Accountable, Home-Based Care Affects Patients Nationwide

With home-based care options growing exponentially, some studies show when given the choice, more beneficiaries prefer in-home care vs in-facility care if feasible.

In an interview with First Report Managed Care, Maryann Lauletta, MD, FACHE, chief medical officer for Dina, discusses implications of the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) model, the Center for Medicare & Medicaid Services’ (CMS) emphasis on accountable care, and how home-based care options will matter for patients nationwide. Dina is a digital platform and network designed and run by a community of health care innovators to help facilitate the industry’s transition to digital, at-home health care models.

Please introduce yourself and tell us a bit about your background.
My name is Maryann Lauletta, MD, FACHE. I am an internal medicine physician by trade, currently serving as chief medical officer for Dina. I had previously worked as a hospital administrator and private practicing physician in every setting of care where the patients traveled from office to nursing home, assisted living, home, and hospital.

I also served as a medical director for a Medicare [Program of All-inclusive Care for the Elderly] PACE Program, which is actually pretty similar to a high-needs population ACO, which I find interesting. I also have been a physician champion for a health system ACO in a prior role, and I’ve spent much of my career focusing on value-based care initiatives such as Bundled Payments for Care Improvement, Delivery System Reform Incentive Payment, and PACE. I've also focused on equity and social determinants of health (SDoH) related initiatives.

I was leading principal investigator for an accountable health communities grant and had served on the board of Camden Coalition of Health Care Providers as well as on county- and state-based coalitions to fight against elder abuse, neglect, and exploitation.

Health equity has been a big focus and passion of mine as well as value-based care. I'm excited to talk about ACO REACH because I feel that it combines both of those passions into one.

Dina combines a curated network of health care providers, both traditional medical and nonmedical providers, as well as a care coordination logistics platform. The reason that I was excited to join Dina is because it was the first product that I saw that was able to connect all the different points of care that I served patients in.

It allows for proper transitions of care of patients to the most appropriate next level of care. It allows for provider to provider by directional communication to keep providers connected, talking about a patient. It allows for providers to connect with patients as well in a HIPAA compliant texting manner to keep the patients engaged on their care journey, and it also has the ability to gather data and present it back to the provider so they can drive change in their practice. I happen to be a former customer of Dina and I love the product so much. I stayed engaged with the company over the years, even though I changed roles and just always was looking for the opportunity to see how I could lend my expertise and passion to their mission and vision. It was a fortuitous event that I was able to join them and I'm very happy to be here.

Wonderful. Thank you so much, Maryann. Can you discuss ACO REACH and its implications?
As we all know, REACH stands for realizing equity, access, and community health, and it was created in response to feedback from stakeholders and participants. The intent is to provide high quality care for people with Medicare through better care coordination, connectivity of the health care providers with the beneficiaries, and to include those who have been traditionally underserved. The vision statement on the CMS webpage is: "A health care system that achieves equitable outcomes through high quality affordable person-centered care."

From my perspective, ACO REACH is elevating the value-based journey to its fullest potential. Not only is there a continued focus on increased quality while containing costs, but now that journey can be available to more beneficiaries regardless of socioeconomic status or geographic location. Addressing key SDoH issues is key to the long-term success of the Medicare program.

Earlier interventions addressing health disparities, and the ability to connect beneficiaries with quality primary care and services will hopefully prevent the care cascade of unnecessary interventions and visits that often happens when patients and beneficiaries are not connected into a good care coordination or care management program.

I do expect and hope that more entities will be willing to participate with the ACO REACH model now that some of the financial barriers and entry for the programs have been removed. There is a beneficiary level benchmark adjustment that will take place, and that is designed to reward providers with greater proportions of historically underserved beneficiaries to participate and receive potentially higher per beneficiary per month payments. It is leveling the playing field so that those who have been doing this work for a long time can receive some sort of credit or adjustment.

And what should health care executives consider as CMS places greater emphasis on accountable care?
CMS recently announced that their goal is to have all Medicare fee-for-service beneficiaries in a care relationship with accountability for quality and total cost of care by 2030. That is a lofty goal.

I think it is clearer now than ever that value-based programs are here to stay and that if you are not participating, now is the time to start. Health care executives need to evaluate any current arrangements in value-based care and assess their performance—looking for the gaps. Not only do they need to assess the performance of their own entities, but they need to have some understanding of what is happening with their postacute providers and the networks to which they are connecting the patients for care.

Executives should be seeking out every bit of education they possibly can. The CMS Innovation Center has an excellent REACH ACO webinar series and also they produce a lot of written guidance. In addition, there are ACO podcasts that are objective and unbiased, and I always find them helpful. It is great to hear it from CMS' perspective, but I would like to hear it from other provider groups that provide this service, what their experiences are, and whether they can share any best practices.

As a hospital executive, you need to find the people or health care executives in your organization that are your champions to help get the other providers who need to be involved in the delivery of care excited and understanding of why this is so important to achieve.

I think providers tend to have biases at times, and it is much easier to accept direction from those who are doing the same work that they are doing. I also think that it is important for executives to stay on top of new regulatory changes because the market is ever changing and without that, they will not be able to remain competitive. Again, I mentioned the provider’s postacute network and I think that is a key focus. You need to not only have a network that taps into traditional medical services, but also extends beyond into non-traditional services such as companion care, meal delivery, non-medical transport. That group of providers is growing rapidly and especially since the pandemic put it in hyper speed.

