Guest Author, Rodney Hornbake, M.D.

I practice medicine in a quiet corner of Connecticut half way between New York and Boston.  But despite my location, I am in close proximity to two Accountable Care Organizations (ACOs).  There are now four in our state approved by CMS and in operation.  Several more are expected to be approved to begin operation January 1, 2013 and one of these will cover the entire state.  Elsewhere, physician organizations and hospital systems are beginning to act as if they were already accountable for the quality and value of the services they provide.

I have taken part in the planning for one of these ACOs, by leading the development and implementation of clinical strategies designed to make the ACO successful. The vehicle for the ACO is a large Independent Practice Association (IPA) known as Medical Professional Services (MPS).  The IPA includes more than 400 physicians in central Connecticut.   The purpose of this blog is to share the deliberations and planning as they relate to home care and to explore how others outside Connecticut are addressing the same issue.

During 2011, MPS explored multiple opportunities that were available as a result of the Affordable Care Act.  The CMS initiatives and health care delivery reform approaches that MPS considered were:

1. The Bundled Payments for Care Improvement Initiative;
2. Independence at Home; and
3. Accountable Care Organizations.

As part of our deliberations in regard to the Bundled Payments initiative, MPS convened a meeting with the leadership of five local home health organizations.  These included not for profit agencies, a hospital-owned agency and a for-profit agency.  In a short time, the group identified strategies to:

1. Shift appropriate patients from facility based post-acute care to lower cost home based care;
2. Improve operations of primary care practices to provide optimal support to home care;
3. Improve operations of home care agencies to provide optimal support to primary care physicians; and
4. Focus care on patient-centered goals.  This last strategy relates directly to the desire of many patients to avoid hospitalization and to focus instead on palliative care or hospice care.

These strategies in turn were accompanied by specific tactics.

1. Share information.  This specifically means sharing discharge summaries and other key clinical documents with the home care agency.  (While the ACO anticipates health information exchange, a web portal or other high tech solutions, most agencies currently rely on faxes.)
2. Support functional teams.  Every home care nurse would share his or her cell phone number with the physician who in turn would provide his or her cell phone number to the home care nurse.  Other providers will be added to the nurse-physician team as needed.
3. Rapid cycle performance improvement.  MPS would host a weekly conference call to discuss every readmission from home care as well as every “near miss.”

In the end, MPS elected to become an Accountable Care Organization (CMS prohibits organizations from sharing in savings for more than one innovation project).  All the strategies and tactics developed to address bundled payments were adopted by the ACO when it began operation on July 1, 2012.

Other ACOs are also working to optimize post-acute care.  Detroit Medical Center includes eight acute care hospitals, multiple out-patient facilities and one post-acute care facility.  The health system has formed a virtual network of partnering post-acute providers and established a joint operating committee to oversee its operations.[1]  The focus is on improving clinical outcomes and efficiencies through collaboration on mutual goals.

HealthEast Care System in St. Paul, Minnesota is also relying on formalizing collaboration with selected post-acute providers to align the continuum of care to the maximum benefit of patients.[2]

Thus, while details vary from market to market, certain themes are emerging.  The most important one is collaboration among high performance organizations to achieve mutual goals.  Home health care organizations that understand this dynamic can strategically position their organizations in a rapidly evolving market place.