How ACOs Are Caring for People with Complex Needs Kristen A. Peck Benjamin Usadi Alexander Mainor Helen Newton Ellen Meara December 2018 How ACOs Are Caring for People with Complex Needs Kristen A. Peck, Benjamin Usadi, Alexander Mainor, Helen Newton, and Ellen Meara ABSTR AC T ISSUE With an incentive to provide high-quality care while controlling costs, accountable care organizations (ACOs) may focus on patients who require the most resources and are most at risk for encountering serious problems with their care. Understanding how ACOs approach care for complex patients requires examination of their organizational strategies, contracting details, and leadership structures. GOALS Describe the specific strategies employed by ACOs that have comprehensive care management programs and processes for complex patients. METHODS Cross-sectional descriptive analysis of the fourth wave of the National Survey of ACOs. KEY FINDINGS Most ACOs report having comprehensive chronic care management processes or programs in place to manage people with complex needs. More labor-intensive interventions, however, are rare. Few ACOs report having advanced programs for engaging patients, in-home visits after hospital discharge, or evidence-based services for patients needing mental health or addiction treatment. CONCLUSION While ACOs have increased their efforts to target populations with complex care needs, there is a need for more varied approaches to improving care delivery. December 2018 2 REPORT How ACOs Are Caring for People with Complex Needs INTRO D U C TIO N People with complex care needs account for nearly one-fifth of all health care spending, even though they comprise only 1 percent of patients.1 These are individuals with multiple chronic conditions or functional limitations; people whose conditions carry significant nonmedical needs; and frail older adults. Their mental health, physical health, and social needs require coordination across numerous providers, family caregivers, and social service agencies. Traditional fee-for-service payment models rarely reimburse for the coordination, care management, and team-based care that this population needs. Emerging models of health care payment and delivery, such as ACOs, present an opportunity to improve quality of care and lower costs for people with complex needs and a range of medical and social issues. Unlike fee-for-service, ACO contracts award providers with bonus payments tied to cost and quality performance for their assigned patients. So far, ACOs have achieved modest reductions in health care spending (with Pioneer and Next Generation ACOs producing more promising results than ACOs in the Medicare Shared Savings Program), and care quality has improved without raising costs — an increase in the value of health care. 2 Given their incentives to reduce cost and improve quality, ACOs often employ care management programs that follow evidence-based strategies for increasing the value of care delivered to people with complex needs. These strategies include: • identifying people who are at high risk for adverse clinical events (often referred to as risk stratification) • separating high-risk patients into subgroups with common needs (segmentation) • improving care transitions across settings • engaging individuals and their families in care decisions • using programs that help patients address chronic illness.3 Understanding the variation in ACOs’ use of these strategies is a useful first step in determining a standard of care for this population. To better gauge ACO efforts to manage care of people with complex needs, we analyzed responses to the fourth wave of the National Survey of ACOs, fielded in 2017–18. Wave 4 included several questions regarding the use of evidence-based approaches to managing care for this population, including risk stratification, segmentation, improvement in care transitions, engagement of patients and families in care decisions, and chronic condition management. Based on responses to those questions, we assessed the extent to which organizations have adopted approaches with special relevance for complex populations. We also created an index of ACOs’ ability to simultaneously implement these approaches. For a full list of survey questions used in this analysis, see Appendix Table 1. December 2018 3 REPORT How ACOs Are Caring for People with Complex Needs FIN DIN G S Care management has emerged as a leading evidence-based approach to meeting the multifaceted needs of people requiringExhibit 1 care.4 The National Survey of ACOs allows us to assess the landscape complex of chronic care management programs and processes and identify where ACOs may need to pay more “To what extent are chronic care management processes and programs attention to the strategies incorporated in care management programs. to manage patients with high-need, high-cost chronic illnesses?” To characterize the current state of EXHIBIT 1 evidence-based approaches