Population Health and Care Transitions 1 PDF

# SECTION 7 ## Population Health and Care Transitions Patricia Resnik, Jennifer Proctor, Christy L. Beaudin, and Luc R. Pelletier ### SECTION CONTENTS | Topic | Page | Topic | Page | |---|---|---|---| | Introduction | 376 | Episodic Care | 396 | | Population Health | 376 | Chronic Disease Mana...

# SECTION 7 ## Population Health and Care Transitions Patricia Resnik, Jennifer Proctor, Christy L. Beaudin, and Luc R. Pelletier ### SECTION CONTENTS | Topic | Page | Topic | Page | |---|---|---|---| | Introduction | 376 | Episodic Care | 396 | | Population Health | 376 | Chronic Disease Management | 397 | | Population Health Management | 379 | Primary Care | 398 | | Data Integration | 380 | AHA Workforce Center-Redesigned Primary Care Model | 398 | | Goal Setting | 381 | Patient-Centered Medical Home and Medical Neighborhood Concept | 399 | | Targeted Interventions | 381 | Behavioral Health Integration | 400 | | Measurement and Improvement | 381 | Skilled Nursing and Inpatient Rehabilitation Care | 401 | | Population Health Models and Frameworks | 382 | Home Healthcare | 403 | | American Hospital Association Population Health Framework | 383 | Managing Care Transitions | 403 | | The Care Continuum Alliance Population Health Improvement Model | 384 | Case Management | 403 | | Centers for Disease Control and Prevention 6/18 Initiative | 384 | Case Management Models | 404 | | County Health Rankings Model | 384 | Standardizing Handoffs | 404 | | National Committee for Quality Assurance Population Health Management Conceptual Model | 385 | Discharge Assessment at Home | 405 | | Pathways to Population Health | 386 | CMS Acute Hospital Care at Home Program| 405 | | URAC Population Health | 388 | Readmission Risk Mitigation | 406 | | Population Health and Value-Based Care | 390 | Population Health and Care Transitions in Practice | 406 | | Value-Based Reimbursement| 390 | Primary Care | 406 | | Medicare Shared Savings Program and Accountable Care Organizations | 391 | Screening | 408 | | Care Transitions | 392 | Transition Coaching | 408 | | Care Management | 394 | Hotspotting | 408 | | Care Management Infrastructure | 395 | Healthcare Efficiency | 408 | | Caring for the Population | 396 | Summary | 409 | | Health and Wellness | 396 | References | 410 | | | | Suggested Readings | 413 | | | | Online Resources | 414 | ## Introduction Population health is rapidly expanding as health systems, healthcare facilities, providers, and payers transition from volume-based to value-based reimbursement models. This section will focus on population health and care transitions, highlighting how the healthcare quality professional is optimally positioned to successfully drive desired care outcomes. The ability to accurately design appropriate data collection tools and analyze vast amounts of population-based data to stratify the population by risk, identify opportunities for improvement, and deploy rapid-cycle process changes is critical to success when operating in a value-based reimbursement arrangement. Care management and care transitions are discussed as they are fundamental to population health management in healthcare. ## Population Health Healthcare is moving beyond the episode of care to determine health outcomes. Population health is a concept that emerged in Canada when Evans and Stoddart of the Canadian Institute for Advanced Research published a model for analyzing the social determinants of health (SDOH). This model embraced the idea that the social environment determines health. On a macro level, this work influenced health policy, approaches to health promotion, and health services research. On a micro level, it brought into view characteristics of the individual in a group context but did not account for individual behavior changes and health. Population health reached the United States in the late 1990s, with discussions in *Crossing the Quality Chasm: A New Health System for the 21st Century* and then took on more traction with the Affordable Care Act in 2010. Population health can be defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group. These populations are often geographic regions, such as nations or communities, but they can also be other groups such as employees, ethnic groups, disabled persons, or prisoners." Further, population health can be defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group." It considers all the determinants of health, including medical care, social and physical environments and related services, genetics, and individual behavior. An inherent byproduct of population health is the identification, reduction, or elimination of inequity and health disparities. Population health management emerged with healthcare reform. This requires data to guide population care delivery underscoring the importance of possessing knowledge of the healthcare organizations and care delivery, essentials of healthcare quality and safety, regulatory issues, health economics, epidemiology, implementation science, health informatics, and data analytics. For discussion on these areas, see the following sections: Quality Leadership and Integration; Quality Review and Accountability; Regulatory and Accreditation; Patient Safety; Performance and Process Improvement; and Health Data Analytics. Determinants of health, such as medical care systems, the social environment, and the physical environment, have biological impact on individuals in part at a population level. Figure 