The prevalence of multiple co-existing chronic conditions in the elderly results in higher utilization of healthcare services. However, the prevalent conversation in the value-based care is the adoption of the utilization reduction goal, which is to work with the patient in reducing the use of potentially avoidable services (e.g., CMS’s Readmissions Reduction Program / Measures), especially of higher cost services such as emergency and inpatient care by having a primary care provider be the center point of care and supplementing with care coordination services that are either centralized, decentralized or a combination of both approaches. Many organizations that take this approach find it very challenging to achieve the goals tied to VBC simply because over-burdened PCPs and care managers with large panel size/s do not have a magic wand to prevent and or proactively intervene to avoid the ED visits and hospitalizations (Tables 8 & 9).

A model or framework of delivery of care designed, bought-in by the clinical and ancillary care team/s and deployed and adopted in organizations, leads to the application of a universal standard of care especially for high demand and critical healthcare services, efficiently. The model at a minimum should include-

1. Figure out the model of care upfront with who (a designated PCP or the specialist) will be the "Captain of the Ship", driving timely clinical decisions and monitoring and coordinating non-clinical needs of the complex patients, especially with clusters of co-existing chronic conditions where multiple specialists are involved. Clearly define expected key (informational review) touchpoints and patient hand-offs between interdisciplinary care team/s during critical milestones in patient care (e.g. transitions of care)

2. A preferred provider roster for in and out-of-network services that is in-line with efficiency of operations (such as access to relevant and timely data on test results) and patient satisfaction (travel time and out-of-pocket cost) criteria

3. Acceptable wait times for appointments for routine, urgent and emergency care

4. Transitions of care processes (medication and therapy management) and standards especially involving ED, inpatient discharges to home and or skilled nursing and long-term care

5. An expected mechanism to funnel emergent decisions related to care on high-needs patients, outside of the normal business hours

6. Partnerships put in-place to address SDOH needs including food, transportation, housing, ability to pay for meds and dealing with loneliness (especially in the elderly)

To reduce future utilization of expensive services, it is imperative that the patient is understood, wholistically, including past care utilization patterns, unresolved issues, current medical and non-medical problems and needs and have a singular, dynamic plan of action that then becomes the GPS or the map and drives actions that impact care outcomes as expected.

Instead of taking simplistic and arbitrary views to a very complex problem, healthcare organizations aiming to be successful in population health and VBC models need to focus on building up core competencies to effectively care for the complex population and it begins with a clear understanding of the challenges associated with this population. The unambiguous marker of success in any VBC model is-If the patient is doing well (evident by outcomes), then you (as a business entity) are doing well (successful in your mission) as well.

Top specialty services that are key for this population are-

1. Cancer (Pulmonary, Breast, Urinary, Prostrate, Colo-rectal, Skin),

2. Cardiovascular (Stroke, CHD)

3. Ortho-Spinal

4. Allergy & Immunology- (COPD, Rheumatoid disorders of bone and joints)

5. Gastroenterology (GERD)

6. Endocrinology (Diabetes, Kidney Disease, Dialysis)

7. Nephrology

8. Neurology (Parkinson’s)

9. Cognitive-Psychiatry (Alzheimer’s, Dementia)

10. Rehab (Cardio, Ortho & Pulmonary)

11. Audiology

12. Ophthalmology

13. Sleep Disorders

14. Wound Care and

15. Alcohol and Substance Abuse

Access to providers and diagnostic services including lab and imaging that are within 10 miles travel distance from a patient location or provision of reliable to-and-fro travel would ensure adherence to appointments and tests. Decline in cognition and functional ability to perform activities of daily living (ADLs) can pave the path of leading individuals to institutional care and is an undeniable marker as to what is ahead. Services focused on keeping a person at-home with functional abilities in-tact for as long as possible are a not-so secret essential ingredient for success in VBC and is a win-win for patients as well as healthcare operators.

