1 Lecture a – New Models of Care DeliveryValue-Based Care Welcome to Value-Based Care, Healthcare Delivery. This is Lecture a – New Models of Care Delivery. This lecture provides an overview of new models of care delivery, the importance of primary care in value-based medicine, and the use of non-physician providers in the provision of value-based care. This lecture focuses on new models of care delivery and how non-physician providers are integrated into healthcare delivery. Healthcare Delivery Lecture a – New Models of Care Delivery This material (Comp 23 Unit 3) was developed by the University of Alabama at Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0007. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit

2 New Models of Care Delivery Learning ObjectivesDescribe new models of care delivery Discuss the importance of primary care in value-based medicine Discuss the ways non-physician providers are used in the provision of value-based care The Objectives for this lecture, New Models of Care Delivery are to: Describe new models of care delivery; Discuss the importance of primary care in value-based medicine; Discuss the ways non-physician providers are used in the provision of value-based care.

3 Overview Definitions New models of care deliveryExamples of new models Primary care in value-based medicine Emergence of non-physician providers We will begin the lecture with a definition of an integrated health care delivery system and the organizations typically involved in providing health care services. We will then describe new models of care delivery and discuss examples of these new models. Then, we will discuss the importance of primary care in value-based medicine. Finally, the emergence of non-physician providers and the role these providers will play in the future of value-based care will be discussed.

4 Integrated Delivery SystemSystems of organizations and providers Coordinate services and work collaboratively to deliver health care services Hospitals, physician organizations, long term care facilities, home health agencies An integrated delivery system is a system of organizations and providers that coordinate services and work collaboratively to deliver health care services. When you think about health care delivery organizations, you typically think about hospitals, physician organizations, long term care facilities, home health agencies, and various other organizations in which providers offer health services. These are all components of integrated delivery systems. Integrated delivery systems continue to broaden and include diverse organizations and models of care delivery as a result of technical advances and innovation. Source: (Landry and Erwin, 2015)

5 Model of Care Delivery Care providers and organizations work together to deliver care to patients Patient-Centered Medical Home Emphasis on care coordination and communication Organizations and providers work together to deliver care to patients. The ways they approach care delivery and coordinate care result in models of care delivery. For example, the patient centered medical home is a model of care delivery that places emphasis on care coordination and communication. Source: (Landry and Erwin, 2015)

6 Factors Driving New Models of Care Delivery 1Emphasis on prevention, primary care, and care coordination Coordination challenging New models needed to address challenges Models of care are evolving and new models are being implemented due to a variety of factors. The Affordable Care Act (ACA) (pronounced A-C-A) is placing an increased emphasis on prevention, primary care, and care coordination. Coordinating care can be particularly challenging for patients with multiple chronic conditions. New approaches to delivering health care in a more coordinated way such as Accountable Care Organizations are being implemented as a result of the ACA. Source: (Kaiser Family Foundation, 2013; Landry and Erwin, 2015)

7 Factors Driving New Models of Care Delivery 2Emphasis on patient centeredness and quality care Medicare’s value-based purchasing Patient-centeredness one of six quality domains recommended by IOM Additionally, the ACA has provisions that are aimed at improving the quality of health care delivered. For example, Medicare’s value-based purchasing program financially incentivizes hospitals to improve the quality of care they provide. One of the ways organizations seek to improve quality is by providing patient-centered care. The Institute of Medicine has recommended “patient centeredness” as one of six domains that define quality care. Patient centered care is “care that is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions.” This has resulted in new models of care including the Patient Centered Medical Home. Source: (Kaiser Family Foundation, 2013; Institute of Medicine, 2001; Landry and Erwin, 2015)

8 Factors Driving New Models of Care Delivery 3Increased demand for primary care services Services focused on consumer convenience Technology facilitating consumer-driven approach Finally, the ACA is increasing the number of insured Americans. This increase has resulted in innovation in care delivery models in an effort to meet increased demand for health care services and particularly primary care services. Health care organizations and providers are becoming more consumer focused and are creating models of care that are “convenient” for consumers. Technology is facilitating this consumer driven approach to care. Examples of this include options for consumers to seek primary health care services outside of typical physician office hours such as retail clinics and telehealth options. Source: (Kaiser Family Foundation, 2013; Landry and Erwin, 2015)

