Importance Of NCQA ACO Accreditation

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Importance Of NCQA ACO Accreditation



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Our Promise Stories: NCQA means more than accreditation

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An actuarial evaluation of four medical home programs in Arizona, Colorado, Ohio, and Rhode Island, based on operation between and for 40, members, found average gross savings of 7. Including the cost of the intervention, the programs saved approximately 6. There are several common threads among studies reporting little or no benefit from the PCMH model. Some have used limited data sets or looked at outdated standards. Others drew conclusions that were not consistent with the design of the PCMH initiative in question or evaluated non-standard medical home models. Studies that reflect only marginal gains in quality and cost reduction have tended to focus on early, outdated demonstrations.

The Pennsylvania and Louisiana studies also both attempted to draw conclusions that were not supported by the goals of the demonstrations they evaluated. They found no cost savings, but neither initiative had cost savings as a goal or provided incentives to reduce spending. PCMH initiatives must provide sustained, meaningful financial incentives in order to achieve real success. Learn more about pandemic program and policy changes. Key Study Characteristics Size Variables of Interest Findings 25 practices providers Care for cardiovascular disease and diabetes 8.

Key Study Characteristics Size Variables of Interest Findings 27 NCQA PCMH practices; 17, attributed patients 29 control practices; 12, attributed patients 4 process measures related to diabetes care quality 1 process measure related to breast cancer screening Utilization of hospitals and emergency departments Utilization of primary vs.

Costs were further broken down into inpatient, outpatient, professional and prescription drug components Total costs savings of about 7. Key Study Characteristics Size Variables of Interest Findings In , 26 PCMH initiatives, including over 14, providers serving almost 5 million patients In , PCMH initiatives, including over 63, providers serving almost 21 million patients Growth in number of initiatives as well as the number of patients served by them Payment models as well as payment reform incentives within each initiative There has been fourfold growth nationally in the number of PCMH initiatives as well as the number of patients served by them, including expansion from only 18 states in to 44 states in The initiatives that included payment reform incentives have evolved from mostly small and time-limited demonstration programs to larger, more open-ended efforts.

The PCMH group experienced a significantly greater reduction in inpatient admissions in all 3 years 61, 48, and 94 hospitalizations per Key Study Characteristics Size Variables of Interest Findings , members in measurement year , in measurement year Adult rates of evidence-based screening Adult diabetes care Adult cardiac care Pediatric counseling for nutrition and physical activity Pediatric weight assessment Adolescent immunizations breast cancer screening rate : 71 PCMH vs. Key Study Characteristics Size Variables of Interest Findings 5 practices, compared with 34 control group practices ER utilization 3 diabetes measures 3 preventive screening You will be prompted to log in to your NCQA account.

Share this page with a friend or colleague by Email. We do not share your information with third parties. Twitter LinkedIn Facebook. Current Customer? Interested in PCMH? Contact Us Today! We're Here To Help. Rate of growth in Emergency Department ED use Rate of growth in costs of ED visits for all causes and ambulatory-care-sensitive conditions. Average Medicare payments Inpatient costs Emergency Department visits. Overall pilot included 16 practices, over K patients 8, were WellPoint Members. Inpatient hospitalizations ER utilization Specialist utilization Health plan return on investment. Care for patients with diabetes, cardiovascular disease Resource use: inappropriate antibiotic use Resource use: ED and hospital utilization, total costs.

Total health care expenditures per-capita Utilization patterns Use of non-medical support services by Medicaid beneficiaries. This paper explores the current landscape of PCMH services for patients with complex needs, details five programs that have addressed the challenges of caring for these patients, and offers programmatic and policy changes that can help smaller practices better deliver services to all patients, including those with the most complex health needs. In light of widespread problems with primary health care in the U. The patient-centered medical home PCMH is a model for strengthening primary care through the reorganization of existing practices to provide patient-centered, comprehensive, coordinated, and accessible care that is continuously improved through a systems-based approach to quality and safety AHRQ, Diverse stakeholders, including Federal and State agencies, insurers, physicians and other clinicians, employers, and patient advocacy organizations, are engaged in numerous efforts to promote primary care practice transformation into PCMHs through payment reform, practice support, and recognition programs Maxfield et al.

