12 Best Practices of a Care Model Transformation Plan

Author's Note: Many people have reached out for the detailed whitepaper that fueled this HIT Consultant Article and thus I share Part One of the 3-part series that was inspired by client work ending, and written, in 2020 at the height of the pandemic but still remains relevant today. The Series includes 1. Care Model Transformation 2. Workforce Considerations and 3. Patient Considerations. Reach out with any questions or for assessment tools/metrics to begin this transformation.

This is Part One: 12 Best Practices of a Care Model Transformation Plan

BACKGROUND

Health systems across the country will require a plan to react to state and federal government deep spending cuts and rising federal debt as well as make up for revenue shortfalls as a result of the global pandemic. Although federal bailouts have kept health systems afloat and able to treat patients during the public health emergency, these funds will not be able to cover all losses. 

The American Hospital Association (AHA) stated that hospitals and health systems would lose an estimated $120.5 billion, adding to a total estimate of 2020 losses to over $323.1 billion. These losses can be attributed to several sources. State and federal governments had instituted restrictive policies that prevented hospitals and health systems from running normal operations, and while only for a limited timeframe, revenue streams were deeply impacted. Although these had been put into place for the health and safety of patients and essential workers, by State, and often local government, they created short term revenue drains for health systems.

In addition, due to ongoing public concern of exposure to COVID-19 and proliferation of variants, hospital services, including outpatient appointments and elective surgeries, have seen a downturn in demand despite all delayed care. With the latest resurgence of COVID-19 cases, there has been another round of postponed elective procedures to make ICU beds available. An increased demand for personal protective equipment (PPE) and other essential equipment and a lack of adequate supply have also put strains on health system resources1. Losses of this magnitude must be appropriately addressed and managed by hospital and health system administration.

Although decreases of this type are alarming, the public health emergency has also resulted in innovation of other parts of the industry. Telehealth and telemedicine have seen unrivaled increases in usage since the onset of the pandemic, and government groups have included interim payment parity for telehealth services to mitigate exposure risks. Telehealth exists in many forms, including telephonics, patient care apps, and virtual video visits with providers. Although this may increase access for some portions of the patient population, many who were previously severely hindered from accessing healthcare are still left out of telehealth considerations. 

The Shift

Now is the time to enact change to mediate these unprecedented losses. I propose a widespread overhaul of all aspects of the care model, from patients, to workforce, to administration, to system partners, payers, and the industry as a whole. Evaluating each of these components and realigning them to achieve systemwide cost-reduction and specialization will unlock savings. Emphasis must be put on eliminating inefficient and underutilized practices to reduce waste and reallocating resources to strengthen the highly effective services that lead to better health outcomes. Health systems that perform detailed assessments of every step of the care model – including services, treatments, technology, access, and payment – and have the foresight to redirect each step towards lower cost-of-care settings will be outfitted perfectly for long-term delivery of care transformation and thus long-term success following the developments of the global pandemic.  

Success in delivery of care transformation will be measured by cost savings and maintained or increased patient satisfaction. Cost reduction can be achieved in multiple ways, but when patient satisfaction suffers as a result of cost-reduction changes, the health system will suffer in the long-term, especially as payers continue the shift towards value-based reimbursement. Therefore, health systems must consider data-driven cost saving techniques that also cater to the fast-changing expectations of a post-COVID-19 consumer base. These expectations include but are not limited to, integration of new technologies, utilization of data analytics, increased convenience in care delivery, and streamlined transitions of care. 

Using this balanced metric technique also stresses the need for transformation customization and problem-based transformation. The assessment and inventory stages are just as important as the integration stage for the new care model. Taking careful consideration of each individual service, workforce role, and partnership and whether or not virtualization, which is one option for a lower cost-of-care medium, is appropriate. Making widespread changes without considering each unique circumstance in the care continuum can create new problems instead of fixing old ones. Health systems must remain cognizant of which avenues require updates and cost-reduction and outcome optimization strategies to prevent overcorrection.

Hospitals and health systems face a year of losses, but COVID-19 consequences like enhanced communication and flexible decision making that mobilized the workforce make now the time to change course and adopt a cost-reduction oriented care model. Long-term care model transformation must be acted upon now for health systems to prosper under current and future market conditions.

VIRTUALIZING THE PATIENT CARE MODEL

To achieve both cost-reduction and outcome goals, care model transformation should always be centered around the patient experience. Reimbursement policies may now reward services based on care quality. Shifting to patient-centered care models puts patient needs at the center and improves outcomes, optimizing reimbursement opportunities. This also opens the door for many alternative treatment models to break into the industry, namely telehealth. Health systems should not wait to integrate alternative care strategies that drive down costs and drive up outcomes.

