November 2017
Learning Update: Improving Healthcare for High-Need Patients

Key Attributes

• This population is defined as those under 65 years with end-stage renal disease or a disability based on Supplemental Security Income eligibility.
• Dually eligible beneficiaries in this category may have an intellectual disability, serious mental illness, or be physically disabled but otherwise healthy.
• Overall, this group spends the most on Medicare Part D medication.

Promising Approaches to Care

• Successful interventions include multidisciplinary care teams and the coordination of clinical services, behavioral health and social services.
  • One Care, a program created by Commonwealth Care Alliance, targets dually eligible individuals under 65. The intervention includes an emphasis on multidisciplinary care teams, individualized care plans, behavioral health integration, and enhanced care team availability. Commonwealth Care Alliance describes one study which found that after 12 months of enrollment, a subset of One Care enrollees had 7.5 percent fewer hospital admissions and 6.4 percent fewer emergency room visits.
  • The Homeless Patient Aligned Care Team (H-PACT) targets homeless, non-elderly veterans regularly coming to the emergency department with medical and social needs. The intervention includes multidisciplinary care teams and emphasizes mental health and social worker staff to develop individual care plans that address housing needs. Since the program launched in 2015, emergency department use and hospitalizations decreased by 25 percent.

More Than a Patient

Sarah is a 26-year-old woman who was recently involved in a car accident that left her paralyzed from the waist down. She was having a lot of trouble not only adjusting to her new reality, but also navigating all of her new healthcare needs. Sarah had been a regular runner before the accident, and she had always been in good health, so she was largely unfamiliar with the ins and outs of doctors’ offices.

She turned to Nora for advice because it seemed as if this family friend was always either coming from or going to one doctor or another. Nora was in her mid-sixties and had been living with diabetes and heart disease for almost 20 years. Nora talked about how her nutritionist had helped her manage her diet, and how helpful she found her general practitioner. Sarah was really hoping Nora would be able to help her understand how to navigate appointments with specialists and to recommend a way to get mental healthcare that wasn’t readily covered by insurance. Even though Nora had tried to help, Sarah left their conversation feeling more confused. It was apparent that even though she and Nora each had a severe illness, their healthcare needs were incredibly different.

Key Attributes

• This population is defined as over 65 years with two or more of the following frailty indicators: gait abnormality, malnutrition, failure to thrive, cachexia, debility, difficulty walking, history of falls, muscle wasting, muscle weakness, decubitus ulcer, senility, or durable medical equipment use.
• Frailty is one of the highest indicators that a patient will require high-cost care that could otherwise be avoided.
• Overall, this group spends the most on post-acute and long-term care, with Part D spending representing only a small portion of the frail elderly’s total spending.

Promising Approaches to Care

• Interventions for this segment often emphasize shared decision-making and focus on reducing hospitalizations.
  • The MedStar Medical House Call program in Washington, DC focuses on elderly frail or disabled patients at high risk of needing hospital, emergency department, or nursing home care. The intervention supports home-based primary care and emphasizes shared decision-making. MedStar reduced Medicare spending by 30 percent for this population within the first year of the program.
  • The PACE program targets frail elderly, dually-eligible individuals with functional and/or cognitive impairments. The program supports independent senior living and includes comprehensive services such as primary care, long-term supports, and transportation. The reimbursement model utilizes per-capita fees rather than a fee-for-service system.

More Than a Patient

Raphael was glad that emergency surgery to fix a pulmonary embolism in his 80-year old mother, Gloria, had gone so well. But he was unsure of what to do afterward. Gloria had steadily advancing dementia, and she wouldn’t be able to take care of herself after surgery, which meant that wound care and other recovery duties would fall on Raphael and his wife, Maria.

When Gloria first returned home, Raphael and Maria struggled. Neither had any medical background beyond Maria’s CPR training, and they weren’t sure how to tell if Gloria’s surgery site was healing correctly. Their insurance offered to pay for a visiting home nurse, however, who came twice a day to change Gloria’s bandages and to check on her. When Gloria began to show signs of infection, the nurse recognized it before Raphael even knew something was wrong, and she was able to have it treated quickly. She also taught them about community resources—which their insurance would cover—that would help them manage Gloria’s dementia symptoms. Raphael was incredibly thankful for the care his mom received that he would not have otherwise been able to provide himself.

Major Complex Chronic

Essential Features of Promising Care Delivery Models

Despite their heterogeneity, successful high-need patient interventions and care models share common features. The sum of these features can be described simply: the right provider team delivering the right care for the right patient, employing the right data.

Beyond the necessary medical considerations, building successful interventions often requires additional services that address social determinants of health, behavioral health, and substance abuse issues. Defining success within these buckets can involve developing and monitoring outcomes with ongoing input from patients and communities. Coordinating these services and implementing the delivery features above can be daunting without the proper tools. These tools include payment models that reward value over volume, technology with advanced interoperability, and healthcare workforce training that allows providers to practice at the top of their license and emphasizes coordination between colleagues. Synchronizing these policies—at the federal, state, organizational, and payer levels—with successful practice models is also critical for expanding these approaches. Together, these approaches can help reduce implementation barriers, develop financially sustainable systems, and scale up these interventions from pilot programs to become the standard in care delivery.

