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Patient-Centered Medical Homes and the Care of Older Adults
posted 02.03.2017

By Robert Schreiber, David Dorr and Robyn Golden

Community-based organizations (CBOs) that provide non-medical services and supports are essential to high quality, patient-centered primary care. And given the changing dynamics of payment reform, CBOs are an increasingly important part of the primary care landscape. A new report from the The John A. Hartford Foundation Change AGEnts Patient-Centered Medical Home Network provides a helpful resource for both primary care practices and CBOs as we all seek to deliver better care for older people.

The paper, entitled Patient-Centered Medical Homes and the Care of Older Adults, describes a comprehensive set of strategies that primary care practices (and particularly those that are organized as PCMHs) can use to serve frail older adults and their caregivers. Connecting with community-based services is one of several critical steps in this effort including better care coordination, a commitment to whole person care and providing improved access to care.

2016: A Big Year for Primary Care Transformation

To put this work in context, it’s important to understand what’s happened during 2016. There has been a great deal of national focus on strengthening primary care, especially for older adults.

  • The Centers for Medicare and Medicaid Services (CMS) released its sweeping changes to Medicare Part B payments, in response to the 2015 Medicare Access and CHIP Reauthorization Act (MACRA).
  • 42 states now recognize and support Patient-Centered Medical Homes through specific legislation, creating opportunities for practices to engage locally, as well.
  • The Senate Finance Committee’s Chronic Care Working Group released a comprehensive bipartisan discussion draft with a number of proposals to improve outcomes for Medicare beneficiaries living with chronic conditions, The Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2016 (PDF).
  • The National Committee for Quality Assurance (NCQA) announced that it is revamping its Patient-Centered Medical Home (PCMH) recognition program, to be more aligned with federal quality initiatives and to better support practice change.
  • CMS’s Innovation Center sought applicants for its five-year demonstration project for advancing primary care, Comprehensive Primary Care Plus.
  • And, CMS released its new physician fee schedule (PDF) with new billing codes for important supports, such as complex chronic care management, and care planning for patients with cognitive impairments.

2017 and Beyond: MACRA and Older Adults

Perhaps the most salient and wide-reaching of these developments is MACRA, which was passed to replace the previous formula for determining Medicare payment rates. While its future remains unclear with the new Administration, MACRA legislation passed with strong bipartisan support, including the vote of the Representative Tom Price, MD (R-GA), President Trump’s choice for Secretary of Health and Human Services. If the new Administration continues MACRA’s roll out as outlined in CMS’s October 2016 implementation plan (PDF), MACRA will grow to touch most Medicare Part B providers during the next several years.

As part of this implementation, most primary care providers will participate in the Merit-Based Incentive Payment System (MIPS) (PDF), an initiative to streamline existing Medicare quality programs into one performance score based on four categories: quality outcomes, resource use, clinical practice improvement activities (e.g. care coordination or a PCMH designation), and advancing care information (e.g. patient engagement and participating in a health information exchange). Moreover, physician practices will be encouraged to build on MIPS goals and participate in an Advanced Alternative Payment Models (APMs) track, taking on risk-based payments and joining a CMS Innovation Center project such as Comprehensive Primary Care Plus or as part of certain types of Accountable Care Organizations. While the fates of MACRA implementation and the Innovation Center are unknown with the new Administration, the trend toward value- and risk-based Medicare payments will likely continue given bipartisan recognition of the need for delivery system and payment reforms.

Opportunities Ahead: The Change AGEnts Road Map and a Central Role for the Aging Network

With the increasing focus on primary care serving as a true medical home for patients, their families, and caregivers, it is critical that practitioners, healthcare administrators, advocates, and policymakers share their stories in how we make this a reality. The Change AGEnts’ PCMH white paper offers several compelling narratives, highlighting the opportunities PCMHs face in five target areas: comprehensive care, whole-person care, patient empowerment and support, care coordination and communication, and ready access to care. It includes specific suggestions and links to resources for partnering with CBOs, as well as several other issues such as ensuring competent care for aging patients (e.g., broaching topics such as cognitive changes, frailty and disability, and advanced care planning), accessing clinical assessment tools, addressing workforce issues, ensuring patient safety, and more.

As primary care practices engage in practice change and adapt to evolving policies and community needs, it is critical for the Aging Network and other CBOs to equip themselves with the workforce, evidence-based programs, and business acumen needed to engage in effective partnerships with PCMHs, as well as other primary care providers, outpatient specialists, hospitals, and payers. This may include participating in the Aging and Disability Business Institute or offering innovative programs in collaboration with primary care practices (such as The Ambulatory Integration of the Medical and Social). These kinds of efforts will help these critical community partners expand their ability to assess and address non-medical health-related needs and work with PCMHs to meet quality goals and improve care.

This work is already underway across the country. For example, in Massachusetts, Dedham Medical Associates, a Level 3 PCMH and part of the Atrius ACO, has hired a community liaison, employed by Springwell Area Agency on Aging, who will be assisting care managers and medical providers in linking community resources to the PCMH high need population. In Indiana, Steve Counsell, MD, is working with the Indiana Association of AAAs on a care model that integrates Waiver Case Management performed through an Area Agency on Aging with primary care practices.

Those interested in getting a better understanding of the broader primary care landscape should take advantage of two sessions at ASA’s annual Aging in America Conference in Chicago, one on Monday, March 20 and the second on Thursday, March 23. And of course, in the meantime, reading and sharing the Change AGEnt’s Patient-Centered Medical Homes and The Care of Older Adults is a great place to start.

Aging and disability CBOs interested in capitalizing on these new opportunities to partner with the health care community should check out the brand-new Aging and Disability Business Institute website—the go-to place for comprehensive, interactive, user-friendly tools and resources to help CBOs build business acumen and successfully adapt to a changing healthcare environment.

Robert J. Schreiber, M.D., A.G.S.F., C.M.D., is medical director of evidence-based programs at Hebrew SeniorLife, and medical director of the Healthy Living Center of Excellence, both in Boston, Mass. David Dorr, M.D., M.S., is associate professor and vice chair, Clinical Informatics, at Oregon Health and Science University in Portland, Ore. Robyn Golden, L.C.S.W., is director, Health and Aging, at Rush University Medical Center in Chicago.

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