Creating a Cost-Effective Service Portfolio and Structuring an Efficient Provider Network

1. Evaluate current service lines. 

In times of widespread financial losses, it is important that health systems realize that all healthcare providers cannot be everything to everyone. It is crucial that health systems create the right size services portfolio to optimize revenue and support the new care model. Transforming each service line to a lower cost-of-care setting may not be possible. Those lines that are not bringing in stable revenue and are resistant to a virtual platform or alternate low-cost sites represent a constant drain on resources at a time where minimizing losses is paramount. 

Health systems should begin with a full evaluation of their existing services portfolio, considering revenue, patient satisfaction, outcomes, operating costs, and potential for transformation to a lower cost-of-care setting, like telehealth. A common theme throughout care model transformation will be utilizing big data to make informed decisions. Determining which services to expand, cut, or manage is one in which data analytics will be useful. Health systems will then have a comprehensive view of where most of their costs are occurring and where they are not receiving reimbursement or high outcomes in return. By taking this step, health systems are already well-poised to make cost-reduction transformations to come out ahead of the post COVID-19 marketplace.

2. Selectively eliminate nonprofitable lines and manage costs of essential lines.

Because health systems today tend to be highly consolidated compared to past years, their service portfolios tend to be more varied. There may be a wide range of profitable and nonprofitable lines, as well as essential lines that cannot be removed. For this reason, service portfolio evaluations must be flexible, as each service line will require its own, appropriate response that is supported by data. There may be several nonprofitable lines that service profitable lines, in which case mapping the interaction between multiple related services will elucidate these profitable relationships, With that said, nonprofitable lines that do not support quality patient outcomes and incur high operating costs or low reimbursement rates should be eliminated from the health system. Instead of investing highly strained time and money to further develop this service at a time where hospital systems must make change swiftly, it may be more efficient to outsource or abandon it completely. In managing essential services, this assessment can also reveal ways to manage high costs in these areas, since these cannot be removed from the portfolio.

This step results in a more focused and efficient heath system with reduced waste and an improved service portfolio for patients to consider when entering their network. In addition to the reduced unique patient population. spending benefit, without diverting funds to nonprofitable lines, there is more revenue flexibility to reallocate to lines that are proved to be better suited to serving the health system’s unique patient population.

Transitioning to a Virtual and Flexible Care Model

3. Transition service lines to appropriate low cost-of-care settings

Once the service portfolio has been optimized to include only those services that are profitable in outcomes and revenue, another assessment is necessary to determine an appropriate low-cost setting for each service line, like telehealth. The public health emergency made transitioning to virtual healthcare a necessity for health systems, but the post-COVID-19 world poses the risk that this trend will not persist. The cost benefits and patient satisfaction benefits that arise from telehealth adoption cannot be ignored, and integrating this technology in any and all service lines long-term is the way of the future. Again, the use of big data and data informatics are essential in identifying where savings can be made and where transitioning to virtual platforms is advantageous. Health systems must consider this a top priority in care model transformation.

An important distinction remains that not all service lines will be conducive to a virtual setting. This is where the importance of customization arises. The key takeaway from this step in the transformation process should be to identify the most cost effective and successful alternate care settings for each service line. If such a setting exists, the transformation should be made a priority. If a service line is not advantageous in alternate settings, cost can be managed in a number of other ways included in this e-book. Forcing a service line into an unsuitable virtual platform is counterintuitive and hinders patient outcomes and satisfaction. 

4. Assess the efficacy of new and existing virtual health technology

Next, existing virtual capabilities, if there are any, integrated during or prior to the pandemic must be developed to fit the service line’s individual needs. Facilitating cooperation between health IT, technology developers, third party telehealth vendors, and the workforce is essential in building customized virtual platforms for each unique service line. Health IT companies are developing new technology constantly to match the current demand, and health systems should test each new tool to decide if it’s a cost-effective alternative for their patient population and workforce. For example, Voice Remote Interpretation (VRI) could save up to 30% translation costs for health systems with diverse patient populations, phone companion apps are useful for helping patients comply with treatment plans and stay connected to their care team, and home monitoring helps reduce homebound patient visits to the medical campus and rehospitalizations.