7.1 illustrates how an integrated healthcare delivery system contextualized the principles of population health (e.g., policies, programs, determinants, outcomes) into its strategies for improving quality of life and well-being at individual and community levels for physical health, mental health, and substance use services. Population health shifts thinking from volume-based reimbursement to value-based reimbursement in pursuit of the Triple Aim. In 2007, the Institute for Healthcare Improvement (IHI) introduced the Triple Aim framework, which focused on enhancing the patient experience, improving population health, and reducing healthcare costs accompanied by high-level measures defining the dimension. Since its introduction, the Triple Aim has evolved with changes in healthcare and may now include a fourth aim referred to as "joy in work," "improving the work life of clinicians and staff," "improved clinician/provider experience," or "care team well-being." Other changes, such as demographics, support the adoption of a population health-based approach. For example, consider that the number of Americans older than age of 65 is projected to reach 80 million by 2040. Add to that the fact that chronic disease prevalence rises as people age. Another consideration is the number of people with multiple chronic conditions. Over the past 2 decades, caring for people with multiple chronic conditions has dramatically driven up healthcare costs. The total economic impact of chronic disease in the United States in 2016 was $4.1 trillion, amounting to 20% of the U.S. gross domestic product. Population health is another area where data are large volume and high velocity. When the data are available, organizations can assess how they are managing high-risk and high-volume patients, as well as how they are managing the general population. For example, it is often helpful to know what percentage of the population is composed of high utilizers for hospital stays or emergency room visits and to determine the characteristics of these patients so they can be better managed (e.g., more visits to their primary care provider, better diet, behavioral health referrals). In another example, these four features contributed to better population management of primary care for older adults with chronic illnesses: 1. Comprehensive assessment of the patient's health conditions, treatments, behaviors, risks, supports, resources, values, and preferences 2. Evidence-based care planning and monitoring to meet the patient's health-related needs and preferences 3. Promotion of the patient's and family caregivers' active engagement in care 4. Coordination and communication among all the professionals engaged in a patient's care, especially during transitions from the hospital These population health management activities are amenable to measurement and data analytics. As payment shifts toward value versus volume, it is more common for organizations to be evaluated based on how they are managing entire populations. Payers are putting providers at risk to achieve the best outcomes for these groups of patients. With good data and robust analytics, it is possible to achieve the goal of being a high-performing organization in meeting the needs of specific populations. How is population health different than public health? It is a reasonable question to ask and important to understand. Population health focuses on the social, cultural, environmental, and physical conditions affecting populations and therefore supports the mission of public health. In 1920, Winslow defined public health as the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health, the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community efforts. Public health's mission covers three Ps-promotion of health in a population, prevention of disease in a population, and protection of the health of a population. Table 7.1 describes the unique features of individual health, population health, and public health. While equally important, population medicine differs from population health in that the principles relate to the impact of clinical care and individual health outcomes. Eggleston noted that population medicine takes a population perspective from a healthcare system approach. It encompasses the intersection between the healthcare system and other determinants of population health (e.g., public health and built and social environments). This includes population-specific activities of the healthcare system itself and intersections of the system with other determinants of population health. Population medicine created a pathway to individualized and precision medicine, which can improve symptom-driven practice using comprehensive patient information with distinguishing factors of illness and health. Population medicine can provide decision support and positively impact patient outcomes. Approaches and techniques to consider in population medicine include artificial intelligence, machine learning, personalized treatment, and data science. See the Health Data Analytics section for more information related to data processing and analysis. Box 7.1 highlights key points in population health. ## Population Health Management Population health management "is the design, delivery, coordination, and payment of high-quality healthcare services to manage the Triple Aim for a population using the best resources available within the healthcare system." The Association of American Medical Colleges (AAMC) describes 10 requirements of a comprehensive population health management program. 