Four years into an ACO pilot program, physicians at Catholic Health Initiatives are easing into a new era of healthcare that requires more care coordination.
When one of the largest integrated healthcare systems in the country issues a stamp of success on a pilot project, it's a good idea to pay attention, especially if that success is rooted in one of the health models that leaders are counting on to transition from volume to value.
The accountable care organization as a model of care has its supporters and detractors. It's supposed accomplish the triple aim of healthcare, but the results from Medicare's 2012 Pioneer ACO program are mixed.
Pioneer ACO Program Ripe for Improvement, Providers Say
On one hand, nine out of the original 32 ACOs shared in savings; 19 reported no savings or losses. On the other hand, nine ACOS left the program. Two departed completely while seven transitioned to the similar, but less-stringent Medicare Shared Savings Program ACO arrangement.
CHI was not part of the Medicare Pioneer ACO group, but rolled out its own ACO pilot in three markets in 2010 anyway to test how well it was prepared for population health. The health system has since enrolled five of its six of its organizations into the MSSP ACO program, but early lessons from its own pilot are helping population health efforts for other patients now.
During its pilot project, CHI focused its efforts on coordinating care and payment for Medicare patients with one of four chronic diseases: coronary artery disease, chronic obstructive pulmonary disease, congestive heart failure, and pneumonia.
The ACO Pilot
Barry Hoover, MD, CHIS's executive sponsor of one of the pilot ACO sites in Nebraska reported reduced readmissions and improved outcomes. Hoover is also vice president and chief medical officer of The Physician Network, a subsidiary of CHI. The Physician Network includes more than 50 locations with PCPs, specialists, as well as urgent care providers.
Hoover maintains that the early ACO pilot helped inform the organization's next step of treating its 20,000 employees in Nebraska as a defined population.
"Employees came after the success of pilot, definitely," says Hoover. "There was a change in philosophy from an illness model to a wellness model."
Health coaches emerged as a success key from the ACO pilots and Hoover incorporated the coaches into the employee model. The health coaches are RNs and available to employees for help on typical wellness initiatives such as encouraging smoking cessation, weight management, and stress reduction.
But the coaches are not passive wellness caretakers, they are an active part of the care team, which Hoover says physicians learned to appreciate after initial skepticism about including another provider in a patient's treatment.
"There were concerns from doctors about sharing responsibility, and it took a while to earn trust, build relationships, and define roles and build team based care," he says. "Doctors learned quickly that health coaching skills are around patient engagement. It's time consuming to visit with patient to find out what they're motivated to work on. Once docs saw patients were benefitting, it was an easy sell."
At the outset of the pilot in Nebraska, Hoover says there were only two health coaches, but requests from physicians increased that to well over two dozen across Nebraska and parts of Iowa. Hoover reasons that investing in health coaches is the right thing to do because patient engagement is going to be a primary driver of successfully transitioning into a healthcare system that values wellness over illness.
The Value of Coaches
"Physicians manage about 20% of a patient's health, the rest is really determined by a patient's lifestyle," he says, adding coaches are trained to get patients to claim more ownership over their health. He points out that as a doctor, he can tell a patient to "lose 30 pounds," but knows that advice may be taken to heart only for the duration of the visit. A health coach has a different approach, an admittedly better one.
"A true skill set of health coaches is motivational interviewing," he says. "Let's say you have a patient who is 30 pounds overweight, smokes, and leads a sedentary lifestyle. What health coaches are skilled at doing is saying, 'Which of these areas would you like to approach now? It's identifying where the patient is motivated to do something now. They feel like it's a collaborative relationship."
Weight management is one of two focus areas Hoover says is most important among employees and patients. The other disease Hoovers says is important to get under control is diabetes.
As far as evidence pointing to the benefit of health coaching, Hoover uses an internal study done by senior year nursing students from the University of Nebraska Medical Center. They specifically wanted to find out the effects of having health coaches for patients who either had hypertension, diabetes, or needed to lose weight.
The study analyzed 80 patients, 40 who had a health coach and 40 who did not. Patients with hypertension had more progression and less regression than those without a health coach. Ninety percent of patients with a health coach improved managing their hypertension and only 10% regressed. The percentage of patients who regressed jumped to 30% without a health coach.
The findings were similar for patients with diabetes: patients who had a health coach reported progress 61% of the time; while only 30% improved when patients had no health coach. Weight management results were the same, too. Health coaches helped patients reduce their BMI and according to Hoover, maintain it, too.
Hoover also says they identify and connect with employees who are at high risk of developing chronic conditions.
"We are reaching out in a very proactive way to assist patients with diabetes, asthma, COPD, weight management, smoking cessation," says Hoover. We're learning to identify risk factors around heart failure, because heart failure patients are likely to be readmission."
Cost is Only One Factor
A side benefit of testing population health with employees is the residual effect on morale. That's not been studied yet, however Hoover says the job satisfaction rate among the health coaches is very high.
As for bending the cost curve for caring for these patients, Hoover says the expenses are not as much as originally thought and patient satisfaction is steady.
"Across our clinics, our patient satisfaction scores have been continued to be high; they haven't decreased," he says, cautiously pointing out that cost is not the only factor to consider when measuring success.
"My compass point is around the triple aim – improving the help of populations, in this case, our covered employees and their family members, decreasing per capita costs, and improving patient satisfaction. The goal is to branch out for other populations, whether it's in an ACO model, or state Medicaid model, or large employers."
Jacqueline Fellows is a contributing writer at HealthLeaders Media.