CREATING VALUE

This pilot seeks to optimize value for both providers and payers. Payers are pooling their funds to support the value-based payments. Currently, the planned payment model allows for two value-based payment streams, though this is being negotiated.

• A per patient payment for all patients (approximately 6,000 per year). All providers and payers will have access to the patient data to learn how socioeconomic and other factors impact disease management, progression, and overall healthcare expenses.
• A bonus payment for health systems that reduce admissions through an evidence-based intervention to a targeted 1,000 patients.

Together, the collaborative has been structuring this project and the payments according to the “wins” they want to achieve. These include:

• Better data on heart failure patients
• Standardized data collection across all health systems
• Ability to learn from the entire Atlanta heart failure population, not just members or patients at a specific organization or hospital
• Shared savings bonus payment when reductions in admissions have been achieved
• The opportunity to include all lessons from the two-year pilot in ongoing contracts

ACTIVITIES

In order to implement this pilot, the program team is focusing on six main activities:

• Data standardization around the International Consortium for Health Outcomes Measurement (ICHOM) Heart Failure dataset, which includes reconciling existing data collection at each health system, adoption of the ICHOMS Heart Failure dataset, obtaining any necessary licenses (such as for the KCCQ12), and building any additional data fields into the EMR.
• Data collection, which begins with three months of baseline data collection using the ICHOMS heart failure dataset and a few additional key outcomes. Because many health systems are not quantitatively capturing information around the social determinants of health, we want to collect standardized data that will inform risk stratification activities.
• Baseline data analysis includes reviewing baseline data; stratifying by age, race, insurance coverage, and other social determinants of health; calculating risk ratios and logistic regression models; and making recommendations for risk stratification.
• Risk stratification is tied to the baseline data analysis and includes developing risk models and informing intervention activities.
• Implementing an intervention that improves post-discharge care for heart failure patients. We’ve initially identified the Coleman Transitions Model as a possible intervention.  The Coleman Care Transitions model focuses on the first four weeks post-discharge, and is designed to help patients with medication self-management, guide them through the care process, help with following-up with a primary care provider or specialist as instructed, and help patients identify red flag indicators of worsening conditions and next steps. Additional intervention activities include identifying gaps in current care transition work, modifying intervention activities based on risk stratification findings, and modeling and testing a payment model.
• Developing a Catalog of Social Support that is comprehensive and specific for heart failure patients. This catalog will be virtual and updated regularly and will initially provide information on assistance around prescriptions, transportation, financial resources, stable housing, and support care.

PHASE 2

Phase 2 of this pilot will solidify the infrastructure built within participating health systems and payers to allow re-negotiation of contracts integrating a value-based payment model designed to improve outcomes and reduce costs of heart failure patients.