DisclaimersThis document is in the public domain and may be used and reprinted without permission except those copyrighted materials that are clearly noted in the document. Further reproduction of those copyrighted materials is prohibited without the specific permission of copyright holders.None of the investigators has any affiliation or financial involvement that conflicts with the material presented in this report. Suggested CitationRich E, Lipson D, Libersky J, Parchman M. Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions. White Paper (Prepared by Mathematica Policy Research under Contract No. AHRQ Publication No. 12-0010-EF.Rockville, MD: Agency for Healthcare Research and Quality.
January 2012.AcknowledgmentsWe would like to thank the following members of the expert panel for their helpful perspectives and insights in the preparation of this white paper: Richard Baron, MD (CMS Seamless Care Models Group, affiliated with Greenhouse Internists at the beginning of the project); Michael Barr, MD (American College of Physicians); Tom Bodenheimer, MD (University of California at San Francisco); Christine Cassel, MD (American Board of Internal Medicine); Lisa Iezzoni, MD (Harvard Medical School, Mongan Institute for Health Policy at Massachusetts General Hospital); K. Charlie Lakin, PhD(University of Minnesota Rehabilitation Research and Training Center on Community Living); Walter Leutz, PhD (Brandeis University); R.“A lot of things I think I can handle myself, but we patients are not medical people and we don’t know the terminology that the doctors use,” said a 71-year-old man.“Sometimes, I have to spend all day on the phone to my doctor, even to get an appointment,” said an 81-year-old woman.“They don’t assist on the transition from the hospital back to home.
You have to be tough; be an advocate I’d like somebody to tell me what’s available. I don’t know,” said an 82-year-old man caring for his wife, who has terminal cancer and dementia.Quotes are from focus groups with patients and caregivers (AARP 2009).The frustration of patients is evident (see Figure 1), and the burden placed on their families is large. Even professionals with expertise in health care delivery and long-term care find it hard to navigate across the two systems.
For example, Drs. Rosalie and Robert Kane prominent long-term-care experts, describe the way the current health care system often causes confusion among their patients, contributes to misunderstanding of patients’ inter-related conditions, and subverts patient privacy and quality of life (Gross, 2005).
Despite their own considerable expertise, the two doctors found it difficult to arrange reliable home care for their own family members who were frail or disabled. Robert transition Kane: “It's technically complex, emotionally taxing, there's not much help out there, and panic is the normal reaction.
If Rosalie and I can't do it, what chance does the average person have?” David Lawrence, the former CEO of Kaiser Permanente, described his mother’s care after she fell as a “pick-up soccer game in which the participants were playing together for the first time, didn’t know each other’s names, and wore earmuffs so they couldn’t hear one another” (Lawrence, 2003). The disjointed, myopic care Dr. Lawrence’s mother received stalled her recovery and taxed—emotionally and physically—the patient and the family.
Unfortunately, these experiences are all too common. Through searches of published and “grey” literature, recommendations from a technical expert panel (selected for their expertise in medical home policy, aging and disability services, end-of-life care, financing, small practice environments, and advocacy on behalf of people with disabilities), and conference presentations, we identified more than 20 promising programs serving complex-needs patients. “A lot of the services that case managers connect patients to are low technology solutions that have a high payoff. For example, we had an asthma patient who kept coming back to the emergency room, and it turned out that she had a problem getting transportation to the pharmacy to fill her medications. The case manager helped her work out a way to get her medications so that she didn’t end up in the ER.”—Dr. Robert Rich, Cape Fear Valley Medical Center(a CCNC provider) Allocation of Case Managers to PCPsWhen deciding how to allocate case management staff and what types of professionals to engage with the PCPs, program leaders almost universally stressed the importance of flexibility in matching staff and resources to the needs and culture of each PCP.
Hence, 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, the types and roles of staff already employed in the practice, and the number of complex patients in the PCP panel (see Table 2). 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. In North Carolina, regional Coordinated Care Networks stratify the practices’ patients based on prior health care use patterns and patient-level data to identify those who need the most supports. Some practices have such a large number of complex-needs patients who require intensive case management services that the regional network assigns one or more case managers directly to the practice.Teams. Case managers in all five 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. In this way, nurse practitioners extend the primary care team, providing “enhanced” primary care outside of the clinic setting. CCA also has team members specializing in geriatric social work, behavioral health care, and palliative care available for consultation. According to one CCA staff member, “We consider our program successful when everyone at the practice views our external team members as internal to the practice.