for the care of people with complex needs, we grouped ACOs by their overall use 4% of care management processes and Few or no care management programs — that is, by whether they programs reported having either comprehensive programs or, alternatively, few or no “To what extent are chronic care management programs. We then analyzed ACOs’ uptake of specific evidence-based 33% processes and programs Some care approaches for the care of patients management in place to manage programs with complex needs. patients with high-need, high-cost In the survey, most ACOs (63%) report having comprehensive care chronic illnesses?” management programs and processes 63% Comprehensive (referred to here as simply “care care management management programs”) in place, based programs on their response of 7 or higher on a 9-point scale (Exhibit 1). In contrast, 33 percent report they have Notes: The National Survey of ACOs uses a National Survey ofwith definitions9-pointlowest, middle,withtop thirds defined as “few or no comprehensive care manag only “some” Notes: The 9-point Likert scale, ACOs uses a for the Likert scale, and definitions for the lowest, middle, and top thirds defined as “few or no comprehensive care management processes or or programs” (1–3); “some comprehensive care management processes or programs” (4–6); or “comprehensive chronic care management processes or programs in pla care management programs in ACOs. n = 394 place, programs” (1–3); “some comprehensive care management processes or programs” (4–6); or “comprehensive chronic care management processes or programs in place” (7–9). n = 394 ACOs. while 4 percent say they have “few or no” such programs. Source: Kristen A. Peck et al., How ACOs Are Caring for People with Complex Needs (Commonwealth Fund, John A. Hartford Milbank Memorial Fund, Peterson Center on Healthcare, Robert Wood Johnson Foundation, and SCAN Foundation, Dec Below, we stratify ACOs according to their implementation of care management programs to compare approaches to three related strategies important for the care of complex populations: patient identification, patient engagement, and care transitions. This information will help ACO leaders, health care delivery and population health experts, and policymakers understand the range of activities that could be incorporated into care management programs to provide better care for people with complex needs. Identification and Engagement People with complex needs are heterogeneous in terms of diagnoses, nonmedical needs, and functional status.5 Health care organizations often try to identify patients at highest risk for poor outcomes so they can deploy limited resources where they are likely to have the greatest impact. By identifying people with complex needs (often through analysis of electronic medical records), providers can better deliver targeted, proactive care. Over half (52%) of ACOs reporting comprehensive care management programs state that they have an advanced system in place to identify and target patients using predictive risk stratification for their attributed patients (Exhibit 2), compared with only 29 percent of other ACOs. December 2018 4 REPORT How ACOs Are Caring for People with Complex Needs A related but distinct approach Exhibit 2 EXHIBIT 2 to tailoring scarce resources for complex populations involves Percent patient ofPercent with comprehensive care management programs parti ACOs of ACOs with comprehensive care management segmentation, or the grouping of patient identification and engagement approaches in programs participating in patient identification and high-risk patients along similar engagement approaches clinical or nonclinical needs based on administrative data.6 Such segmentation is used to design more 1 Clinicians are trained in patient activation and engagement 38% effective interventions.7 Most survey respondents (66%), regardless of their ACO’s care management score, report 2 Clinicians encourage ACO patients to be actively involved in decisions 38% that their organization segments high-risk patients into subgroups based on common needs, such as 3 Advanced* system is in place for predictive risk stratification 52% frailty, mental illness, or combination of chronic conditions. 4 Segment high-risk patients into subgroups based on common needs 68% Engaging and activating patients has been shown to decrease long-term Notes: Full text of NSACO questions: 1. Most or all clinicians are trained in patient activation and health care costs and to improve engagement methods and techniques (e.g., two-way communication, motivational interviewing, health care experiences.8 Yet even etc.). 2. Comprehensive* processes in place for clinicians to encourage ACO patients to be actively involved in decisions involving their care and self–management of their conditions. among ACOs with comprehensive 3. Comprehensive* systems are in place for predictive risk stratification for patients attributed to Full text of NSACO questions: 1. Most or all clinicians are trained in patient activation and engagement methods and techniques (e.g., two-way communication, motivat the ACO. 4. Segment high-risk patients into subgroups based on common needs (e.g., frailty, mental care management programs, clinician etc.). 