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Alternative payment models lead to strategic care coordination workforce investments
Accepted Manuscript Alternative Payment Models Lead to Strategic Care Coordination Workforce Investments Clese E. Erikson, M.P.Aff., Patricia Pittman, Ph.D., Associate Professor, Alicia LaFrance, MPH, MSW, Research Analyst, Susan A. Chapman, PhD, RN, FAAN, Professor PII:
S0029-6554(17)30063-5
DOI:
10.1016/j.outlook.2017.04.001
Reference:
YMNO 1246
To appear in:
Nursing Outlook
Received Date: 26 January 2017 Revised Date:
3 April 2017
Accepted Date: 6 April 2017
Please cite this article as: Erikson CE, Pittman P, LaFrance A, Chapman SA, Alternative Payment Models Lead to Strategic Care Coordination Workforce Investments, Nursing Outlook (2017), doi: 10.1016/j.outlook.2017.04.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title: Alternative Payment Models Lead to Strategic Care Coordination Workforce Investments
Clese E. Erikson, M.P.Aff. (corresponding author)a Deputy Director, Health Workforce Research Center [email protected] Ph: (202) 994-4122
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Fax: (202) 994-3500
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Authors:
Associate Professor Health Policy and Management Alicia LaFrance, MPH, MSW b Research Analyst, Healthforce Center
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Patricia Pittman, Ph.D. a
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Philip R. Lee Institute for Health Policy Studies Susan A. Chapman, PhD, RN, FAAN b Professor, UCSF School of Nursing
a
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Department of Social & Behavioral Sciences The George Washington University
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2175 K Street, NW, Suite 500 Washington, DC 20037 b
University of California, San Francisco
3333 California Street, Suite 445 San Francisco, CA 94118
This study was made possible by funding from the Health Resources and Services Administration (HRSA).
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Title: Alternative Payment Models Lead to Strategic Care Coordination Workforce
ABSTRACT
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Investments
Background: Care coordination is generally viewed as a key to success for health systems
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seeking to adapt to a range of new value-based payment policies.
Purpose: This study explores care coordination staffing in four health systems participating in
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new payment models, including Medicaid payment reform and Accountable Care Organizations.
Methods: Comparative case study design is used to describe models of care coordination. Analysis of 43 semi-structured interviews with leadership, clinicians, and care coordination staff
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at four health systems engaged in value-based contracts. Findings: Each of the sites engaged in significant task shifting of low complexity care
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coordination activities to licensed professional nurses (LPNS), medical assistants (MAs), and other unlicensed personnel freeing up RNs and social workers for more complex patients. Few
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have care coordination experience requiring a significant investment in on-the-job training. Conclusions: Payment reform is leading to a greater investment in the care coordination workforce however, demonstrating the return-on-investment remains a challenge. Keywords: Care management, workforce, payment reform
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Introduction Care coordination has long been recognized as an effective way to improve quality and prevent avoidable complications.1-3 Implementation of care coordination, however, is far from
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standardized, and organizations are adopting vastly different approaches to its organization and staffing.4 Defined by the Agency for Health Care Research and Quality (AHRQ) as “the deliberate organization of patient care activities between two or more participants (including the patient)
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involved in a patient’s care to facilitate the appropriate delivery of health care services”5, care
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coordination has been shown to lower the cost of care, particularly for complex patients6-9. However, studies also reveal that care coordination is not always immediately successful10-11 and little is understood about which care coordination activities are most effective. 12 Furthermore, the term care coordination is often used interchangeably with care management and case management despite those two roles having a more specific focus on care for
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medically and socially complex patients.13
Historically, care coordination has been constrained by fee-for-service payment models that do
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not reimburse for it.14-15 New payment models, such as Accountable Care Organizations (ACOs) and bundled payments, that hold providers accountable for cost and quality, are presumably
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enhancing incentives to provide care coordination.16-18 In this context, several studies have found that health systems are devoting more workforce resources to care coordination, such as hiring nurse care managers to manage complex patients, using medical assistants to assist with coordination between visits, and moving to a team-based care model.19-21 Policy leaders are also pointing out the potential for an enhanced coordination of primary care, specialty, behavioral, and social services to address social
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determinants of health that may have received little attention in the past.22-23 Emerging evidence shows that some ACOs are starting to hire staff to address social determinants of
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health, but there can be significant challenges with scalability.24-25 Research on the care coordination workforce has been limited partly by the absence of a clear taxonomy and overlap of jobs and roles. The primary terms used include care manager, case
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manager, care coordinator, patient navigator, and in some cases, even community health
worker.26 In addition, there is variation in the professional base (social work, nursing, or no
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professional training) of those who perform care coordination and few health professionals are explicitly trained in these roles or in how to work in team-based care models.27-28 While there is a growing body of literature that evaluates ACOs and other value-based demonstration projects focused on improving care coordination29-30 only a few explicitly
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examine the care coordination workforce in new care models.4,31 Given that care coordination can vary in intensity, staffing models, site of care, patient population served, and mode of interaction33, it is important to better understand how and why various implementation
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strategies are emerging and evolving to support the transition to value-based care.
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This study explores the workforce dimensions of care coordination in the context of four health systems that are committed to expanding their participation in value-based payments. We document the similarities and differences across these four cases in terms of jobs, roles, integration with the health care team, and how payment policies may simultaneously advance and potentially limit optimal care coordination staffing. Methods
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We used a comparative case study design largely because the absence of standardized job descriptions or reliable data sources on the care coordination workforce impedes quantitative
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comparisons. To examine the role of alternative payment models and payment reform, we selected four health systems that were at different stages of adoption of risk-based contracts, and were engaged with different payment programs, including Medicaid reforms, Pioneer
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ACOs, Next Generation ACOs, Medicare Advantage, and commercial Shared Savings ACOs. Our selection criteria also included geographic variability (West, East, and Mid-West), as well as
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examples from academic and community based practices. Lastly, we included systems of varied size (ranging from 140,000 to 440,000 patients) and percent of population at risk (ranging from 40 to 100 percent). See Table 1.
The research team included three senior researchers and one research analyst. We conducted a
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total of 43 interviews across the four systems. Participants at each setting included executive officers, clinical directors, program leaders, and a variety of care coordination staff. Interviews were conducted by phone or in-person and were recorded and later transcribed. Two
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researchers took the lead interviewing two case study sites each and preparing summary
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reports based on the interview transcripts. The full research team reviewed all four summary reports. Interviews were semi-structured and focused on four domains: 1) Overview of the Care Management/Care Coordination program, 2) Risk Stratification and Role Definition, 3) Education, Training and Certification, and, 4) Payment and Reimbursement. Interviews were recorded and transcribed. These four domains formed the initial structure for a descriptive comparison of the cases. Analysis continued in an iterative process to identify emerging
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themes across the case studies. The study was reviewed and approved by the University of California, San Francisco Human Research Protection Program, Committee on Human Research.