We employ and deploy resources, but it requires leadership from the practice and CCA program directors to ensure the CCA team is integrated into the practice.”A physician leader of one PCP in North Carolina said, “The case managers are physically in our practice, sitting down the hall, and available to answer questions. They interact with the physicians and with the network staff and practice consultants to jointly determine what support or services are needed to lower inappropriate utilization.” One of the regional networks in CCNC added, “We want our care managers embedded in practices.
We want the care management staff integrated into the team so that care managers are seen as an extension of the health care team. We push for full integration so that care managers can gain ready access to patient records and provide real-time consultations.”The team-building process is not without tensions, however, and 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. A program official said they deal with this concern by “trying to reassure and remind everyone that the goal is to move care coordination closer to the patient and the doctor.” CHP in Wisconsin described variable relationships with the several large health systems managing practices in their region.
They noted these systems “ shouldn’t reinvent the wheel. They should go out and see if there are existing programs like ours that they might engage with and work with existing partners who are already working to tackle the problem.” Other Support to PCPs in Managing Care for Complex PopulationsIn addition to providing case management staff, four of the five programs dedicated considerable resources to support practices by helping them reorganize workflow and systems, conducting home assessments, and providing tools to enhance PCP capacity to assure continuous access and ensure care coordination. 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. The Minnesota Department of Health makes small grants (up to $5,000) available to small practices to help them meet the State’s HCH standards; clinics have used the funds for registries, care planning, and patient-engagement initiatives, among other things.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. EHRs/Health ITEHRs and other health IT are important tools for case management and care coordination.
Some comprehensive, integrated care models for patients with complex needs rely on a closed panel of health professionals. For example, the Program for All-Inclusive Care for the Elderly (PACE) is a fully integrated care program operating in 29 States.
Each PACE program receives capitated Medicare and Medicaid payments to provide and coordinate health and long-term care services and supports to frail older adults. Several studies show that PACE programs maintain or even improve health and functioning at lower costs, while increasing patient and family satisfaction (National PACE Association, 2010; Beauchamp, Cheh, Schmitz, et al., 2008). However, the program may be better suited to people who do not already have a primary care clinician or do not want to continue with one. There are also local requirements, including patient volume, that affect the feasibility of PACE programs for small communities and rural settings. In addition, PACE programs have not to date focused on meeting the needs of working-age adults with disabilities.Federally Qualified Health Centers (FQHCs) participating in the Centers for Medicare and Medicaid Services’ (CMS’s) Advanced Primary Care Practice demonstration offer another potential model. Over the3-year demonstration, CMS will pay a $6 PMPM care management fee in addition to its regular payments to help the FQHC cover the cost of transforming into a patient-centered medical home, as defined by National Committee for Quality Assurance (NCQA) Level 3 standards. The demonstration will encourage FQHCs to implement electronic health records, help patients manage chronic conditions, and actively coordinate care for patients (CMS FQHC Demonstration Factsheet, 2011).
While FQHCs are uniquely positioned to serve as safety net providers for many patients with complex needs, the demonstration pays only for each eligible Medicare beneficiary attributed to the practice and does not directly support care for working-age patients. As with the PACE model, relying on this approach to address the range of needs for most complex-needs patients would require expansion of the programs into communities and neighborhoods not currently served, and would require patients to switch to a different source of primary care.Programs that specialize in comprehensive care of adults with specific types of disabilities represent a different model. For example, some programs have been developed to manage and coordinate the health, mental health, and social services needed by people with severe and persistent mental illness. Similarly, medical home models have been proposed for patients with specific conditions, ranging from heart failure to cancer (Heart Failure Society of America, 2010; Community Oncology Alliance, 2011). However, each of these specialized medical homes for patients with complex needs would need to develop all the previously described capabilities and competencies for accessible, coordinated, comprehensive care of the broad array of their patients’ medical and social service needs. And they would need to have robust capabilities for managing multiple conditions or adjudicate transfers from one specialized medical home to another as new conditions arose or previous difficulties flared.
