As the health care system continues to move toward a value-based model, at-home care providers are eager to show their worth. Many hope to do that in part by coordinating with clinical and community partners to deliver holistic care and improved patient outcomes.
But despite those ambitions, care coordination is easier said than done.
“Projects go back to the 1970s on how to coordinate care for these frail, vulnerable, home-bound individuals,” Lucy Theilheimer, chief strategy and impact officer at Meals on Wheels, told Home Health Care News. “That’s not an easy answer. And it might be a different answer in every community.”
However, there are two prevailing factors that tend to complicate care coordination: payment hurdles and communication complexities.
In health care, it doesn’t matter how revolutionary an innovation or idea is if no one is paying to make it possible. That’s long been the case when it comes to care coordination.
Slowly, that’s starting to change. In 2018, the U.S. Department of Health and Human Services (HHS) launched its “Regulatory Sprint to Coordinated Care.” The goal is to reduce regulatory burden and incentivize care coordination. But as is often the case, the bureaucratic sprint is more like a crawl, as changes are slow going.
In the meantime, many organizations are looking to value-based programs as the answer. The Centers for Medicare & Medicaid Services (CMS) continues to encourage participation in such programs, but the opportunities they create for care coordination are accompanied by uncertainty.
“The move toward more value-based payment arrangements … opens a lot of doors for making the case for investing in coordinated care initiatives,” Bonnie Ewald, associate director of the Center for Health and Social Care Integration at Rush University Medical Center in Chicago, told Home Health Care News.
The Center for Health and Social Care Integration houses the National Coalition on Care Coordination (N3C), which attempts to address issues related to care coordination between clinical and social organizations.
However, care coordination can entail many different elements and partners depending on an individuals’ care needs, making it complicated to identify the impact of care coordination efforts, Ewald said.
“A truly comprehensive care coordination initiative identifies someone’s strengths and care needs, assesses for underlying complexities and then follows up to get the pieces in place,” she said. “Doing that all takes time, and we don’t always see our impact right away.”
Another way providers have succeeded in getting care coordination efforts paid for is by hooking up with private payers and Medicare Advantage (MA) plans. Take, Arlington, Virginia-based Meals on Wheels, for example.
“Nobody’s really paying for this service,” Theilheimer told HHCN. “We have been conducting a pilot with Aetna, but that is outside the [MA] benefit structure.”
Meals on Wheels often partners with MA plans and private insurers to deliver its services, which include community connections and care coordination. Its partnership with the Hartford, Connecticut-based Aetna specifically targeted four markets, going beyond meal delivery and focusing on change of condition monitoring and care coordination for high-risk, high-need members.
In addition to delivering food, Meals on Wheels volunteers monitor a client’s condition and report changes to program staff, who would follow up with the senior and Aetna to prompt necessary interventions.
While results of the project are not yet public, previous research demonstrates that Meals on Wheels has improved seniors’ health while also saving money, further validating the power of the Meals on Wheels service model, which includes care coordination.
Research has shown that eight out of 10 seniors who had fallen reported that Meals on Wheels helped them not fall again. On top of that, the organization can serve a senior for a year for the cost of one day in the hospital.
“We’re hopeful that eventually, local community-based services like Meals on Wheels will one day be covered,” Theilheimer said. “Ideally, they’d be covered through Medicare and Medicaid. Through Medicare Advantage there’s currently more opportunity because they have more flexibility to cover some of these supplemental services.”
Meanwhile, HIPAA is regulatory hurdle that can be harder to clear.
“One thing that’s being looked at is what the federal government can do to clarify what HIPAA guidelines do allow for,” Ewald said. “HIPAA is often cited as a reason for providers to not share information with cross-sector partners, but since it is part of someone’s treatment, it actually generally would be allowed.”
N3C submitted comments asking HHS to clarify HIPAA earlier this year so that clinical providers can better identify what health information they can share.
“More guidance on that would be helpful because understandably, providers don’t want to cross the boundary if it’s potentially violating HIPAA,” Ewald said.
In the meantime, Signify Community has come up with its own solution — literally.
Part of Dallas, Texas-based Signify Health, Signify Community has rolled out a care coordination solution to tackle problems presented by HIPAA and other regulations by ensuring providers can only share what they’re legally allowed.
“We’re really trying to help an individual identify the needs and barriers that they have and those people in the community who can solve them in a coordinated way,” Jamo Rubin, president of Signify Community, told HHCN.
The ultimate goal is to help with information sharing to ensure that organizations are operating within the law but can also share important information between providers to deliver holistic care to patients.
“[Value-based care] is mashing together a clinical set of information and a nonclinical social set of information that tells a story about [a patient] holistically,” Rubin said. “That idea of mashing together data sets is governed by a matrix of state and federal laws that nobody has brought together onto a system where the viewing permissions can be controlled in a way that’s complaint with all the laws.”
Another common area of confusion in coordinating care is determining who is in charge or who is leading the care of a patient.
“There’s so many players that even the clients are being contacted by three, four, six or eight different people who are all trying to coordinate their care,” Theilheimer said. “I think there’s just so much confusion and chaos in this that it makes it really complicated to know exactly how to proceed.”
Given its boots on the ground, Meals on Wheels can quarterback care coordination at the community level. But at some point there will need to be agreement as to who is playing this role and how information will be shared among various providers.
There’s currently no right answer in terms of who should be calling the care coordination shots, Ewald said.
“Sometimes an insurance company will have a lead care coordinator, sometimes a hospital will, sometimes the Area Agency on Aging will, sometimes the home health agency will,” she said. “That’s good — all of those agencies should be stepping up and trying to help patients navigate issues; however, it gets confusing and inefficient at a certain point.”
To fix this issue, Ewald says there needs to be more research on who is best suited to quarterback a senior’s care. Currently, such research does not exist.