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Findings Overview of the Four Care Management/Care Coordination Programs
Montefiore Health System (Montefiore), located in the Bronx, NY, has a long history of care
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coordination activities dating back at least twenty years. They currently participate in risk-based
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contracts for their Medicare and Medicaid populations and many of their privately insured patients. With approximately 400,000 at risk lives, they have developed a subsidiary called the Care Management Organization (CMO) that provides care coordination across the system. The CMO employs approximately 1,200 employees and is responsible for developing new care coordination programs and managing their “at risk” population. A little under half of the CMO
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staff are involved in direct patient interaction for care management and care transition services, including licensed practical nurses (LPNs), registered nurses (RNs), nurse practitioners,
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case management analysts, social workers, housing experts, certified diabetes educators, care transition staff embedded in hospitals, and patient navigators. The balance are behind the
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scenes supporting care management activities through data analytics, information technology, finance, claims, and enrollment. CMO activities include health education, linkages with social services, health system navigation, provider communication, chronic care management, care transitions management, and medication review and reconciliation. High-risk patients are identified monthly using a risk stratification algorithm that primarily uses claims data but also incorporates social determinants of health when possible. Patients are primarily contacted
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telephonically, with the majority of patients assigned to LPNs under a nurse’s supervision, unless a patient is escalated to a very acute category, in which case patients are cared for by a
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nurse care manager or a social worker depending on the degree of need for social services. The Health Plan of San Mateo (HPSM) in California, serves about 140,000 San Mateo county Medicare and Medicaid (Medi-Cal in California) enrollees and is engaged in a demonstration
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project for their dual Medicare and Medi-Cal population. The care coordination division was established in 2006 with the Medicare Special Needs Plans program and was expanded and
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strengthened with the initiation of the dual eligible care coordination project in 2014. High-risk patients are primarily identified for care coordination through claims analysis and through an annual health risk assessment (HRA) survey. Some patients are referred by providers and a few patients self-refer. Patients are primarily contacted telephonically. Less frequently, assessment
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and care is provided in the patients’ home either by a nurse practitioner or a specialty focused RN case manager with a goal of transferring to telephonic engagement when the patient is stabilized. The team of twelve is comprised of care coordination technicians, care coordination
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nurse case managers, a dialysis nurse case manager, a nurse practitioner, and an unfilled
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position for a social worker. In addition they have a referral relationship with county behavioral health specialists and care transitions specialists. Their stated goal of care coordination is to create a system of care that minimizes silos and duplication of services. Bellin Health (Bellin), in Green Bay, WI, redesigned their care model to adopt a team-based approach to care in recognition of the need to focus on value over volume. They were a Medicare Pioneer ACO and are now in the first cohort of Medicare Next Generation ACOs. They currently have about 40 percent of their population at risk but are working to achieve 80
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percent over the next five years. As a result, they have expanded their care coordination activities beyond hospital transitions to integrate two care team coordinators (CTCs) in each
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primary care provider’s (PCPs) practice and added an extended care team of RN care coordinators, case managers, clinical pharmacists, diabetes educators, and behavioral health specialists to support high-risk patients. They are supported by a central care management
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team made up of certified nurse assistants, LPNs and RNs who are behind the scenes doing outreach to patients. Patients are referred to the extended care team using “warm hand-offs”
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where the provider does a face-to-face introduction of a patient to the person to whom they are being referred. Care managers conduct home visits and accompany patients to medical appointments as part of their standard high-risk population care model. Currently, 35 percent of their PCPs are engaged in this new care team model with the goal of full implementation by
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mid-2018. They are also integrating a behavioral health specialist into each primary care clinic after a pilot study showed 25% percent of their patients would benefit from these services. Rush University Medical Center (Rush), in Chicago, IL, is an academic medical center with three
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care management programs housed within the department of Health and Aging. The models
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have evolved over the past decade based on point of care and payer and include: 1) Ambulatory Integration of the Medical and Social (AIMS) model, which embeds social workers within primary and specialty care settings to provide assessment, care planning, and connection to community-based services for adult patients of any payer; 2) a Triad model, targeting the managed Medicaid population, with the goal of connecting patients with primary care and addressing social determinants of health; and 3) Bridge and Advanced Bridge Care models for Medicare beneficiaries that have been discharged from the hospital, with the goal of
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connecting patients to primary and specialty care follow-up, addressing psychosocial barriers, and preventing readmission. Two of the three care management models are staffed primarily
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by social workers. The Triad model, which serves the managed Medicaid population, uses a team of three professions: 1) RN care coordinator; 2) clinical social worker; and 3) non-licensed patient navigator. Care management workers are situated on the hospital campus but patient
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engagement is primarily telephonic. In a few instances, a care manager will co-locate part-time at a primary or specialty care clinic or visit a patient during an inpatient visit. The Triad model is
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managed by a third party and includes an adult Medicaid population served by Rush as well as by other providers. Comparison of Models
As we explored similarities and differences across these four cases in more depth, we identified
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three major themes. First we examine the core elements of the care coordination staffing roles and some of the specific innovations in each. Second, we review informants’ views and practices with regard to the educational requirements and certification for staff. Third, we
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examine how care coordination is financed.
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Risk Stratification and Role Definition Generally, care coordination and care management activities were directed toward patients with a history of multiple ER visits, hospitalizations and/or poorly-controlled chronic conditions, and therefore at risk for further costly but potentially avoidable complications. Additionally, all four sites emphasized inquiring about social determinants of health, such as housing or transportation needs, as an additional means for identifying patients who would benefit from
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care coordination activities. While the sites had fairly similar general criteria for defining their high-risk population, each used their own methods for identifying high-risk patients which
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included varying combinations of the following: running monthly algorithms using claims data, provider referrals, patient self-referrals, and/or health risk assessment surveys.
Despite the differences among the four study sites in terms of size, location, and organizational
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history, we found significant commonality in terms of how they delegated care coordination staff among high and low complexity patient care activities. Mostly they reported using LPNs
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and MAs or other unlicensed personnel for low complexity care coordination activities, such as patient outreach, scheduling follow-up appointments, completing health risk assessment surveys, prevention, and documenting the care plan.
RNs and social workers were reserved for more complex patient care needs. Generally, RNs
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were assigned to develop the overall care plan and supervise implementation, in addition to providing ongoing care management for medically complex patients such as those who have been unable to get their diabetes or blood pressure under control with more routine care
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coordination, or who have wound care needs or other complex conditions that require ongoing
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medical attention. Social workers provided case management for patients when psychosocial factors impeded a patient’s ability to successfully manage their care, such as when a patient is dealing with an eviction notice and no food, needs help paying for medications, in cases of domestic violence or elder abuse, mental health or substance abuse disorders, or when the patient has significant legal issues. Typically, they engage in problem solving and connecting patients with available community resources in short- or long-term interventions.
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For some of the sites, like Montefiore, their high reliance on LPNs represents a shift in thinking relative to their prior roles for nurses. At Montefiore, LPNs typically provide support to two care
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teams and manage about 125-150 patients each and RNs now take on a more managerial and supervisory role for lower complexity patients. LPNs focus on assessment and prevention and help make sure that patients get their prescriptions filled and keep their appointments. LPNs
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are empowered with the chief medical officer’s backing to expedite visits when necessary. LPNs also reach out to patients during transitions of care when they are most at risk for readmission.
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Bellin is in the process of embedding two care team coordinators (CTCs), typically LPNs or CMAs, into each PCP’s practice to assist with care coordination for the entire population. CTCs participate in team huddles every morning and contribute to care plan development. They scribe during the encounter and reinforce the plan of care after the provider leaves. CTCs are
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empowered to identify and refer patients for care management when needed. While not all providers are immediately comfortable with delegating some of these functions to CTCs, Bellin reports that once providers are engaged in team-based care they would never go back.