From Identification to Validation and Testing

The National Academy of Medicine (NAM) special publication provides a solid foundation from which we, as a field, can engineer solutions that enable health systems and providers to deliver better care for high-need patients. The Peterson Center on Healthcare, its partners and grantees are going deeper to understand what characteristics of proven models hold the most promise for the most patients. For example, while “care coordination” is often cited as an attribute of high-quality care for patients with complex needs, it can be operationalized in many ways depending on a patient's goals, preferences and circumstances. We need to ask ourselves: coordination by whom, for whom, and in what setting?

To address some of these questions, the Center has started a multi-phase project with Stanford University’s Clinical Excellence Research Center (CERC). CERC will work with the Harvard T.H. Chan School of Public Health to analyze claims data from the dually eligible population to identify high-performing care delivery settings for the patient segments identified in the NAM special publication. Researchers will conduct site visits in primary care practices that both provide better quality of care and incur lower annual per capita healthcare spending to extract the features that are believed to drive exemplary performance. This design will allow the researchers to examine attributes of high-value care for high-need populations in the absence of strong payment incentives to improve value. From there, a change package can be prototyped to enable providers to adopt the features into their organizations and local contexts.

We also need to understand where there are gaps in our knowledge for certain patient types and bring urgency to finding care delivery innovations that fill those gaps. The Center recently announced new work with Brown University, which aims to identify features of high-performing hospital systems that provide care for high-need Medicare patients. Brown will apply a positive deviance methodology to identify top-ranking hospitals based on quality outcomes and cost as well as the care delivery features that are correlated with high-performance. As with the CERC initiative, a prototype change package can then be developed to address adoption in new contexts.

Our collaboration with four other foundations—The Commonwealth Fund, The John A. Hartford Foundation, the Robert Wood Johnson Foundation, and The SCAN Foundation—is helping us align on goals and strategies that can support knowledge transfer and uptake of promising interventions. To maximize the impact of investments in this area and avoid duplication, we are working together to coordinate execution of strategies to spread high-performance healthcare for high-need patients. These strategies include accelerating adoption of high-impact care delivery models, promoting policy and payment reforms, improving measurement and evaluation of these efforts, executing effective communication and partnering on stakeholder engagement strategies. Our first jointly-funded effort, the Better Care Playbook, was developed by the Institute for Healthcare Improvement to help healthcare organizations participating in value-based payment models adopt evidence-based interventions to improve outcomes and lower overall costs of care for high-need individuals.

Creating Fertile Ground for Change

As promising care delivery models are identified, validated and tested, investments are also needed to help create the right environment for the uptake of those models. One dimension of this environment is the policy and incentives context under which patients, families, providers, administrators and system executives operate. We’ve learned from our grantees and partners that adoption of proven care delivery models will depend on high-need individuals being able to access both clinical and non-clinical services with minimal burden. Those who are dually eligible for Medicaid and Medicare often face significant barriers to receiving integrated care because essential benefits are siloed by payers. Improving coordination of these services through an integrated benefit plan was part of a set of recommendations released by the Bipartisan Policy Center (BPC) to address the issue.

BPC also released recommendations for Medicare to create pathways for MA plans, ACOs, and other providers to better tailor care plans for high-need individuals, especially those who are managing multiple chronic illnesses and frailty. Similar to the duals, the Medicare population will increasingly rely on non-Medicare-covered social supports and, as more models demonstrate how providers coordinate this care, it will be critical for policymakers to support more appropriate benefit structures.

In May of 2017, BPC testified before the U.S. Committee on Finance on the BPC recommendations and legislation drafted by the Senate Chronic Care Working Group. Several of BPC’s recommendations were included in the Senate-passed CHRONIC Care Act of 2017. Provisions included changes to permit targeting of services for patients with chronic conditions and permitting supplemental services not otherwise covered under Medicare to be provided to patients with high-cost chronic conditions. The legislation also included provisions similar to BPC recommendations permanently authorizing Medicare Advantage dual eligible special needs plans (D-SNPS), and improved integration of Medicare and Medicaid services provided through those plans.

A second and often overlooked dimension of an environment conducive to uptake is implementation capability. Incentives need to meet execution “know-how” to take root and be sustained. The Center is engaging with organizations such as the National Center for Complex Health and Social Needs and the Institute for Healthcare Improvement, which are building hubs for innovators and newcomers alike to share in the "how" of care delivery transformation for high-need individuals. When such hubs are connected to innovative health systems, practice transformation networks and like-minded physician-leaders, it is possible to envision a “scale architecture” for accelerating adoption.

Lastly, by collaborating with The Commonwealth Fund, The John A. Hartford Foundation, the Robert Wood Johnson Foundation, and The SCAN Foundation—we’re building an evidence base of ideal conditions for change and translating these conditions into practical and actionable steps. Key elements include:

• Gaining buy-in from leadership;
• Forging effective teamwork across disciplines;
• Measuring process and outcomes with improvement in mind;
• Supporting rapid testing and iterative learning;
• Effectively using health IT;
• Training care managers who focus on relationships; and
• Using standardized processes throughout the organization.