1. Data infrastructure. This includes the ability to track information in the electronic health record and data registries. Value-based reimbursement is structured around demonstrated improvement in successful outcomes while reducing costs, and it requires effective collection and monitoring of data. Additionally, patient-specific clinical registries are increasingly available directly within the electronic health record, making it easier to identify and collect data on specific patient populations, such as those with chronic health conditions. 2. Community engagement. This focuses on understanding the needs of the community and developing relationships with community partners. 3. Team-based care. Involves the creation of an interdisciplinary care team, including registered nurses, social workers, and pharmacists. 4. Panel management. This refers to caring for the defined population, leveraging evidence-based care for preventive and chronic care, ensuring timely completion of related tasks, identifying and addressing inequities, and engaging with patients to close care gaps. 5. Patient risk stratification. This requirement involves the placing of patients into subgroups as determined by the clinic. 6. Care management. This requirement involves care for patients with chronic health conditions. 7. Complex care management. This refers to identifying high-cost patients and patients with high needs and using a team-based approach to managing the needs of these patients. 8. Self-management support. Engaging with patients to provide education and support as the patient actively manages their chronic health condition or preventive health measures. 9. Addressing social determinants of health. This identifies social needs that may be affecting the patient's well-being and developing a plan to address those social needs. 10. Ensuring health equity. This requirement focuses on identifying and addressing inequities and gaps within the population to reduce health disparities and improve health outcomes. Critical to understanding the population is a comprehensive assessment and establishment of a detailed understanding of differences between the types of payers, such as governmental plans and commercial insurers and those who are uninsured. As the National Committee for Quality Assurance (NCQA) describes, "over 60 percent of health and longevity is driven by nonclinical factors" known as SDOH such as "the conditions in which people are born, grow, live, work, and age-which include socioeconomic status, education, neighborhood and physical environment, employment, social support networks and access to health care." Addressing social determinants of health is important for health improvement and reduction of long-standing disparities in health and healthcare." Figure 7.2 provides SDOH examples. Challenges to addressing SDOH include a lack of concise assessment models, screening tools that are not linked to evidence-based studies, and a lack of provider time and resources to collect information. Healthy People 2030 addresses the latest health priorities and includes a strong focus on health equity. One of the overarching goals of Healthy People 2030 is to "eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all." Population goals are categorized by health conditions, health behaviors, populations, settings and systems, and SDOH (e.g., economic stability, education access and quality, healthcare access and quality, the neighborhood and built environment, and social and community context). ### Data Integration Data integration from a variety of sources is necessary to perform a thorough evaluation and risk stratification of the population while balancing privacy and security of healthcare data. Sources of data may include the electronic health record, health information exchanges, claims data, patient monitoring devices, screening tools, and other internal and external information technology systems. Stratification should leverage real-time data to the extent possible. The what and how to stratify need clarity. As an example, using test results may depend on demographic characteristics of the population including age, race, and sex where laboratory test results should be interpreted based on similar individuals. Other examples include admission and discharge data that can be integrated to automatically update the population risk stratification. Predictive modeling may help identify certain high-risk situations, such as the risk of readmission within a designated time period; however, predictive modeling does not offer interventions that may help to mitigate the readmission risk. Adding artificial intelligence to predictive modeling could reduce the readmission risk. Quality, safety, and performance improvement can be enhanced in population health through the application of clinical epidemiology (e.g., case-control studies, cohort studies, propensity score matching) to data collected on many patients for little cost. This comports to a recent emphasis in the healthcare industry related to population health. Comprehensive linked databases have enormous potential to provide information on the influence of tests and treatments on health. The potential value of these data can be realized if the actual receipt of these interventions, health outcomes, and potentially confounding variables can be ascertained accurately for individual patients. Selection