How Patient-Centered Outcomes Drive Care Transformation: the Arizona Coalition Model

Introduction

This Quality Outlook series has focused on defining and measuring value in health care and discussed how quality measures can be used across multiple layers of the health care system to enhance clinical care, promote quality improvement, and hold providers and payers accountable for care and outcomes. 

This month, the Arizona Coalition to Transform Serious Illness Care (Arizona Coalition) released a white paper describing a new care model for holistic interdisciplinary support to address care and social determinants of health (SDoH) needs of people with serious illness and their family caregivers. The Arizona Coalition is a group of 40+ statewide stakeholders (eg, Area Agencies on Aging, palliative care providers, payers) in Arizona led by the Arizona Hospital and Healthcare Association (AzHHA) in collaboration with Discern Health, part of Real Chemistry, the Arizona End of Life Care Partnership, and the Coalition to Transform Advanced Care (C-TAC). AzHHA, Discern Health, and TopSight Partners conducted research, facilitated Arizona Coalition discussions, and led the development of the Arizona Coalition Model: Home- and community-based palliative care for the seriously ill. 

For the purposes of the model, “serious illness” refers to one or more chronic conditions that carry a higher risk of mortality and either negatively impacts a person’s daily function or quality of life, or excessively strains their caregivers. As many as 4 in 10 adult Americans have two or more chronic conditions like heart disease, cancer, chronic lung disease, stroke, Alzheimer disease, diabetes, and chronic kidney disease. Nationally, people with chronic and mental health conditions account for 90% of the 3.8 trillion dollars of health care expenditures. Many people with serious illness may need care beyond the traditional medical model, but do not have access to services that meet these needs. 

Many care model designs have prioritized payment over patients. The Arizona Coalition Model focuses instead on how to achieve key patient-centered outcomes. This blog post describes how a paradigm shift in care model design has the potential to transform clinical care, promote quality improvement, and hold providers accountable for delivering the care that patients with serious illness and their caregivers need.

Outcomes-focused Planning

The initiative to create the Arizona Coalition Model started with a deceptively simple goal: to improve the quality of care and outcomes for people with serious illness in Arizona. Rather than limiting what care program could be implemented based on which services would be covered by current payment mechanisms, the Arizona Coalition began by aligning on which outcomes to improve that would most meaningfully impact the lives of people with serious illness in Arizona. 

To select outcomes of focus, the Arizona Coalition reviewed quality measures data from the C-TAC Advanced Care Transformation Index and learned that Arizona was lagging behind other states in measures of community support and had higher use of intensive care. The Arizona Coalition decided their opportunity for highest impact was to identify which community services and supports could help patients and caregivers manage conditions at home, so they prioritized increasing “days at home” as the primary measure of success. For the purposes of evaluating the Arizona Model, the Arizona Coalition defined “days at home” as the average number of days that people in their last two years of life spend at home (ie, not in an institutional care setting, like the hospital). A recent study of ACOs found that people with serious illness spend 25 fewer days at home per year than people without serious illness. 

To evaluate the evidence for which services and supports might increase days at home, the Arizona Coalition conducted a best practices study and decided to “design and pilot a patient-centered home- and community-based palliative (HCBP) care and payment model that features comprehensive palliative care in collaboration with primary care and community-based services.” 

Patient-centered Design

Because identifying outcomes was the first step of design, the other elements of the model were selected with a primary goal of improving these outcomes. The Arizona Coalition focused on designing a care model that would meet patient needs to increase days at home, as well as these other patient-centered outcomes: improved patient and caregiver experience, more appropriate hospice utilization, lower utilization of crisis acute services, and improved equity in health outcomes.

The Arizona Coalition specified the population of serious illness patients as those with chronic conditions and either unmet care needs, uncoordinated patterns of care, excess hospitalizations, or SDoH-related challenges. The Coalition then conducted a literature review and interviews with a patient, caregivers, providers, payers, and other stakeholders to determine what the population would need to achieve the outcomes of interest and identify the services that should be included in the Arizona Coalition Model. Finally, after studying consensus standards and guidelines, conducting a survey of Arizona programs, reviewing best practices from other palliative care models, and consulting with experts, the Coalition identified the operational requirements (eg, staffing, workflows, partners, and resources) that would be needed to deliver the services and meet patient needs. 