9 New Models of Care DeliveryAccountable Care Organizations Patient Centered Medical Homes Retail Clinics Telemedicine Services Health Homes Community-Based Solutions Although a variety of new models of care delivery have been introduced in recent years, we briefly review the following new models: Accountable Care Organizations, Patient Centered Medical Homes, Retail Clinics, Telemedicine, Health Homes, and Community-Based Solutions Source: (Landry and Erwin, 2015)

10 Accountable Care OrganizationsGroups of providers jointly responsible for the health of a particular population of patients Improvements in quality More limited results in cost savings Accountable care organizations or ACOs (pronounced A-C-Os) are a result of innovations included in the Affordable Care Act. Although the idea of a group of providers and provider organizations taking on responsibility for the health of a distinct population or group of people is not unique, the ACA reintroduced this concept. The ACA created a pilot ACO program for Medicare patients, and other ACO type organizations are forming around other populations including the commercially insured and Medicaid patients. ACOs are responsible for providing high quality coordinated care to patients while sharing care delivery and financial responsibility for the defined patient group. Early results of the Medicare ACO program suggest that many of the participants are improving the quality of care for patients, but only a few ACOs have been able to achieve cost savings. Banner Health Network (BHN) in Arizona is an example of an ACO that is experiencing success with regard to quality improvement and cost savings. BHN includes a variety of provider organizations including acute care hospitals, clinics, home health organizations, hospice, behavioral health facilities, and a payor organization. These providers and provider organizations work collaboratively to manage the health of a defined population. Source: (Landry and Erwin, 2015)

11 Patient Centered Medical HomesModel emphasizes care coordination and communication Many have been effective in improving quality and reducing costs The Patient Centered Medical Home, or PCMH, is a model of primary care that emphasizes coordination and communication. The patient is at the center of this model of care delivery, and the PCMH model has demonstrated effectiveness at improving health care quality and reducing costs in various settings. The National Committee for Quality Assurance has standards that physician practices must meet to become certified as a PCMH. These standards include enhanced access and continuity of care, the identification and management of patient populations, care plans and care management, the provision of self-care support and community resources, the ability of the practice to track and coordinate care, and the ability of the practice to measure and improve performance. One example of a successful PCMH is Group Health Cooperative in Seattle, Washington. Group Health includes physician groups, medical facilities, and health plans that work together to meet the standards for a PCMH. Group Health has demonstrated the ability to improve patient experience and quality. They have also reduced physician burnout within their PCMH practices. Source: (Landry and Erwin, 2015; NCQA, 2011)

12 Retail Clinics Preventive care and routine acute careHoused in pharmacies, grocery stores Fueled by demand for convenience Young adults primary consumers Growing use by senior citizens May meet demands of newly insured Retail Clinics are clinics that provide preventive care and routine acute care in a “retail” setting. Retail clinics are often housed in larger stores such as pharmacies, grocery stores, and “big box” stores like Target. This model of care emerged as a result of consumer demand for more convenient care. Consumers want routine care at convenient locations that do not require an appointment. Retail clinics are frequently open extended hours and on weekends when traditional physician offices are closed. Research suggests that young adults are the primary consumers of care in retail clinics. However, the number of senior citizens using the retail clinic option is increasing. Retail clinics also offer the potential to meet the increased demand for primary care by the newly insured under the ACA. Source: (Landry and Erwin, 2015)

13 Telemedicine ServicesPrimary and specialty care Remote patient monitoring Single or multiple organizations Ability to increase access to care, especially in underserved areas Efficient access to specialty consultations Telemedicine Services facilitate the exchange of medical information between sites via electronic communications to improve a patient’s clinical health status. Primary care and specialist referral services might be conducted via telemedicine. Remote patient monitoring may also be conducted via telemedicine. Telemedicine services might be offered within a single health care organization such as a large health system or they may be used to facilitate communication and collaboration among different health care organizations. Hospitals, specialty clinics, physician offices, and home health agencies are just a few of the provider organizations that utilize telemedicine services. Telemedicine services have great potential to increase access to care for individuals in underserved areas. For example, telemedicine services may be utilized in rural communities to provide access to psychiatry services if no behavioral health providers are available in the area. Telemedicine also offers the ability for specialty consultations in a fast, efficient way that is convenient for the patient. Source: (Landry and Erwin, 2015)