bias can be minimized by identifying an appropriate basis for comparison. For example, it is possible to assess changes in patient outcomes after an improvement intervention on a specific nursing unit by comparing those outcomes to a matched group of patients from other units in a hospital or over a prior period for the same unit when adjusting for any confounding variables. Using data available in electronic records and appropriate statistical methods makes it possible to test for statistical differences related to a quality, safety, or process improvement initiative compared to current practice. This level of analysis makes the results more robust, leading to wider acceptance across an organization and broad adoption of the improvement effort (also known as "spread"). For more information, see the Health Data Analytics section. ### Goal Setting Goal setting should include goals that are specific, measurable, achievable, relevant, and timely (SMART). In addition, consider these key factors when setting goals: 1. Characteristics and needs of the population. 2. Stakeholder obligations, such as alignment of performance measures with accreditation standards, regulatory requirements, and contractual stipulations. 3. The Quadruple Aim, which intends to * improve the experience of care, * improve the health of populations, * reduce the per capita cost of healthcare and incorporate smarter spending, and * support positive workforce experiences or joy in work. Once set, the plan-do-study-act performance improvement cycle may be leveraged to achieve the goals. For more information on the improvement cycle, see the Performance and Process Improvement section. ### Targeted Interventions Targeted interventions include those that are patient centered and evidence based, including a variety of care coordination and care management activities. Targeted interventions are critical for the success of a population health management program and may include wellness and prevention programs with personal coaching and self-management tools (e.g., well-being and resilience), preventive care, and educational activities. Additionally, the care management team can develop patient-specific care plans that consider patient needs, include prioritized goals, and contain a mechanism to track progress toward goals. The care management team also provides the necessary facilitation of care transitions and ensures the patient has self-management support. Providing practitioner support through partnership is an important driver for success with interventions. Examples of support may include data sharing and analytics, training, embedding care managers, and technical assistance. Informatics and analytics are used to target and reach individuals who are most at risk. Information technology tools such as portals, mobile applications, and telehealth expands the reach of practitioners in engaging patients and their families, and impacts desired outcomes. ### Measurement and Improvement Value-based care reimbursement models are driving the need for quality measurement and improvement focused on quality, cost, and patient experience. Further, improvement in population health outcomes demands a disciplined and structured approach to measuring health outcomes. For additional information, see the Quality Review and Accountability and Performance and Process Improvement sections. The Centers for Medicare & Medicaid Services (CMS) suggests that a population health measure should be defined as a "broadly applicable indicator that reflects the quality of a group's overall health and well-being." Examples of population health measures include access to care, clinical outcomes, coordination of care and community services, health behaviors, preventive care and screening, and health service utilization. Acknowledging population health depends on a variety of factors, including economic, social, environmental, cultural, and behavioral factors. Figure 7.3 shows population health's intersections with the Triple Aim. Further, CMS spells out that population health improvement requires commitment across multiple sectors, including government and tribal agencies, measured entities and payers, community service providers, and private sector partners. Community health centers are essential partners on any road to population health improvement. The National Association of Community Health Centers encourages quality improvement/performance measurement as one population health management strategy to achieve its Quadruple Aim of improved patient experiences, improved clinical outcomes, and lower costs while improving the work life of healthcare providers. To help achieve these significant goals, the association calls on quality improvement and performance measurement, which it defines as a "formal methodology that enables health centers to leverage data collection and analysis, process improvement, and performance benchmarking." Viewing measurement and improvement through the additional lens of population health can seem overwhelming. According to IHI, a key part of the population health journey is to understand the needs and assets of the patients and individuals in your chosen population. This understanding is core to defining aims; engaging the right partners in the work; and designing effective, equitable, and sustainable care and service delivery systems. While focusing on needs is an important part of the process, solely using this approach can focus only on deficiencies within a population. This is why it's also key to consider an assets-based approach, which suggests that all individuals and populations have multiple strengths and capacities, which could be harnessed to make them thrive more fully. Using an assets-based approach, IHI proposes a three-part data review process, which follows: 1. Review available data to identify overall patterns that impact the population. 