Even if all of these problems could be resolved, assuring 24/7 access to competent, specialized medical homes for complex-needs patients in communities throughout the U.S. Is not likely to be feasible.
CONCLUSION AND THE PATH FORWARDTo achieve the promise of improved quality and reduced costs through primary care delivery by the PCMH, primary care clinicians and policymakers must take concerted steps to ensure that the model can address the needs of patients with complex health needs. Indeed, it is these patients—people with multiple conditions and functional impairments using greater amounts and variety of health services in many settings and requiring long-term services and supports from community organizations—for whom the PCMH may have the greatest benefits.But to serve these challenging populations well, most small PCPs will need help in overcoming several substantial barriers.
It is unrealistic to expect small PCPs already stretched for time and resources to address these barriers on their own. Compensation for the extra effort involved in caring for patients with complex needs is clearly important. However, even if these practices were given sizable additional payments for care of complex-needs patients, external expertise and ongoing community partnerships would likely be required to provide high-quality primary care.The programs highlighted in this paper demonstrate that there are several organizational approaches to helping smaller PCPs surmount the barriers; these include providing staff, special expertise, and other resources to support primary care clinicians serving these populations. While their experiences offer insights regarding promising solutions and options, important differences exist in their program structure and operations. Thus, several areas remain for research on the most effective organizational and policy approaches for creating the needed partnerships between small PCPs and other community resources to serve complex-needs patients. Policies and Strategies to Surmount Barriers to Serving Complex-Needs Patients in Small PCPs.
“We can’t serve people who don’t qualify for Medicaid (right now), but we can illustrate what effective care looks like when funding for all health and social services is combined into one payment that programs can use flexibly to meet each patient’s needs.”—Bob Master, Commonwealth Care AlliancePCP Payment ReformsPCPs need compensation to offset their additional costs related to the care of complex-needs patients. Among the programs reviewed, CCA appears to pay the greatest amount, by paying a capitated rate for primary care services and sharing with PCPs a portion of savings for lower-than-expected utilization of costly health services. While several other programs have offered practices PMPM care coordination fees, they may not cover all the extra costs to the practice for care of complex-needs patients.
Furthermore, private health insurers may be reluctant to pay primary care clinicians a separate fee to coordinate HCBS not covered by the individuals’ health plan benefit. Federal rules governing Medicare Advantage managed care plans also limit payment for coordination of non covered social support services. Most leaders of the programs examined in this paper believe their organizational approaches to supporting primary care of complex patients can succeed only with a fundamental change in payment model. One said, “We can’t bring value without global payment.” Another program representative similarly said, “The care coordination function needs to be included in the patient’s total care bill.” Whether provided through capitation or modified FFS, 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.
Augmenting Clinical CompetenceThe programs featured in this paper illustrate some different ways to support clinicians in PCPs who provide high quality clinical care to complex-needs patients. CCA and Summa Health System employ teams that offer geriatric consultation to PCPs. Several programs include mental health and other disability-specific clinicians to work in consultation with primary care clinicians. Most also employ advanced practice nurses with specialized expertise to conduct in-home assessments and relay the results to primary care clinicians to facilitate clinical decision making.Other types of resources could also augment primary care clinicians’ competence in managing the care of complex-needs patients. In some cases, the primary care clinician for the complex-needs patient could efficiently provide care that meets high clinical standards if he or she had the time to obtain the additional information relevant to the patient’s problem. In many other cases, with the right supporting resources (computer-based decision-support tools or ready access to telephone or video consultation, for example), the primary care clinician could address the problem without specialized referral.
Unfortunately, in the current specialist-dominated, FFS-oriented health care system, there is not sufficient motivation for specialists to provide timely telephone advice to the primary care clinicians, much less to develop and implement more sophisticated consultative support technologies (or the incentives for primary care clinicians to use them). Some clinical or social support problems for complex-needs patients require so much advanced knowledge and skill that it will be more efficient to have that problem addressed by a specialized team member in the “medical neighborhood.” Several programs described in this paper have developed mechanisms to support PCPs in this way, through ready access to either nurse practitioners or physicians with relevant specialized expertise. Systematic Quality ImprovementMany small PCPs do not see a sufficient number of complex-needs patients to be able to discern internal opportunities for care improvement or to reliably compare the outcomes of their patients with those in other practices.
