By Pat M. Irwin
Mr. Jaffray’s family had talked with several members of the hospital staff about his discharge. While the rehabilitation unit’s social worker advocated for a “transitional care bed,” the hospital discharge planner
wanted to look into a return to his home with subsidized home care. A few days later, with Mr. Jaffray settled in a transitional bed in a local nursing home, his daughter received an annoyed phone call the home care supervisor was outside his condo, wanting to assess him for home care. “He’s not coming home yet, he doesn’t need home care – don’t you people talk to each other?”
What had gone wrong? Were these departments out of the loop? Were they unaware of the options? Were they incompetent? Definitely not! Were they working at cross-purposes? Unfortunately, yes.
While much of the world envies Canada’s health care system, it is not immune to the impact of many-tiered patient records, computer systems and protocols, and the generally increased complexities of health conditions in an aging population. Health units are consolidated, then localized and then consolidated again, as political regimes change and health care professionals struggle to maintain care standards. Information and authority to act are often in “silos,” so that one entity may, with the best of intentions, act at cross-purposes with what has been recommended by another.
Payments tied to outcomes
However, many communities are adopting a new model: Accountable care. An accountable care organization is a health care organization that ties payments to measurement of the quality and cost of care. A typical accountable care organization is comprised of coordinated health care practitioners, including physicians, nurse practitioners and therapists. Their salary is based on “capitation,” which pays a set amount for each enrolled individual assigned to them, whether or not that person seeks care. Remuneration is based on the average expected health care utilization of an individual, with higher payments for those with a significant medical history. Employee contracts specify the outcomes and other objectives they are required to achieve within the given budget over a period of time. Accountable care is already operating in the USA, UK, New Zealand and Spain.
How does it work in health care?
The definition of “accountable” is answerable, subject to giving an account. The aim of accountable care is to define and measure each element of the health care process and follow the outcomes, such as the impact on an individual’s experience, as well as monitoring the quality and cost of that care. All parties share a common desire to achieve the triple aim of improving the experience of care, improving population health and reducing the per capita cost of health care.
Business and practical sense
Individuals are part of a delivery network that aims to service a population in a specific area using a specific provider. The provider assumes the risk for and the goal of systematically ensuring that the appropriate and right amount of care is being delivered and that waste is eliminated to reduce per member per month costs. Each person is seen as a holistic entity rather than a collection of symptoms. This model anticipates that individuals’ will feel involved, empowered and more positive about their possibilities. Indeed, both hospitals and rehabilitation centres should report faster, better progress and quicker discharges.
Shared electronic records
A central feature of accountable care organizations is the collection and use of secured electronic health records by affiliated care providers. Electronic health records document each individual’s medical history, medical conditions, prescriptions and past visits. These medical data are used to monitor and evaluate whether the accountable care organization is eligible to benefit from shared savings by meeting specific quality and efficiency goals such as reducing emergency department visits, increasing the efficiency of specialists for high-risk individuals or providing coordinated clinical or social supports to systematically improve health.
Where it applies
To date this model has mostly been implemented in hospitals and clinics, but it can also be applied to community care from health and social care services to public health and other services. Let us look at the example of an individual who visits an accountable care practice complaining of knee pain, and explore the benefits. Here is the type of treatment plan that an integrated accountable care practice might design.
• The clinical team investigates the possible causes of the knee pain (e.g., a sprain, cartilage issues, arthritis, osteoporosis) using X-rays and other scans, with the resulting images available online to all team members.
• The physiotherapy team develops exercises for strength and balance, and liaises with the clinical staff to be sure these exercises are feasible given their findings.
• The occupational therapy team visits the individual’s home to review its overall safety and recommend safety devices that are practical and affordable for this person. They then apply to the provincial health plan or organization to subsidize the cost of assistive devices, on the person’s behalf. The same team trains the individual and caregivers in the use of devices, and teaches safety practices in a follow-up home visit.
• The clinical team prescribes anti-inflammatory or pain medications as required.
• The community care team implements regular home visits to check on safety, pain and general wellness. They may also recommend day programs if they think the individual would benefit from ongoing activation and social support.
• The individual is encouraged to make follow-up calls or visits as required, rather than feeling they are “being a bother.” A phone call is scheduled weekly at first and then for every few months to stay in touch and learn of any “red flags” that should be attended to.
If untreated, this person may have been a candidate for a bad fall or broken hip. This would have entailed a hospital stay and possibly surgery, admission to a rehabilitation centre or, worst-case, not being able to return home to an independent life. The accountable care model offers prevention, education, cost savings of hospital resources and, potentially, reduced pressure on the long-term care home system.
The accountable care unit (ACU) model has been trialed with significant success in Regina’s Pasqua Hospital, and has now been expanded to Saskatoon’s St. Paul’s Hospital. Their ACUs have four features that differ from those of traditional care units.
• A physician and nurse manager share leadership of a ward.
• A physician is responsible for one unit, rather than being spread across the entire facility.
• Structured bedside rounds are made every day at the same time.
• Individual units are responsible for improving their own performance.
Daily in-room visits by physicians, nurses and other team members give everyone the chance to review and update care plans. The team goes from room to room at the same time every day. Patients are actively engaged in discussions and decisions around their care, and care providers are held accountable by patients, family members and each other for their part in ensuring care is delivered. A staff member observes: “Accountable care gets rid of the chaos and fosters teamwork and a much improved relationship with the patient and their families.”
“We are already seeing how physically locating these physicians in one place and the subsequent regular interactions through standardized rounding are improving teamwork and communication among our care provider partners,” says the Saskatoon Health Region’s senior medical officer and vice president practitioner staff affairs, Dr. George Pylypchuk. “The accountable care unit makes patient interactions more meaningful and predictable, which is decreasing patient length of stay by eliminating barriers to discharge.”
What else can be done?
Among other things, the Pasqua Hospital has developed a
patient guide that describes the accountable care process and outlines exactly what patient’s should to expect. It provides reassurance and a sense of control, manages expectations, anticipates the questions that many anxious patients have and gives answers. It even mentions where to get donuts!
Pat M. Irwin, BA, AICB, CPCA, is founder and president of ElderCareCanada, which helps seniors and their families negotiate every aspect of the elder care journey. She is also a professor of Distance Learning at Centennial College in Toronto.