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Rush uses unlicensed patient navigators in the Triad model to perform some routine tasks such
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as conducting initial health risk assessments with patients and monitoring ongoing health care utilization. The patient navigators are also responsible for providing tailored resources to lowrisk populations that address social determinants of health as indicated by the health risk assessment.
At HPSM, the realization that not every care coordination activity needs to be performed by licensed staff led to the decision to bring in a technician role into the care coordination team.
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Low-risk designated members are triaged to care coordinator technicians who are also responsible for triaging calls from members and providers and following up with patients to
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complete health risk assessments. This frees up the care management nurses to be able focus on members that require more intensive assessment or intervention.
At each of the case study sites, care coordinators have access to a larger care team of
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pharmacists, diabetes educators, dieticians, behavioral health specialists, and others who can provide expertise and support on specific care needs. For example, at Bellin clinical pharmacists
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meet face-to-face with patients who have 15 or more medications to help them with medication management, such as identifying lower cost options or contra-indicated medications, and conducting phone check-ins between visits to help patients meet goals. At Montefiore, pharmacists are strategically aligned with asthma and diabetes teams to maximize
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their connection to patients with complex medication needs and improve medication adherence by walking them through how to use an inhaler or arranging to have a respiratory therapist do a home visit to be sure patients don't have any triggers in the home. Some of the
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pharmacists are also certified diabetes educators who can work with patients to develop a care
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plan that works best for them given the housing, food security or other challenges they may be facing. HPSM has a dialysis case manager to serve their end stage renal population. In Rush’s Triad model, patient navigators help patients identified through risk assessments as having some pyscho-social barriers but who are not currently deemed medically at-risk. Education, Training and Certification
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The study sites uniformly report that a key attribute of this role is the ability to connect with both patients and providers. They also need to be able to multitask and have good knowledge
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of the community and resources. The sites reported that they recruit for those attributes and are willing to provide training on care coordination functions. New hires receive fairly intensive on-the-job training that is developed in-house. Rush, Bellin and HPSM training occurs over the
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course of several weeks and includes a shadowing component where new employees shadow more experienced care managers before working independently. At Bellin, PCPs also
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participate in the training. None of the health systems studied require that care managers or case managers have certification, though two of the systems offer in-house certification upon completion of training. Bellin, Montefiore, and Rush work closely with their local nursing and vocational schools to stress the need for training on risk stratification, motivational
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interviewing, and team-based care; in addition, Rush advocates for this with social work schools at both local and national levels. They also serve as faculty or preceptors for students in order to increase the supply of qualified candidates.
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Payment and Reimbursement
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The challenge of financing care coordination is a major concern. At HPSM care management services are part of the overall capitation rate, but at the others there are few sources of explicit coverage. Montefiore has direct per-member-per-month arrangements for a portion of their population, such as their high-risk Medicaid population, but the bulk of their reimbursement incentives are derived from shared savings or other at risk-based contracts. Bellin was hoping that the new team-based model and increased emphasis on care coordination would allow them to increase primary care capacity and generate enough
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additional fee-for-service revenue to offset the workforce investments as they transition to value-based models. So far, that has not occurred and they report that they are hoping to
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negotiate explicit coverage of care management services in future contracts with private payers. They are also in the process of requiring that providers have 20 visits per day to have 2 CTCs assigned to their team. Rush discussed how the business case is made to the hospital
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leadership; they have focused on metrics such as 30 day readmissions, ED visits, and physician follow-up to demonstrate the impact of care management efforts.
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Discussion
We found that each of the organizations in our study has made a significant investment in their care coordination workforce in response to alternative payment models. This is consistent with a recent survey of ACO leaders that found nearly all ACOs have invested in new staff to support
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quality and care coordination activities.33 In contrast, a recent study of 12 sites that were just establishing patient-centered medical homes that were not necessarily tied to alternative payments found that not all had explicitly hired staff to fill care management roles with some
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distributing those functions to existing team members instead.4 This reinforces the power of
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creating new financial incentives that reward a greater focus on care coordination. This study supports earlier research which finds that care coordination is no longer a single profession but comprises an array of professionals working together as a team, aided by data analysts and other behind-the-scenes support, and requiring significant task delegation.34 Interestingly, all four sites were task shifting low complexity care coordination activities to LPNs and MAs and reserving RNs and social workers for more complex cases. This is not necessarily
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an easy transition and requires adapting organizational culture. For example, physicians may not initially trust their MAs or LPNs to take on these new roles. This is further compounded by
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the general lack of health professions training on care coordination and team-based care. The health systems in our case studies had to address important education gaps with on-the-job training or access to online training, with some offering in-house certification. This could be a
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costly investment, particularly if turnover of care managers, especially nurses, is as high as reported by one of our sites.
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The practice of care coordination is a very different nursing role than traditional beside care and involves additional skills and competencies, such as motivational interviewing and risk management, which are typically not a part of standard nursing education and training. Furthermore, study participants indicated that not all nurses enjoy providing telephonic care,
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which is the standard at three of the four sites, and they miss the face-to-face interactions. On the other hand, the role also involves longer-term patient relationships, more independence and an opportunity to have a profound impact on the health outcomes of complex patients
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with significant care needs which is seen as professionally rewarding. As with the RN role, the
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LPN role in care coordination is very different, too. Some sites preferred using LPNs versus MAs for their care coordination activities because LPNs have more clinical training and experience. Several of the sites are working with local nursing schools to refine the curriculum to include more training on care coordination related activities but this may be leading to a significant duplication of effort as they each look to develop training programs that meet their needs. In nursing education programs there has been some growth in graduate programs focused in care management. Organizations engaged in new payment and delivery models can enrich the
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nursing pipeline by supporting their RN case managers in helping to train the next generation, such as serving as preceptors for nursing students who need clinical experiences or taking on a
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faculty role at a local nursing school. We found that new payment incentives are not always fully aligned with making the necessary investments in care coordination. Under most of the new alternative payment models,
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providers continue to bill under fee-for-service 35 and hope that the costs of any care
coordination efforts will be recovered later in savings from improved health and reduced
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utilization of unneeded services such as repeat emergency room visits. Under these circumstances, making the business case for the needed investments in care coordination can be a challenge.36 In recent years, there has been some progress at the national level in producing better workforce data. The Center for Medicare Medicaid Innovation (CMMI)
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collected some workforce data as part of the evaluation of a new Comprehensive Primary Care Initiative (CPCI) 37 and the Centers for Disease Control and Prevention (CDC) now collects more
(NAMCS).38
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workforce elements as part of their annual National Ambulatory Medical Care Survey
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It will be important to continue to study how the care coordination workforce will evolve as more practices participate in alternative payment and as payment models continue to be refined. The sites we spoke with are very interested in getting better data on the overall return on investment, and in better understanding the effect of various care coordination staffing models on outcomes. The current lack of evidence on the care coordination workforce may be limiting investments during this important transition from fee-for-service to value-based payment systems.39
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Our study has several limitations. First, the sites are a convenience sample and are not representative of all health care organizations engaged in alternative payment models. We
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made an effort to ensure we included a mix of organizational characteristics such as region, payer mix, and percent of population at risk. Second, the interviewees may not represent all views at the organization but we tried to mitigate that by getting multiple perspectives at each
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site. This is intended as an exploratory project to identify important areas for further research. Conclusions
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Our findings suggest that coordination is now a team-based activity, with RNs playing a more defined role than they may have in the past, and new team members such as LPNS and MAs becoming more important. Payment arrangements are the major driver of care coordination but the need for reimbursement for care coordination services continues to be a top priority for
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health systems. Reimbursement is often indirect and it is difficult to demonstrate the returnon-investment. Given the variety of models, limited comparative effectiveness research, and general high expectations of care coordination activities, there remains a strong need for the
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research community to provide tools and resources that can help organizations that are looking
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to implement care coordination activities make the best use of limited workforce resources. In particular, the evolving role of nurses in care coordination team needs additional investigation and analysis to ensure their unique skills and training are used to maximum effect to support value-based care.
