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Long-Term Supports and Services as a Logical Next Step in the Evolution of Bundled Payments
The historical progression of bundled payments from acute care to post-acute care and the growing recognition of the value of home and community-based services create an interesting opportunity for sustainably integrating medical services with other long-term supports and services (LTSS). With increasing involvement by LTSS providers in care transition programs, there is a growing overlap between traditionally separate medical and LTSS. The low cost and community connectedness of LTSS providers may give them an advantage over traditional providers of care transition services, especially when their services are augmented by emerging mobile technology. Building on past lessons from efforts to incorporate community-based LTSS into traditional medical care models, such as care transitions, may help to inform successful future strategies to enable bundles to more efficiently achieve the Triple Aim.
Key words: home and community-based services, long-term supports and services, bundled payments, Medicare, Affordable Care Act, long-term care, prospective payment system
Healthcare policy makers have been attempting to link payments for multiple services that patients receive during an episode of care for more than 20 years.1 This bundling of services originated in the early 1980s with the establishment of the Medicare prospective payment system (PPS), in which the Medicare payment is based on a predetermined, fixed amount. The PPS was replaced by several similar iterations, the most recent of which is the Bundled Payments for Care Improvement (BPCI) initiative through the Affordable Care Act.2 In January 2015, the bundled payments model received a large boost when US Secretary of Health & Human Services (HHS) Sylvia Mathews Burwell announced that the HHS would aim to have 50% of Medicare payments tied to quality or value through alternative payment models, such as bundled payments, by the end of 2018.3
Although the healthcare reimbursement landscape grows increasingly supportive of bundled payments, there is increasing pressure to make bundles more cost-effective.4,5 To better understand how bundles may be more cost-effective in the future, it may be instructive to explore how bundled payment models have evolved. The historical progression of bundled payments from acute to post-acute care, combined with a growing recognition of the value of home and community-based services (HCBS) create an interesting opportunity for sustainably integrating medical services and long-term supports and services (LTSS) into bundles to more efficiently achieve the Triple Aim:6 to improve the individual experience of care, to improve the health of populations, and to reduce the per capita costs of care for populations.
History of Bundled Payments
The first attempt to use the PPS to replace the Medicare fee-for-service payment system with payment for an aggregation of services came in the form of diagnosis-related groups (DRGs). Beginning in the 1980s, patient episodes in acute care hospitals were reimbursed based on DRGs with a fixed fee, regardless of the actual costs incurred. As a result of the progressive DRG protocol, inpatient lengths of stay decreased and clinical outcomes improved.7
Over the next decade, the PPS model expanded beyond the hospital setting and into the post-acute care setting. In 1998, the PPS model was applied to skilled nursing facilities (SNFs) in the form of resource utilization groups (RUGs), which are the equivalent of DRGs for SNFs.8 The use of RUGs quickly became defined by standardized assessments using the Minimum Data Set and care management pathways, which were based on acute and chronic patient populations. The PPS next evolved beyond SNFs into home health in 2000, and home health resource groups were used as the equivalent of RUGs and DRGs for home care.9 These included acuity-based assessments and general care management pathways that were independent of patient acuity or chronicity.
The enactment of the Affordable Care Act in 2010 prompted the next and most recent generation of prospective payment: the BPCI initiative. This initiative uses DRGs but they can be applied to four models of care, each of which has different risk timeframes and parameters related to reimbursement of a bundle. These models of care include acute (Models 1 and 4), post-acute (Model 3), or both acute and post-acute care services (Model 2).2
Bundles in post-acute care have involved care transition models that are predominantly staffed by doctors and nurses, including the Care Transitions Intervention Model (caretransitions.org/), the Transitional Care Model (www.transitionalcare.info/), Guided Care (www.guidedcare.org/), and Geriatric Resources for Assessment and Care of Elders (GRACE).10 These care transition models each have been shown to reduce hospital readmissions.11–15 Major barriers to the sustainability of traditional transitional care interventions, however, are the costs to support nurse salaries and the growing nursing shortage in the United States.16 Furthermore, a substantial proportion of health determinants are upstream of the typical scope of practice and time bandwidth of a nurse transition coach, necessitating care coordination or functional supports that would more appropriately fall in the domain of LTSS provider expertise and reimbursement level.17,18
Role of LTSS
One opportunity to overcome the threat to sustainability facing transitional care interventions is leveraging an existing, underused workforce of more than 5 million frontline workers who provide LTSS to help the aging population maintain function and address nonmedical health determinants in the community.19,20 According to the Administration for Community Living (www.acl.gov), HCBS are services provided to individuals, such as frail older adults or adults with disabilities, who require daily living assistance due to physical, cognitive, or chronic health conditions.21 This workforce includes personal care attendants, home-delivered meal drivers, health coaches, community health workers, case managers, and other essential care providers who serve nonmedical functions,22,23 whom we will refer to as nonmedical workers. Nonmedical workers are involved in 8 of 10 hours of paid services to older patients and to individuals with disabilities,24 and there is growing evidence demonstrating that they can improve patient experience and outcomes.25–27 Furthermore, the average nonmedical worker is paid an hourly salary that is approximately 70% and 90% less than a nurse or physician salary, respectively.28
Although most transitional care interventions fail to tap into the nonmedical workforce, there are emerging technology-enabled care transition models using LTSS staff that minimize program cost while significantly improving outcomes.29,30 Additionally, at one point, there were more than 100 LTSS organizations engaged in the Community-based Care Transitions Program (CCTP), which was created by Section 3026 of the Affordable Care Act. According to the CCTP Website,31 “The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings to the Medicare program.” These HCBS providers, most of which are Area Agencies on Aging, have the staffing and processes in place to expand their transitions programs into bundled payment reimbursement models.31 The progression of bundled payments from acute care to postacute care to HCBS would be a logical way for bundles to lower care transition–related costs and more comprehensively reduce admissions by addressing upstream health determinants.