2. Understand the perspectives and experiences of care teams and other professionals providing care or supporting the population to understand a population's greatest needs and assets. 3. Understand the perspectives and experience of the patient to understand what is important to them, the real-world challenges in managing health and living situations, and what might help. Healthcare quality professionals should understand how to implement standard performance and process improvement methods, such as the plan-do-study-act cycle to track performance measures in value-based payment arrangements. See the Performance and Process Improvement section for more information. ## Population Health Models and Frameworks There is a variety of population health models to enable healthcare organizations and public health programs in their efforts to improve the health of populations rather than limiting interventions and improvements to the health of individuals. Friedman and Starfield note that "Although no single public health program can address the wide range of influences on population health, the use of [a variety of models] in public health practice can reorient programs away from more isolated and categorical approaches to more integrated approaches." Examples of different population health models and frameworks follow: ### American Hospital Association Population Health Framework The American Hospital Association (AHA), a national organization that represents hospitals, healthcare networks, patients, and communities, presents its framework in support of accountable, equitable care. These groups may include but not be limited to "those who are attributable to or served by a hospital or health care system, those living in a specified geographic area or community, or those experiencing a certain condition or disease." The AHA Population Health Framework is shown as Figure 7.4. The importance of driving improvement through integrated models and community partnerships as outlined by AHA was noted in a systematic literature review of hospital-community partnerships. Community or population health improvement is aided by "a better understanding of how health systems engage with community partners for population health and should be of interest to hospital administrators focused on population health management [and] organizations interested in collaborating with health systems ...." Further, healthcare leaders and professionals overseeing population health management activities can * identify the best partners to support population health efforts, * leverage and sustain partnerships beyond initial efforts to meet regulatory and accreditation requirements, and * use partners to support interventions focused on social determinants of health. The elements of the AHA framework offer population health program developers anchors for transformation initiatives. ### The Care Continuum Alliance Population Health Improvement Model Another strong voice in population health is the Care Continuum Alliance, which aims to promote health status through the promotion and alignment of population health improvement. The Care Continuum Alliance identifies the key components of the population health improvement model including strategies and processes, needs assessments (physical, psychological, economic, and environmental needs), health promotion, person-centric health management goals and education (e.g., primary prevention, behavior modification, coordination of care), self-management interventions targeting behavioral changes in the population, evaluation of outcomes (e.g., clinical, humanistic, and economic), and reporting and feedback to the patient, physicians, health plan and ancillary providers. This population health improvement model highlights three components. 1. Central care delivery and leadership roles of the primary care physician 2. Critical importance of patient activation, involvement, and personal responsibility 3. Patient focus and expansion of care coordination (e.g., wellness, disease, and chronic care management programs) The Care Continuum Alliance suggests that the consolidation of these population health dynamics ensures better healthcare quality and patient satisfaction. By extension, the group proposes that, through coordination and integration, healthcare can more effectively address workforce shortages, access, and affordability. Like population health itself, the focus of this model is the delivery and coordination of appropriate, cost-effective care. The model encourages and rewards improvement and goal achievement. ### Centers for Disease Control and Prevention 6/18 Initiative In July 2018, the U.S. Centers for Disease Control and Prevention (CDC) introduced its 6/18 Initiative, targeting 6 common and costly health conditions with 18 proven interventions. The 6 conditions and aims are 1. reduce tobacco use; 2. control high blood pressure; 3. improve antibiotic use; 4. control asthma; 5. prevent unintended pregnancy; and 6. prevent type 2 diabetes. For the project, CDC partners with healthcare purchasers, payers, and