Operationalizing Value-Based Care: Why Inter-Organizational Communication is Critical

Why Inter-Organizational Communication is Critical

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The Center for Medicare and Medicaid Services [CMS] has the vision of enrolling all Medicare beneficiaries & most  Medicaid beneficiaries in accountable, value-based care  (VBC) programs by 20301. This is based on data demonstrating that aligning remuneration with activities is yielding savings as well as better outcomes for the significant investment of public funds2.

To cater to this transition, the traditional system of fee-for-service, with its unit-based economic structure, is continuing to lose its footing. Value-based care, which has been taking shape for the last half century, emerged as the future of healthcare in 2020 after COVID-19 hit3

Balancing clinical outcomes with cost savings is perhaps the Holy Grail in healthcare, provided it doesn’t come at the expense of provider and patient satisfaction.  We can’t simply further burden providers, nor can we create programs and care methods that patients resist.  This, of course, is the premise of the Quadruple Aim. With such a strong and clear direction from CMS, the effectiveness of VBC is obvious and the momentum for its scaling is irrefutable.  

Value-based care is largely predicated on a patient-centered model of care rather than an episodic-centered or organizationally-centered approach.  Various  models of care have emerged such as Accountable Care Organizations (ACOs) and ACO Reach, aiming to improve healthcare quality and efficiency; generally defined as “value.”  That said, many perspectives exist on how to define “value” in healthcare, and there are many peer-reviewed definitions4.  Regardless, what’s common among them all is a set of variables to be considered in the applied algorithm.  

Patient Outcomes [“health” or “wellness”]

: In the context of VBC “outcomes” are more dependent on systemic approaches than episodic, fee-for-service approaches. No longer is ‘discharging the patient within a pre-defined length of stay’ a complete metric when that patient is readmitted with a wound infection or other complication within 2 weeks, for example. VBC is about optimizing the patient’s entire health or wellness, given their status.  It includes preventive activities [i.e., screening, vaccination] as well as efforts to align the daily lifestyles and behaviors of the patient and those supporting them.  It may even include daily awareness of family members and encouragement for a healthy lifestyle] care as well.  It can consist of follow-up activities outside one provider’s control. 

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As has been suggested, a patient having to go to the hospital is an overt failure of “the system” to optimize health; outcomes.  Avoiding hospitalization is not only better for patients but system economics, and is the essence of VBC. For example, avoiding hospital-acquired infections could save $35.7 to $45 billion annually alone as the National Institute of Health [NIH] reports5.

So, what is the mechanism that makes the preventative and proactive interventions workable? Effective and real-time communication between the entire ‘health team’ supporting the patient even when they are in separate and distinct organizations.  This includes primary care, specialists, community care (i.e., pharmacists), chronic disease educators and supports (i.e., Certified Diabetes Educators, Registered Dietitians), mental health practitioners, other allied health professionals such as physical therapists, and the patient and their family themselves.  And in the case of post-acute care, it may include the staff in facilities or communities where the patient resides such as skilled nursing, hospice, palliative care, home care, and so forth. 

Patient/family satisfaction:

when the care team and its participants listen actively to the patient and the family, consider their priorities and beliefs, and are effective in collaborating and coordinating their activities it naturally satisfies the patients and their families, nurturing trust and confidence.  This in turn results in both greater adherence to the guidance and instructions given, as well as retention of the patient in the practice, in the facility. The UK NHS (National Health Services)also defines the following core values for the caregivers6;

  • Respect
  • Independence
  • Individuality
  • Privacy 
  • Partnership
  • Choice
  • Dignity
  • Rights 
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Effective communication plays a major role in the process of delivering on all of these attributes. When patients and their families feel heard and respected, they are more likely to adhere to treatment plans, follow medical advice, and actively participate in their own care. Clear and empathetic communication also helps alleviate fears, address concerns, and provide reassurance, fostering a supportive environment leading to healing. Moreover, open communication enables patients and their families to voice their preferences, express any uncertainties, and collaborate with healthcare providers in decision-making, inclined towards a more personalized and patient-centered approach to care. Ultimately, prioritizing communication and involving patients and their families as active partners in the care process is a fundamental component of Value-Based Care.

Optimized resources:

The economic premise of VBC is dependent on efficient resource utilization.   This too can be achieved through improved data sharing, of course, but also improved communication.  If a care team member is unaware that new information such as a lab result is now available in the EHR or a shared record, it’s akin to the data not being there at all.  Furthermore, data that is shared but unclear to other members of the team can be worse than the data not being there at all.  It can increase risk of misinterpretation, as well as added communication challenges as care team members chase one another to get clarity on the information’s interpretation.  

Accumulate Data for Healthy Population:

Along with an individual’s health, Value-based care also has a broader horizon that extends to the health of entire populations through data analytics to identify trends and patterns in patient population [according to their geography, demographics, lifestyle habits, socioeconomic status, etc]. However, effective communication among all stakeholders is crucial for the successful collection of this data. Through well-coordinated efforts and clear communication, healthcare actors can ensure that relevant information is collected accurately and efficiently. This data can then be used to predict potential outbreaks and trigger proactive interventions such as targeted vaccination drives, public health awareness campaigns, and resource allocation to prepare and enable healthcare facilities for a potential surge in cases.

It’s all about Care Coordination

Care Coordination is the key element in operationalizing value-based care, making sure that every element of the healthcare ecosystem works in harmony. Effective and real-time communication acts as the catalyst for seamless coordination among multidisciplinary and disparate teams, including primary care physicians, consultants, nurses, social workers, and other healthcare professionals. By sharing comprehensive patient information through integrated health records and utilizing advanced communication platforms, these teams can synchronize their efforts, and ensure continuity of quality care. This interconnected approach not only streamlines workflows but also fosters a cohesive patient journey from diagnosis to treatment and follow-up.

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Health economist, Uwe Reinhardt posits that “A utopian vision” of Value-Based Healthcare can actually be achieved with integrated coordination through effective communication. This vision is realized by preventing conditions from worsening, which can lead to more expensive treatments, thereby saving both lives and resources. Additionally, effective coordination mitigates clinician burnout by keeping the care process in harmony, allowing healthcare providers to focus on delivering high-quality care without being overwhelmed by inefficiencies. Moreover, it can also diminish medical errors that are significant drivers of preventable diseases and fatality rates.

In conclusion, operationalizing value-based care (VBC) is not just a vision but a necessity in modern healthcare. To successfully achieve the aims of VBC we need to not only have shared & aggregated data accessible to all members of the team, but efficient and secure ways of communicating amongst them regardless of their organization of employment and it’s infrastructure.  






  1.  https://www.cms.gov/blog/cms-innovation-centers-strategy-support-high-quality-primary-care
  2.  https://www.naacos.com/press-release–naacos-statement-on-aco-growth-in-2024
  3. https://www.enlacehealth.com/value-based-care-is-the-future-of-healthcare-here-is-its-origin-story/
  4.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9162129/
  5.  https://pubmed.ncbi.nlm.nih.gov/
  6.  https://www.themedicportal.com/blog/the-6-nhs-core-values-explained/

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