Translating Evidence into Practice: ACOs' Use of Care Plans for Patients with Complex Health Needs

Taressa K Fraze, Laura B Beidler, Adam D M Briggs, Carrie H Colla, Taressa K Fraze, Laura B Beidler, Adam D M Briggs, Carrie H Colla

Abstract

Background: Care plans are an evidence-based strategy, encouraged by the Centers for Medicare and Medicaid Services, and are used to manage the care of patients with complex health needs that have been shown to lead to lower hospital costs and improved patient outcomes. Providers participating in payment reform, such as accountable care organizations, may be more likely to adopt care plans to manage complex patients.

Objective: To understand how Medicare accountable care organizations (ACOs) use care plans to manage patients with complex clinical needs.

Design: A qualitative study using semi-structured interviews with Medicare ACOs.

Participants: Thirty-nine interviews were conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff.

Approach: Development, structure, use, and management of care plans for complex patients at Medicare ACOs.

Key results: Most (11) of the interviewed ACOs reported using care plans to manage care of complex patients. All care plans include information about patient history, current medical needs, and future care plans. Beyond the core elements, care plans included elements based on the ACO's planned use and level of staff and patient engagement with care planning. Most care plans were developed and maintained by care management (not clinical) staff.

Conclusions: ACOs are using care plans for patients with complex needs, but their use of care plans does not always meet the best practices. In many cases, ACO usage of care plans does not align with prescribed best practices: ACOs are adapting use of care plans to better fit the needs of patients and providers.

Keywords: accountable care organizations; care plans; complex patients; primary care.

Conflict of interest statement

The authors declare that they do not have a conflict of interest.

Figures

Figure 1
Figure 1
Scope and function of care plans used by ACOs.