PCMH standards have focused thus far on improved access to and coordination of medical services. There are, however, some groups of patients with more complex health care needs who require more intensive medical services coordinated across multiple providers, as well as a wide range of social supports to maintain health and functioning. Because of the range and intensity of services needed, these patients tend to be the most costly, and PCMHs that can effectively coordinate the full range of medical, mental health, and social services may have special benefit for them.

In the process of acquiring such capabilities, primary care practices may become more effective in providing care to their broader patient population and better ready to serve when those patients suffer complex problems as well. This paper describes the challenges, as well as some promising approaches, for improving the capacity of primary care practices PCPs to deliver coordinated and comprehensive care to patients with complex needs. To explore this topic we consider two groups of community-dwelling, noninstitutionalized patients 1 with especially complex health and social support needs: 1 the frail elderly and 2 working-age adults with disabilities.

According to the American Community Survey, about 10 percent of adults ages 18 to 64 19 million individuals and 37 percent of adults age 65 and older 14 million individuals have a disability U. Census Bureau, Like all people with chronic health conditions, these patients generally use more health services and receive care from more and different health professionals than do people without chronic conditions. But most of these patients with complex care needs also have functional limitations, which means they often need assistance from family members or paid personal care assistants to perform activities of daily living, such as toileting, eating, and getting dressed.

They also frequently rely on such social services as accessible transportation or home-delivered meals provided by community organizations. Furthermore, given the complexity of their health problems, they are more likely to have chronic, progressive illnesses or experience life-threatening complications. Thus, palliative care and hospice services are more often a consideration for these patients than for others in primary care, further expanding the range of potential services that must be coordinated to optimize quality of life. In considering the challenges of providing high-quality primary care for these complex-needs patients, we focus particular attention on the capabilities of small practices. While the transformation of a practice into one that meets PCMH standards is difficult for most PCPs, it can be especially challenging for smaller practices where managing the workload is a daily struggle and where limited financial reserves, staff time, and administrative infrastructure may complicate practice redesign efforts.

Yet, most primary care clinicians work in such settings: 78 percent work in practices of 5 or fewer physicians Hing, The goal of this paper is to promote broader understanding and stimulate discussion about policies and strategies that could help typical smaller PCPs transform into effective medical homes that appropriately serve complex-needs patients. Accordingly, our audience includes private and public payers, policymakers, primary care professional leaders, primary care researchers, and advocates for the PCMH. We first discuss the importance and potential benefits of transforming current PCPs to serve these complex-needs population groups Chapter 2.

We then turn to the current challenges that prevent many primary care clinicians from doing so Chapter 3 and review the key elements of coordinating care for complex-needs populations Chapter 4. We next describe several successful programs across the country that work in collaboration with smaller PCPs to provide comprehensive, coordinated care across health and community social service systems. In this discussion, we identify lessons from their experiences Chapter5 and conclude by highlighting promising ways of overcoming the barriers to providing primary care to complex-needs patients, and we also identify topics for future research Chapter 6. Because of their severe or multiple health conditions and functional limitations, these patients are more likely to go to hospitals, emergency rooms, and long-term care facilities, and to need more supportive services to help with activities of daily living or arrange for transportation.

The frustration of patients is evident see Figure 1 , and the burden placed on their families is large. Even professionals with expertise in health care delivery and long-term care find it hard to navigate across the two systems. For example, Drs. Despite their own considerable expertise, the two doctors found it difficult to arrange reliable home care for their own family members who were frail or disabled.

Said Dr. If Rosalie and I can't do it, what chance does the average person have? The disjointed, myopic care Dr. Unfortunately, these experiences are all too common. An AARP survey showed that a significant proportion of older adults experience problems with their medical care, including a medical error 23 percent , poor communication 20 percent , readmission 15 percent , and lack of follow up 6 percent AARP, Indeed, the pediatrics profession first articulated the medical home concept more than 30years ago as a way to enhance primary care through better coordination of care for children with special health care needs Cooley, Because complex-needs patients receive services from multiple health professionals and social service agencies, they are at the highest risk for fragmented care and poor outcomes.

