Blog Post | March 27, 2017

Best Practices for High Risk Populations


Part One:  Best practices for high risk populations

We’re Always Learning from Colleagues…and Happy to Share: 

Written By: Terri Maxwell Ph.D., APRN Chief Clinical Officer, Turn-Key Health and Matthew Harker MPH, MBA, Associate Director, Health Policy Hub, Duke Clinical Research Institute

Last week, I was happily in sunny Orlando rather than snowy Philadelphia where I was invited to participate on a panel discussing alternative care models at the Best Practices for High Risk Populations Including Care Transitions and Palliative Innovations conference.

It was an opportunity to share information with some key industry leaders who are pioneering new programs aimed at improving the quality of care for those with advanced or serious illness. These platforms serve both Medicare and Medicaid plans that reflect a variety of approaches to managed care.

It’s exciting to witness and be part of emerging models of population health approaches to palliative care which are gaining momentum in true community resourcing and outreach. Although these vary, all are demonstrating improvements in quality and cost for those with serious and advanced illness in various markets, organizational structures, and leadership styles.

Here are some of the key themes of the conference speakers:

With the health policy debate roiling Washington DC, the conference opened with a discussion of the changing regulatory and policy landscape and its potential impact on palliative care. Chuck Lee, CEO of Cornerstone Hospice likened Federal policy to a hurricane that will drive action, for better or worse.

He underscored the need to continue moving from a fee-for-service (FFS) system to a model based upon value, however that is defined. Emerging population health approaches require new care delivery models to address the growing needs of those with chronic illness, advanced illness and those addicted to opioids.

While there was initial concern about the future viability of CMS Innovation (CMMI) with the new administration, the position has softened from early targeted budget cuts.  However, its focus will certainly go in a different direction as a new HHS Secretary and CMS Administrator will be dealing with their own priorities.

Lee also noted bipartisan support for palliative care, but despite the diffusion of inpatient palliative care, there remains a long road in building bridges across post-acute settings, including hospice. Key stakeholders such as C-TAC have submitted a focused Alternative Payment Model for PTAC consideration while NHPCO continues to work on keeping palliative care on the legislative agenda.

He noted that the discussion of the Medicare hospice benefit is included as a “carve-in” into Medicare Advantage plans continues to be a subject being considered in the Bipartisan Chronic Care Working Group of the Senate Finance Committee, along with a continued alignment of those for and those opposed.

Denise Kress, Vice President of Care Management Programs for Senior Products described Tufts Medicare Preferred comprehensive geriatric and advanced illness management programs offered through the Tufts health plan.

Case managers call each patient who went to the ED, review all readmissions to better understand the utilization drivers, and then assign actions and accountability to address these issues. Other program innovations include face time “virtual joint visits” with pharmacists, nurse practitioners (NPs), behavioral health specialists, as well as a geriatric NP consult team.

Denise also oversees a culturally sensitive Advanced Illness Management (AIM) program that follows multiple steps depending upon the member’s needs and goals of care. Tufts health plan contracts with individual palliative care providers in the community to extend the care team reach. Their model has a high degree of nurse leadership, compassionate dialogue training, and a well-outlined risk stratification program to align resources appropriately.

Torrie Fields, a Senior Program Manager for Palliative Care, described Blue Shield of California’s palliative care strategy for contracted Accountable Care Organizations (ACOs). Palliative care is a fundamental strategic component of Blue Shield of California’s ACO agreements, and home-based palliative care will be a requirement by 2020, which Torrie described as “the wave of the future”.

Their groundbreaking program offers up-front training and implementation funding to help build out the service since they are traditional services of care coordination that have not typically been reimbursed. Palliative teams are compensated with a shared savings program with a PMPM based upon staffing costs, geographic variability and claims based benchmarks.  The services are tracked as a professional care coordination fee represented by a test assigned CPT S0311 representing “comprehensive management and care coordination for advanced illness, per calendar month”.

Quality and satisfaction targets are tied to quality incentive payments and shared savings. Program evaluation is provided through funding from a PCORI 5 year grant, which we are excited to see as a formal assessment of home-based palliative care conducted through a clinical trial

Suzi Johnson and Daniel Hoefer described Sharp Healthcare’s Transitions program. This provider-led ACO home-based palliative care program is a concurrent model of care performed in partnership with the patient’s primary care providers that focus on proactive disease and psychosocial management.

Specially trained nurses and social workers follow patients using standardized evidence-based tools and resources until they are appropriate for and ready for hospice. The program has been highly successful in decreasing both hospital and non-hospital costs, creating net savings of up to $4,248 per month for those with cancer and improving utilization and length of stay in hospice regardless of diagnosis.

Part two of this post can be found here: Best Practices for High Risk Populations – Part 2

Terri Maxwell Turn Key Health CCO

Terri Maxwell, Ph.D., APRN
Chief Clinical Officer, Turn-Key Health

Matthew Harker Associate Director Health Policy Hub

Matthew Harker, MPH, MBA
Associate Director, Health Policy Hub within Health Services Research at Duke Clinical Research Institute


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