Care Redesign

Value-Based Care Must Strengthen Focus on Chronic Illnesses

Article · November 6, 2018

Most value-based care models encompass various care coordination models in primary care to help high-cost patients improve positive health behaviors (e.g., checking blood sugar regularly, eating healthier) and monitor those patients more proactively to prevent high-cost services (e.g., hospitalizations, ED visits, progression of chronic illness).

But while many value-based models of care are being designed for a host of chronic conditions, similar care models for Alzheimer’s disease and related dementias (ADRD) are lagging behind. This lack in dementia care is a critical health concern for three reasons:

  • Millions of people will have dementia over the next 20 years,
  • No cure or disease modifying therapy is on the horizon for Alzheimer’s disease, and
  • People with dementia utilize health care at much higher rates when not proactively managed.
People Living with Dementia Around the World - Value-Based Chronic Illness and Dementia Care

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If a cure is nowhere in sight, what does this mean for health systems and health care providers? I think we can liken it to a tsunami of patients who will challenge our ability to maintain access, quality, and cost given that dementia is a slowly progressive illness. In particular, capitated and value-based financial arrangements may prove unsustainable if models of care are not tested and implemented to prevent unnecessary hospital admissions for dementia patients.

Let’s take a look into the demographic future of our patient populations. We will have an increasingly older patient population given that many Americans are expected to live into their mid-80s, but the single greatest risk factor for Alzheimer’s disease is age. So, as the number of patients with Alzheimer’s disease and dementia increases over the next 20 years, it becomes increasingly important to address current economic models that show vastly increasing costs for such patients.

Intersecting together, we have two key health care challenges. Rates of ADRD are nearly doubling every 10 to 15 years with no cure or substantive treatment to delay/improve the course of the disease. Also, health care financing is moving into a value-based world where systems and providers are assuming more financial risk.

Growth in Alternative Health Care Payments in Relation to Medicare

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Target the Key Care Intervention Points

While the health care economics around dementia care can be daunting, health systems have years of expertise around other chronic conditions. Leveraging that expertise while piloting innovative programs to care for patients with dementia will be critical to ensure their quality of life, caregiver’s quality of life, and ensure long-term financial sustainability for the health systems that care for these patients.

Of course, challenges also present opportunity. The first is to identify unnecessary costs and develop tactics to reduce those costs. For health systems, much of the financial risk attached to caring for patients with ADRD, fortunately, can be mitigated by strategies preventing high-cost episodes of care. Most studies of larger populations of ADRD show several key intervention points, and suggest ways to eliminate or minimize the potential impact of these occurrences:

  1. Prevent the first hospitalization by proactively ensuring caregivers are supported and educated to optimally care for patients with ADRD through a hospital-wide dementia care program.
  2. Coordinate care and follow-up after a first hospitalization to prevent sequential hospitalizations by addressing issues that can be dealt with via phone or telehealth technology through a care manager.
  3. Identify patients with ADRD when admitted to streamline discharge procedures and reduce hospital length of stay.
  4. Stratify patients with ADRD into a highest-cost/risk group and place them in a more intensive care management program targeting key metrics to prevent events that can lead to hospitalization, such as UTIs, falls, poorly managed pain, nutritional status, and cardiac concerns.
  5. Implement advance care planning early in the dementia process to help patients and families become more aware of factors that increase the risk of hospitalizations (e.g., infections) and develop a plan for palliative/hospice options toward the end of life rather than reactive and unnecessary emergent/hospital-based care.

Develop Goals, Strategies, and Models for Dementia Care

Nationally, many researchers and work groups are convening to organize policies and research priorities to improve dementia care, such as the Research Summit on Dementia Care. However, many health systems are lagging behind in developing goals and tactics around a comprehensive dementia care strategy. Having such a strategy is a must, particularly as health systems face heightened financial risk when caring for larger groups of patients that need more care with fewer avenues to reimburse those needed services.