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Table 1. Overview of Health Workforce Care Coordination Innovation Models, Organizational Context and Staffing Montefiore Health System
Health Plan of San Mateo
Rush University Medical Center
Location
Green Bay, WI
The Bronx, NY
Chicago, IL
Organizational Context
Integrated delivery system; Major investment in primary care redesign to team based care. Preparing for transition from feefor-service to Value Based Payments; Goal to be 80% At Risk in next five years; Was a Pioneer ACO now Next Generation ACO
Academic medical center serving primarily low SES population; Continuing to build Care Management Organization (CMO) Strategic Plan to be 100% At Risk; Pioneer ACO, Medicare Advantage, Medicaid managed care, and private risk contracts.
San Mateo County, CA California managed Medicaid plan that includes patients enrolled in MediCal and Medicare
Number of Patients and Percent At Risk
125,000 (40% At Risk)
440, 000 (90% At Risk)
Who Does Care Management Activities
Extended Care Team: • RN Care Managers • Case Managers (SW) • Clinical Pharmacists • Behavioral Health (LPC) • Support staff
Education / Certification
16 week in-house training on team based care; developing extended care team training Developing in-house
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Primary Care Teams: • Care Team Coordinators (2:1 PCP; expanded MA/LPN role) • Behavioral Health (1:4 PCPs)
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Bellin Health
• •
•
•
• • •
LPNs and MAs RN care managers SW case managers Diabetes and asthma care teams Clinical pharmacists Certified diabetes educators Care transition specialists
In house training that includes three phases: • Core competencies • Care Transitions and
Academic medical center with strong commitment to case management and social determinants of health. Participates in a multiple fee for service and managed care contracts.
140,000 (100% at risk)
664 bed hospital (Medicaid Managed care at risk)
• Care coordination technicians • Care coordination nurse case managers • Dialysis nurse case manager • Nurse practitioner • Social worker
Heavily staffed by social workers; one particular model uses a team of nurses, social workers, and unlicensed patient navigators
In-house training Staff can voluntarily complete during work hours, a modularized, webbased course on
In-house training
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How Care Managers Interact with Patients
Mostly in primary care practices and inpatient settings; moving to specialists and nursing homes; involved significant construction budget to covert offices
CMO headquarters, some work from home; a few embedded in ER
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Where Care Managers Work
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Embedded in practice; Providers refer through warm hand-off if possible; If high risk score at discharge consult with provider regarding likelihood of patient engagement if referred Mostly face-to-face interactions; for high risk patients they also conduct home visits and accompany to visits
fundamental topics of care management
Faxing and phone referrals with physician network.
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How Care Managers Work Together with Providers
care management • Systems training The total hours of training vary by job from 34 hours to 109 hours. Limited. Centralized CMO; automatic referral for care management based on risk algorithm; notes/progress shared with PCP through EMR Primarily telephonic, rare home visits
Primarily telephonic NP conduct home visits to assess high risk patients and perform in home care until patient stabilized At the managed care organization administrative site
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certification.
Care team meetings, emails, pager, electronic health record
Primarily telephonic; some in-person clinic and inpatient visits
Throughout the medical center campus
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10. Dale S, Ghosh A, Peikes D, et al. Two-Year Costs and Quality in the Comprehensive Primary Care Initiative. N Engl J Med 2016;374:2345-2356.
11. Werner RM, Duggan M, Duey K, et al. The patient-centered medical home: an
2013;51(6):487-93.
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evaluation of a single private payer demonstration in New Jersey. Med Care
12. Wagner EH, Sandhu N, Coleman K, et al. Improving care coordination in primary care.
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Med Care 2014;52(11 Suppl 4):S33-8.
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13. McDonald K, Sundaram V, Bravata D, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality; 2007.
14. Davis K. Paying for Care Episodes and Care Coordination. N Engl J Med 2007;356:11661168.
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15. Blumenthal D, Chernof B, Fulmer T, et al. Caring for High-Need, High-Cost Patients — An Urgent Priority. N Engl J Med 2016;375:909-911.
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16. Berenson R, Burtona R, McGrath M. Do accountable care organizations (ACOs) help or hinder primary care physicians' ability to deliver high-quality care? Healthc 2016;4(3):155-159.
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17. Evans M. Demand grows for care coordinators [Modern Healthcare web site]. March 28, 2015. Available at:
Accessed on October 16, 2016.
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http://www.modernhealthcare.com/article/20150328/MAGAZINE/303289980.
18. Chen C, Ackerly D. Beyond ACOs and bundled payments: Medicare’s shift toward accountability in fee-for-service. JAMA. 2014;311:673–674.
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19. Ladden MD, Bodenheimer T, Fishman NW, et al. The emerging primary care workforce: preliminary observations from the primary care team: learning from effective
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ambulatory practices project. Acad Med 2013;88(12):1830-4. 20. Peiris D, Phipps-Taylor M, Stachowski C, et al. ACOs Holding Commercial Contracts are
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Larger and More Efficient than Noncommercial ACOs. Health Aff 2016;35(10):18491856.
21. Taylor E, Dale S, Peikes D, et al. Evaluation of the Comprehensive Primary Care Initiative: First Annual Report [cms.gov web site]. January 2015. Available at: https://innovation.cms.gov/files/reports/cpci-evalrpt1.pdf. Accessed on October 15, 2016.
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22. Taylor L, Coyle C, Ndumele C, et al. The Social Determinants of Health: What Works? [Blue Cross Foundation [web site]. Available at:
quity_Report_Final.pdf. Accessed on October 20, 2016.
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http://www.bluecrossfoundation.org/sites/default/files/download/publication/Social_E
23. Blumenthal D, Anderson G, and Burke S, et al. Tailoring Complex-Care Management,
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Coordination, and Integration for High-Need, High-Cost Patients: A Vital Direction for Health and Health Care [National Academy of Sciences web iste]. Available at:
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https://nam.edu/wp-content/uploads/2016/09/Tailoring-Complex-Care-ManagementCoordination-and-Integration-for-High-Need-High-Cost-Patients.pdf. Accessed on October 19, 2016.
24. Fraze T, Lewis V, Rodriguwz H, et al. Housing, Transportation, and Food: How ACOs Seek
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to Improve Population Health by Addressing Nonmedical Needs of Patients. Health Aff 2016:35(11);2109-2115.
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25. Sandberg S, Erikson C, Owen R, et al. Hennepin Health: A Safety-Net Accountable Care Organization for The Expanded Medicaid Population. Health Aff 2014: 33(11):1975-
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1984.
26. Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs [IHI web site]. 2011. Available at: http://www.ihi.org/resources/pages/IHIWhitePapers/IHICareCoordinationModelWhiteP aper.aspx. Accessed on October 18, 2016.
