Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. 3.2. Initiatives to Support Care Coordination and Transitions in Care on Behalf of Persons Receiving Long-Term and Post-Acute Care/Long-Term Services and Supports

10/29/2013

This section describes some of the funding and programmatic initiatives and incentives that promote care coordination around transitions and shared care including programs that include or expand HIE involving LTPAC/LTSS providers. These include new health care payment and delivery models, and initiatives to reduce LTPAC/LTSS transfers and readmissions to hospitals.

The Federal Government has established a number of incentives and programs designed to reduce the escalating costs of health care in the United States and close well-documented gaps in care and care coordination that occur in the fee-for-service (FFS) reimbursement environments. Many of these programs support implementation of service delivery models intended to improve care and reduce costs. Several of these programs are described below and in more detail in Appendix A.

Accountable Care Organizations

One model of care is the Accountable Care Organization (ACO). ACOs are groups of providers ranging from IDSs and primary care medical groups to hospital-based systems and virtual networks of physicians, who are jointly accountable for achieving measured QIs and reducing the rate of health care spending growth.61

On November 2, 2011, CMS finalized new rules under the Affordable Care Act to help physicians, hospitals, and other health care providers (in some cases including LTPAC/LTSS providers) improve and coordinate care for Medicare patients through the Medicare Shared Savings Program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare FFS beneficiaries and reduce unnecessary costs.

HIE is considered essential for ACO success. In 2012, a majority of HIE initiative stakeholders responding to the annual eHealth Initiative survey indicated that they are either participating in an ACO and/or patient-centered medical home (PCMH) efforts or intend to do so in the near future.6

One of the ACO initiatives relevant to LTPAC/LTSS is the Pioneer ACO Model, a population-based payment initiative for health care organizations and providers experienced in coordinating patient-centered care across care settings.62 At least ten of these Pioneer ACOs include LTPAC/LTSS providers (Table 3-1).

TABLE 3-1. ACOs Identified with LTPAC/LTSS Providers

ACO Organization Service Area   Participating LTPAC/LTSS  
Provider Type
Beacon, LLC (formerly Eastern Maine Healthcare System, ME) -- IDS Central, Eastern, & Northern Maine SNF, HHA, HCBS
Fairview Health Services (MN) -- IDS Minneapolis, Minnesota Metropolitan Area HHA, Senior services
Franciscan Alliance (IN) -- IDS Indianapolis & Central Indiana HHA
HealthCare Partners of Nevada (NV) -- IPA Clark & Nye Counties, Nevada SNF
Montefiore ACO (NYC) -- Partnership in an IDS & IPA New York City (the Bronx) & lower Westchester County, New York   HHA
OSF Healthcare System -- IDS Central Illinois HHA
Partners HealthCare (MA) -- IDS Eastern Massachusetts HHA, other LTPAC
Plus! (formerly North Texas ACO, TX) -- IPA (recently announced no longer participating in Pioneer program)   Tarrant, Johnson & Parker counties in North Texas HHA, also participates in an regional HIEO  
Steward Health Care System (MA) -- IDS Eastern Massachusetts Hospice, HHA
Trinity Pioneer ACO, LC (formerly TriHealth, Inc) IA -- IDS Northwest Central Iowa HHA, Mental Health

SOURCE: Descriptions of Pioneer ACO projects from CMS Innovations web site: http://innovation.cms.gov/Files/x/Pioneer-ACO-Model-Selectee-Descriptions-document.pdf.

NOTE: Independent physician association (IPA).


Patient-Centered Medical Homes

A PCMH is a team-based model of care led by a physician who provides continuous, coordinated care throughout a patient's lifetime to maximize health outcomes.63 This care model promotes improved access and communication; care coordination and integration; and care quality and safety.