14 Health Homes Medicaid patients with chronic conditionsFacilitate access to health services Utilize multidisciplinary teams Assisted by information technology The ACA created Health Homes to provide a PCMH type structure for Medicaid patients suffering from multiple chronic conditions. Medicaid patients typically have poorer health status than patients with commercial insurance or those of higher socioeconomic status. Health Homes create a system that facilitates access to a variety of health services including primary, specialty, acute, behavioral, and long term community-based services for this population. Under this model, multi-disciplinary care teams are put into place to help manage the care of Medicaid patients qualifying for this service. Care management and coordination is assisted by the use of health information technology. Source: (Landry and Erwin, 2015)

15 Community Based SolutionsDesigned to keep high-risk patient populations out of institutional settings Community-based Care Transition Program Support for patients returning to community Avoid readmissions Community based solutions are models of care designed to keep high-risk patient populations out of institutional settings such as acute care hospitals and nursing homes. One example of a community based solution is the Community-based Care Transition Program (CCTP). The goal of CCTP is to reduce avoidable hospital readmissions in the Medicare population. Acute care hospitals collaborate with community-based organizations such as faith based initiatives, senior centers, etc., to make sure that patients have support when they transition from the inpatient to the outpatient setting. Providing community support can ease the transition back home and prevent avoidable hospital readmissions. Source: (Landry and Erwin, 2015)

16 Primary Care ProvidersDeliver care on a routine basis Basic acute care and prevention services Family practice, pediatrics, internal medicine Nurse practitioners and midwives Other non-physician professionals including physician assistants All of the new models of care delivery we have reviewed have one thing in common: the primacy of primary care providers in delivering care. Primary care providers deliver care on a routine basis including basic acute care and prevention services. Primary care providers include doctors with specialization in family practice, internal medicine, and pediatrics. Also, nurse practitioners and midwives and other non-physician professionals including physician assistants provide primary care services. Source: (Knickman and Kovner, 2015)

17 Primary Care Providers: An Increasingly Important RoleIncreased demand for primary care providers Increase in the insured population Focus on prevention Primary care providers are playing an increasingly important role in the delivery of health care in the United States. One of the primary goals of the ACA is to increase access to health care services for Americans through increasing the availability of private health insurance and the expansion of Medicaid. Increasing numbers of insured Americans are driving demand for primary care services. Additionally, the ACA emphasizes prevention and preventive services are considered an essential benefit that health insurance plans must offer beneficiaries. Primary care providers play a crucial role in the delivery of preventive care services. Source: (Kaiser Family Foundation, 2013; Landry and Erwin, 2015)

18 Primary Care PhysiciansIncreased number of insured Population growth Aging of the population Geographic maldistribution Increased rates of chronic illness Supply less than demand However, a shortage of primary care physicians is projected in the United States over the next 15 – 30 years. An increase in the number of insured, population growth, aging of the population, geographic maldistribution of providers, and increased rates of chronic illness will increase the demand for primary care physicians in the next decade. Due to significant time and cost constraints, the supply of primary care physicians is not projected to keep up with demand. Source: (Spetz and Chapman, 2015)

19 Non-Physician Primary Care ProvidersNurse practitioners and physician assistants Critical team members in new models of care Expanded roles offer potential solution Non-physician providers with advanced clinical training include nurse practitioners and physician assistants. These primary care providers play an important role in the new models of care we have discussed. For example, in the PCMH model of care delivery nurse practitioners or physician assistants work in collaborative teams with primary care physicians and specialty care providers to coordinate and manage the care of patients. Non-physician providers also offer a possible solution to the primary care physician shortage projected in the United States. Expanding the role of non-physician providers with advanced clinical training can alleviate some of the demand pressures on primary care physicians as a result of the newly insured, chronically ill, and aging population. Source: (Spetz and Chapman, 2015)