Prioritizing Patients Over Payment

In building a holistic model of care, the Arizona Coalition advanced its goal of prioritizing patients over payment. With patient and family needs at the center of planning and delivery, organizations implementing the Arizona Coalition Model will deploy an interdisciplinary team or partner with community-based organizations to provide comprehensive assessment and care planning; address physical, psychosocial, and SDoH needs; offer education and caregiver support; leverage telehealth; and ensure services are delivered in an age-appropriate manner.

The Arizona Coalition is currently planning its next project to design a value-based payment model to pay for the holistic care model and pilot both the care and payment models at several sites across Arizona. In addition to the primary measures of success, the Arizona Coalition Model white paper suggests additional measures to support pilot evaluation and value-based payment: care planning and advance care planning, pain and symptom management, addressing SDoH, and staff experience.

Conclusions

By grounding design work in patient outcomes rather than payment limitations, the Arizona Coalition created a novel care model that can be used to develop programs supported by a variety of value-based and/or fee-for-service payment mechanisms, and administered by existing palliative care providers and hospices, hospitals and health systems, and health plans. The Arizona Coalition believes that the details of the Arizona Coalition Model could also inform development of the next CMS or CMMI payment model for serious illness.

The Arizona Coalition Model of Care has yet to be tested in its entirety, but the Arizona Coalition believes that the white paper will offer a starting point to provider and payer organizations that are interested in implementing programs to meet the holistic needs of people with serious illness and their families. 

About the Quality Outlook Commentary Series

Breakthrough treatments in cancer care, including precision therapies tailored to specific patient factors, are driving rapid changes in the definitions of oncology quality and value. Efforts to implement value-based care models in oncology must meet the demands of evolving science, new best care practices, and shifting patient priorities. Quality measures must be up-to-date and relevant. Payment models must recognize the challenges and costs of managing complex patient populations with diverse needs. In this JCP blog series, Quality Outlook, Discern Health will explore key issues in oncology quality and value through posts focused on measurement, value-based payment, and quality improvement.

About Theresa Schmidt, MA
Theresa Schmidt, MA has over 16 years of experience in health care policy, quality, and health information technology. As a Vice President at Discern Health, part of Real Chemistry she leverages a strong background in non-acute care, analytics, quality measures and quality improvement, value-based payment, and research to help Discern clients and partners achieve their business goals. Theresa has a diverse health care background and has held prior positions at the National Partnership for Hospice Innovation, Healthsperien, Avalere Health, and eHealth Data Solutions. She serves on the board of the Advancing Excellence in Long Term Care Collaborative.

About Alexis Malfesi, MSHS
Alexis Malfesi, MSHS is a Director at Real Chemistry. She works with stakeholders across the healthcare system to improve patient and caregiver outcomes and develop strategies for success in value-based environments. Alexis has expertise in quality measure development, patient and family engagement, and practice transformation.

About Vicki Buchda, MS, RN, NEA-BC
Vicki Buchda, MS, RN, NEA-BC serves as the Vice President, Care Improvement for the Arizona Hospital and Healthcare Association.  She is responsible for contributing to the organization’s mission: “Making Arizona the healthiest state in the Nation” by leading collaboratives to improve patient safety, patient experience, healthcare outcomes, and health equity. She is a highly skilled professional with demonstrated expertise in clinical and system leadership. Vicki is passionate about harm prevention, including harm from opioids, maternal health, advance care planning and health equity. Vicki has served in nursing and leadership roles within health systems including Mayo Clinic, Hawaii Pacific Health and Banner Health. 

About Tom Valuck, MD, JD
Tom Valuck is a Partner at Discern Health, part of Real Chemistry. He is a thought leader on health care system transformation and helps lead the firm’s focus on achieving better health and health care outcomes at a lower cost. Tom’s work at Discern includes facilitating the exploration of next-generation measurement and accountability models for health care delivery systems. He also helps clients develop strategies to achieve success within the value-based marketplace. 

 About Discern Health
Discern Health, part of Real Chemistry, uses research and strategic advisory services to help our clients improve health and health care through value-based payment and delivery models. These models align performance with incentives by rewarding doctors, hospitals, suppliers, and patients for working together to improve quality while lowering total costs. Real Chemistry is an independent provider of analytics-driven, digital-first research, marketing services, and communications to the healthcare sector.

About Arizona Hospital and Healthcare Association
AzHHA is the association giving Arizona hospitals a voice to collectively build better healthcare and health for Arizonans. As the champion for healthcare leadership in Arizona, AzHHA and its member hospitals explore ideas and take collaborative action at the state capitol, in hospitals and at home to attain the best healthcare outcomes for our community. Above all else, we put people and patients first through Better Care, Better Health and Lower Costs.