Models for Dual Eligibles

Based on new authority in the Affordable Care Act, CMS is testing capitated and managed FFS financial alignment models to improve care and control costs for the dual eligible population (i.e., persons who are dually eligible for Medicare and Medicaid).64 These demonstrations change the payment approach and financing arrangements among CMS, the state, and providers. The capitated demonstrations will use managed care plans to coordinate services for beneficiaries through a person-centered planning process. Some states require its plans to contract with community-based organizations (CBOs) to provide LTSS coordinators, and may require its plans to contract with Area Agencies on Aging (AAAs) to coordinate with HCBS. These models of care can benefit from effective exchange of information across providers engaged in care coordination.

Community-Based Care Transitions Program

Another initiative is the Community-Based Care Transitions Program (CCTP), designed to improve transitions of high-risk Medicare beneficiaries from inpatient hospitals to home or other care settings, improve quality of care, reduce readmissions, and document measurable savings to the Medicare program. Participating CBOs are paid an all-inclusive rate per eligible discharge based on the cost of care transition services provided at the patient level and implementing systemic changes at the hospital level. According to information from the CMS Innovations web site, at least half of the CCTP recipients were determined to have LTPAC or LTSS participation in their program. Examples of these CBOs identified with participating LTPAC/LTSS providers are provided in Appendix F, based on detailed summaries available for organizations funded in the first two of four funding rounds.

State Innovation Model

The CMS State Innovation Model awards incorporate incentives and funding for HIE and EHR adoption among LTPAC providers, federally qualified health centers (FQHCs) and other safety net providers to enable multi-payer service delivery and payment models.

Medicare-Medicaid Initiatives to Reduce Avoidable Hospitalizations

Other CMS Innovations use bundled care payment models to reduce hospitalizations, one model is targets acute care and post-acute care episodes, and another model targets post-acute care only. These models are designed to lead to higher quality, more coordinated care at a lower cost to Medicare, and may benefit from HIE to support care coordination.

CMS Innovations -- Hospital Readmissions Reduction Program

A CMS Innovations initiative called the Hospital Readmissions Reduction Program focuses on long-stay nursing facility residents who are enrolled in the Medicare and Medicaid programs. The goal of the program is to reduce avoidable inpatient hospitalizations.6566 Payments will be reduced for hospitals with high 30-day admission rates for acute myocardial infarction, heart failure, and pneumonia. CMS has proposed expanding the list of conditions in fiscal year 2015.

Changes to Medicare Physician Payment Policy

Medicare Physician Fees for Care Transition

Under the Medicare 2013 Physician Fee Schedule, CMS created a "G" billing code that enables physicians to bill for delivery of care transition services to Medicare beneficiaries in the 30 days following a discharge from a hospital, an SNF, or a community mental health center.

Medicare Physician Fees for Chronic Care Management Services

Under the Medicare 2014 Physician Fee Schedule, CMS proposes to cover physician services to pay for non-face-to-face complex chronic care management services for Medicare beneficiaries who have two or more significant chronic conditions. Complex chronic care management services include regular physician development and revision of a POC, communication with other treating health professionals, and medication management.67

Medicaid Payment Models

Balancing Incentive Program

The Balancing Incentive Program makes grants available to states to increase access to non-institutional LTSS and lower costs through improved systems performance and efficiency, creating tools to help consumers with care planning and assessment, and improving quality measurement and oversight.

Other Care Coordination Interventions and Activities

A number of public and private entities, including AHRQ, the Partnership for Patients, the Society of Hospital Medicine, Medicare QIOs, and Patient Safety Organizations have developed initiatives to reduce hospital readmissions. These initiatives include tools, resources, and technical assistance to help hospitals and communities understand and address the factors that lead to frequent readmissions21 and make it easier to improve care coordination and care transitions.

The Medicare QIO program includes a focus on post-acute care providers, transitions in care, and care coordination/management. One QIO initiative provides technical assistance to LTPAC and other providers in Colorado, Minnesota, and Pennsylvania through the HIT for Post-Acute Care Special Innovation Project. The QIOs help providers optimize their use of HIT to support medication management and care coordination in transitions of care, and advancing HIE. Selected QIO resources related to care transition improvement efforts are available from state QIO sites.68


 

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