The general but key underlying challenges associated with the high-healthcare utilizing, elderly population besides the multitude of medical diagnoses are-1. Cognitive Decline 2. Mobility and Functional Issues 3. Lower Income and 4. Loneliness. The consequences of these existing factors are manifested in ways such as, lower adherence to medically necessary treatment regimen (drugs, appointments), vulnerability to falls and infections, increase in rates of obesity, hearing and vision loss, reduced access to nutritional food and transportation, prevalence of fear, depression and anxiety resulting in a variety of behavioral health issues which can sometimes lead to reliance on illegal drugs and alcohol dependence. No primary care provider, care manager or healthcare system is poised to address, succeed, and thrive such non-medical complexity at-scale with such a direct impact on clinical and financial outcomes.

The five foundational competencies needed for success in Medicare population management are-

1. An easily accessible interdisciplinary provider network comprising of primary care and specialist providers. “Build” or “Buy” approaches to creating a self-sustaining network are common but partnership and leasing have been seen also. More autonomy in the model means less tighter control centrally. This can have an impact on the availability of clinical and administrative data for monitoring quality, cost, utilization, and decision-making among providers. Consistent application and execution of care delivery model, policies, and standards of care across the network can be impacted also

2. Inter-disciplinary care planning, patient-centered care coordination and complex care management are essentially approaches relied upon to drive expected patient outcomes and are at the heart and center of population management in value-based care. Centralized and de-centralized teams of care managers, care navigators, social workers, pharmacists, providers (primary care and specialties) work together and with the patient and their families in monitoring patients, outcomes, and needs through the different continuums of care namely-Home, ER, Surgery, Inpatient (including Psychiatric), Ambulatory (including Psychiatric), Skilled Nursing, Rehabilitation, Long-Term Care, Hospice and Palliative Care

3. Whether you are in the ever-expanding or a lights-on mode, having a critical eye on your robust partner network, with a continuous feed-back loop on gaps, deficiencies and performance against set and agreed upon standards within the model of care delivery is essential for your continued success in managing populations, their needs and for your operations to run efficiently and smoothly besides allowing you to be in a better place to negotiate reimbursement based on quality, cost, efficiency and outcomes

4. It is imperative to build a an integrated, wholistic model of care involving seamless communication and shared decision making between clinical and non-clinical providers because a patient can have co-existing medical and non-medical needs and that clinical and cost outcomes can be dependent on addressing social needs simultaneously. The strength of your care model can be assessed by how well your system is set-up to respond, address and close the gaps and needs of all colors (clinical and non-clinical) expressed by the patient and their families

5. Technology and data (information, insights, wisdom) plays a crucial part in your success in population management after you have the above key ingredients in place. Now that you have established standards of care, model for delivery of services, robust clinical and non-clinical providers, and a good understanding of the needs of your population, you can specify goals to achieve, criteria for measurement and start measuring and sharing the results. You can improve once you know what the deficiencies are. But adoption of newer technology needs to be based on criteria that are important to serve your strategy and align and aid in achieving your goals. Patient convenience and comfort, safety, efficiency in operations, revenue gains through previously un-tapped, newer, or enhanced services could be such criteria that need evaluated in making the investments in technology or else it could quickly become a distraction from achieving your goals. Patient-centered care plan, Appointment and Medication reminders, Medication pickup sync, Tele-health, Remote monitoring (synchronous and asynchronous), Home-based care and diagnostics, genetic testing

Set up systems to continuously measure patterns in

1. Cost of services (episodic, disease-based, lifetime)

2. Efficacy (therapies and meds based on evidence and standards of care)

3. Utilization (based on evidence and standards of care)

4. Shifts in market share, reimbursements, patient preferences, loyalty, and satisfaction and

5. Provider and staff engagement and ownership in outcomes

Success is when knowledge is used habitually to formulate strategy that is executed meticulously, armed with discipline. Work confidently with Numiny as your trusted partner.