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27. Fraher E, Ricketts T, Lefebvre A, et al. The role of academic health centers and their partners in reconfiguring and retooling the existing workforce to practice in a
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transformed health system. Acad Med 2013:88(12):1812-1816. 28. Ladden MD, Bodenheimer T, Fishman NW, et al. The emerging primary care workforce: preliminary observations from the primary care team: learning from effective
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ambulatory practices project. Acad Med 2013;88(12):1830-4.
29. McWilliams JM, Hatfield LA, Chernew ME, et al. Early Performance of Accountable Care
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Organizations in Medicare. N Engl J Med 2016; 374:2357-2366.
30. Song Z, Rose S, Safran D, et al. Changes in Health Care Spending and Quality 4 Years into Global Payment. N Engl J Med 2014;371:1704-1714.
31. Taylor E, Dale S, Peikes D, et al. Evaluation of the Comprehensive Primary Care
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Initiative: First Annual Report [cms.gov web site]. January 2015. Available at: https://innovation.cms.gov/files/reports/cpci-evalrpt1.pdf. Accessed on October 15,
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2016.
32. Agency for Healthcare Research and Quality. Section 4: Selecting Care Management
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Interventions [AHRQ web site]. Content last reviewed October 2014. Available at: http://www.ahrq.gov/professionals/systems/long-termcare/resources/hcbs/medicaidmgmt/medicaidmgmt4.html. Accessed on October 19, 2016
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33. Peiris D, Phipps-Taylor M, Stachowski C, et al. ACOs Holding Commercial Contracts are Larger and More Efficient Than Noncommercial ACOs. Health Aff 2016;35(10):1849-
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1856. 34. Lamb, G., (September 30, 2015) "Overview and Summary: Care Coordination: Benefits of Interprofessional Collaboration" OJIN: The Online Journal of Issues in Nursing Vol. 20,
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No. 3, Overview and Summary
35. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid
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Services. Accountable Care Organizations: What Providers Need to Know [CMS web site]. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/Downloads/ACO_Providers_Factsheet_ICN907406.pdf. Accessed on October 19, 2016.
1168
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36. Davis K. Paying for Care Episodes and Care Coordination. N Engl J Med 2007;356:1166-
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37. Peikes D, Taylor EF, Dale S, et al. Evaluation of the Comprehensive Primary Care Initiative: Second Annual Report 2016. [cms.gov web site]. April 2016. Available at:
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https://innovation.cms.gov/files/reports/cpci-evalrpt2.pdf. Accessed on Oct 12, 2016. 38. The Centers for Disease Control and Prevention’s National Center for Health Statistics. National Ambulatory Medical Care Survey [CDC web site]. 2015. Available at:
http://www.cdc.gov/nchs/data/ahcd/2015_NAMCS_Physician_II_Sample.pdf. Accessed on October 12, 2016.
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39. Blumenthal D, Anderson G, Burke S, et al. Tailoring Complex-Care Management, Coordination, and Integration for High-Need, High-Cost Patients: A Vital Direction for
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Health and Health Care [National Academy of Sciences web site]. September 19, 2016. Available at: https://nam.edu/wp-content/uploads/2016/09/Tailoring-Complex-CareManagement-Coordination-and-Integration-for-High-Need-High-Cost-Patients.pdf.
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Accessed on October 7, 2016.
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Title: Alternative Payment Models Lead to Strategic Care Coordination Workforce Investments
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Highlights: Value based payment is leading to enhanced care coordination staffing
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Sites are task shifting low complexity care coordination to unlicensed staff
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Important care coordination education gaps necessitate in-depth on-the-job training
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Demonstrating the ROI of care coordination staffing remains a challenge
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S0029-6554(17)30063-5
DOI:
10.1016/j.outlook.2017.04.001
Reference:
YMNO 1246
To appear in:
Nursing Outlook
Received Date: 26 January 2017 Revised Date:
3 April 2017
Accepted Date: 6 April 2017
Please cite this article as: Erikson CE, Pittman P, LaFrance A, Chapman SA, Alternative Payment Models Lead to Strategic Care Coordination Workforce Investments, Nursing Outlook (2017), doi: 10.1016/j.outlook.2017.04.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title: Alternative Payment Models Lead to Strategic Care Coordination Workforce Investments
Clese E. Erikson, M.P.Aff. (corresponding author)a Deputy Director, Health Workforce Research Center [email protected] Ph: (202) 994-4122
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Fax: (202) 994-3500
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Authors:
Associate Professor Health Policy and Management Alicia LaFrance, MPH, MSW b Research Analyst, Healthforce Center
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Patricia Pittman, Ph.D. a
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Philip R. Lee Institute for Health Policy Studies Susan A. Chapman, PhD, RN, FAAN b Professor, UCSF School of Nursing
a
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Department of Social & Behavioral Sciences The George Washington University
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2175 K Street, NW, Suite 500 Washington, DC 20037 b
University of California, San Francisco
3333 California Street, Suite 445 San Francisco, CA 94118
This study was made possible by funding from the Health Resources and Services Administration (HRSA).
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Title: Alternative Payment Models Lead to Strategic Care Coordination Workforce
ABSTRACT
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Investments
Background: Care coordination is generally viewed as a key to success for health systems
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seeking to adapt to a range of new value-based payment policies.
Purpose: This study explores care coordination staffing in four health systems participating in
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new payment models, including Medicaid payment reform and Accountable Care Organizations.
Methods: Comparative case study design is used to describe models of care coordination. Analysis of 43 semi-structured interviews with leadership, clinicians, and care coordination staff
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at four health systems engaged in value-based contracts. Findings: Each of the sites engaged in significant task shifting of low complexity care
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coordination activities to licensed professional nurses (LPNS), medical assistants (MAs), and other unlicensed personnel freeing up RNs and social workers for more complex patients. Few
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have care coordination experience requiring a significant investment in on-the-job training. Conclusions: Payment reform is leading to a greater investment in the care coordination workforce however, demonstrating the return-on-investment remains a challenge. Keywords: Care management, workforce, payment reform
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Introduction Care coordination has long been recognized as an effective way to improve quality and prevent avoidable complications.1-3 Implementation of care coordination, however, is far from
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standardized, and organizations are adopting vastly different approaches to its organization and staffing.4 Defined by the Agency for Health Care Research and Quality (AHRQ) as “the deliberate organization of patient care activities between two or more participants (including the patient)
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involved in a patient’s care to facilitate the appropriate delivery of health care services”5, care
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coordination has been shown to lower the cost of care, particularly for complex patients6-9. However, studies also reveal that care coordination is not always immediately successful10-11 and little is understood about which care coordination activities are most effective. 12 Furthermore, the term care coordination is often used interchangeably with care management and case management despite those two roles having a more specific focus on care for
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medically and socially complex patients.13
Historically, care coordination has been constrained by fee-for-service payment models that do
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not reimburse for it.14-15 New payment models, such as Accountable Care Organizations (ACOs) and bundled payments, that hold providers accountable for cost and quality, are presumably
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enhancing incentives to provide care coordination.16-18 In this context, several studies have found that health systems are devoting more workforce resources to care coordination, such as hiring nurse care managers to manage complex patients, using medical assistants to assist with coordination between visits, and moving to a team-based care model.19-21 Policy leaders are also pointing out the potential for an enhanced coordination of primary care, specialty, behavioral, and social services to address social
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determinants of health that may have received little attention in the past.22-23 Emerging evidence shows that some ACOs are starting to hire staff to address social determinants of
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health, but there can be significant challenges with scalability.24-25 Research on the care coordination workforce has been limited partly by the absence of a clear taxonomy and overlap of jobs and roles. The primary terms used include care manager, case
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manager, care coordinator, patient navigator, and in some cases, even community health
worker.26 In addition, there is variation in the professional base (social work, nursing, or no
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professional training) of those who perform care coordination and few health professionals are explicitly trained in these roles or in how to work in team-based care models.27-28 While there is a growing body of literature that evaluates ACOs and other value-based demonstration projects focused on improving care coordination29-30 only a few explicitly
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examine the care coordination workforce in new care models.4,31 Given that care coordination can vary in intensity, staffing models, site of care, patient population served, and mode of interaction33, it is important to better understand how and why various implementation
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strategies are emerging and evolving to support the transition to value-based care.
