Community Health Teams (Montrose, 2012)
Care coordination is mentioned in the Affordable Care Act (ACA) under sections on quality improvement, payment reform, and monitoring savings, as well as within special considerations of patients with diabetes or depression, full Medicare-Medicaid beneficiaries, and health home members. Section 3502 of the Act establishes “Community Health Teams” (which bridge clinical and community settings) to support Patient-Centered Medical Homes and defines the role of these teams. They coordinate disease prevention and chronic disease management, develop interdisciplinary care plans, and involve patients and caregivers. They support primary care physicians (PCPs) by coordinating access to prevention, and services that are quality-driven, cost-effective, culturally appropriate, and patient- and family-centered. Community Health Teams provide access to pharmacist- delivered medication management services (including medication reconciliation) and coordination of the appropriate use of complementary and alternative medical services; they also promote effective strategies for monitoring health outcomes and resource use by sharing information, supporting treatment decisions, and organizing care to avoid duplication.
Patient-Centered Medical Homes, a.k.a. Health Homes (CMS, 2010)
Section 2703 of the Affordable Care Act directs CMS to develop health home services for Medicaid beneficiaries with chronic conditions. A health home is a Medicaid State Plan Option that provides a comprehensive system of care coordination for Medicaid individuals with chronic conditions. Health home providers will integrate and coordinate all primary, acute, behavioral health and long term services and supports to treat the “whole-person” across the lifespan. The health home services include:
- Comprehensive care management;
- Care coordination;
- Health promotion;
- Comprehensive transitional care/follow-up;
- Patient and family support; and
- Referral to community and social support services
The Accountable Care Organization (ACO) Final Rule Nov. 2, 2011 (Montrose, 2012)
Section 1899(b)(2)(G) of the Affordable Care Act requires an ACO to ‘‘define processes to…coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.’’ CMS suggests creating systems to identify high-risk individuals and processes to develop individualized care plans for targeted patient populations. Such care plans are to be tailored to—(1) the beneficiary’s health and psychosocial needs; (2) account for beneficiary preferences and values; and (3) identify community and other resources to support the beneficiary in following the plan. CMS establishes 65 Quality Performance Standards that ACOs must meet to receive shared savings. Six measures relate to care coordination; including measures of readmissions, EHR incentive payments, medication reconciliation and screening for falls risk. CMS will consider adding new care coordination measures for future years.
Center for Medicare and Medicaid Innovation Health Care Innovation Awards (Montrose, 2012)
The Center for Medicare & Medicaid Innovation announced 107 Health Care Innovation Awards in May and June of 2012. Of these, 37 projects were specifically geared toward achieving the Triple Aim through improved care coordination. The setting varied from home care and hospice to hospitals and primary care – and to centers devoted to care coordination. Most projects either focused on complex multi-condition individuals flagged for high risk of readmissions or on specific conditions such as asthma or diabetes. Other projects focused on safe transitions and cultural competency. A number of projects planned to use technology to improve information sharing and communication between the patients and the health systems
In these pilots, care coordinators ranged from high school and college students to registered nurses and primary care physicians. Most projects involved training existing staff, as well as creating new positions such as care coordinator, case manager, community health worker, lay health worker, patient navigator, or patient coach. Many projects described a care coordination team with stratified qualifications or the use of an “embedded” care coordinator at an FQHC or school.
References
Centers for Medicare & Medicaid Services (CMS). (2010). Patient Protection and Affordable Care Act, Section 2703- Health Homes. Medicaid. Retrieved from http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/Health-Homes-FAQ-5-3-12_2.pdf
Montrose, S. (2012). Care coordination. Prepared for the Colorado Department of Health Care policy and Financing., Retrieved from http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251848040284&ssbinary=true