2. Comprehensive* processes in place for clinicians to encourage ACO patients to be actively involved in decisions involving their care and self–management of th 3. Comprehensive* systems are insimilar combinations stratification for patients attributed to the ACO. 4. Segment high-risk patients into subgroups based on comm illness, place for predictive risk of chronic conditions). training in activation and engagement mental illness, similar combinations of chronic conditions). (e.g., frailty, * The NSACO instrument*used “comprehensive” in multiple variable response options. To avoidvariable response options. To avoidfor the “Comprehensive Care M The NSACO instrument used “comprehensive” in multiple confusion, we use “comprehensive” only is limited, as are programs to encouragerefer to all others as “advanced.” “comprehensive” only for the “Comprehensive Care Management” variable and variable and confusion, we use patient involvement in care decisions. refer to all others as “advanced.” Source: Kristen A. Peck et al., How ACOs Are Caring for People with Complex Needs (Commonwealth Fund, John A. Hartford Only two of every five (38%) ACOs with Milbank Memorial Fund, Peterson Center on Healthcare, Robert Wood Johnson Foundation, and SCAN Foundation, Dec comprehensive care management programs report that most or all their affiliated clinicians are trained in patient activation and engagement methods. And just 38 percent of these ACOs have advanced programs in place for clinicians to encourage ACO patients to be actively involved in decisions involving their care and in self-managing their conditions. The percentages are even lower for other ACOs, only 16 percent of which respond that most or all their clinicians are trained in patient engagement and 15 percent of which report having comprehensive programs to encourage patient involvement. Care Transitions The National Survey of ACOs asked organizations about seven components of evidence-based interventions designed to reduce risk of readmission for hospitalized individuals who are transitioning to home or a postacute care facility. ACO-reported use of interventions requiring one-on-one interaction between providers and patients is low. Despite being a prominent component of evidence-based care transition models, in-home follow-up is the least commonly used strategy for patients undergoing a care transition.9 Only 21 percent of surveyed ACOs with comprehensive care management programs report that most or all patients receive an in-home follow-up visit within 72 hours of discharge. And only 11 percent of the remaining ACOs said that most or all patients receive this in-home visit. December 2018 5 REPORT How ACOs Are Caring for People with Complex Needs Use of similarly labor-intensive programs is notably lower in ACOs that do not report comprehensive care management programs. For example, use of a postdischarge care manager or health coach is twice as common in ACOs with comprehensive care management programs (62%) as compared with other ACOs (31%). As shown in Exhibit 3, other strategies to reduce risk of hospital readmission — particularly processes facilitated through technology or automation — were more common in ACOs. Exhibit 3 EXHIBITmany of your ACO-attributed hospitalized patients undergoing a care transition to “How 3 home or a post-acute care facility receive the following services to reduce the risk of Percent of NSACO respondents reporting that most or all ACO-attributed hospitalized patients readmission?” receive the services Less comprehensive care management 11% In-home follow-up within 72 hours of discharge Comprehensive care management 21% 40% Inpatient patient navigator or care manager 52% 31% Postdischarge care manager or health coach 62% 65% Transmission of discharge summaries 76% 63% Process for timely follow-up with provider 79% 76% Medication reconciliation 78% 64% Telephone follow-up within 72 hours of discharge 83% Notes: NSACO response options were: all, most, some; none; and don’t know. ACOs with “less comprehensive care management” were defined as a response of 1–6, and ACOs with “comprehensive care management” were defined as a response of 7–9 on a Likert scale of 1–9 in response to NSACO question regarding chronic care management programs and processes. Source: Kristen A. Peck et al., How ACOs Are Caring for People with Complex Needs (Commonwealth Fund, John A. Hartford Foundation, Milbank Memorial Fund, Peterson Center on Healthcare, Robert Wood Johnson Foundation, and SCAN Foundation, Dec. 2018). Organizational Characteristics of ACOs Reporting Comprehensive Chronic Care Management Approaches The organizational characteristics