20 Challenges Associated with Non-Physician Primary Care ProvidersScope of practice regulations States regulate Limited autonomy of non-physician providers Many nurse practitioners practice under supervision of a licensed physician Although research suggests that non-physician primary care providers such as nurse practitioners and physician assistants provide similar quality of care and often better patient communication than primary care physicians, individual states regulate the scope of practice for non-physician providers. State regulations are put into place to ensure that providers are only performing duties that are appropriate for the given level of education, competence, and skill. However, such regulations limit the autonomy of non-physician primary care providers. For example, only 22 states allow nurse practitioners to provide care without the supervision of a licensed physician. Source: (Spetz and Chapman, 2015)

21 Non-Physician Primary Care Providers in the FutureRegulatory reform needed Address outdated practice regulations Increase autonomy Remove regulatory barriers Many researchers and policy analysts are calling for widespread regulatory reform to address outdated scope of practice regulations for non-physician primary care providers. Non-physician providers are often critical parts of care teams. These providers have the potential to alleviate primary care physician shortages in the future with increased autonomy. Removing regulatory barriers will allow these providers to practice at their fullest potential. Source: (Spetz and Chapman, 2015)

22 New Models of Care in PracticeMay improve access to quality health care Effectiveness still limited Continued growth of retail clinics, telemedicine, health homes Findings not conclusive Evaluation continuing This lecture has presented information on several new models of care that have the potential to improve access to quality health care for many Americans that are newly insured via the ACA, particularly when these approaches are integrated into traditional health systems. Many of these approaches are promising; however, evidence of their effectiveness is still limited. The research on ACO and PCMH effectiveness suggests these approaches to coordinating care have promise. Likewise, findings are not yet conclusive on retail clinics, telemedicine, health homes, and community based solutions. This has not curbed the growth of these new approaches. The number of retail clinics continues to grow, and experts estimate over 1900 are operating in the United States. Organized physician groups, including the AMA, have been critical of the quality of care offered at these clinics. However, no evidence exists to suggest these clinics provide poor quality care. The use of telemedicine is increasing, and research suggests that it has potential to improve access to primary care for underserved children and adults in both urban and rural areas. Health homes and community based solutions are also being evaluated in a variety of ways. It is encouraging to see the interest in new models of care delivery developing around the country. Source: (Iglehart, 2016; Landry and Erwin, 2015 ; Marwick, et al 2015)

23 Healthcare Delivery Summary – Lecture aNew models of care delivery Accountable Care Organizations Patient Centered Medical Homes Retail Clinics Telemedicine Services Health Homes Community-Based Solutions Roles and challenges for non-physician providers This concludes lecture a of Healthcare Delivery. In summary, we defined the health care delivery system, and we reviewed new models of care delivery. We discussed the ways that non-physician providers are used in delivering health care services, and we explored the challenges these providers face.

24 Healthcare Delivery References – Lecture aIglehart, J. K. (2016). The expansion of retail clinics–Corporate titans vs. organized medicine. New England Journal of Medicine, 373(4), 301–303. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Knickman, J. R. & Kovner, A.R. (2015). Health care delivery in the United States. New York: Springer. Landry, A. Y. & Erwin, C. (2015). Organization of care. In: Knickman, J. R., & Kovner, A. R. (Eds.), Health care delivery in the United States. ( ). New York: Springer. Marwick, L., McConnochie, K., & Wood, N. (2015). Expanding telemedicine to include primary care for the urban adult. Journal of Health Care for the Poor and Underserved, 26(3), Patient-Centered Medical Home Recognition. (2015). Retrieved March 22, 2016, from Spetz, J, Chapman, SA. The health workforce. In: Knickman, J. R., Kovner, A.R. (Eds.), Health care delivery in the United States. ( ). New York: Springer. Summary of the Affordable Care Act. (2013). Retrieved March 22, 2016, from No audio

25 Value-Based Care, Healthcare Delivery, New Models of Care DeliveryThis material was developed by The University of Alabama at Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0007. No audio.