Examples include poor chronic disease care for those with persistent mental illness Frayne et al. A fully transformed PCMH practice should be able to address many of these shortcomings. We use the framework from Agency for Healthcare Research and Quality AHRQ for the core functions of the PCMH to describe in more detail how the medical home model could support the delivery of high quality primary care for patients with complex needs.

Patient-centered: The primary care medical home provides primary health care that is relationship-based with an orientation toward the whole person. Primary care clinicians typically cannot provide on their own the broad array of services often required by complex-needs patients, so medical homes may have to employ or partner with diverse teams of care providers. For patients with complex needs, the team might also include community mental health workers, personal care assistants, physical and occupational therapists, and family caregivers.

Coordinated care: The primary care medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, rehabilitation centers, home healthcare, and community services and supports. Patients with complex needs typically require not only abroad range of medical services provided by diverse clinicians and health care institutions but also home and community-based services HCBS to overcome functional limitations and maintain independence personal assistants, home modifications, home care aides, physical therapy, assistive technology, and respite programs supporting family caregivers, for example. Such patients may also need services to facilitate social participation in the community, such as accessible transportation and adult day care Peikes, Brown, Peterson et al.

The diversity of services calls for robust care coordination; without it, there is great risk of diffused professional responsibility and fragmented care that does not meet patient needs. Primary care coordination may also call for the medical home team to serve as an advocate for patients with complex needs. Superb access to care: The primary care medical home delivers accessible services.

For complex patients, the emphasis on enhanced access to timely care by medical homes is especially important, yet highly challenging. Over time, patients with multiple serious chronic conditions are subject to more health concerns and acute events, thus warranting more consultations with medical professionals. Patients nearing the end of life are often medically unstable and require timely access to medical advice to improve comfort and provide reassurance to family.

A systems-based approach to quality and safety: The primary care medical home demonstrates a commitment to quality and quality improvement. There are a host of challenges to assuring and improving the quality of care for patients with multiple chronic conditions Ostbye et al. Primary care clinicians can be overwhelmed by the task of keeping up with all of the recommended services and clinical guidelines for their care. Therefore, patients with complex needs would particularly benefit from the systems-based approach to quality and safety inherent to the PCMH, drawing on decision-support tools, taking into account patient experience, and using population health management approaches.

The organization and financing of the U. Many of the problems are compounded for PCPs trying to provide high quality care to patients with complex needs. The predominant method of paying physicians in the U. While this creates a barrier to effective primary care for any patient, it imposes even greater challenges to comprehensive and coordinated care for patients with complex illness. For example, it is more efficient under current FFS payment mechanisms to identify and document the health problems of a complex-needs patient and then refer that individual to specialists for diagnosis or treatment.

Moreover, physician fees do not cover the extra costs of comprehensive geriatric assessments Brangman and Hansen, , nor do they cover the additional time required to communicate with patients with cognitive impairments or to examine those with physical disabilities. Furthermore, FFS payments are generally based on documented services provided during encounters, which means there is no additional payment for non-visit-related care coordination activities like outreach to patients, collaborating with community agencies on care plans, determining patient eligibility for public assistance benefits, or consultations with specialists, family members, or home care providers.

For most PCPs, the additional effort to provide comprehensive assessment and management as well as care coordination for patients with complex needs will result in a financial loss to the practice, even if these efforts generate savings for the overall health system. The current FFS system also makes it hard for PCPs to provide enhanced access to care, an important service for complex-needs patients who often have urgent issues. Some of these patients, in fact, have considerable difficulty getting to the office for face-to-face encounters due to limited physical mobility, frailty, transportation issues, or cognitive impairment. Compounding the problem of limited reimbursement is the fact that complex-needs patients often have highly specific diagnostic and management issues.