included in the survey, including leadership structure and contracts with payers, vary according to ACOs’ self-reported level of care management. The majority of ACOs in both groups report having a Medicare contract: 82 percent of ACOs with comprehensive care management programs versus 85 percent for other ACOs. However, it is slightly more common for ACOs with comprehensive care management programs to have Medicaid ACO contracts compared to other ACOs (25% vs. 20%). A similar gap exists for commercial ACO contracts (75% vs. 67%). December 2018 6 REPORT How ACOs Are Caring for People with Complex Needs There are only modest differences between the leadership structures of ACOs with comprehensive care management programs and ACOs with no, few, or some care management programs. Fifty-two percent of ACOs in the former group are led by physicians, 32 percent are jointly led by hospitals and physicians, 9 percent are hospital-led, and 8 percent have other leadership arrangements such as coalitions or state, regional, or county organizations. The leadership structure of ACOs in the latter group are 56 percent physician-led, 25 percent jointly led, 9 percent hospital-led, and 10 percent have other leadership arrangements. Behavioral Health More than half of people with complex needs are estimated to have significant behavioral health comorbidities, suggesting that behavioral health services should be integrated with their primary care.10 In fact, there is growing evidence that effective integration of these services into primary care can improve behavioral health outcomes. These strategies, broadly labeled “collaborative care,” are similar to strategies used to improve care transitions. For example, collaborative care programs often employ care managers to address medical and nonmedical needs; have a consulting mental health clinician; and use a symptom registry to track mental health symptoms.11 In the survey, ACOs with comprehensive care management programs are more likely to use these strategies than ACOs without them, particularly with regard to care managers for nonmedical needs (75% vs. 53%) (Exhibit 4). However, less than 30 percent of NSACO respondents report using registries to track mental health symptoms, even though these registries are considered a critical component of evidence-based collaborative care models. Care Across Multiple Domains EXHIBIT 4 Exhibit 4 To better assess the simultaneous “Do any providers uptake of three domains above — patient in“Do any providerstheyour ACO use the followingintegrate primary your ACO use in following strategies to strategies to integrate primary care and treatment for depression care and treatment for depression and/or anxiety?” identification, patient engagement, and care transitions — we formed a measure and/or anxiety?” based on three questions, one from Less comprehensive care management each domain (Exhibit 5). We computed Comprehensive care management how many ACOs reported advanced approaches for three, two, one, or none of Patient registry 22% the domains. to track mental health symptoms 28% ACOs reporting comprehensive care management programs more frequently Mental health clinician 51% (not colocated) consulting have advanced approaches in one or more primary clinicians 61% of the three domains than other ACOs. However, 17 percent of these ACOs 53% Care manager for report no advanced approach for patient nonmedical needs 75% identification, patient engagement or care transitions, and only 21 percent have Care manager 57% evidence-based strategies in all three for mental health treatment 54% areas. More than half (55%) of ACOs that coordination* do not report having comprehensive care Percent of NSACO respondents replying “yes.” management programs indicate they have (Response options were “yes” and “no.”) zero advanced approaches to patient identification, patient engagement, or * This question was included on only the paper-based survey and reflects 78 responses. Peer support specialistsurvey and reflectsnot part of evidence-based collaborative care models. * This question was included on only the paper-based and telemedicine are 78 responses. Peer support care transitions. specialist and telemedicine are not part of evidence-based collaborative care models. Source: Kristen A. Peck et al., How ACOs Are Caring for People with Complex Needs (Commonwealth Fund, John A. Hartford Foundation, Milbank Memorial Fund, Peterson Center on Healthcare, Robert Wood Johnson Foundation, and SCAN Foundation, Dec. 2018). December 2018 7 REPORT How ACOs Are Caring for People with Complex Needs DISCUSSIO N EXHIBIT 5 AN D PO LIC Y 5 Exhibit ACO advanced care approaches for people with complex IM PLICATIO N S needs ACO advanced care approaches for people with complex needs More attention is being paid to Percent comprehensive care management ACOs improving the quality of care for people Percent less comprehensive care management ACOs with complex needs while