However, it is sometimes hard to assess the quality of care of those deeper in the network, which is why it is becoming important to partner with companies or organizations that can help evaluate that postacute network more fully.

Thank you for those insights. And how will home-based care options matter for patients nationwide?
Many studies have shown that when given the choice, beneficiaries prefer in-home care over in-facility care, if possible. The list of services available in the home, like I said, has been growing exponentially. But it can be a challenge to assess the quality and service delivery of those different service providers. The overarching goal of the ACO REACH model is to make sure care is coordinated appropriately, and beneficiaries receive services that are not only timely and effective, but pleasing to the beneficiary and create a positive impact on health outcomes. That is a tall measure to attain.

ACO REACH providers need to find new and creative ways to monitor and measure these home-based services to inform network curation going forward. Some ways to think creatively about measuring and monitoring is to solicit feedback from the beneficiaries in real time, when services are being rendered. This can be accomplished in simple ways such as text-based HIPAA compliant platforms. Keeping the home-based provider of the service in contact with the care coordination team from the ACO is key.

Another way to engage in HIPAA compliant, bidirectional, texting, or bidirectional communication on a platform so that those care coordinators know what is happening in the home, when those services are being rendered, and could be more proactive as opposed to trying to unravel or fix issues once they have risen. 

How do you think this will impact the future of health care?
I anticipate a lot more focus on SDoH screening. I know we have been talking about SDoH in the media for a while, but we do not always have it figured out in terms of how to get information from patients. The traditional history and physical examination and questions that are asked when a provider is interacting with a patient, do not always get to the root of those socioeconomic, psychologic issues that are happening in that patient's home. There are standardized screening questions and we need to be able to use some of those standardized questionnaires in a non-threatening, non-judgmental way.

One thing I found when I was overseeing the Accountable Health Communities grant was that patients or beneficiaries were more likely to answer when it was presented to them as something that was commonplace. We are asking everyone these questions as opposed to them feeling like they are singled out. For example, questions that could have sensitive answers when you're responding about personal safety issues such as access to food or safe housing. We need to create an environment for patients that makes them comfortable to tell the truth, because without them revealing what is happening in a home setting, we will not be able to create a proper care plan that fits and matches their needs.

Questionnaires can be given over a texting type of app to make it something that they're used to doing—like answering questions online for when they're signing up for StitchFix or some other service that collects preferences.

However, we need to not only ask the questions—we need to act on them. I think this is often frustrating for both providers, patients, and beneficiaries. We are gathering all this information, then what? It can't just be a data collection experiment, it has to be acted on in real time in a meaningful way. A one-size-fits-all approach in medicine is no longer appropriate. We need to consider the personal situation of the patient, again, going way beyond the clinical information.

We need to understand if the beneficiaries have trust in their providers, how they would like to receive care or information, whether they have the ability to pay for services, and whether they understand the impact of the services being offered. We need to have insight into their support systems or lack thereof. And then again, create plans that include them in the planning.

One of my biggest frustrations as a physician or a health care provider has always been that we tend to make care plans for patients or around patients, but not with patients. The patient needs to be not only included but at the center. That is where I think the future of health care is headed, placing the patient at the center of the journey, including them in the decision-making, activating them, and engaging them so they feel protected, heard, and understanding of the journey that needs to be undertaken.

Thank you so much. And is there anything else you would like to add to the conversation today that we didn't touch upon?
Patients do often choose to receive care in the home and there is now, like we said, a plethora of in-home care offerings. They are not all equal and you do not always have visibility into that because they may not be rated by CMS. There may not be a star rating. There may not be even anecdotal feedback online about a service.

I do think we need to find better ways to collect data both from the organization providing that care and the patient receiving the care, or their caregiver in the home's perception of the care to combine that information, to make it meaningful, present it back to the ACO or health care provider so that they can decide who is really on board with accomplishing the value-based mission or not. Perhaps the curating of data that is not publicly available that you solicit both by keeping those providers engaged as well as the patient.

The home environment is an unpredictable setting. That consideration needs to be given to limitations that happen in the home. Not all care can be 100% safely and effectively accomplished in the home setting. But I do think that with doing more SDoH screening, you will identify some of those issues beforehand so that you can ascertain who is and who is not appropriate for the home-provided services.

About Dr Lauletta
As Dina’s chief medical officer, Dr Lauletta helps the company advance its mission of delivering more care in the home and community. Dr Lauletta most recently served as medical director for Inspira Health’s Medicare PACE/LIFE program, a full risk-bearing model, providing all-inclusive care for the elderly, and as ACO physician champion for the Inspira Network. Prior to Inspira, Dr Lauletta was vice president of medical operations at Jefferson Health’s 3 hospital campuses in New Jersey (formerly Kennedy Health System), where she oversaw Case Management and Transitions of Care, Post-Acute Network Relations, and Utilization Management, and oversaw the Hospital Readmission Reduction Program and Bundled Payment Care Initiative. She is a member of the American Board of Internal Medicine, a Fellow of the American College of Healthcare Executives, and has earned many other industry certifications, including a Black Belt certification in Lean Six Sigma for Healthcare. She was appointed to the Camden Coalition of Healthcare Providers Board of Trustees in 2018 and served on the New Jersey State Task Force on abuse of persons who are elderly or disabled. She earned her medical degree in 1998 at the Hahnemann University School of Medicine (now Drexel University School of Medicine).