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This study explores the workforce dimensions of care coordination in the context of four health systems that are committed to expanding their participation in value-based payments. We document the similarities and differences across these four cases in terms of jobs, roles, integration with the health care team, and how payment policies may simultaneously advance and potentially limit optimal care coordination staffing. Methods
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We used a comparative case study design largely because the absence of standardized job descriptions or reliable data sources on the care coordination workforce impedes quantitative
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comparisons. To examine the role of alternative payment models and payment reform, we selected four health systems that were at different stages of adoption of risk-based contracts, and were engaged with different payment programs, including Medicaid reforms, Pioneer
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ACOs, Next Generation ACOs, Medicare Advantage, and commercial Shared Savings ACOs. Our selection criteria also included geographic variability (West, East, and Mid-West), as well as
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examples from academic and community based practices. Lastly, we included systems of varied size (ranging from 140,000 to 440,000 patients) and percent of population at risk (ranging from 40 to 100 percent). See Table 1.
The research team included three senior researchers and one research analyst. We conducted a
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total of 43 interviews across the four systems. Participants at each setting included executive officers, clinical directors, program leaders, and a variety of care coordination staff. Interviews were conducted by phone or in-person and were recorded and later transcribed. Two
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researchers took the lead interviewing two case study sites each and preparing summary
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reports based on the interview transcripts. The full research team reviewed all four summary reports. Interviews were semi-structured and focused on four domains: 1) Overview of the Care Management/Care Coordination program, 2) Risk Stratification and Role Definition, 3) Education, Training and Certification, and, 4) Payment and Reimbursement. Interviews were recorded and transcribed. These four domains formed the initial structure for a descriptive comparison of the cases. Analysis continued in an iterative process to identify emerging
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themes across the case studies. The study was reviewed and approved by the University of California, San Francisco Human Research Protection Program, Committee on Human Research.
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Findings Overview of the Four Care Management/Care Coordination Programs
Montefiore Health System (Montefiore), located in the Bronx, NY, has a long history of care
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coordination activities dating back at least twenty years. They currently participate in risk-based
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contracts for their Medicare and Medicaid populations and many of their privately insured patients. With approximately 400,000 at risk lives, they have developed a subsidiary called the Care Management Organization (CMO) that provides care coordination across the system. The CMO employs approximately 1,200 employees and is responsible for developing new care coordination programs and managing their “at risk” population. A little under half of the CMO
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staff are involved in direct patient interaction for care management and care transition services, including licensed practical nurses (LPNs), registered nurses (RNs), nurse practitioners,
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case management analysts, social workers, housing experts, certified diabetes educators, care transition staff embedded in hospitals, and patient navigators. The balance are behind the
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scenes supporting care management activities through data analytics, information technology, finance, claims, and enrollment. CMO activities include health education, linkages with social services, health system navigation, provider communication, chronic care management, care transitions management, and medication review and reconciliation. High-risk patients are identified monthly using a risk stratification algorithm that primarily uses claims data but also incorporates social determinants of health when possible. Patients are primarily contacted
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telephonically, with the majority of patients assigned to LPNs under a nurse’s supervision, unless a patient is escalated to a very acute category, in which case patients are cared for by a
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nurse care manager or a social worker depending on the degree of need for social services. The Health Plan of San Mateo (HPSM) in California, serves about 140,000 San Mateo county Medicare and Medicaid (Medi-Cal in California) enrollees and is engaged in a demonstration
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project for their dual Medicare and Medi-Cal population. The care coordination division was established in 2006 with the Medicare Special Needs Plans program and was expanded and
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strengthened with the initiation of the dual eligible care coordination project in 2014. High-risk patients are primarily identified for care coordination through claims analysis and through an annual health risk assessment (HRA) survey. Some patients are referred by providers and a few patients self-refer. Patients are primarily contacted telephonically. Less frequently, assessment
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and care is provided in the patients’ home either by a nurse practitioner or a specialty focused RN case manager with a goal of transferring to telephonic engagement when the patient is stabilized. The team of twelve is comprised of care coordination technicians, care coordination
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nurse case managers, a dialysis nurse case manager, a nurse practitioner, and an unfilled
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position for a social worker. In addition they have a referral relationship with county behavioral health specialists and care transitions specialists. Their stated goal of care coordination is to create a system of care that minimizes silos and duplication of services. Bellin Health (Bellin), in Green Bay, WI, redesigned their care model to adopt a team-based approach to care in recognition of the need to focus on value over volume. They were a Medicare Pioneer ACO and are now in the first cohort of Medicare Next Generation ACOs. They currently have about 40 percent of their population at risk but are working to achieve 80
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percent over the next five years. As a result, they have expanded their care coordination activities beyond hospital transitions to integrate two care team coordinators (CTCs) in each
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primary care provider’s (PCPs) practice and added an extended care team of RN care coordinators, case managers, clinical pharmacists, diabetes educators, and behavioral health specialists to support high-risk patients. They are supported by a central care management
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team made up of certified nurse assistants, LPNs and RNs who are behind the scenes doing outreach to patients. Patients are referred to the extended care team using “warm hand-offs”
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where the provider does a face-to-face introduction of a patient to the person to whom they are being referred. Care managers conduct home visits and accompany patients to medical appointments as part of their standard high-risk population care model. Currently, 35 percent of their PCPs are engaged in this new care team model with the goal of full implementation by
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mid-2018. They are also integrating a behavioral health specialist into each primary care clinic after a pilot study showed 25% percent of their patients would benefit from these services. Rush University Medical Center (Rush), in Chicago, IL, is an academic medical center with three
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care management programs housed within the department of Health and Aging. The models
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have evolved over the past decade based on point of care and payer and include: 1) Ambulatory Integration of the Medical and Social (AIMS) model, which embeds social workers within primary and specialty care settings to provide assessment, care planning, and connection to community-based services for adult patients of any payer; 2) a Triad model, targeting the managed Medicaid population, with the goal of connecting patients with primary care and addressing social determinants of health; and 3) Bridge and Advanced Bridge Care models for Medicare beneficiaries that have been discharged from the hospital, with the goal of
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connecting patients to primary and specialty care follow-up, addressing psychosocial barriers, and preventing readmission. Two of the three care management models are staffed primarily
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by social workers. The Triad model, which serves the managed Medicaid population, uses a team of three professions: 1) RN care coordinator; 2) clinical social worker; and 3) non-licensed patient navigator. Care management workers are situated on the hospital campus but patient
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engagement is primarily telephonic. In a few instances, a care manager will co-locate part-time at a primary or specialty care clinic or visit a patient during an inpatient visit. The Triad model is
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managed by a third party and includes an adult Medicaid population served by Rush as well as by other providers. Comparison of Models
As we explored similarities and differences across these four cases in more depth, we identified
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three major themes. First we examine the core elements of the care coordination staffing roles and some of the specific innovations in each. Second, we review informants’ views and practices with regard to the educational requirements and certification for staff. Third, we
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examine how care coordination is financed.