slowing growth in their medical costs. The 55% adoption of evidence-based strategies to care for this population, however, varies widely across ACOs. Even among ACOs that have comprehensive care 38% management programs, relatively few have in place multiple evidence-based 29% strategies to enable those programs 24% to succeed. And while the majority of 21% ACOs identify and segment patients 17% with complex needs, these strategies are 13% more common in ACOs that also report 3% comprehensive care management programs. The majority of ACOs have 0 1 2 3 room to increase or enhance their Number of advanced care approaches programs to support patients with complex needs. Notes: The response options for the NSACO variables used for the “Number of Advanced Care Approaches Employed by ACO” summary measure was based on a 9-point Likert scale, where 1–3 “little or no”; 4–6 = “some”; and 7–9= “comprehensive” or “nearly all.” (The NSACO instrument used “comprehensive” in multiple variable response options. For simplicity, we use “comprehensive” the item on “Comprehensive Care Management Programs” and describe the “comprehensive” or “nearly all” response to other“Number ofas “advanced.”Carethree questions used include: Notes: The response options for the NSACO variables used for the survey items Advanced ) The While there is wide•variation in the to the ACO, to what extent is a system in place for predictive risk stratification? was based on a 9-point Likert scale, where 1–3 For patients attributed Approaches Employed by ACO” summary measure • To what extent are systems in place to assure smooth transitions of care across all practice settings including hospitals, long–term“nearly all.” (The NSACO and community–based hea = “few or no” or “little or no”; 4–6 = “some”; and 7–9= “comprehensive” or care, home care, adult day care, evidence-based care received by people services as needed? instrument used “comprehensive” in multiple variable response options. For simplicity, we use • To what extent are processes in place for clinicians to encourage ACO patients to be actively involved in decisions involving their care and self–management of their conditions? with complex needs, processes that “comprehensive” to describe only the item on “Comprehensive Care Management Programs” and describe the “comprehensive” or “nearly all” response to other survey items as “advanced.”) The incorporate one-on-one interaction three questions usedPeck et al., How ACOs Are Caring for People with Complex Needs (Commonwealth Fund, John A. Hartford Fou Source: Kristen A. include: are notably less common than other Milbank Memorial Fund, Peterson Center on Healthcare, Robert Wood Johnson Foundation, and SCAN Foundation, Dec. 201 • For patients attributed to the ACO, to what extent is a system in place for predictive risk processes. Only 30 percent of ACOs stratification? report that most or all clinicians receive • To what extent are systems in place to assure smooth transitions of care across all practice training and have processes available to settings including hospitals, long–term care, home care, adult day care, and community– based health and social services as needed? them to encourage patient engagement • To what extent are processes in place for clinicians to encourage ACO patients to be actively and activation. involved in decisions involving their care and self–management of their conditions? For people with complex physical conditions, co-occurring behavioral health needs require additional integration of behavioral health services into other general medical care.12 Despite the known behavioral health challenges of people with chronic conditions, ACOs incorporate collaborative care strategies unevenly. This implies that ACOs perceive their care management programs as comprehensive, even when their efforts to integrate behavioral health services with other care are modest. The findings above suggest there is opportunity for further collaboration between behavioral health providers, social service agencies, health systems, and payers to more fully address the care needs for complex patients. December 2018 8 REPORT How ACOs Are Caring for People with Complex Needs Finally, while research suggests that physician-led ACOs are more likely to generate spending reductions to achieve shared savings compared with other ACOs,13 organizations with comprehensive care management programs are not more likely to be physician-led than ACOs with less comprehensive care management programs. CO N CLUSIO N Although the majority of ACOs report in the survey that they have comprehensive chronic care management programs and processes for people with complex needs, there are several evidence-based strategies in which ACOs are not investing. There are many opportunities for ACOs to increase uptake of evidence-based strategies to address the needs of complex populations. Additional research is needed, however, to understand the value of more