While primary care clinicians may receive relevant training early in their careers, medical knowledge evolves over time, and needed competencies decline without use Choudhry, Fletcher, and Soumerai, ; Lin, Xirasagar, Lin, et al. Busy primary care clinicians generally cannot devote much time to maintaining skills and knowledge in narrow topics applicable to the care of just a few patients. For example, comprehensive care of frail elders requires skill in recognizing subtle depression; differential diagnosis of delirium, frailty, and cognitive impairment; management of poly-pharmacy; and knowledge of gero-pharmacology. Primary care clinicians with many older patients may keep abreast of new developments in geriatrics, but clinicians serving a predominantly younger population may not.

Similar issues arise for the care of patients with severe and persistent mental illness Croghan and Brown, , developmental disabilities, spinal cord injuries, and a host of other specific disabling conditions. Likewise, providing excellent palliative care requires its own specific knowledge base and competencies AAHPM, Thus, accountability for the comprehensive care of patients with uncommon problems can pose a substantial professional burden and an additional barrier to delivering high-quality primary care. Coordinated and comprehensive care of patients with complex needs is further challenged by new acute medical problems that these patients frequently present to primary care clinicians.

The natural history of chronic illnesses common to complex patients includes increased risk of acute complications, fluctuations in symptoms from the underlying condition, and incremental progression to organ failure. Therefore, primary care clinicians are compelled to address these acute medical issues when they arise. However, the time, attention, and emotional energy spent by the providers and the patient on these acute medical problems distracts from other important albeit less pressing activities, such as updating needs assessments in nonmedical domains, talking with family caregivers, and coordinating long-term support and community-based services.

The health and social service systems often have separate and distinct financing streams, delivery systems, professional training programs, eligibility rules, and terminology Leutz, These divisions further complicate the ability of primary care clinicians to manage the full range of services used by patients with complex care needs. Depending on their income and level of disability, these patients may or may not be eligible for Medicaid and other programs for the aged and disabled, which can provide services not covered by Medicare or traditional private insurance. A variety of community-based organizations, such as Area Agencies on Aging AAAs and community mental health programs, may provide access to needed resources for some patients with complex needs.

Depending on the covered benefits and reimbursement policies of State Medicaid programs, including those provided through waivers, other services may be available to some patients. Over three quarters of primary care clinicians in the United States work in practices of five or fewer physicians Hing, While larger medical groups may have more complicated governance, they can draw upon a greater number and breadth of personnel, sometimes including nurse practitioners, social workers, dietitians, pharmacists, and other health professionals who can assist in the management of some patients with complex needs. Larger practices can also permit and even encourage areas of special focus among primary care clinicians, allowing, for example, one to stay up-to-date on resources for people with severe mental illness and another on services for people with spinal cord injury.

Additionally, the substantially greater population of patients served by larger practices increases the likelihood of a critical mass of complex-needs patients with shared conditions and requirements. For smaller practices, the diverse range of impairments afflicting complex patients and the relatively low prevalence of such cases can create serious challenges. While some PCPs address this challenge through adopting a focus on patients with particular conditions for example, geriatrics and HIV medicine , most do not specialize this way or are located in communities without a sufficient number of patients of each type to make this model clinically appropriate or financially viable.

Thus, small PCPs rarely have sufficient numbers of patients with similar complex needs to make efficient use of any extra investments to develop relevant expertise and capabilities. When combined with inadequate provider payment and complicated health insurance and social service eligibility rules, few small practices can build and maintain the full range of internal expertise needed to effectively serve diverse complex patients. While the demonstration neither provided additional financial resources nor altered the underlying FFS system for participating practices, even the practices that had support from transformation facilitators were unable to put all of the basic components of a medical home in place during the 2-yeardemonstration.

Virtually all practices had difficulty integrating with community services or working in teams. Smaller PCPs will need additional resources and expertise to effectively coordinate and integrate care for complex-needs patients. In a PCMH, the level of care coordination depends largely on the complexity of needs of each patient:. Over the past 40 years, a variety of innovative care coordination programs have been developed and tested for these patient populations with complex needs.

