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Supplement sponsor: American Academy of Family Physicians

Fam Pract Manag. 2021;28(2):21-25

The goal of care management and coordination is to individualize health care to meet each patient’s specific needs. Health care systems that are patient centric, outcome driven, and include payment structures that support services which patients need will be better aligned to meet this goal. In the current fee-for-service (FFS) health landscape, this alignment is often difficult to accomplish, as outcomes are based on how care is incentivized. But the landscape is changing.

Care Management and Coordination in VBP

Cost and patient outcomes are closely tied to effective care management and coordination in VBP arrangements with all payers. Depending on your practice’s specific payment arrangements and the needs of your patient population, the following core concepts can lead to better health outcomes for your patients and improve performance in your VBP contracts.

Patient education – Providing patients with education to help manage their chronic conditions is an essential care management activity. It may include providing patients with health tracking instruments and reviewing results with them; holding classes to help them manage chronic conditions; and offering education and referring patients to community resources. For example, your practice might host monthly diabetes group visits to improve A1C. The frequent touches and support from these group visits can lead to better health outcomes for patients with type 2 diabetes and help the practice meet quality measure requirements.

Care planning – Care plans are an opportunity to better align health care goals with patient and caregiver preferences. They are essential to care management — particularly for patients with multiple complex chronic conditions. Thorough care planning involves patients, caregivers, and the care team developing goals and action steps together; sharing the care plan with patients and all caregivers; and regularly reviewing and updating the care plan to determine if changes or additional resources are needed. This planning process ensures patients and caregivers are equipped to manage care in a way that meets the patients’ needs, while aligning with the practice goals of improved patient care and performance on quality and utilization in VBP arrangements.

Managing medications – Medication management is a necessary and ongoing process throughout a patient-physician relationship. It entails:

• reconciling medications after any transition of care;

• reconsidering and/or changing medications based on patient feedback;

• checking available medications periodically for better options; and

• ensuring medications prescribed are clinically necessary, have acceptable side effects, and do not pose a significant cost burden to the patient.

As prescription costs continue to rise, more patients are concerned with health care costs. Managing their medications can result in cost savings, avoid emergency department visits and hospital utilization, and lead to better patient outcomes.

Risk stratifying populations and managing data – Risk stratification guides physicians and care teams to group their patients into levels of risk based on factors such as diagnosis, condition severity, social determinants of health, and care utilization. It is intended to support longitudinal care management and allocate practice resources and services proportional to patients’ needs and based on their level(s) of risk. Typically, risk stratification is done by an algorithm in the electronic health record (EHR), registry, or population health system. These systems may identify patients who need outreach, have care gaps, or have upcoming preventive screenings due. Once identified, the care team can reach out to patients with reminders and follow up via telephone, automated calls, the patient portal, or mailings to patients.

Coordinating care across the health system – Care management and coordination require communication through multiple modalities. Physicians and care teams discuss patient care with specialists and hospitals; incorporate specialist and hospital provider input into patients’ care plans; and engage with patients about ongoing care management through the patient portal and by telephone. Care coordination spans the health care system with care teams reviewing hospital admissions, discharges, and emergency department visits; tracking tests and referrals to make sure results are returned; and providing appropriate community resources and patient education. Monitoring emergency department visits and hospital utilization are beneficial in VBP arrangements for many reasons, including ensuring appropriate use of services, and, when appropriate, scheduling follow-up care to reduce avoidable readmissions.

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