ACO Reach Depends on Great Transitional Care Management


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Due to Value-Based Care’s positive impact on many tiers of our society, individual and organizational levels, this model of care is taking root in our healthcare system. To facilitate it, the Center for Medicare and Medicaid (CMS) is managing the platform of Accountable Care Organizations (ACO), to deliver high-quality, cost-effective care.

ACO Reach

In order to be effective, ACOs make a collaborative effort to serve their Medicare and Medicaid [CMS] patients most efficiently across the care continuum. Their bar of success is determined by the reflection on how far-reaching and effective the ACO is, in ensuring that patients receive the right care at the right time. Furthermore, avidly monitoring the cost along the way and not compromising on the quality of care. The latest iteration of ACO opportunities is the  ACO Reach Program. This model prioritizes health equity, provider-led organizations, and beneficiary involvement. It emphasizes compliance, applicant screening, and monitoring for participant accountability. The model builds on CMS’ decade-long experience, offering new tools for accountable care and focusing on Traditional Medicare beneficiaries. A key aspect is addressing health disparities through mandatory plans for underserved communities. Innovative payment approaches aim to enhance care delivery in these areas.

Transitional Care Management [TCM]

Success in ACO Reach depends significantly on effective Transitional Care Management [TCM]. TCM is a well-thought-out and comprehensive approach or process, designed to support patients during transitions between different healthcare settings. Like, after being discharged from a hospital or any inpatient facility to their homes or a skilled nursing facility. This fragile transitional phase was traditionally addressed by the family or primary care physician.

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Elements of TCM

Below are the basic elements of Transitional Care Management

a.    Follow-up care planning

b.    Communication between healthcare providers

c.     Medication management

d.    Patient education

e.    Cost management

f.      Quality metrics

TCM Coding

The two Current Procedural Terminology CPT codes used to report TCM services are:

·   CPT code 99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge

·   CPT code 99496 – high medical complexity requiring a face-to-face visit within seven days of discharge

Industry Leaders Describe Best Practices in  ACO Reach at NAACO’s Fall Conference;

There were very illuminating discussions and presentations from a few ACOs at NAACO’s current year’s Fall Conference.

Josh Romney, Medical Director for Population Health from Castell Health started his presentation with the basics which is to analyze high-risk patient readmission. They have a team of inpatient schedulers to develop a 7-day follow-up plan in primary care while the patient is still hospitalized.

A non-clinical person is constantly in touch with the primary care physician to plan and schedule everything and every care person the moment after the discharge from the hospital for that follow-up plan. By carefully monitoring this follow-up plan they reduced the rehospitalization by 2 percent.

The next step for Castell was to add a pharmacist to the collaboration, as they realized that medication factors can lead to rehospitalization. The pharmacist must monitor patients after being discharged from the hospital when medications might indicate high risk or patients take medications for high-risk diseases like congestive heart failure. Castell’s experience was that the follow-up/phone call within two days and changing the medication as needed reduced the readmission from 20 percent to 12 percent.

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Castell Transition of Care infrastructure is made up of a care coordinator, a pharmacist and pharmacy tech, a nurse care manager, a home visit social worker and provider, and a data analytic.

So, their process for transitional care starts with

a. Patient identification while the patient is still hospitalized.

b. Next comes the care coordinator who identifies immediate risks and needs and schedules support accordingly.

c. That support consists of a pharmacist, a care manager, and a social worker.

d. The doctor’s visit, which, at this stage has all the necessary information.

At each stage, he acknowledged definite obstacles that impede the flawless attainment of their goal. It is definitely not only them who have to face these hurdles but almost every ACO faces them. And they are, to begin with,

a.    Timely information The structure of care collaborators usually loses the thread of information on the patient. This can be a big hazard for a real-time response.

b.    Complexity of measures the care team needs to know the progress and the process in the simplest ways. Their time and energy must be used for patient care.

c.    Access to the specialist the patient does not always need only the primary care doctor. They must have access to the concerned specialist as well.

d.    Coordination to make all this a success, coordination is needed at every step. supports this workflow for more and more ACO Reach providers.

Hucu is providing a patient-centered specific channel where all the care collaborators can report on their activity, whether it’s a visit, a change of medication, or a lab report.

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The concerned doctors and specialists are already engaged in that care team, so they can be tagged and notified immediately for a real-time response.

As the healthcare industry shifts its focus from quantity to quality, the significance of Transitional Care Medicine (TCM) services is expected to grow. Hucu is there to make their process flawless to enhance the quality of care and plays a decisive role in preventing rehospitalization thus, ultimately leading to cost reduction.


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