labor-intensive and costly programs, such as those related to patient engagement, one-on-one care transitions, and integration of physical and behavioral health services, as well as the outcomes associated with these programs. It is also important to learn how ACOs can accelerate their adoption of proven strategies. H OW WE CO N D U C TE D THIS STU DY NSACO Methods The most recent National Survey of ACOs was conducted by SSRS from July 20, 2017, to February 15, 2018. The survey was completed online by most respondents (77%). A paper survey with a subset of questions also was provided to potential respondents in December 2017 and again in January 2018. After screening out ineligible and overlapping organizations, our sample included an estimated 862 ACOs; we contacted an average of 3.2 potential respondents at each organization. Our outreach methods included email, phone calls, and physical mailings. About 55 percent of the sample returned a survey and 48 percent completed at least half of the core survey questions. ACOs with a Medicare ACO contract had a 69 percent response rate while ACOs without a Medicare contract had a 36 percent response rate. This survey is the fourth wave of the NSACO. We identified our sample through multiple sources including Centers for Medicare and Medicaid Services data, internet data collection, professional networking, and information from Leavitt Partners. Among the wave 4 survey responses, 394 ACOs provided data for all variables related to this report. Respondents typically had leadership roles in the ACO including ACO Executive Director (29%), ACO Vice President (7%), ACO Chief Executive Officer (15%), ACO Medical Director (9%) and Other (e.g., Chief Operating Officer, ACO Director, and Account Manager) (41%). December 2018 9 REPORT How ACOs Are Caring for People with Complex Needs NSACO Variables The NSACO variables used for this report: Question Response options To what extent are chronic care management 9-point Likert scale processes and programs in place to manage patients • 1–3: Few or no chronic care management processes or programs in place with high-need, high-cost chronic illnesses? • 4–6: Some chronic care management processes or programs in place • 7–9: Comprehensive chronic care management processes or programs in place For patients attributed to the ACO, to what extent is 9-point Likert scale a system in place for predictive risk stratification? • 1–3: Little or no ability to identify and target patients • 4–6: Some ability to identify and target patients • 7–9: Comprehensive ability to identify and target patients Do you segment high-risk patients into subgroups • No based on common needs (e.g., frailty, mental illness, • Yes similar combinations of chronic conditions)? To what extent are clinicians trained in patient 9-point Likert scale activation and engagement methods and • 1–3: Few or no clinicians receive training techniques (e.g., two-way communication, • 4–6: Some clinicians receive training motivational interviewing, etc.)? • 7–9: Most or all clinicians receive training To what extent are processes in place for clinicians 9-point Likert scale to encourage ACO patients to be actively involved in • 1–3: Few or no processes in place decisions involving their care and self–management • 4–6: Some processes in place of their conditions? • 7–9: Comprehensive program in place For how many of your ACO-attributed hospitalized • None patients undergoing a care transition to home or • Some a post-acute care facility receive the following • Most services to reduce the risk of readmission? • All • Medication reconciliation • Don’t know • Telephone follow-up (within 72 hours of discharge) • In-home follow-up (within 72 hours of discharge) • Standardized process in place to ensure timely follow-up with primary/specialty care • Discharge summaries are transmitted to clinicians accepting care of the patient • Use of a patient navigator or care manager while patient is in the hospital • Use of a care manager or health coach post-discharge Medicare contract Based on screeners Medicaid contract Based on screeners Commercial contract Based on screeners Which of the following best describes the leadership • Physician-led structure of your ACO? • Hospital-led • Jointly led by physicians and hospital • Coalition-led • State, region, or county-led • Other, please specify December 2018 10 REPORT How ACOs Are Caring for People with Complex Needs Question Response options Do any providers in your ACO use the following • No strategies to integrate primary care and treatment • Yes for depression and/or anxiety? • Care manager to primarily address mental health treatment coordination* • Care manager to address nonmedical needs (e.g., job support, housing) • Mental health clinician (not colocated) consulting primary care clinicians • Patient registries to track mental health symptoms • Telemedicine to treat a patient by phone or video • Peer support specialist To what