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Risk Stratification and Role Definition Generally, care coordination and care management activities were directed toward patients with a history of multiple ER visits, hospitalizations and/or poorly-controlled chronic conditions, and therefore at risk for further costly but potentially avoidable complications. Additionally, all four sites emphasized inquiring about social determinants of health, such as housing or transportation needs, as an additional means for identifying patients who would benefit from
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care coordination activities. While the sites had fairly similar general criteria for defining their high-risk population, each used their own methods for identifying high-risk patients which
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included varying combinations of the following: running monthly algorithms using claims data, provider referrals, patient self-referrals, and/or health risk assessment surveys.
Despite the differences among the four study sites in terms of size, location, and organizational
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history, we found significant commonality in terms of how they delegated care coordination staff among high and low complexity patient care activities. Mostly they reported using LPNs
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and MAs or other unlicensed personnel for low complexity care coordination activities, such as patient outreach, scheduling follow-up appointments, completing health risk assessment surveys, prevention, and documenting the care plan.
RNs and social workers were reserved for more complex patient care needs. Generally, RNs
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were assigned to develop the overall care plan and supervise implementation, in addition to providing ongoing care management for medically complex patients such as those who have been unable to get their diabetes or blood pressure under control with more routine care
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coordination, or who have wound care needs or other complex conditions that require ongoing
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medical attention. Social workers provided case management for patients when psychosocial factors impeded a patient’s ability to successfully manage their care, such as when a patient is dealing with an eviction notice and no food, needs help paying for medications, in cases of domestic violence or elder abuse, mental health or substance abuse disorders, or when the patient has significant legal issues. Typically, they engage in problem solving and connecting patients with available community resources in short- or long-term interventions.
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For some of the sites, like Montefiore, their high reliance on LPNs represents a shift in thinking relative to their prior roles for nurses. At Montefiore, LPNs typically provide support to two care
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teams and manage about 125-150 patients each and RNs now take on a more managerial and supervisory role for lower complexity patients. LPNs focus on assessment and prevention and help make sure that patients get their prescriptions filled and keep their appointments. LPNs
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are empowered with the chief medical officer’s backing to expedite visits when necessary. LPNs also reach out to patients during transitions of care when they are most at risk for readmission.
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Bellin is in the process of embedding two care team coordinators (CTCs), typically LPNs or CMAs, into each PCP’s practice to assist with care coordination for the entire population. CTCs participate in team huddles every morning and contribute to care plan development. They scribe during the encounter and reinforce the plan of care after the provider leaves. CTCs are
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empowered to identify and refer patients for care management when needed. While not all providers are immediately comfortable with delegating some of these functions to CTCs, Bellin reports that once providers are engaged in team-based care they would never go back.
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Rush uses unlicensed patient navigators in the Triad model to perform some routine tasks such
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as conducting initial health risk assessments with patients and monitoring ongoing health care utilization. The patient navigators are also responsible for providing tailored resources to lowrisk populations that address social determinants of health as indicated by the health risk assessment.
At HPSM, the realization that not every care coordination activity needs to be performed by licensed staff led to the decision to bring in a technician role into the care coordination team.
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Low-risk designated members are triaged to care coordinator technicians who are also responsible for triaging calls from members and providers and following up with patients to
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complete health risk assessments. This frees up the care management nurses to be able focus on members that require more intensive assessment or intervention.
At each of the case study sites, care coordinators have access to a larger care team of
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pharmacists, diabetes educators, dieticians, behavioral health specialists, and others who can provide expertise and support on specific care needs. For example, at Bellin clinical pharmacists
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meet face-to-face with patients who have 15 or more medications to help them with medication management, such as identifying lower cost options or contra-indicated medications, and conducting phone check-ins between visits to help patients meet goals. At Montefiore, pharmacists are strategically aligned with asthma and diabetes teams to maximize
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their connection to patients with complex medication needs and improve medication adherence by walking them through how to use an inhaler or arranging to have a respiratory therapist do a home visit to be sure patients don't have any triggers in the home. Some of the
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pharmacists are also certified diabetes educators who can work with patients to develop a care
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plan that works best for them given the housing, food security or other challenges they may be facing. HPSM has a dialysis case manager to serve their end stage renal population. In Rush’s Triad model, patient navigators help patients identified through risk assessments as having some pyscho-social barriers but who are not currently deemed medically at-risk. Education, Training and Certification
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The study sites uniformly report that a key attribute of this role is the ability to connect with both patients and providers. They also need to be able to multitask and have good knowledge
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of the community and resources. The sites reported that they recruit for those attributes and are willing to provide training on care coordination functions. New hires receive fairly intensive on-the-job training that is developed in-house. Rush, Bellin and HPSM training occurs over the
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course of several weeks and includes a shadowing component where new employees shadow more experienced care managers before working independently. At Bellin, PCPs also
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participate in the training. None of the health systems studied require that care managers or case managers have certification, though two of the systems offer in-house certification upon completion of training. Bellin, Montefiore, and Rush work closely with their local nursing and vocational schools to stress the need for training on risk stratification, motivational
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interviewing, and team-based care; in addition, Rush advocates for this with social work schools at both local and national levels. They also serve as faculty or preceptors for students in order to increase the supply of qualified candidates.
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Payment and Reimbursement
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The challenge of financing care coordination is a major concern. At HPSM care management services are part of the overall capitation rate, but at the others there are few sources of explicit coverage. Montefiore has direct per-member-per-month arrangements for a portion of their population, such as their high-risk Medicaid population, but the bulk of their reimbursement incentives are derived from shared savings or other at risk-based contracts. Bellin was hoping that the new team-based model and increased emphasis on care coordination would allow them to increase primary care capacity and generate enough
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additional fee-for-service revenue to offset the workforce investments as they transition to value-based models. So far, that has not occurred and they report that they are hoping to
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negotiate explicit coverage of care management services in future contracts with private payers. They are also in the process of requiring that providers have 20 visits per day to have 2 CTCs assigned to their team. Rush discussed how the business case is made to the hospital
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leadership; they have focused on metrics such as 30 day readmissions, ED visits, and physician follow-up to demonstrate the impact of care management efforts.
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Discussion
We found that each of the organizations in our study has made a significant investment in their care coordination workforce in response to alternative payment models. This is consistent with a recent survey of ACO leaders that found nearly all ACOs have invested in new staff to support
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quality and care coordination activities.33 In contrast, a recent study of 12 sites that were just establishing patient-centered medical homes that were not necessarily tied to alternative payments found that not all had explicitly hired staff to fill care management roles with some
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distributing those functions to existing team members instead.4 This reinforces the power of
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creating new financial incentives that reward a greater focus on care coordination. This study supports earlier research which finds that care coordination is no longer a single profession but comprises an array of professionals working together as a team, aided by data analysts and other behind-the-scenes support, and requiring significant task delegation.34 Interestingly, all four sites were task shifting low complexity care coordination activities to LPNs and MAs and reserving RNs and social workers for more complex cases. This is not necessarily
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an easy transition and requires adapting organizational culture. For example, physicians may not initially trust their MAs or LPNs to take on these new roles. This is further compounded by
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the general lack of health professions training on care coordination and team-based care. The health systems in our case studies had to address important education gaps with on-the-job training or access to online training, with some offering in-house certification. This could be a
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costly investment, particularly if turnover of care managers, especially nurses, is as high as reported by one of our sites.
