The Affordable Care Act (ACA) had a huge impact on healthcare delivery. Most notably, it gave our system a massive push toward value-based reimbursement schemes that reward providers for delivering the best quality care at the lowest cost.
To maximize value over time, providers must take an active role in promoting the health of the populations they serve — even when those patients do not proactively seek care. This presents quite a challenge in a healthcare system beset by a rapidly aging population, access issues and an acute provider shortage.
To meet the goals of healthcare reform, we must design new care delivery pathways that address patients' complex needs. We also need to maximize the capacity of our healthcare workforce by utilizing physician assistants (PAs) and nurse practitioners (NPs) to their full scope of practice.
In this post, I'll explore how interdisciplinary and community-based care models can improve access, reduce costs and add value for both patients and providers. I'll also highlight some promising examples from current practice.
Changing Needs
In addition to the ACA, several social and demographic factors are increasing the need for new models of care delivery:
- Aging population. One in five Americans will be over age 65 by 2030, which will sharply increase the demand for healthcare services.
- Physician shortage. Traditionally, Americans have viewed physicians as their default healthcare providers. However, the American Association of Medical Colleges estimates our country will face a shortage of 46,000 to 90,000 physicians by 2025.
- Chronic disease burden. Half of all American adults currently have a chronic health condition such as heart disease, obesity or diabetes. These chronic illnesses account for over 85 percent of healthcare spending.
- Barriers to access. While the ACA was a step forward, many patients still face financial and practical barriers to care. Examples include narrow insurance networks, wait times for appointments, care fragmentation and transportation issues.
Healthcare Delivery Trends
To manage population health in these challenging times, providers need alternatives to traditional fee-for-service delivery models. One promising approach is the use of interdisciplinary teams to address patients' complex needs and coordinate care services. Such teams often include representatives from medicine, nursing, pharmacy, rehabilitation, behavioral health, case management and social work.
Another promising trend is the shift toward community-based care. In order to more effectively manage population health, providers must sometimes bring services to patients — whether through home healthcare, a community paramedicine program or a clinic situated in a highly accessible location such as a food pantry.
A third trend, and one explicitly endorsed by the ACA, is the increased utilization of PAs and NPs to provide direct care to patients. These professionals are explicitly trained to work within physician-led teams, and as such, can be valuable assets to interdisciplinary care delivery systems. To meet the growing demand for healthcare services, PAs and NPs will need to practice at the top of their licenses. In addition, some states will need to
remove barriers that unreasonably limit PAs' and NPs' scope of practice.
Examples of Team-Based Care Models
Team- and community-based models of care are relatively new and still taking shape. Research is underway to determine which approaches are the most cost-effective at improving patient outcomes. Here are just a few programs that have shown promise for managing population health:
Telemedicine is the use of telecommunications equipment for real-time video conferencing and image sharing between care teams, consultants, patients and families.
Telemedicine programs take many forms. For example, home telehealth allows care teams to closely monitor patients who have been recently discharged from the hospital or who are working to manage a chronic illness. Wireless monitoring devices that measure blood pressure, blood glucose, weight and much more are expanding the possibilities of home telehealth.
Example: The Veterans Health Administration's Patient-Aligned Care Team (PACT) program provides team-based care to patients with complex medical and social needs. Patient contact occurs through a variety of modalities, including home telehealth visits. The PACT model often utilizes PAs and NPs as primary care providers.
Interdisciplinary telehealth teams can also be used to support hospital-based providers — especially in areas with critical physician shortages.
Example: UMass Memorial Health Care utilizes a centralized "eICU" to enhance critical care in three of its hospitals. The eICU is staffed by intensivists, PA/NPs and pharmacists who monitor patients remotely and work with the on-site care team to address problems early, before complications develop.
Community paramedicine expands the scope of care provided by emergency medical services (EMS), often in collaboration with hospitals and community health organizations. Community paramedicine teams may:
- Treat non-emergent conditions on the spot (urinary tract infections, sprains).
- Transport patients to non-hospital destinations (pharmacy, urgent care center, psychiatric emergency services).
- Provide in-home primary care, post-acute follow-up and chronic disease management.
Example: The Mesa Fire Department Transitional Response Vehicle Program uses a paramedic/NP/PA team to clear psychiatric patients in the field in order to minimize preventable ED visits and psychiatric admissions.
Post-acute care and rehabilitation programs help to prevent hospital readmissions by ensuring patients get needed follow-up care. At present, 20 percent of Medicare beneficiaries are readmitted within 30 days of a hospital discharge. These readmissions are distressing for patients and families and costly for both hospitals and the public. Research suggests that effective care coordination can prevent readmissions and improve patient outcomes.
Example: The Transitional Care Model utilizes an NP-led multidisciplinary team to facilitate discharge planning and follow-up care for elderly, chronically ill hospital patients. Patients receive periodic home visits, telephone contacts and are accompanied by team members to follow-up appointments. Studies of this model demonstrate a 30 to 50 percent reduction in hospital readmissions plus an average savings of $4,000 per patient.
Chronic disease management. Chronic disease patients often have complex needs that can best be addressed by an interdisciplinary team approach:
- Medical (multiple conditions, disability, aging)
- Social (caregiver burden, housing instability, food uncertainty)
- Emotional/behavioral (substance abuse, dementia, mental illness)
In addition, management of chronic conditions requires frequent patient contact, care coordination, education and other time-intensive services. Research suggests that an interdisciplinary team approach may be an effective solution.
Example: One study compared outcomes among diabetes patients cared for by their primary care physician versus those cared for by an NP-physician team. After one year, the NP-physician patients had received more comprehensive preventive care (flu shots, foot exams, etc.), showed more improvement in their hemoglobin A1C values and were more satisfied with their care.
The Way Forward
While team- and community-based care delivery models show promise, they also face many barriers to implementation:
- In the current healthcare culture, physicians are still viewed as default providers rather than care supervisors, consultants and team leaders.
- Skills like teamwork and communication are still not taught in many health professions training programs.
- Care coordination requires time and coordination of schedules, which sometimes takes away from direct patient care.
- Reimbursement structures are still rooted in fee-for-service models and don't compensate services like patient education, care coordination and interdisciplinary team meetings.
None of these changes is insurmountable, and indeed, positive change is already occurring. (For example, Medicare recently rolled out a
modest reimbursement for "care coordination management.") But it will also be up to front-line providers to make our voices heard and demand the changes we need to manage the health of our patients.