extent are systems in place to assure 9-point Likert scale smooth transitions of care across all practice • 1–3: Few or no systems in place settings including hospitals, long–term care, home • 4–6: Some systems in place care, adult day care, and community–based health and social services as needed? • 7–9: Nearly all/all necessary systems program in place Note: Except for variables based on 9-point Likert scales, “seen but skipped” and “don’t know” responses were collapsed into the “No” or “None” categories. Care Management Across Domains To summarize ACO activity in each of the domains discussed above, we summarized answers to three questions. These three questions were selected to allow comparisons between wave 4 and prior NSACO survey waves in future work: a) “For patients attributed to the ACO, to what extent is a system in place for predictive risk stratification?” b) “To what extent are systems in place to assure smooth transitions of care across all practice settings including hospitals, long–term care, home care, adult day care, and community–based health and social services as needed?” and c) “To what extent are processes in place for clinicians to encourage ACO patients to be actively involved in decisions involving their care and self–management of their conditions?” For each of these three questions, a response of 1–6 was assigned 0 points and a response of 7–9 was assigned 1 point, yielding a range of 0 to 3 possible points per ACO. December 2018 11 REPORT How ACOs Are Caring for People with Complex Needs N OTES 1.Susan L. Hayes et al., High-Need, High-Cost Patients: Who 34, no. 3 (Mar. 2015): 431–37; and Susan L. Ivey et al., Are They and How Do They Use Health Care? A Population- “Patient Engagement in ACO Practices and Patient- Based Comparison of Demographics, Health Care Use, and Reported Outcomes Among Adults with Co-Occurring Expenditures (Commonwealth Fund, Aug. 2016); and Chronic Disease and Mental Health Conditions,” Medical Peter Long et al., eds., Effective Care for High-Need Patients: Care 56, no. 7 (July 2018): 551–56. Opportunities for Improving Outcomes, Value, and Health 9.Keane K. Lee et al., “Post-Discharge Follow-Up (National Academy of Medicine, 2017). Characteristics Associated with 30-Day Readmission 2.David Muhlestein et al., “Recent Progress in the Value After Heart Failure Hospitalization,” Medical Care 54, no. 4 Journey: Growth of ACOs and Value-Based Payment (Apr. 2016): 365–72. Models in 2018,” Health Affairs Blog, Aug. 14, 2018. 10.Joynt et al., “Segmenting High-Cost,” 2017; Blumenthal 3.Hayes et al., High-Need, 2016; Long et al., Effective Care, et al., “Caring for High-Need,” 2016; David Mancuso, 2017; and Center for Health Care Strategies, Programs Daniel J. Nordlund, and Barbara Felver, Frequent Focusing on High-Need, High-Cost Populations, fact sheet Emergency Room Visits Signal Substance Abuse and Mental (CHCS, Apr. 2016). Illness (Washington State Department of Social and Health Services, June 2004); and Susan L. Hayes, 4.Christine Vogeli et al., “Multiple Chronic Conditions: Douglas McCarthy, and David C. Radley, “The Impact of a Prevalence, Health Consequences, and Implications for Behavioral Health Condition on High-Need Adults,” To the Quality, Care Management, and Costs,” Journal of General Point (blog), Commonwealth Fund, Nov. 22, 2016. Internal Medicine 22, Suppl. 3 (Dec. 2007): 391–95; and Timothy W. Farrell et al., Care Management: Implications for 11.Jürgen Unützer et al., “Collaborative Care Management Medical Practice, Health Policy, and Health Services Research of Late-Life Depression in the Primary Care Setting: A (Econometrica, for the Agency for Healthcare Research Randomized Controlled Trial,” Journal of the American and Quality, Feb. 2015). Medical Association 288, no. 22 (Dec. 11, 2002): 2836–45; and Emily Woltmann et al., “Comparative Effectiveness 5.Karen E. Joynt et al., “Segmenting High-Cost Medicare of Collaborative Chronic Care Models for Mental Health Patients into Potentially Actionable Cohorts,” Healthcare Conditions Across Primary, Specialty, and Behavioral 5, no. 1–2 (Mar. 2017): 62–67. Health Care Settings: Systematic Review and Meta- 6.Hayes et al., High-Need, 2016; and Joynt et al., “Segmenting Analysis,” American Journal of Psychiatry 169, no. 8 (Aug. 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December 2018 12 The Commonwealth Fund How High Is America’s Health Care Cost Burden? 