However, the programs described here show that there are other ways to engage local primary care clinicians in systematic, population-based quality improvement efforts. North Carolina Community Care Networks involve physicians in regional quality improvement initiatives, based in part on their historical affiliations with Area Health Education Centers. Minnesota and Summa Health System sponsor peer-to-peer learning sessions that bring together primary care clinicians, care coordinators, community agencies, and other players to work toward a common goal of improving the care process. However, much untapped potential remains; most of the programs cannot interface directly with local PCPs’ EHRs. Furthermore, since they do not support cross-provider EHRs, they cannot provide integrated clinical information, computerized reminders, or other computer-based clinical decision support to facilitate quality improvement for the care of complex-needs patients. Extra Resources to Manage the “Tyranny of the Urgent”The programs described here also provide some tangible resources to help primary care clinicians manage the urgent concerns of complex-needs patients.
Several programs augment after-hours coverage, providing24/7 call service staffed by program nurses, sometimes with access to program patient records to facilitate effective triage over the telephone. For nonemergency problems, some program staff may provide in-home assessments as well. This support is not always tightly integrated with the existing practices’ urgent care or after-hours services, however. And support for clinical assessment in the patient’s home for urgent medical problems is not routine. In addition, these systems do not address the high level of competing demands generated by complex patients during the office visit for an acute care problem. Care CoordinationManaging the care of patients with complex needs requires substantially more time and care coordination resources than more typical patients with chronic conditions. This is a tall order for most small practices, even those that meet the basic requirements for a medical home.
Even with a fully integrated clinical information system organizing complex patient information across the “medical neighborhood,” the current financing environment would have to change dramatically for small PCPs to afford to “go outside their walls” to do home visiting and comprehensive assessment with individualized care planning, or to effectively coordinate with community-based long-term care providers. Accordingly, most of the programs described in this paper provide resources that are shared across several small practices. These shared resources include specially trained advance practice nurses and social workers available to help the small PCPs assess and plan care of their complex patients.
These resources are different from the time-limited technical assistance that facilitates medical home transformation in many PCMH demonstrations (Highsmith and Berenson, 2011). The programs for complex patients share expert clinical staff (sometimes placed part-time or full-time within the practice) who conduct assessments, manage information exchange between PCPs and community agencies, and build partnerships with caregivers and social service organizations. Research to Inform More Effective Ways of Financing and Organizing Support for PCPs Serving Patients with Complex NeedsSeveral initiatives of the Affordable Care Act (ACA) promise greater funding and resources that might help small PCPs improve their capacity to deliver the full spectrum of primary care services to their patients (Figure 3). Several of these policies directly target complex-needs populations, and each of these initiatives raises some specific research questions relevant to the effectiveness of the policy in improving primary care for complex-needs patients. Furthermore, individually and collectively, these programs elicit some broader research questions as well.
Amount of Payment to PCPsMany questions remain regarding the best approach to reforming payment in ways that will strengthen and enhance primary care for complex-needs patients. In recent years, several State Medicaid programs, commercial health plans (CareFirst Blue Cross and Blue Shield of Maryland, for example) and other private payers, as well as the Medicare program, have launched initiatives to promote and reward practices(through extra payment to primary care clinicians) that adopt PCMH standards.
Clearly, effective care of complex-needs populations requires primary care practices to devote more professional time and other resources to them than to their less complicated patients. While the care coordination payments offered in programs discussed are relatively modest ($5 per month in one program), previous estimates by the Centers for Medicare & Medicaid Services (CMS) suggest much higher reimbursement may be needed to support medical home services for even moderately complex Medicare beneficiaries. One analysis estimated more than $100 per beneficiary per month for medical home services for Medicare patients with greater disease burden and higher predicted future costs to Medicare (those with a hierarchical condition categories HCC score greater than or equal to 1.6 25 percent of beneficiaries) (Maxfield, Peikes, Shapiro et al., 2008). It was beyond the scope of this paper to determine how each example program targets complex patients for varying levels of care coordination and enhanced services. Also, it remains unclear how much payment is required to compensate PCMHs for the extra time and resources required to provide high-quality, appropriate care to patients with complex and varying needs, so these are critical research questions. “The more we can get multiple payers to the table, the better. It’ll be easier for practices to bill and sustain their care coordination efforts if all payers are paying for them.
