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The Hospital at Home Model: Bringing Hospital-Level Care to the Patient

August 18, 2016

Presbyterian's Hospital at Home program, launched in 2008, is based on a model developed in the mid-1990s by Bruce Leff, M.D., a geriatrician and health services researcher at Johns Hopkins University, who noticed that many of his patients suffered poor outcomes after hospital stays.1 At Johns Hopkins, teams of physicians, nurses, and other clinical staff make house calls to treat elderly patients, many of whom either refuse to go to the hospital or are at such high risk for adverse events that physicians prefer not to admit them. For select patients, this approach produces superior outcomes at a lower cost than hospital care (see Results).The Hospital at Home model has struggled to gain traction elsewhere in the United States, however, in part because Medicare's fee-for-service program will not pay for its services. Presbyterian is able to secure reimbursement from its health plan, which covers 470,000 Medicare Advantage, Medicaid, and commercially insured members throughout the state and has incentives to reduce costs and improve care.Presbyterian's program fits within a suite of services designed to deliver care in the home. These include home-based primary care, home health, hospice, and Complete Care, a care management program designed to improve coordination of services for patients with advanced illness and, when desired, avoid unwanted aggressive care at the end of life.

Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community

August 11, 2016

Mountain Empire is one of the newest of more than 100 independent PACE organizations across the nation that serve both as health plans and as medical and long-term service providers to elders—offering meals, checkups, rehabilitation services, home visits, and many other supports that enable enrollees to preserve their independence. The model for PACE dates back to 1971, when a public health dentist and social worker from the San Francisco Public Health Department working in Chinatown-North Beach noticed that as their clients aged, many needed extra support but dreaded moving into nursing homes. They founded On Lok Senior Health Services as an alternative to institutional care that would allow elders to "age in place" in their homes; on lokis Cantonese for "peaceful, happy abode."On Lok's founders were particularly concerned about elderly clients who suffered when their various clinicians failed to work together, sometimes leading to complications that necessitated moves into institutional care. They designed On Lok to promote what was then an innovative approach: coordinating care from an interdisciplinary team of professionals who provide all primary care services and oversee specialists' services.A Medicare-funded demonstration spanning 1979 to 1983 found this approach had many benefits. Care teams were able to prevent or quickly address problems, resulting in better health and quality of life and producing 15 percent lower costs than traditional Medicare. In the decades since, the model has spread slowly, though enrollment has grown nearly 40 percent in the past three years. As of January 2016, there were 118 PACE organizations in 31 states serving some 39,000 elders.

Bringing Primary Care Home: The Medical House Call Program at MedStar Washington Hospital Center

July 26, 2016

MedStar's program offers round-the-clock access to a care team comprising a geriatrician, nurse practitioner, and social worker. The house calls reveal and address problems that are missed when care is poorly coordinated, enabling team members to identify social supports for patients that can improve quality of life, reduce the burden on caregivers, and head off problems that can lead to high-cost institutional care.Based on the cost savings it achieved, the program became one of the models for the federal Center for Medicare and Medicaid Innovation's Independence at Home Demonstration, which is testing whether providing primary care at home to frail elderly patients with multiple chronic conditions or advanced illnesses improves outcomes and lowers health care spending. MedStar participates in the demonstration as part of a consortium that includes Virginia Commonwealth University and University of Pennsylvania Health System, both of which are implementing an approach similar to MedStar's. The consortium is one of nine participating groups to earn a share of the savings they produced for Medicare.

Designing More Affordable and Effective Health Care

February 8, 2016

Spiraling health care costs in the U.S. place untenable burdens on an increasing share of Americans and divert money from education, research, and economic development. In 2010, Stanford University launched its Clinical Excellence Research Center (CERC) to develop new ways of delivering health care that might slow this spending growth. "What we want is affordable clinical excellence, and that's what is distinctive about what we're doing," says Arnold Milstein, M.D., M.P.H., CERC's director, who was recruited to lead CERC in part because of his success redesigning ambulatory care for medically fragile patients. The center identifies diseases, conditions, and health care services for which spending could be lowered by 30 percent or more for certain populations while also improving patient health and care experiences.This case study, Designing More Affordable and Effective Health Care, is part of ongoing research by The Commonwealth Fund to track how health systems are transforming care delivery, particularly to meet the needs of high-need, high-cost patients and other vulnerable populations. The first publication in the series profiled thePenn Medicine Center for Health Care Innovation.

Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis

October 29, 2015

This brief analyzes experts' reviews of evidence about care models designed to improve outcomes and reduce costs for patients with complex needs. It finds that successful models have several common attributes: targeting patients likely to benefit from the intervention; comprehensively assessing patients' risks and needs; relying on evidence-based care planning and patient monitoring; promoting patient and family engagement in self-care; coordinating care and communication among patients and providers; facilitating transitions from the hospital and referrals to community resources; and providing appropriate care in accordance with patients' preferences. Overall, the evidence of impact is modest and few of these models have been widely adopted in practice because of barriers, such as a lack of supportive financial incentives under fee-for-service reimbursement arrangements. Overcoming these challenges will be essential to achieving a higher-performing health care system for this patient population.

