Policy and payment reforms created by The Centers for Medicare & Medicaid Services (CMS) drive much of the healthcare industry’s move toward value-based care — providing the best outcomes at an optimal price. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 changed the way Medicare pays clinicians. Rather than just paying for volume, Medicare rewards physicians who provide lower-cost care of higher quality.
As Medicare implements more rule changes to reduce overall costs, and the nation’s healthcare system continuously moves toward this quality, providers must move in this direction as well. Cuyahoga Falls-based Unity Health Network, the largest independent physician group in Northeast Ohio, has been doing just that.
Unity Health Network’s providers have concurrently focused their efforts on comprehensive care initiatives that have yielded extremely positive results in achieving improved outcomes and lowered costs of care. The physician group’s value-based care model encourages an all-inclusive team approach, with coordination and communication between its physicians across all specialties and settings.
“Much time and many resources have been invested by our physicians and staff over the past five years to ensure we designed and implemented programs that led to improved quality of care and satisfaction for our patients,” says Kevin Mineo, MD, Medical Director, Unity Health Network. “I’m happy to say that our efforts have led to success.”
Dr. Mineo points out that what is vital in a value-based care organization is to understand that there isn’t one “magic bullet” activity that will allow healthcare providers to move toward a quality approach in a swift and effective manner. Rather, it requires a careful and comprehensive method of first understanding the true goals of value over fee-for-service, followed by a plan of action to achieve those objectives, a plan firmly supported by all stakeholders involved.
“At Unity Health Network, our multi-pronged plan of action includes such activities as a performance program for providers and staff, a high-risk care management team, a focus on data analytics, and a purposeful alignment with hospitals, skilled nursing facilities and home health agencies,” says Dr. Mineo. “Through these deliberate actions, we have been able to lower hospital admissions, reduce readmissions, improve diabetic scores, and improve cancer screening rates, just to name a few of the resulting benefits.” An example of one of the initiatives used by the group is their eponymous “Call Unity First” initiative.
“Call Unity First” was a program created by Unity Health Network’s Quality Improvement Committee (QI) with the goal to improve the appropriateness of care settings and access for patients. To help ensure care was being delivered in a manner that was best-suited to specific clinical need, a campaign was started to promote that the first call a patient should make — in a non-life-threatening or serious medical situation — is to the patient’s primary care office. Whether during office hours or after-hours, patient calls get directed to a nurse triage team that assesses the patient’s condition. The triage team, in conjunction with a physician when necessary, helps direct the patient to the appropriate setting — an office visit, urgent care or emergency room. Patients with conditions treatable in the primary care setting are quickly scheduled with their attributed physician or in an open appointment with another Unity Health Network primary care physician.
“This program has not only allowed for a decrease in avoidable emergency room admissions, urgent care visits and hospital readmissions (all of which reduce costs), but the approach also maintains a higher degree of continuity of care for our patients as they are able to stay within our network of providers,” says Dr. Mineo.
The “Call Unity First” initiative has met with extremely positive results. As an example, between 2017 and 2018, avoidable emergency room visits were reduced by 18% following implementation and promotion of the program to Unity Health Network patients. Additionally, in 2018, an average of 263 patients per month were kept in the physician group’s network due to this campaign. Patients calling were found open appointment times either in extended hour settings or in primary care offices other than their attributed physician.
“Call Unity First” has been promoted in a number of ways to expose patients to this important program. Exam room “door-backers” advertise the initiative, taking advantage of the “captive” audience waiting to see a physician. Refrigerator magnets were passed to patients with their discharge reports, flyers were included with billing and all office staff received talking points and instruction to remind patients about the program while interacting with them during an appointment.
Dr. Kevin Mineo of Unity Health Network maintains an active primary care practice in addition to his leadership role with the group.
Another action Unity Health Network has taken in its move toward becoming a fully value-based care organization is assuming greater care management responsibilities to better control the clinical and financial risk associated with high-risk patients.
“Our patients with complicated health and often accompanying social conditions are at risk for poor health outcomes, inadequate quality of care, and increased costs,” says Dr. Mineo. “Thus we designed and initiated a process of managing the care of high-risk patients, using a number of tools that could be deployed in a supportive one-on-one environment to assist us in achieving three goals: delivery of the right care at the right time and at the right place.”
The first step was to identify high-risk patients, and better understand the number and complexity of this patient pool. Using data analytics and selection criteria tied to chronic conditions and quality targets, Unity Health Network discovered that approximately 3–5% of its primary care physicians’ patient lives could be identified as high-risk. Concurrently, while they were getting their hands around the data, Unity Health Network began structuring a team of care providers and a process that would best serve the patients in need. The group’s “High Risk Care Management” team includes a physician, Dr. Troy Bishop, who provides oversight to the work of RNs, medical assistants and a clinical nurse specialist specifically working with the program.
After the team was put in place and patients were identified as high-risk, the High Risk Care Management program began to enroll patients through a number of paths. First, going back to the data, patients are identified as possessing the characteristics needed for participation. That information is then vetted by the program’s nursing staff to ensure the patient is indeed a good candidate. Once the team feels comfortable with enrolling the patient, a letter is sent introducing and explaining the program, followed by a phone call to hopefully encourage the patient to enroll.
Patients may also be enrolled by a direct referral from the patient’s primary care provider, and while as an inpatient at a regional hospital after being identified as someone that may benefit from participating in the program.
Once a patient has agreed to participate, a home visit is scheduled and fulfilled by one of the program’s nurses. At this meeting, the RN does a total health and home assessment, closely detailing the patient’s health history, current conditions, goals, lifestyle factors and environment. The patient is also provided a comprehensive description of the program, initiatives and activities to expect and a preliminary schedule of follow-up visits and calls.
“The care plan is specific to each patient’s individual needs, and that is where the power of our High Risk Care Management program, and other initiatives, comes to bear,” says Dr. Mineo. “A successful values-based methodology does not allow for “cookie-cutter” care — it must look for the gaps that have led to or are exacerbating current conditions, and work to provide care to stop or reverse the negative effects. By doing this, Unity Health Network has begun its earnest commitment to a quality-based care approach and we look forward to the quality, cost and access gains these actions will bring our patients as we continue to expand the approach.”