3 Ways Episodic Care Drives Value for Participants in Population Health Payment Structures

For champions of value-based care, it may feel like a marathon versus a sprint to achieve the Triple Aim. 

Many value-based care proponents believed that the Global and Professional Direct Contracting Model (GPDC) was the way to get on track. However, Elizabeth Fowler, the Centers for Medicare & Medicaid Services (CMS) Deputy Administrator, acknowledged on C-SPAN that it was destined for “disruptors and innovators” and not appealing to a wide range of organizations. Now, allowing for two voluntary risk options, GPDC has been redesigned as ACO REACH.

While the CMS Innovation Center carries on with the long-distance event, one model can offer significant learnings as a payment model and delivery-of-care example. In the following article, Integrated Care Solutions’ (ICS) experts explain how taking an episodic approach to care in managing patients can significantly pay off for value-based care organizations, including ACO REACH participants. 

Episodes of Care as Payment Structure vs. Care Delivery

An episodic payment model (commonly referred to as a “bundle”) measures the quality of a patient’s care across a “health episode,” such as a single illness or through the course of treatment, and reimburses care providers in one lump sum. 

Fowler and other leading healthcare experts agree that episodic modalities “aren’t going anywhere.” They offer a pathway to value-based care that is approachable for smaller and less experienced organizations. Yet, Brian Fuller, Chief Executive Officer at ICS and advocate of VBC organizations taking on more risk—beyond the bundle structure—addresses the broader implication of episodic models as it affects population health. 

“How can we take what we’ve learned from excelling at working within the bundled structure and delivering episodic clinical care and now plant that into a population-based structure?”

In a population-based arrangement, an organization agrees to accept responsibility for a population in exchange for a defined amount of money. VBC organizations that can capitalize on this model by tactically providing superior individual “episodic” clinical care within chronically ill populations stand to benefit most.  

The correlation is undeniable. According to ICS’ analysis of VBC partners, single patient “episodes” can compound the total cost of care for a population.  

“About 20% of beneficiaries have an episode of care in a given benefit year,” Fuller says. “If you look at those episodes of care over the year, it’s about 40% of the total cost of care for the entire population—we’re talking the sickest and hardest-to-manage census with the most chronic conditions, most comorbidities, most deficient in activities of daily living. If you don’t tackle what comprises 40% of your total cost of care, then you’re not going be successful.”

3 Considerations When Setting Up an ‘Episodic’ Clinical Framework 

“The capability and high degree of care coordination specialization generates very compelling financial and clinical quality results for a population health payment participant using that episode-of-care mindset.”

—Brian Fuller, ICS CEO

No. 1—Implement a Trifecta of Care Coordination
To address an “episode of care,” Fuller suggests implementing a trifecta of care coordination, which includes in-person and virtual support that’s directed by a registered nurse (RN). Implementing a care coordination framework through the lens of episodes of care has significant capability to close gaps.

Andrea Rizik, RN, and ICS’ Vice President of Clinical Integration and Operations, notes some major issues organizations deal with when it comes to standard care coordination.  

• Service support relies heavily on telephones versus integrated technology to connect patients to their care team.
• Minimal rounding in hospitals and hardly ever in skilled nursing facilities (SNFs)
• In-person oversight is often done by a social worker, health coach, licensed practical nurse (LPN), but rarely a registered nurse. 

As a comparison, the ICS model is designed to micromanage an episode. A Clinical Integration Nurse (CIN) oversees patient transitions from care settings and communicates with care providers, the patient, and family to ensure care continuity, a better overall experience, and avoid emergency room utilization, as well as hospitalization. Additionally, ICS provides a Care Transition Specialist who transitions patients back into their community and coordinates access to resources and services as needed. Lastly, the care team, including the provider, is connected through technology that provides valuable insights and analytics on the patient’s health and costs associated with care. 

ICS’ Director of Project Management Kristen Croke says data utilization is invaluable for applying an episodic mindset to population health.

“By diligently collecting and examining patient health data from multiple sources,” she says, “we gain a deep understanding of a patient population and can uncover where there are opportunities for us to fill gaps through targeted care initiatives that will directly impact patient outcomes.” 

No. 2—Ensure the Right Tools are in the Toolbox
“There’s a whole host of issues that patients face throughout an ‘episode,’” Rizik says. “You better have a tool or solution within your model that matches whatever it is that comes up. If you don’t, that care gap is going to potentially lead to lower quality outcomes and higher costs.”

The myriad issues that patients face include social determinants of health (SDoH), behavior health-related challenges, palliative / hospice, or advanced care planning. A clinical model must be able to address not only the primary clinical condition but any other underlying issues as well. 

“For example,” Rizik says, “A patient goes to the hospital for a chronic condition, but also has a behavioral issue like unmanaged Schizophrenia. For a variety of reasons, like forgetting to take medication, the behavioral issue keeps perpetuating that readmissions cycle. Not being able to address the health of the whole person could heavily influence the cost and utilization of medical services.”

A way ICS addresses an underlying issue is to focus on community-based care and provide the patient with resources. In every market, ICS built an asset inventory of service and health providers to close care gaps. In this case, it’s psychiatry support and other behavioral health community resources. As part of ICS’ risk-sharing model with partners, they will often directly fund services if they cannot identify the resources in their inventory to serve the patient’s needs.

No. 3—Map Care Plans with Well-Defined Interventions
Fact: Medicare-aged patients on average receive care at 2.2 settings following a hospitalization before transitioning to home or self care. 

Ensuring success across settings requires a value-based care organization to have a detailed understanding of the clinical, operational, regulatory, and reimbursement environment of all care settings within delivery-of-care models. 

“You have to understand the details across the episode of care—not just one setting,” Fuller says. “We’re talking long-term acute care, inpatient rehabilitation, skilled nursing, home health, hospice, and others.”  

To effectively work across episodes of care requires that VBC organizations know how each provider makes decisions, how operations may affect care, what the discharge process is like, and then, be able to nimbly plug into that system as a value-added partner to remove any barriers. 

ICS has built a Transition and Throughput Expectations (TTE) Checklist to inform care and transitions across settings. In addition to CIN patient check-ins every three days, the list includes: 

• Ensuring CIN communicates with patient within 24 hours
• Establishing Anticipated Date of Discharge (ADOD) based on nursing and therapy goals
• Making an appointment with primary community provider for 5-7 days post-discharge
• Reconciling medications with post-discharge providers

Though this sample list only highlights a few bullets, the actual checklist has nearly 30 to-do’s—within defined timelines of the patient stay—that cover process, quality, and patient oversight through the continuum, preventing any gaps in care. 

Relying on a care coordination partner that is really good at managing episodes of care will provide long-term value to organizations working within population health payment models. 

For value-based care organizations, successfully managing episodes of care can directly correlate with improved population health, and therefore, reduce total cost of care.

As the jog slogs on to define the best payment model to Triple Aim glory, the healthcare industry should pick up the pace—one step at a time—by incorporating an episodic mindset.

Additional Resources

How is Population Health Evolving? 
Are MSSP ACO Savings Gains Repeatable?
Discharge Planning: A Critical Component of the Care Continuum

ICS helps organizations transform from fee-for-service to value-based care and delivers ongoing care coordination, consulting, and expertise in data-driven processes necessary to achieve quality care and financial success. info@integratedcaresolutions.com
860-622-7645