providers to improve health and control healthcare costs. CDC provides its partners with "rigorous evidence about high-burden health conditions and associated interventions to inform their decisions to have the greatest health and cost impact. This initiative aligns evidence-based preventive practices with emerging value-based payment and delivery methods," with an intention to improve health and control costs. The six high-burden health conditions with effective interventions that the CDC is prioritizing are shown in Figure 7.5. CDC also provides fuller descriptions of the conditions, evidence summaries, and resources and tools on the 6/18 website ### County Health Rankings Model The County Health Rankings is a program of the University of Wisconsin Population Health Institute. A model of community health was developed by the institute, emphasizing factors and measures that relate to community health. The model can be used by healthcare quality professionals and others to convey the influence of SDOH and to profile the health of a community. Descriptions and statistics show how different health behaviors, clinical care, social and economic factors, and physical environment may determine health status and health outcomes (Figure 7.6). The rankings use more than 30 measures to aid in the understanding of how healthy community residents are today (health outcomes) and the impact of different determinants in the future (health factors). The years of data available for each measure vary. Table 7.2 lists selected measures that are available. ### National Committee for Quality Assurance Population Health Management Conceptual Model NCQA offers Population Health Program accreditation. NCQA defines population health management as "a model of care that addresses individuals' health needs at all points along the continuum of care, including in the community setting, through participation, engagement, and targeted interventions for a defined population." The goal of population management is to maintain or improve "the physical and psychological well-being of individuals and address health disparities through cost-effective and tailored health solutions." Population health management encompasses data integration, understanding the population, population stratification, targeted interventions, practitioner support, and measurement and quality improvement. The population health management (PHM) conceptual model developed by NCQA outlines the key activities necessary for a comprehensive population health management strategy. As illustrated in Figure 7.7, this model may be applied to any entity conducting population health functions. The patient is at the center of the PHM conceptual model, with a focus on providing care that addresses patient needs, preferences, and values. Considering the components surrounding the patient is vital to the successful implementation of a population health management strategy and creating a comprehensive approach to population health management. Pertaining to the PHM strategy, NCQA highlights four recommendations: 1. Importance of leadership buy-in and strong organizational culture 2. Practitioner leadership 3. Goal setting and alignment 4. Creation and communication of a PHM strategy NCQA also developed a road map for population health management that is intended for integrated delivery networks, accountable care organizations, health systems, and other provider entities seeking to understand population health and how it is leveraged for success in value-based care. The road map contains seven milestones configured as a path to value-based care and leverages the activities of the PHM conceptual model (Figure 7.8). ### Pathways to Population Health Aiming to give healthcare leaders pathways to improve the health of the communities served, five organizations-AHA, IHI, the Network for Regional Healthcare Improvement, the Public Health Institute, and Stakeholder Health came together to create Pathways to Population Health. The experience of the supporting organizations is shown in the pathways framework (Figure 7.9). The Pathways to Population Health partnership draws on six foundational concepts that signal a developing perception of health itself as well as the importance of partnership across healthcare and community sectors. 1. Health and well-being develop over a lifetime. 2. Social determinants drive health and well-being outcomes throughout the life course. 3. Place is a determinant of health, well-being, and equity. 4. The health system needs to address the key demographic shifts out of time. 5. The health system can embrace innovative financial models and deploy existing assets for greater value. 