13 REPORT How ACOs Are Caring for People with Complex Needs Appendix Table 1. NSACO Questions and Response Frequencies by Care Management Capability Comprehensive Less comprehensive care management care management All capabilities capabilities Question Response category (n=394) (n=250) (n=144) To what extent are chronic care management 1–3: Few or no chronic 15 (4) processes and programs in place to manage care management patients with high-need, high-cost chronic illnesses? processes or programs [9-point Likert scale] Number (%) in place 4–6: Some chronic care 129 (33) management processes or programs in place 7–9: Comprehensive 250 (63) chronic care management processes or programs in place For patients attributed to the ACO, to what extent Advanced 173 (44) 131 (52) 42 (29) is a system in place for predictive risk stratification? Number (%) No/Little/Some 221 (56) 119 (48) 102 (71) Do you segment high-risk patients into subgroups Yes 261 (66) 171 (68) 90 (63) based on common needs (e.g., frailty, mental illness, similar combinations of chronic conditions)? No 133 (34) 79 (32) 54 (38) Number (%) To what extent are clinicians trained in patient Advanced 117 (30) 94 (38) 23 (16) activation and engagement methods and techniques (e.g., two-way communication, motivational No/Few/Some 277 (70) 156 (62) 121 (84) interviewing, etc.)? Number (%) To what extent are processes in place for clinicians Advanced 117 (30) 95 (38) 22 (15) to encourage ACO patients to be actively involved in decisions involving their care and self–management No/Few/Some 277 (70) 155 (62) 122 (85) of their conditions? Number (%) For how many of Medication reconciliation Most/All 303 (77) 194 (78) 109 (76) your ACO-attributed hospitalized patients None/Some 91 (23) 56 (22) 35 (24) undergoing a care Telephone follow-up (within Most/All 300 (76) 208 (83) 92 (64) transition to home 72 hours of discharge) or a post-acute care None/Some 94 (24) 42 (17) 52 (36) facility receive the following services In-home follow-up (within Most/All 68 (17) 52 (21) 16 (11) to reduce the risk of 72 hours of discharge) readmission? None/Some 326 (83) 198 (79) 128 (89) Number (%) Standardized process in Most/All 288 (73) 198 (79) 90 (63) place to ensure timely follow-up with primary/ None/Some 106 (27) 52 (21) 54 (38) specialty care Discharge summaries are Most/All 283 (72) 189 (76) 94 (65) transmitted to clinicians accepting care of the None/Some 111 (28) 61 (24) 50 (35) patient Use of a patient navigator or Most/All 187 (47) 130 (52) 57 (40) care manager while patient is in the hospital None/Some 207 (53) 120 (48) 87 (60) Use of a care manager or Most/All 201 (51) 156 (62) 45 (31) health coach post-discharge None/Some 193 (49) 94 (38) 99 (69) Medicare contract (based on screeners) Yes 328 (83) 205 (82) 123 (85) Number (%) No 66 (17) 45 (18) 21 (15) Medicaid contract (based on screeners) Yes 91 (23) 62 (25) 29 (20) Number (%) No 303 (77) 188 (75) 115 (80) December 2018 13 The Commonwealth Fund How High Is America’s Health Care Cost Burden? 14 REPORT How ACOs Are Caring for People with Complex Needs Comprehensive Less comprehensive care management care management All capabilities capabilities Question Response category (n=394) (n=250) (n=144) Commercial contract (based on screeners Yes 284 (72) 188 (75) 96 (67) Number (%) No 110 (28) 62 (25) 48 (33) Which of the following best describes the leadership Physician-led 210 (53) 130 (52) 80 (56) structure of your ACO? Number (%) Hospital-led 35 (9) 22 (9) 13 (9) Jointly led by physicians 115 (29) 79 (32) 36 (25) and hospital Other 34 (9) 19 (8) 15 (10) Do any providers in Care manager to primarily Yes 43 (55) 22 (54) 21 (57) your ACO use the address mental health following strategies treatment coordination* No 35 (45) 19 (46) 16 (43) to integrate primary care and treatment Care manager to address Yes 265 (67) 188 (75) 77 (53) for depression and/or nonmedical needs (e.g., job anxiety? Number (%) support, housing) No 129 (33) 62 (25) 67 (47) Mental health clinician Yes 226 (57) 152 (61) 74 (51) (not colocated) consulting primary care clinicians No 168 (43) 98 (39) 70 (49) Patient registries to track Yes 103 (26) 71 (28) 32 (22) mental health symptoms No 291 (74) 179 (72) 112 (78) Telemedicine to treat a Yes 118 (30) 75 (30) 43 (30) patient by phone or video No 276 (70) 175 (70) 101 (70) Peer support specialist Yes 74 (19) 49 (20) 25 (17) No 320 (81) 201 (80) 119 (83) To what extent are systems in place to assure Advanced 175 (44) 147 (59) 28 (19) smooth transitions of care across all practice settings including hospitals, long–term care, home care, adult No/Few/Some 219 (56) 103 (41) 116 (81) day care, and community–based health and social services as needed? Number (%) Number of advanced care approaches 0 122 (31) 43 (17) 79 (55) 1 136 (35) 94 (38) 42 (29) 2 79 (20) 60 (24) 19 (13) 3 57 (14) 53 (21) 4 (3) Table shows number (%) of ACO respondents reporting a given response. December 2018 14 This report is based on the fourth wave of the National Survey of ACOs. This wave was supported by the Commonwealth Fund (Grant no. 20160616), the National Institute of Mental Health of the National Institutes of Health (Grant no. R01MH109531), and the California Health Care Foundation (Grant no. 20249). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. For more information about this report, please contact: Kristen A. Peck Research Project Director The Dartmouth Institute for Health Policy and Clinical Practice kristen.a.peck@dartmouth.edu