Incorporating HCBS-based care transition interventions into bundles could benefit the consumer, the bundle convener, and the HCBS provider. Consumer care would become more comprehensive due to the integration of medical care with functional supports. Conveners could reinforce their referral network by outsourcing to an HCBS provider and they would have a lower-cost care transition program compared with relying on their more expensive internal skilled nursing staff. Further, the HCBS provider would have the opportunity to diversify its revenue streams. This is particularly timely because Older Americans Act funding, a major source of funding for Area Agencies on Aging, is stagnating32 and a growing percentage of Medicaid funding for LTSS is shifting from fee-for-service to managed care, which is forcing LTSS providers to be more accountable for outcomes and have less guaranteed Medicaid revenue.33
Incorporating LTSS Into Bundles
The incorporation of an LTSS-supported care transition intervention could resemble the following process.
First, the Medicare beneficiary would be enrolled into a bundle for 60 days as part of a heart failure–related hospitalization. During this hospitalization, the patient would receive standard-of-care assessment, treatment, and stabilization.
The patient would be discharged 2 days after his or her hospital admission and subsequently transferred to a SNF. He or she would be clinically managed in the SNF by the staff in parallel with a transition coach from the LTSS provider.
The transition to home would begin just 6 days after the patient’s admission to the SNF. Once he or she achieves enough functional and clinical progress to safely transition to his or her residence, the transition coach in consultation with nurse colleagues would arrange adequate in-home supports to transition the patient. The transition coach from the LTSS provider could risk stratify the bundled patient in the SNF prior to being discharged to home, and the home care clinical staff could perform a start-of-care visit the day of the patient’s discharge. The convener’s nurse care manager could create a care plan in collaboration with the LTSS transition coach.
For the subsequent 60 days, the nonclinical transition coach would interact with the patient on an as-needed basis. The coach would be prompted by an app to answer smart surveys with adaptive, conversational questions that could be completed within 3 minutes. The evidence-based algorithms of that survey tool would assign a risk score to the response and risk-stratify the patient so that nurse care managers would be notified when it is appropriate for them to provide targeted interventions.34
Research has shown that in-person nurse involvement is needed in response to as many as 41% of elevated risk alerts.34 With daily communication among care team members and risk stratification of each consumer providing early indication of medical and nonmedical risk factors for readmission, the convener would be able to provide a gold standard of care while minimizing the use of expensive staff. A single entity, the convener, would manage the entire episode, since they are at risk for the financial costs of the care program.
Conclusion
As bundles programs mature and optimize their cost-effectiveness, it remains unknown if and how LTSS will be incorporated into the dynamic PPS. Reviewing lessons from previous efforts to incorporate LTSS into traditional medical care models, such as the CCTP program, may help to build on what was previously learned to more efficiently achieve the Triple Aim for the patients being served. Further research and quality improvement efforts are needed to better understand the value that LTSS may hold for other innovative care and financing models, such as chronic disease self-management, long-term care coordination, and other evolving opportunities to create value for consumers through the Affordable Care Act.
1. Altman SH. The lessons of Medicare’s prospective payment system show that the bundled payment program faces challenges. Health Aff (Millwood). 2012;31(9):1923-1930.
2. Mechanic R, Tompkins C. Lessons learned preparing for Medicare bundled payments. N Engl J Med. 2012;367(20):1873-1875.
3. Burwell SM. Setting value-based payment goals—HHS efforts to improve U.S. health care. N Engl J Med. 2015;372:897-899.
4. Lave JR. The effect of the Medicare prospective payment system. Annul Rev Public Health. 1989;10:141-161.
5. Coulam RF, Gaumer GL. Medicare’s prospective payment system: a critical appraisal. Health Care Financ Rev Annu Suppl. 1991:45-77.
6. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff. 2008;27(3):759–769.
7. Morrisey MA, Sloan FA, Valvona J. Shifting Medicare patients out of the hospital. Health Aff (Milwood). 1988;7(5):52-64.
