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Perspectives

Long-Term Supports and Services as a Logical Next Step in the Evolution of Bundled Payments

Andrey Ostrovsky, MD1; Arnie Cisneros, PT2; Abigail Morgan, MSS, MLSP3

November 2015

The historical progression of bundled payments from acute care to post-acute care and the growing recognition of the value of home and community-based services create an interesting opportunity for sustainably integrating medical services with other long-term supports and services (LTSS). With increasing involvement by LTSS providers in care transition programs, there is a growing overlap between traditionally separate medical and LTSS. The low cost and community connectedness of LTSS providers may give them an advantage over traditional providers of care transition services, especially when their services are augmented by emerging mobile technology. Building on past lessons from efforts to incorporate community-based LTSS into traditional medical care models, such as care transitions, may help to inform successful future strategies to enable bundles to more efficiently achieve the Triple Aim.

Key words: home and community-based services, long-term supports and services, bundled payments, Medicare, Affordable Care Act, long-term care, prospective payment system
 

Healthcare policy makers have been attempting to link payments for multiple services that patients receive during an episode of care for more than 20 years.1 This bundling of services originated in the early 1980s with the establishment of the Medicare prospective payment system (PPS), in which the Medicare payment is based on a predetermined, fixed amount. The PPS was replaced by several similar iterations, the most recent of which is the Bundled Payments for Care Improvement (BPCI) initiative through the Affordable Care Act.2 In January 2015, the bundled payments model received a large boost when US Secretary of Health & Human Services (HHS) Sylvia Mathews Burwell announced that the HHS would aim to have 50% of Medicare payments tied to quality or value through alternative payment models, such as bundled payments, by the end of 2018.3

Although the healthcare reimbursement landscape grows increasingly supportive of bundled payments, there is increasing pressure to make bundles more cost-effective.4,5 To better understand how bundles may be more cost-effective in the future, it may be instructive to explore how bundled payment models have evolved. The historical progression of bundled payments from acute to post-acute care, combined with a growing recognition of the value of home and community-based services (HCBS) create an interesting opportunity for sustainably integrating medical services and long-term supports and services (LTSS) into bundles to more efficiently achieve the Triple Aim:6 to improve the individual experience of care, to improve the health of populations, and to reduce the per capita costs of care for populations.

History of Bundled Payments

The first attempt to use the PPS to replace the Medicare fee-for-service payment system with payment for an aggregation of services came in the form of diagnosis-related groups (DRGs). Beginning in the 1980s, patient episodes in acute care hospitals were reimbursed based on DRGs with a fixed fee, regardless of the actual costs incurred. As a result of the progressive DRG protocol, inpatient lengths of stay decreased and clinical outcomes improved.7

Over the next decade, the PPS model expanded beyond the hospital setting and into the post-acute care setting. In 1998, the PPS model was applied to skilled nursing facilities (SNFs) in the form of resource utilization groups (RUGs), which are the equivalent of DRGs for SNFs.8 The use of RUGs quickly became defined by standardized assessments using the Minimum Data Set and care management pathways, which were based on acute and chronic patient populations. The PPS next evolved beyond SNFs into home health in 2000, and home health resource groups were used as the equivalent of RUGs and DRGs for home care.9 These included acuity-based assessments and general care management pathways that were independent of patient acuity or chronicity.

The enactment of the Affordable Care Act in 2010 prompted the next and most recent generation of prospective payment: the BPCI initiative. This initiative uses DRGs but they can be applied to four models of care, each of which has different risk timeframes and parameters related to reimbursement of a bundle. These models of care include acute (Models 1 and 4), post-acute (Model 3), or both acute and post-acute care services (Model 2).2

Bundles in post-acute care have involved care transition models that are predominantly staffed by doctors and nurses, including the Care Transitions Intervention Model (caretransitions.org/), the Transitional Care Model (www.transitionalcare.info/), Guided Care (www.guidedcare.org/), and Geriatric Resources for Assessment and Care of Elders (GRACE).10 These care transition models each have been shown to reduce hospital readmissions.11–15 Major barriers to the sustainability of traditional transitional care interventions, however, are the costs to support nurse salaries and the growing nursing shortage in the United States.16 Furthermore, a substantial proportion of health determinants are upstream of the typical scope of practice and time bandwidth of a nurse transition coach, necessitating care coordination or functional supports that would more appropriately fall in the domain of LTSS provider expertise and reimbursement level.17,18