6. Health creation requires partnership because healthcare only holds a part of the puzzle. The four portfolios of population health are interconnected and represent a "comprehensive scope of population health-related improvements a health care organization may pursue" focusing on physical and/or mental health, social and/or spiritual well-being, community health and well-being, and communities of solutions. Together these form meaningful transformation of community well-being creation and population health management with health equity at the core. ### URAC Population Health URAC established standards for provider and employer-based population health. By adopting its accreditation framework, organizations can demonstrate their approach to achieve the Quadruple Aim as described earlier (e.g., experience of care, health outcomes, satisfaction of healthcare workers, and costs of care). There are two types of population health accreditation-provider based and employer based. They include standards that address areas such as population health (assessment, status, needs, improvement, risk management) and access. Healthcare organizations can evaluate which are best aligned with near-term and long-term needs and with strategic goals and objectives. ## Population Health and Value-Based Care Success in value-based contracting requires complete buy-in from leadership and practitioners, along with an alignment of goals. Creating and communicating the population health management strategy includes activities such as creating one governing board led by practitioners and employing practitioners under one tax ID to align payment structures. Creating a PHM strategy also includes aligning one strategy across the organization, meeting with practitioners to encourage two-way dialogue and address concerns and including strategy and goals in the network participation agreement. The Guide to Health Care Partnerships for Population Health Management and Value-Based Care discusses how "the business model for U.S. healthcare is transforming from a volume-driven model to a consumer-centric, value-driven model." The focus of the value-based care model is to "improve quality, access, and outcomes, while reducing costs through the effective management of a population's health over the continuum." This new model of managing the health of a population requires new skills and competencies, "including clinical integration; consumer, clinical, and business intelligence; operational efficiency; customer engagement; and efficient network development." Figure 7.10 illustrates this new model. Hospitals and healthcare systems need to partner with other organizations to capitalize on the capabilities and efficiencies to provide services under care delivery and payment arrangements (i.e., risk-bearing, value-based, targeted investments). This includes partnerships to address nonmedical factors that impact the health status of a community including SDOH, environmental factors, and economic factors. The types of risk for hospitals and health systems and population health management contracting arrangements fall into two categories as shown in Table 7.3. ### Value-Based Reimbursement Value-based reimbursement requires skill in comprehensive care management, data analytics and predictive modeling, and population risk stratification, along with a full continuum of care and a high-performing network of providers and partners to care for the population. The government also is recognizing the importance of population health, which is addressed in the 2010 Affordable Care Act (ACA). The ACA contains four provisions related to population health: 1. Increased access to healthcare through expanded coverage options, Medicaid expansion, and subsidies available through health insurance exchanges 2. Creation of the National Strategy for Quality Improvement 3. Increased focus on preventive health through new payer requirements to cover certain preventive services and the creation of accountable care organizations (ACOs) enabling providers to assume responsibility for the health outcomes of populations 4. Establishment of the National Prevention, Health Promotion, and Public Health Council, in addition to workplace wellness incentives, thus promoting community-based population health CMS value-based programs include the five original value-based programs that link provider performance of quality measures to provider payment. There are two additional programs that have been added over time, so the programs now include the following: * End-Stage Renal Disease Quality Incentive Program * Hospital Value-Based Purchasing Program * Hospital Readmission Reduction Program * Value Modifier Program (also called the Physician Value-Based Modifier) * Hospital Acquired Conditions Reduction Program * Skilled Nursing Facility Value-Based Purchasing * Home Health Value Based Purchasing These programs move pay-for-performance forward based on the quality of patient care versus the quantity of care providers give patients. The Center for Medicare & Medicaid Innovation has taken steps to incorporate population health and launched 54 payment and service delivery models over the past 10 years. The models enable providers to enter value-based reimbursement arrangements to deliver better care while lowering costs. Population-health models include the traditional Medicare Quality Payment Program, which launched in 2017 as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The Medicare Quality Payment Program replaces the Sustainable Growth Rate methodology for payment increases. It enables Medicare to reimburse providers according to high-quality performance while reducing payments to providers not meeting performance expectations. The Quality Payment Program focuses on paying for value and health outcomes. ### Medicare Shared Savings Program and Accountable Care Organizations Another model conceived by the Center for Medicare & Medicaid Innovation is the Medicare Shared Savings Program (Shared Savings Program), which launched in 2012. The Shared Savings Program focuses on value-based reimbursement and health outcomes, allowing healthcare providers and suppliers to creatively work together under an ACO framework. The Shared Savings Program is an alternative payment model that "promotes accountability