8. White C. Rehabilitation therapy in skilled nursing facilities: effects of Medicare’s new prospective payment system. Health Aff (Milwood). 2003;22(3):214-223.
9. Murtaugh CM, McCall N, Moore S, Meadow A. Trends in Medicare home health care use: 1997-2001. Health Aff (Milwood). 2003;22(5):146-156.
10. Counsell SR, Callahan CM, Buttar AB, Clark DO, Frank KI. Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors. J Am Geriatr Soc. 2006;54(7):1136-1141.
11. Verhaegh KJ, MacNeil-Vroomen JL, Eslami S, Geerlings SE, de Rooij SE, Buurman BM. Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Health Aff (Millwood). 2014;33(9):1531-1539.
12. Leff B, Reider L, Frick KD, et al. Guided care and the cost of complex healthcare: a preliminary report. Am J Manag Care. 2009;15(8):555-559.
13. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.
14. Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675-684.
15. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-1828.
16. Juraschek SP, Zhang X, Ranganathan VK, Lin V. United States registered nurse workforce report card and shortage forecast. American Journal of Medical Quality. 2012;27(3):241-249.
17. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annu Rev Public Health. 2011;32:381-398.
18. Schroeder SA. We can do better—improving the health of the American people. N Engl J Med. 2007;357:1221-1228.
19. PolicyWorks: State-By-State Projected Demand for New Direct-Care Workers, 2006-16. Paraprofessional Health Institute (PHI) Website. http://phinational.org/fact-sheets/state-state-projected-demand-new-direct-care-workers-2006-16. Published December 2009; accessed September 30, 2015.
20. Brooks BA, Davis S, Frank-Lightfoot L, Kulbok PA, Poree S, Sgarlata L. Building a Community Health Worker Program: The Key to Better Care, Better Outcomes, & Lower Costs. Community Health Works. www.nursing.virginia.edu/media/2014-06-27_BCHWP.pdf. Published June 2014; accessed September 30, 2015.
21. Center for Disability and Aging Policy (CDAP). Administration on Community Living. http://www.acl.gov. Accessed March 4, 2015.
22. National Association for Area Agencies on Aging (n4a), Miami University Scripps Gerontology Center. Trends and New Directions Area Agencies on Aging Survey 2014. www.n4a.org/files/AAA%202014%20Survey.pdf. Accessed September 30, 2015.
23. Peebles V, Bohl A. The HCBS taxonomy: a new language for classifying home- and community-based services. MMRR. 2014;4(3):1-17.
24. Foster L, Brown R, Phillips B, Schore J, Carlson BL. Improving the quality of Medicaid personal assistance through consumer direction. Health Aff. 2003;W3-162-W3- 175.
25. Ritter PL, Ory MG, Laurent DD, Lorig K. Effects of chronic disease self-management programs for participants with higher depression scores: secondary analyses of an on-line and a small-group program. Transl Behav Med. 2014;4(4):398-406.
26. Tennstedt S, Howland J, Lachman M, Peterson E, Kasten L, Jette A. A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. J Gerontol B Psychol Sci Soc Sci. 1998;53(6):P384-P392.
27. Li F, Harmer P, Stock R, et al. Implementing an evidence-based fall prevention program in an outpatient clinical setting. J Am Geriatr Soc. 2013;61(12):2142-2149.
28. Bureau of Labor and Statistics Website. www.bls.gov. Accessed September 30, 2015.
29. Health Care Innovations Exchange. Service Delivery Innovation: Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology to Identify and Support At-Risk Medicare Patients After Discharge. Agency for Healthcare Research and Quality (AHRQ) Website. https://psnet.ahrq.gov/resources/resource/28219. Published July 30, 2014; accessed September 30, 2015.
30. Munevar D, Drozd E, Ostrovsky A. Correlation between Medicare A spending and hospitalization risk score using mobile technology. Avalere Idependent Analysis. Published September 2015.
31. Community-based Care Transitions Program. Centers for Medicare & Medicaid Services (CMS) Website. http://innovation.cms.gov/initiatives/CCTP/. Accessed September 30, 2015.
32. Ostrovsky A, Mate K. Learning from Starbucks: How to Keep the Cup Full as Older Americans Act Funding Dries Up. Institute for Healthcare Improvement Website. www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=84e15604-08bf-4317-8323-cf46b485b7c0&ID=17. Published August 15, 2014; accessed September 30, 2015.
33. Burwell B, Kasten J. Transitioning long term services and supports providers into managed care programs. Centers for Medicare and Medicaid Services website. http://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/downloads/transitioning-ltss.pdf. Published May 2013; accessed November 9, 2015.
34. Ostrovsky A, O’Connor L, Marshal O, et al. Predicting 30-120 day readmission risk among Medicare FFS patients using non-medical workers and mobile technology. Perspectives in Health and Information Management. In press.
