short-term improvements in overall quality of life and patient satisfaction