In 2015, researcher Elizabeth Phelan, MD, and her team conducted a meta-analysis of interventions seeking to prevent hospitalizations of adults with dementia living in the community from 1990 to 2013. Their meta-analysis revealed no significant hospitalization reduction out of all the studies. Only one study significantly reduced number of days in the hospital. Thus, it’s clear much more work is needed, especially when considering the cost of care among elderly patients.

Medicare Total Allowed Charge by Age - 2006 to 2010 - health care costs and dementia care

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Inpatient Facility Costs by Age and Experience Year - Medicare Total Allowed Charge

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Where do health systems go from here? The old adage from Stephen Covey — begin with the end in mind — is key. The “end” is typically health care that is high quality, accessible, and cost effective. One key model shown to successfully address those ends is the Integrated Practice Unit (IPU) as conceived by Michael Porter and his team at Harvard. The IPU — unlike other attempts at integrating care — has been shown to be more streamlined, more integrated/coordinated, and to actually move the dial on quality, access, and cost.

So, are there any similar models showing promise that utilize many principles from an IPU? The Care Ecosystem Model developed at the University of California, San Francisco and piloted at other sites around the country may be such a model, though data is still being captured and analyzed. This model leverages care coordination strategies with clinical expertise in dementia, person-centered care plans, and continuous care support to improve quality of life and reduce health care costs. More models such as these need to be piloted and adjusted to optimally care for patients with dementia and their caregivers.

What Your Health System Can Do Now

Health care leaders can take a variety of actions to position their organization to effectively deal with the growth of dementia patients: data, metrics, care team structure, and care coordination are core areas for consideration.

Population health data. Utilize your electronic health record (EHR) to size your past, current, and future dementia population. Avenues to identify patients include using the problem list, certain dementia medications, and admission diagnoses often related to dementia. Also, utilize population health experts and epidemiologists to look at dementia incidence in your area. Engage finance analysts to provide some projections about cost, financial risk, and preventable costs.

Disease registry and monitoring. Build a dementia registry within the EHR to deploy key metrics (e.g., advance care planning, caregiver burden, mini-mental status scores) for monitoring dementia patients who may be at greater risk for unnecessary health care utilization.

Care team structure. Establish an IPU built around dementia patients, such as a memory or dementia clinic. This type of program can begin to stratify patients into risk levels associated with higher health care utilization or poor quality of life. Examples of higher risk may include: a recent hospitalization, caregivers reporting high caregiver burden, or those with frequent ED visits. Any such IPU should ensure a data and accounting infrastructure to monitor the “value” of such a program and adjust the model over time to ensure program agility.

Care management. For higher-risk patients, utilize a care management model of care. Many hospital systems already have existing complex case management systems in place. So, piggybacking on existing expertise and networks is even easier. With a care team model, more coordinated, integrated, personalized, and proactive care will be delivered for these patients. When this happens, several benefits may emerge. Higher-risk dementia patients will not be “lost to follow-up” and preventable problems may be managed consistently. Care can be also be delivered via telehealth because many dementia issues do not require in-person medical visits. Problems can be addressed faster, before they escalate to emergencies requiring ED or hospitalizations. Also, caregivers frequently report that in-person medical appointments are often a major drain on time, expense, and quality of life for everyone.

License optimization. Effective care coordination models emphasize top-of-license optimization. What does this mean? Social or behavioral issues are often a major factor for dementia patients. Consequently, these factors often increase heavy ED use, lead to urgent doctor visits, prolong hospital length of stays, and result in burnout for caregivers. Instead of having physicians manage these issues, less expensive but fully qualified team members can manage those social-behavioral issues before they rise to the level of an office or ED visit. Cost is not only reduced, but physicians can spend their time on other value-generating activities, such as new patient visits.

While health care organizations have demonstrated some success in developing value-based care and reimbursement models aimed at primary care, the extension of such innovations to chronic care — especially among the expanding population of patients with dementia — is increasingly urgent.

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