Findings from a Survey of Health Care Delivery Innovation Centers

April 28, 2015

Health care innovation centers around the country are working to discover, develop, test, and spread new models of care delivery--in hospitals, clinics, and patients' homes. Between November 2014 and January 2015, The Commonwealth Fund conducted an online survey of innovation centers affiliated with health care organizations to learn about their potential role in promoting health system transformation.Survey findings presented in this chartpack reveal how innovation centers define innovation, what factors into investment decisions, which technologies are most commonly used, and much more. While innovation centers have the potential to contribute to health system transformation, it appears that to succeed they will need sustainable funding and greater integration with clinical enterprises. The survey also reveals that innovation centers may benefit from collaboration to identify solutions to common problems and develop a mechanism for spreading their work.

Accountable Care: Building Systems for Population Health Management

October 6, 2014

This case study series describes how three diverse organizations are developing accountable care systems to improve the quality and reduce the costs of care, and ultimately improve the health of populations of patients insured by Medicare, Medicaid, and commercial health plans. They employ a constellation of strategies to identify and address unmet medical needs, improve care transitions, and reduce inefficiencies and unnecessary variation in care. Care managers, outreach workers, or virtual care teams help improve outcomes for patients with complex needs that are costly to treat. Data integration and analytics are key to their efforts, although the sophistication of these capabilities varies. Two study sites have established a record of savings, while the third is still proving the potential of its approach. Their progress to date suggests that payment reforms can foster the will and accountability necessary to transform care.

Marshfield Clinic: Demonstrating the Potential of Accountable Care

October 6, 2014

Marshfield Clinic, a nonprofit multispecialty group practice in central Wisconsin, joined Medicare's Shared Savings Program in 2013, following its success in Medicare's Physician Group Practice demonstration—the program's forerunner. The clinic's Medicare ACO benefits from the organization's past investment in advanced primary care infrastructure and disease-specific care management capabilities, which have yielded reductions in hospitalization and readmission rates. The clinic has an advanced, internally developed electronic health record system and enterprise data warehouse, which allow internal performance reporting and identification of best practices that have galvanized physician support for quality improvement efforts. Marshfield Clinic's track record of achieving cost savings and quality targets set by Medicare suggests the importance of combining missiondriven performance improvement initiatives with a commitment to mutual accountability among providers in group practice.

Health Share of Oregon: A Community-Oriented Approach to Accountable Care for Medicaid Beneficiaries

October 6, 2014

Health Share of Oregon is a nonprofit founded in 2012 to coordinate the provision of medical, dental, and behavioral health care for Medicaid beneficiaries in a tricounty region encompassing Portland. As one of 16 coordinated care organizations designated by the state to oversee and improve the delivery of these services for a geographically defined population, it receives a global budget. It distributes per-capita payments to health plans— some of which are integrated delivery systems—and county-run mental health agencies that have agreed to accept risk for providing or ensuring access to defined services. These risk-bearing entities—all founders of Health Share—serve on its governing board, along with representatives of community-based organizations and social service agencies committed to this population. Health Share brings these stakeholders together to improve care for high-need, high-cost patients; achieve efficiencies by centralizing certain administrative and enrollment functions; and create accountability for performance.

Hill Physicians Medical Group: A Market-Driven Approach to Accountable Care for Commercially Insured Patients

October 6, 2014

Hill Physicians Medical Group—Northern California's largest independent practice association (IPA)—joined local hospitals and commercial health plans in forming four separate accountable care organizations (ACOs) aimed at improving quality, reducing fragmentation, and lowering the cost of care as a means of retaining business. This profile focuses on the first and largest ACO, which was established in January 2010 to reduce premiums for 41,000 public sector employees and retirees covered by the California Public Employees' Retirement System (CalPERS). The ACO has decreased hospital use and permember per-month spending in its first three years, resulting in $59 million in savings to CalPERS or $480 per member per year. Leaders credit success to developing a mutual understanding of one another's strengths and challenges, which was a prerequisite for improving care coordination, increasing patient education, and reducing unwarranted variations in care.

Taking Digital Health to the Next Level: Promoting Technologies That Empower Consumers and Drive Health System Transformation

October 1, 2014

Digital health technologies offer the potential to transform health care by making it more responsive to consumers' needs, convenient for patients to access, and efficient and satisfying for providers to deliver. Yet there are significant barriers to the adoption of such technologies, including a dearth of evidence of their impact on cost and outcomes and a lack of collaboration between clinicians and technologists in product development. In this report, we draw on the views and experiences of experts and innovators in the field to make recommendations for overcoming such barriers. These include: defining opportunities to focus on the country's greatest health and delivery system problems; closing knowledge gaps among consumers, technology developers, entrepreneurs, health care executives, and investors; creating test beds in care settings; enabling consumer-centered design and valuations of new technologies; and addressing operational factors and challenges related to an evolving reimbursement and policy landscape.

A Vision for Using Digital Health Technologies to Empower Consumers and Transform the U.S. Health Care System

October 1, 2014

Digital technologies that serve as a communication bridge between providers and consumers have the potential to disrupt the U.S. health care system by enabling consumers to get care and support when and where they need it, while also making their needs and preferences known. This report describes early efforts to use digital technologies—ranging from remote monitoring devices and teleconferencing devices for virtual office visits to data mining tools—to redesign care models around the common needs of discrete patient populations. The approaches described, including those designed to increase patient engagement and close communication gaps, focus on the needs of patients with complex and costly medical and behavioral health conditions as these efforts may present the greatest opportunity for simultaneously improving care and reducing costs.