As an observer of trends in healthcare delivery, “value-based care” has represented a ubiquitous theme of the 2000s. While on-going debate exists regarding the cost savings and quality improvement actually realized by value-based care initiatives like CMS’ variety of episode-based bundled payment programs, it is clear that the value-based care conversation has resulted in an evolution in how healthcare organizations think about, and plan for, the services they provide.
“Care delivery transformation” encompasses the myriad considerations healthcare organizations have come to incorporate within any planning efforts tied to value-based care. And “Clinical Integration” continues to represent a foundational concept of care delivery transformation. In order to mature in their care delivery transformation journeys, healthcare organizations must move beyond a “check-the-box” approach to Clinical Integration. In comparing the evolution of activities traditionally associated with Clinical Integration against CMS’ 2019 update to the Medicare Conditions of Participation, it is evident that room for growth exists specifically when planning for patient transitions from one care setting to another.
Clinical Integration, Defined:
Amid the peak of HMO (Health Maintenance Organization) popularity, the Federal Trade Commission (FTC) first provided guidance on Clinical Integration in 1996 in order to allow affiliated healthcare organizations to pursue value-based performance improvement work while avoiding anti-kickback, Stark Law and similar regulatory violations. With the proliferation of Clinically Integrated Networks came increased scrutiny in fulfilling the statutory requirements necessary for healthcare organizations to coordinate efforts while remaining separate entities. For those involved in day-to-day efforts, Clinical Integration evolved from a mechanism enabling cross-organization care coordination to a specific type of legal arrangement for which compliance takes precedence.
2019 Medicare Conditions of Participation Update:
In late 2019, CMS finalized updates to the regulations governing expectations healthcare organizations must fulfill in order to receive reimbursement for care provided to Medicare beneficiaries, otherwise known as Medicare Conditions of Participation (Medicare CoP). Among other changes, a central focus of the Medicare CoP revisions involves establishing more rigorous expectations for coordination among healthcare organizations when beneficiaries transition from one care setting to another. Although interpretive guidelines remain pending, CMS’ perspective is made clear throughout the Medicare CoP update: clinical and cost outcomes will improve when proactive, transparent and data-driven communication occurs across care settings, particularly at the point of discharge planning.
While ensuring compliance with Medicare CoP is paramount to on-going operations, healthcare organizations should also recognize, and embrace, an implicit call to action posited by the updated Medicare CoP to re-position Clinical Integration in practice. In order to meaningfully progress in achievement of value-based care, the spirit of Clinical Integration must be embraced by healthcare organizations with equal weight as legal compliance (i.e. communicating with other healthcare providers makes patient care more effective). Transitions of care represent a point-of-entry opportunity for healthcare organizations to demonstrate this spirit.
Steps to Redefine Transitions of Care in the Spirit of Clinical Integration:
An instrumental step in care delivery transformation includes redefining an approach to care transitions to embody the spirit of Clinical Integration. Launching a performance improvement initiative related to improving patient transitions of care represents a high yield, low point-of-entry opportunity for healthcare organizations. The following steps outline one approach to launching such work:
1. Define a focus area for your performance improvement initiative.
Intuitively, start by identifying what matters most to your organization. This will allow your organization to hone-in on priorities for performance improvement specific to care transitions. Prompting questions may include:
- Is there a particular clinical condition or procedure where care pathways are not consistently followed within the post-acute setting?
- What are the top reasons leading to avoidable readmissions at your organization?
- What are the clinical priorities of the alternative payment models your organization is considering? How might transitions of care impact performance in these payment models?
- What support is currently given to high-risk patients once discharged to a post-acute care setting?
- What are key differences in your organization’s communication protocols between affiliated and non-affiliated post-acute care providers?
2. Identify stakeholders to include in your performance improvement work.
Once your organization has developed a prioritized list of opportunities for improvement, spend some time identifying stakeholders to include in a performance improvement initiative specific to patient transitions of care. Internal stakeholders should include multi-disciplinary representation. When identifying external stakeholders, consider a “bang for your buck” approach. Consider what relationship, if strengthened, would result in a more coordinated approach to transitioning patients from one care setting to another. Identification of preliminary external stakeholders may be simple if your organization maintains affiliations with post-acute care facilities, but avoid excluding external stakeholders who do not have formal relationships with your organization. Characteristics of potential external stakeholders may also include:
- Post-acute care providers who receive a high volume of patients discharging from your organization
- Post-acute care providers who cater to treatment of conditions identified as “high priority” for your organization
- Most importantly, post-acute care providers who share similar cultural beliefs and strategic priorities as your organization. External stakeholders must have leaders willing to promote accountability to changes in existing workflows or protocols that may result from the performance improvement initiative.
3. Utilize a performance improvement framework to organize your work.
Take a formalized approach to improvement activities by structuring work using a performance improvement methodology. Consider applying concepts from Lean, Six Sigma or the Institute for Healthcare Improvement’s Model for Improvement. Focus on adding structure to your initiative without getting bogged down by jargon. Preemptively define time-bound expectations for the work to be completed, including a process for measuring improvement and providing visibility into performance once any changes in workflow or protocols are deployed (i.e. actionable performance reports). Be sure to communicate key learnings and updates across stakeholder organizations in order to ensure that improvements are sustained over time.