References

    1. Bynum JPW, Meara E, Chang C-H, Rhoads J, Bronner K. Our Parents, Ourselves: Health Care for an Aging Population. The Dartmouth Institute for Health Policy and Clinical Practice;2016.
    1. Pham HH, Schrag D, O’Malley AS, Wu B, Bach PB. Care patterns in Medicare and their implications for pay for performance. N Engl J Med. 2007;356(suppl):1130–1139. doi: 10.1056/NEJMsa063979.
    1. Vogeli C, Shields AE, Lee TA, et al. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med. 2007;22(Suppl 3(Suppl 3)):391–395. doi: 10.1007/s11606-007-0322-1.
    1. Center for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries: 2012 Edition. 2012.
    1. Ganeshan S, Gheihman G, Palmor M, Choi S, Wohler D, Rotenstein LS. Shared care planning: Realizing the promise of team-based person-centered care. Healthc (Amst). 2018;6(2):110–111. doi: 10.1016/j.hjdsi.2018.03.001.
    1. Grant RW, Adams AS, Bayliss EA, Heisler M. Establishing visit priorities for complex patients: A summary of the literature and conceptual model to guide innovative interventions. Healthcare (Amst) 2013;1(3-4):117–122. doi: 10.1016/j.hjdsi.2013.07.008.
    1. Rudin RS, Gidengil CA, Predmore Z, Schneider EC, Sorace J, Hornstein R. Identifying and Coordinating Care for Complex Patients: Findings from the Leading Edge of Analytics and Health Information Technology. (2162-8254 (Print)).
    1. Schoen C, Osborn R, Squires D, Doty M, Pierson R, Applebaum S. New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. (1544-5208 (Electronic)).
    1. Coulter A, Entwistle V, Eccles A, Ryan S, Shepperd S, Perera R. Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database Syst Rev. 2015;2015(3):CD010523. Published 2015 Mar 3. 10.1002/14651858.CD010523.pub2.
    1. Lion KC, Mangione-Smith R, Britto MT. Individualized plans of care to improve outcomes among children and adults with chronic illness: a systematic review. Care Manag J. 2014;15(1):11–25. doi: 10.1891/1521-0987.15.1.11.
    1. Mercer T, Bae J, Kipnes J, Velazquez M, Thomas S, Setji N. The highest utilizers of care: individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center. J Hosp Med. 2015;10(7):419–424. doi: 10.1002/jhm.2351.
    1. Department of Health and Human Services. Connected Care Toolkit. 2018; . Accessed June 6, 2019.
    1. Center for Medicare and Medicaid Innovation. Comprehensive primary care plus. 2016; . Accessed June 6ß, 2019.
    1. Center for Medicare and Medicaid Innovation. Primary care first. 2019; . Accessed June 6, 2019.
    1. Baker A, Cronin K, Conway PH, Desalvo KB, Rajkumar R, Press MJ. Making the Comprehensive Shared Care Plan a Reality. NEJM Catalyst. 2016; . Accessed 2019, May 16.
    1. Burt J, Rick J, Blakeman T, Protheroe J, Roland M, Bower P. Care plans and care planning in long-term conditions: a conceptual model. Prim Health Care Res Dev. 2014;15(4):342–354. doi: 10.1017/S1463423613000327.
    1. Edwards ST, Dorr DA, Landon BE. Can Personalized Care Planning Improve Primary Care? JAMA. 2017;318(1):25–26. doi: 10.1001/jama.2017.6953.
    1. Lhussier M, Eaton S, Forster N, Thomas M, Roberts S, Carr SM. Care planning for long-term conditions - a concept mapping. Health Expect. 2015;18(5):605–624. doi: 10.1111/hex.12063.
    1. Agency for Healthcare Research and Quality (AHRQ). Integrating Behavioral Health in Primary Care Playbook: develop a shared care plan. . Accessed October 11, 2018.
    1. Lewis VA, Colla CH, Schoenherr KE, Shortell SM, Fisher ES. Innovation in the Safety Net: Integrating community health centers through accountable care. J Gen Intern Med. 2014;29(11):1484-1490.
    1. Reuben DB, Tinetti ME. Goal-oriented patient care--an alternative health outcomes paradigm. N Engl J Med. 2012;366(9):777–779. doi: 10.1056/NEJMp1113631.
    1. Lewis VA, Schoenherr K, Fraze T, Cunningham A. Clinical coordination in accountable care organizations: A qualitative study. Health Care Manage Rev. 2018(1550-5030 (Electronic)).
    1. Colla CH, Lewis VA, Kao L-S, O’Malley AJ, Chang C-H, Fisher ES. Association Between Medicare Accountable Care Organization Implementation and Spending Among Clinically Vulnerable Beneficiaries. JAMA Intern Med. 2016;176(8):1167–1175. doi: 10.1001/jamainternmed.2016.2827.
    1. Wammes JJG, van der Wees PJ, Tanke MAC, Westert GP, Jeurissen PPT. Systematic review of high-cost patients’ characteristics and healthcare utilisation. BMJ Open. 2018;8(9):e023113–e023113. doi: 10.1136/bmjopen-2018-023113.
    1. Tumlinson A, Burke M, Alkema G. The CHRONIC Care Act of 2018: Advancing Care for Adults with Complex Needs. The SCAN Foundation March, 2018 2018.
    1. Center for Medicare and Medicaid Services. Connected Care: The Chronic Care Management Resource. 2020ß; . Accessed February, 13, 2020.
    1. Centers for Medicare and Medicaid Services. Innovation Models. . Accessed February, 13, 2020.
    1. NVivo for Mac [computer program]. 2014.
    1. Colla CH, Lewis VA, Shortell SM, Fisher ES. First National Survey of ACOs finds that physicians are playing strong leadership and ownership roles. health aff (Millwood). 2014;33(6):964-971.
    1. Miles MB, Huberman AM. J S. Qualitative data analysis: A sourcebook of new methods. Thousand Oaks: Sage; 2014.
    1. Reeves D, Hann M, Rick J, et al. Care plans and care planning in the management of long-term conditions in the UK: a controlled prospective cohort study. Br J Gen Pract. 2014;64(626):e568–e575. doi: 10.3399/bjgp14X681385.
    1. Sessums LL, McHugh SJ, Rajkumar R. Medicare’s Vision for Advanced Primary Care: New Directions for Care Delivery and Payment. JAMA. 2016;315(24):2665–2666. doi: 10.1001/jama.2016.4472.
    1. Tinetti ME, Esterson J, Ferris R, Posner P, Blaum CS. Patient Priority-Directed Decision Making and Care for Older Adults with Multiple Chronic Conditions. Clin Geriatr Med. 2016;32(2):261–275. doi: 10.1016/j.cger.2016.01.012.
    1. Tinetti ME, Naik AD, Dodson JA. Moving from disease-centered to patient goals–directed care for patients with multiple chronic conditions: Patient value-based care. JAMA Cardiol. 2016;1(1):9–10. doi: 10.1001/jamacardio.2015.0248.
    1. Council LS, Geffken D, Valeras AB, Orzano AJ, Rechisky A, Anderson S. A Medical Home: Changing the Way Patients and Teams Relate Through Patient-Centered Care Plans. Fam Syst Health. 2012;30(3):190–198. doi: 10.1037/a0029832.
    1. Leach B, Morgan P, Strand de Oliveira J, Hull S, Ostbye T, Everett C. Primary care multidisciplinary teams in practice: a qualitative study. BMC Fam Pract. 2017;18(1):115. Published 2017 Dec 29. 10.1186/s12875-017-0701-6.
    1. Lemueux-Charles L, McGuire WL. What Do We Know about Health Care Team Effectiveness? A Review of the Literature. Med Care Res Rev. 2006;63(3):263–300. doi: 10.1177/1077558706287003.
    1. Muntinga ME, Van Leeuwen KM, Schellevis FG, Nijpels G, Jansen APD. From concept to content: assessing the implementation fidelity of a chronic care model for frail, older people who live at home. BMC Health Serv Res. 2015;15:18. doi: 10.1186/s12913-014-0662-6.
    1. Gorbenko KO, Fraze T, Lewis VA. Redesigning Care Delivery with Patient Support Personnel: Learning from Accountable Care Organizations. Int J Care Coord. 2016;19(3-4):73–83. doi: 10.1177/2053434516676080.
    1. Lewis VA, Tierney KI, Fraze T, Murray GF. Care Transformation Strategies and Approaches of Accountable Care Organizations. Med Care Res Rev. 2019;76(3):291-314. 10.1177/1077558717737841
    1. Hudon C, Chouinard MC, Diadiou F, Lambert M, Bouliane D. Case Management in Primary Care for Frequent Users of Health Care Services With Chronic Diseases: A Qualitative Study of Patient and Family Experience. Ann Fam Med. 2015;13:523–538. doi: 10.1370/afm.1867.
    1. Peck KA, Usadi B, Mainor AJ, Fisher ES, Colla CH. ACO Contracts With Downside Financial Risk Growing, But Still In The Minority. (1544-5208 (Electronic)).
    1. McCarthy D, Ryan J, Klein S. Models of care for high-need, high-cost patients: an evidence synthesis. Commonw Fund. 2015;31:1–19.
    1. McWilliams JM. Cost Containment and the Tale of Care Coordination. N Engl J Med. 2016;375(23):2218–2220. doi: 10.1056/NEJMp1610821.

Source: PubMed

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