Practices find it hard to dedicate case management resources when Medicare only allows billing for certain types of codes, Medicaid has different codes, and private insurers don’t even cover case management services.”—Chris Collins, Community Care of North Carolina Organizational Models and FeaturesAs discussed, a variety of organizational arrangements and sponsors exist for providing the infrastructure to support care coordination for patients with complex needs. These include health plans (both nonprofit and for-profit), State health departments and Medicaid agencies, regional integrated health systems, and regional physician-led networks of care coordinators. Other possibilities include Accountable Care Organizations and other community-based organizations, like Area Agencies on Aging or hospice agencies.In view of the current diversity of organizational approaches, many questions arise regarding which arrangements will prove most effective and efficient in helping PCPs serve patients with complex needs. This research may need to take into consideration such characteristics as PCP size and focus, number of complex-needs patients in the practice panel, rural versus urban practice location, and current configuration of community resources. Research could compare care coordination characteristics, including the setting (health plan versus community organization, for example), approaches to comprehensive assessment and care planning (establishing when home visits are essential), intensity of care coordination, degree of care coordinator integration into the PCP, and different ways of engaging PCPs in team-based care.
Several more subjective program features appear to be important as well, such as practice engagement, primary care clinician leadership and motivation, and program flexibility and collaboration. To be of practical use to payers interested in developing these models, and to providers seeking to replicate them, studies also should examine program structure and operations in detail, and determine what components are essential to their success and which can be adapted in response to different circumstances (Au, Simon, Chen et al., 2011). There is also an opportunity to develop appropriate and feasible performance metrics for decision makers. Finally, research is needed on approaches that are critical to the successful implementation of these strategies across a diversity of primary care practice types and locations. Professional Competencies Required by Populations, Practices, and ProgramsPrimary care clinicians vary considerably in their original clinical training relevant to the care of complex-needs populations, as well as the competencies they have acquired through the ongoing care of patients prevalent in their practices. Furthermore, different programs currently employ different types of clinical experts and could deploy into PCPs various combinations of onsite and remote human and computer-based resources. Academic health centers could have their own special role to play, providing regional resources to support primary care-based management of specific complex conditions (Arora, Thornton, Murata et al., 2011).
Thus, for any given mix of complex-needs patients in a community, a variety of approaches may be available to provide clinicians the knowledge and skills required to optimize primary care. While it is clear that a team of professionals with a broad range of skills is needed to efficiently and effectively provide primary care for patients with complex needs, a host of research questions remain regarding the optimal training of the relevant professionals, both in their individual disciplines and ineffective collaboration in medical home teams. Other research questions relate to the proper deployment and support of these distinct professions, both in the practice and in the community, to achieve integrated are. SummaryPatients with complex health care needs may represent the greatest challenge to transforming existing primary care practices into high-functioning medical homes, and they also represent one of the greatest opportunities for this transformation to make a dramatic impact on cost and quality. There are a variety of promising strategies to help PCPs serve these populations through a supportive medical neighborhood knitting together social services and supports with specialized expertise in relevant areas, such as mental health, disability, and geriatrics. These approaches provide skilled care coordinators as a shared resource and often also compensate the primary care clinicians for their time spent “in-between the progress notes.” Integrated clinical information systems, clinical decision support, and additional resources to support enhanced access (including home visits) are often part of these as well. Health care payment and delivery reforms hold the potential to expand these strategies to PCPs in communities across the United States, but concerted effort and attention is needed to ensure they do not leave the most vulnerable and challenging patients behind.
Additional research would help to clarify the optimal strategies and policies to ensure that high quality primary care services are more widely available to these patients.
Pace Program Boston Ma
The Controlled substance Utilization Review and Evaluation System (CURES) was certified for statewide use by the Department of Justice on April 2, 2018. Therefore, the mandate to consult CURES prior to prescribing, ordering, administering, or furnishing a Schedule II-IV controlled substance became effective October 2, 2018.CURES contains the following information: patient name, patient date of birth, patient address, prescriber name, prescriber DEA number, pharmacy name, pharmacy license number, date prescription was dispensed, prescription number, drug name, drug quantity and strength, and number of refills remaining.