Numerous trials, pilot programs, and demonstration shave produced consensus on the basic elements of coordinated care and case management 3 for them: 1 comprehensive needs assessment, 2 individualized care planning, 3 facilitating access to needed services, and 4 communication and monitoring Leutz, ; Nolte and McKee, ; Boult and Wieland, In describing each of these components of care coordination, we discuss the potential challenges faced by small PCPs in trying to deliver patient-centered primary care for patients with complex needs. This involves much more than a standard medical history and complete physical examination.

In addition to evaluation of medical diagnoses and the traditional family and social history, a comprehensive assessment should note how individuals function in their daily lives and with their family and other social supports. The purpose of this comprehensive assessment is to identify all care needs and preferences of both the patient and the caregivers that can be used to formulate the individualized care plan.

Ensuring complete assessment of each of these domains often requires a multidisciplinary team of health and mental health professionals, as well as social workers and therapists, depending on individual circumstances. Clearly, comprehensive needs assessment is much more than most primary care clinicians presently have the training or resources to perform. For example, the medical and social support service needs of an year-old patient with diabetes, double amputation, and renal failure are quite different from those of a year-old woman with diabetes, schizophrenia, and neuropathy.

Moreover, the knowledge, skills, and tools needed to assess the value of various long-term support services for these specific complex patients will be quite different from those a primary care clinician employs to diagnose the neuropathy or manage renal disease. In many cases, developing such a comprehensive assessment requires teamwork between the primary care practice team and those outside of the primary care setting, such as home health nurses, social workers, and caregivers. Patients, their families, and the care team should jointly create this plan. Ideally, it should reflect current and long-term needs and goals for care; specify the types and frequency of all planned health, rehabilitation, and mental health treatments, medications, home care services and supports, and other services; identify who is responsible for providing each service; and flag any critical issues that trigger a need to revise the plan.

In addition, the process of developing the care plan should involve the individual—and family members if appropriate—to ensure that it reflects their values and preferences. Additionally all members of the care team, including the patient, should have easy access to the plan. Even primary care clinicians trained to conduct comprehensive assessments of complex patients such as geriatricians and geriatric nurse practitioners will often need additional knowledge and resources to develop a realistic care plan for a specific patient with complex illness. The typical PCP does not determine which services someone with a specific disability may qualify for, through private health or disability insurance or public programs, so they may not be aware of the available benefits.

Family or other informal caregivers can also serve the needs of patients with complex illness, and their roles should be included in the care plan. Thus, to develop an adequate care plan, the medical home for these patients would need to devote the time and expertise to include family caregiving, reflecting cultural issues and family dynamics at play for each patient. Complex populations often have conditions and needs that require a multitude of health and long-term services and supports, so care coordination requires attention to a broader set of services than is typically offered by most PCPs. These services include assistive technology and durable medical equipment, ranging from canes and commodes to motorized wheelchairs, to provide mobility and independence.

Frequently, if individuals have disabilities that prevent them from performing activities of daily living, they might need hands-on help in the form of physical therapy, personal care assistance, transportation inaccessible vans to get to medical appointments or shop for groceries, and home-delivered meals. In addition, they often need help accessing public benefit programs, such as Medicaid or food stamps.

Assuming all of this—the comprehensive needs assessment, determining eligibility for public and private benefits, and selecting appropriate and accessible vendors—is done well, someone must arrange and facilitate receipt of these services. This poses another challenge to the small practice wanting to provide comprehensive primary care services to complex patients. Even if practice staff members can correctly determine what services are needed and whether the patient is eligible for benefits, they must find providers willing and able to deliver the services.

Primary care clinicians already struggle to coordinate care within the traditional medical care infrastructure Taylor, Lake, Nysenbaum et al. Experts in Behavioral Health and Medical Standards of Care With our services, BHM promises to meet or exceed client requested turnaround times and deliver accurate results. BHM provides behavioral health and medical review services, utilization and case management documentation to health plans, providers, TPAs, and other insurers nationally. BHM stands behind our expert results by offering delegated entity option. On-demand, in-depth reports inspire insights and metrics for continuous improvements.

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