Role of LTSS

One opportunity to overcome the threat to sustainability facing transitional care interventions is leveraging an existing, underused workforce of more than 5 million frontline workers who provide LTSS to help the aging population maintain function and address nonmedical health determinants in the community.19,20 According to the Administration for Community Living (www.acl.gov), HCBS are services provided to individuals, such as frail older adults or adults with disabilities, who require daily living assistance due to physical, cognitive, or chronic health conditions.21 This workforce includes personal care attendants, home-delivered meal drivers, health coaches, community health workers, case managers, and other essential care providers who serve nonmedical functions,22,23 whom we will refer to as nonmedical workers. Nonmedical workers are involved in 8 of 10 hours of paid services to older patients and to individuals with disabilities,24 and there is growing evidence demonstrating that they can improve patient experience and outcomes.25–27 Furthermore, the average nonmedical worker is paid an hourly salary that is approximately 70% and 90% less than a nurse or physician salary, respectively.28

Although most transitional care interventions fail to tap into the nonmedical workforce, there are emerging technology-enabled care transition models using LTSS staff that minimize program cost while significantly improving outcomes.29,30 Additionally, at one point, there were more than 100 LTSS organizations engaged in the Community-based Care Transitions Program (CCTP), which was created by Section 3026 of the Affordable Care Act. According to the CCTP Website,31 “The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings to the Medicare program.” These HCBS providers, most of which are Area Agencies on Aging, have the staffing and processes in place to expand their transitions programs into bundled payment reimbursement models.31 The progression of bundled payments from acute care to postacute care to HCBS would be a logical way for bundles to lower care transition–related costs and more comprehensively reduce admissions by addressing upstream health determinants.

Incorporating HCBS-based care transition interventions into bundles could benefit the consumer, the bundle convener, and the HCBS provider. Consumer care would become more comprehensive due to the integration of medical care with functional supports. Conveners could reinforce their referral network by outsourcing to an HCBS provider and  they would have a lower-cost care transition program compared with relying on their more expensive internal skilled nursing staff. Further, the HCBS provider would have the opportunity to diversify its revenue streams. This is particularly timely because Older Americans Act funding, a major source of funding for Area Agencies on Aging, is stagnating32 and a growing percentage of Medicaid funding for LTSS is shifting from fee-for-service to managed care, which is forcing LTSS providers to be more accountable for outcomes and have less guaranteed Medicaid revenue.33

Incorporating LTSS Into Bundles

The incorporation of an LTSS-supported care transition intervention could resemble the following process.

First, the Medicare beneficiary would be enrolled into a bundle for 60 days as part of a heart failure–related hospitalization. During this hospitalization, the patient would receive standard-of-care assessment, treatment, and stabilization.

The patient would be discharged 2 days after his or her hospital admission and subsequently transferred to a SNF. He or she would be clinically managed in the SNF by the staff in parallel with a transition coach from the LTSS provider.

The transition to home would begin just 6 days after the patient’s admission to the SNF. Once he or she achieves enough functional and clinical progress to safely transition to his or her residence, the transition coach in consultation with nurse colleagues would arrange adequate in-home supports to transition the patient. The transition coach from the LTSS provider could risk stratify the bundled patient in the SNF prior to being discharged to home, and the home care clinical staff could perform a start-of-care visit the day of the patient’s discharge. The convener’s nurse care manager could create a care plan in collaboration with the LTSS transition coach. 

For the subsequent 60 days, the nonclinical transition coach would interact with the patient on an as-needed basis. The coach would be prompted by an app to answer smart surveys with adaptive, conversational questions that could be completed within 3 minutes. The evidence-based algorithms of that survey tool would assign a risk score to the response and risk-stratify the patient so that nurse care managers would be notified when it is appropriate for them to provide targeted interventions.34

Research has shown that in-person nurse involvement is needed in response to as many as 41% of elevated risk alerts.34 With daily communication among care team members and risk stratification of each consumer providing early indication of medical and nonmedical risk factors for readmission, the convener would be able to provide a gold standard of care while minimizing the use of expensive staff. A single entity, the convener, would manage the entire episode, since they are at risk for the financial costs of the care program.

Conclusion

As bundles programs mature and optimize their cost-effectiveness, it remains unknown if and how LTSS will be incorporated into the dynamic PPS. Reviewing lessons from previous efforts to incorporate LTSS into traditional medical care models, such as the CCTP program, may help to build on what was previously learned to more efficiently achieve the Triple Aim for the patients being served. Further research and quality improvement efforts are needed to better understand the value that LTSS may hold for other innovative care and financing models, such as chronic disease self-management, long-term care coordination, and other evolving opportunities to create value for consumers through the Affordable Care Act. 

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