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The practice of care coordination is a very different nursing role than traditional beside care and involves additional skills and competencies, such as motivational interviewing and risk management, which are typically not a part of standard nursing education and training. Furthermore, study participants indicated that not all nurses enjoy providing telephonic care,
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which is the standard at three of the four sites, and they miss the face-to-face interactions. On the other hand, the role also involves longer-term patient relationships, more independence and an opportunity to have a profound impact on the health outcomes of complex patients
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with significant care needs which is seen as professionally rewarding. As with the RN role, the
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LPN role in care coordination is very different, too. Some sites preferred using LPNs versus MAs for their care coordination activities because LPNs have more clinical training and experience. Several of the sites are working with local nursing schools to refine the curriculum to include more training on care coordination related activities but this may be leading to a significant duplication of effort as they each look to develop training programs that meet their needs. In nursing education programs there has been some growth in graduate programs focused in care management. Organizations engaged in new payment and delivery models can enrich the
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nursing pipeline by supporting their RN case managers in helping to train the next generation, such as serving as preceptors for nursing students who need clinical experiences or taking on a
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faculty role at a local nursing school. We found that new payment incentives are not always fully aligned with making the necessary investments in care coordination. Under most of the new alternative payment models,
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providers continue to bill under fee-for-service 35 and hope that the costs of any care
coordination efforts will be recovered later in savings from improved health and reduced
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utilization of unneeded services such as repeat emergency room visits. Under these circumstances, making the business case for the needed investments in care coordination can be a challenge.36 In recent years, there has been some progress at the national level in producing better workforce data. The Center for Medicare Medicaid Innovation (CMMI)
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collected some workforce data as part of the evaluation of a new Comprehensive Primary Care Initiative (CPCI) 37 and the Centers for Disease Control and Prevention (CDC) now collects more
(NAMCS).38
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workforce elements as part of their annual National Ambulatory Medical Care Survey
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It will be important to continue to study how the care coordination workforce will evolve as more practices participate in alternative payment and as payment models continue to be refined. The sites we spoke with are very interested in getting better data on the overall return on investment, and in better understanding the effect of various care coordination staffing models on outcomes. The current lack of evidence on the care coordination workforce may be limiting investments during this important transition from fee-for-service to value-based payment systems.39
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Our study has several limitations. First, the sites are a convenience sample and are not representative of all health care organizations engaged in alternative payment models. We
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made an effort to ensure we included a mix of organizational characteristics such as region, payer mix, and percent of population at risk. Second, the interviewees may not represent all views at the organization but we tried to mitigate that by getting multiple perspectives at each
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site. This is intended as an exploratory project to identify important areas for further research. Conclusions
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Our findings suggest that coordination is now a team-based activity, with RNs playing a more defined role than they may have in the past, and new team members such as LPNS and MAs becoming more important. Payment arrangements are the major driver of care coordination but the need for reimbursement for care coordination services continues to be a top priority for
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health systems. Reimbursement is often indirect and it is difficult to demonstrate the returnon-investment. Given the variety of models, limited comparative effectiveness research, and general high expectations of care coordination activities, there remains a strong need for the
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research community to provide tools and resources that can help organizations that are looking
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to implement care coordination activities make the best use of limited workforce resources. In particular, the evolving role of nurses in care coordination team needs additional investigation and analysis to ensure their unique skills and training are used to maximum effect to support value-based care.
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Table 1. Overview of Health Workforce Care Coordination Innovation Models, Organizational Context and Staffing Montefiore Health System
Health Plan of San Mateo
Rush University Medical Center
Location
Green Bay, WI
The Bronx, NY
Chicago, IL
Organizational Context
Integrated delivery system; Major investment in primary care redesign to team based care. Preparing for transition from feefor-service to Value Based Payments; Goal to be 80% At Risk in next five years; Was a Pioneer ACO now Next Generation ACO
Academic medical center serving primarily low SES population; Continuing to build Care Management Organization (CMO) Strategic Plan to be 100% At Risk; Pioneer ACO, Medicare Advantage, Medicaid managed care, and private risk contracts.
San Mateo County, CA California managed Medicaid plan that includes patients enrolled in MediCal and Medicare
Number of Patients and Percent At Risk
125,000 (40% At Risk)
440, 000 (90% At Risk)
Who Does Care Management Activities
Extended Care Team: • RN Care Managers • Case Managers (SW) • Clinical Pharmacists • Behavioral Health (LPC) • Support staff
Education / Certification
16 week in-house training on team based care; developing extended care team training Developing in-house
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Primary Care Teams: • Care Team Coordinators (2:1 PCP; expanded MA/LPN role) • Behavioral Health (1:4 PCPs)
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Bellin Health
• •
•
•
• • •
LPNs and MAs RN care managers SW case managers Diabetes and asthma care teams Clinical pharmacists Certified diabetes educators Care transition specialists
In house training that includes three phases: • Core competencies • Care Transitions and
Academic medical center with strong commitment to case management and social determinants of health. Participates in a multiple fee for service and managed care contracts.
140,000 (100% at risk)
664 bed hospital (Medicaid Managed care at risk)
• Care coordination technicians • Care coordination nurse case managers • Dialysis nurse case manager • Nurse practitioner • Social worker
Heavily staffed by social workers; one particular model uses a team of nurses, social workers, and unlicensed patient navigators
In-house training Staff can voluntarily complete during work hours, a modularized, webbased course on
In-house training
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How Care Managers Interact with Patients
Mostly in primary care practices and inpatient settings; moving to specialists and nursing homes; involved significant construction budget to covert offices
CMO headquarters, some work from home; a few embedded in ER
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Where Care Managers Work
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Embedded in practice; Providers refer through warm hand-off if possible; If high risk score at discharge consult with provider regarding likelihood of patient engagement if referred Mostly face-to-face interactions; for high risk patients they also conduct home visits and accompany to visits
fundamental topics of care management
Faxing and phone referrals with physician network.
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How Care Managers Work Together with Providers
care management • Systems training The total hours of training vary by job from 34 hours to 109 hours. Limited. Centralized CMO; automatic referral for care management based on risk algorithm; notes/progress shared with PCP through EMR Primarily telephonic, rare home visits
Primarily telephonic NP conduct home visits to assess high risk patients and perform in home care until patient stabilized At the managed care organization administrative site
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certification.
Care team meetings, emails, pager, electronic health record
Primarily telephonic; some in-person clinic and inpatient visits
Throughout the medical center campus
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39. Blumenthal D, Anderson G, Burke S, et al. Tailoring Complex-Care Management, Coordination, and Integration for High-Need, High-Cost Patients: A Vital Direction for
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Accessed on October 7, 2016.
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Title: Alternative Payment Models Lead to Strategic Care Coordination Workforce Investments
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Highlights: Value based payment is leading to enhanced care coordination staffing
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Sites are task shifting low complexity care coordination to unlicensed staff
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Important care coordination education gaps necessitate in-depth on-the-job training
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Demonstrating the ROI of care coordination staffing remains a challenge
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