of a patient population, coordinates items and services for Medicare fee-for-service beneficiaries, and encourages investment in high-quality efficient services." ACOs can share in the cost savings it achieves for Medicare if the ACO is successful in delivering high-quality care, while reducing the overall cost of care. Leadership and culture are important to the success of an ACO. Accountable care organizations achieve high-quality care and reduced spending when the physicians, hospitals, and other suppliers of healthcare join and provide comprehensive care coordination, ensuring patients receive "the right care at the right time." Comprehensive care coordination is vital in a value-based payment arrangement. Understanding the characteristics of the population, identifying those most at risk for costly healthcare utilization, and developing targeted interventions to manage the population across the care continuum are essential components of a population health program focused on providing "better care for individuals, better health for populations, and lowering growth in expenditures." In the early years of the Shared Savings Program, adoption of risk arrangements was slow for ACOS, with most initially opting for risk-free, upside-only risk. According to Daly, the participation in the no-risk accountable care organization track has trended downward since 2017, when 91% of all Shared Savings Program ACOs were in the no-risk track. In 2020, 26% of ACOs were in the no-risk track. As of January 1, 2022, the Shared Savings Program has cared for millions of Medicare beneficiaries while achieving high average overall quality scores and earning millions of dollars in shared savings. CMS offers several types of alternative payment models, “a payment approach that gives added incentives to provide high-quality and cost-efficient care. Alternative payment models can apply to a specific clinical condition, a care episode, or a population." In value-based care, there are steps a physician practice can take to prepare for value-based healthcare by promoting the Triple Aim or Quadruple Aim. These steps include: 1. Identify the population and opportunity. 2. Design the care model. 3. Partner for success. 4. Drive appropriate utilization. 5. Quantify impact and continuously improve Identifying the patients who are driving the highest utilization and highest cost of care is critical to successfully identifying and implementing a model of care for high-risk populations. Patients with uncontrolled chronic conditions and multiple health issues may miss follow-up appointments, experience challenges adhering to their treatment plan, and need heightened coordination of care. CMS established a framework for value-based care aligned with empowering patients and clinicians to make decisions about their healthcare using innovative approaches to improve quality, accessibility, and affordability. Areas of focus at the patient and population levels are outlined in Table 7.4. These may be instrumental to better manage patient care. A list of key points for population health and value-based care can be found in Box 7.3. ## Care Transitions Care transitions occur when a patient moves from one healthcare provider or setting to another. Historically, the focus has been from the inpatient hospital setting to another care setting, and improvement efforts have surrounded readmissions due to excessive costs and poor health outcomes. However, given the continuum of care, there are settings across which a person might traverse that require treatment planning and coordination for care (e.g., outpatient surgery to home care, acute hospital care at home). Care transitions can present opportunities and challenges for healthcare providers and systems of care. Some opportunities are seamless handoffs and movement to other levels of care that are better aligned with the needs of the patient and their support system. Some challenges are linkages with downstream providers and lack of systematic care management. The ACMA Transitions of Care Standards serve as a guide for care managers and other healthcare professionals to ensure optimal transitions of care. ACMA refers to the American Case Management Association. Effective care transitions can "prevent medical errors, identify issues for early intervention, avert unnecessary hospitalizations and readmissions, support consumers' preferences and choices and avoid duplication of services" leading to the improvement in the quality of care and effective utilization of resources. The five transitions of care (TOC) standards were assessed through the ACMA TOC Learning Collaborative with six major health systems participating (Figure 7.11). The four primary goals of the collaborative were to 1. test the implementation of the TOC standards in real-world health system environments across a variety of U.S. regions; 2. identify innovative or effective practices as well as challenges and barriers that may impact implementation of the standards; 3. ask healthcare organizations to assess their compliance with the TOC standards, identify and pursue opportunities for improvement, and then reassess compliance to determine progress made; and 4. share results and lessons learned from the TOC Learning Collaborative to guide broader adoption of ACMA'S TOC standards . The collaborative provided benchmarking to help identify the standards where improvement efforts can be focused including advance care planning, medication reconciliation