The pandemic supplies a perfect backdrop to analyze telehealth performance. Any new telemedicine tactics that were introduced in response to the public health emergency can be used as indicators to measure cost, patient outcomes, and satisfaction. Extending pandemic programs can also help maintain continuity and prevent patient and workforce reeducation with new telehealth technology.

Virtual platforms should also be responsive to patient expectations, which have changed drastically throughout the pandemic. Convenience of care and accessibility while maintaining outcomes are among the top priorities for patients and telehealth capabilities must be able to deliver. Opening communication lines to patients brings in much needed feedback to improve telehealth services and navigability. This also supports better management of chronically ill patients.

In addition to virtualizing healthcare, each health system should also explore alternative low cost-of-care options. These may be used as substitutes for virtual visits, like a home healthcare or mobile healthcare units that can reach patients outside of the medical campus. Other strategies can be used in conjunction with telehealth, like integrating more preventative health service lines that can help reduce expensive ER overutilization and rehospitalizations. 

Data and informatics will again be critical in assessing and perfecting new care model techniques, especially fast-growing telemedicine capabilities. Reassessing and improving processes for each service line will produce optimized, custom iterations that have proven to provide the best outcomes in efficiency.

5. Consider data on social determinants of health to assess if new care model actually improves access

As previously mentioned, improving access for a health system’s patient base results in improved patient satisfaction, outcomes, and cost-reduction. Removing barriers to healthcare, especially for those groups that have struggled with access due to socio-economic status and racial inequities, reduces administrative struggle and improves revenue flow and patient loyalty. Establishing access also improves health system standing in their community. It allows providers to gain access to more of the population, fostering a greater understanding of their unique needs and working towards a healthier and happier community. This is particularly important as the trend towards value-based reimbursement continues. 

Although virtual healthcare capabilities do improve access, they often still exclude portions of the population who do not have access to internet. It is estimated that 44% of low-income Americans do not have access to broadband internet at home (3). Many telehealth offerings rely on internet reach patients, so health systems who treat a large low-income patient population must offer alternative virtual healthcare technologies. Maintaining convenient care delivery through a virtual platform is still pragmatic, as another large barrier for low-income patients is the inability to schedule in-person appointments due to rigorous work schedules. One suggestion is optimizing telephonics as a new method of care delivery where applicable appointments and follow-ups can be fully conducted over the phone. It is crucial that health systems know more about their target patient population and receive feedback from a wide range of respondents to help develop a care model that caters to all needs. 

Data collection, monitoring, and reporting are key tools in determining the effects of social determinants of health. The ability to act on determinants specific to a health system’s community assists in managing care for the patient population. This feedback cycle must be ongoing and incorporated seamlessly into the workflow for the new care model. Surveys to measure access to different types of technology in the home will give a better indication of what types of telehealth resources to offer. After rolling out the new technology, maintain an open line of communication with the public to gain insight into where improvements need to be made and whether or not the new technology is reaching all patients in one way or another. Training the workforce to ask each patient how they can better access their health is also another method of gaining this useful information that will also make the patient feel cared for. Steps must be taken to correct the care model to fit the health system’s needs. 

Changing Treatment Procedures to Implement Care Model Tactics

6. Measure accuracy of diagnostic and treatment equipment and replace the obsolete

Keeping up with the latest diagnostic and treatment technology can boost patient outcomes, improve workforce engagement, and massively decrease costs. Obsolete technology represents money trapped in assets and a drain on health system resources. Although investing in new technology raises costs in the short-term, the cost reduction benefits that arise from lower operating costs, more efficient and accurate testing and diagnosis, and less unnecessary testing will more than make up for the initial investment in the long-term. In addition, new technology is a selling point for patient to increase patient engagement and compliance to treatment plans. 

Health systems should be selective when it comes to which new technologies they incorporate. Every new release may not deliver the benefits to outweigh the costs. With new tools comes the need to train the workforce and or hire technicians to operate the machinery. Health systems should consider this investment of money and time, as well as what they stand to gain in outcomes from the new technology, when deciding which service lines should receive updates. Again, data analytics can assess current asset performance and present opportunities for renovation.

7. Establish patient-centered care tactics

Patient-centered care aligns with value-based care trends arising in payer reimbursement plans. The concept is based on creating highly customized treatment plans for individual patients through consideration of their socio-economic, personal, and medical ideals and values. This treatment tactic moves away from pre-generated care plans ascribed to a medical condition and instead encourages providers to make logical treatment prescriptions in response to these ideals. Patients receive treatments they need specifically in a way that agrees with their life and schedule. Value-based care bases reimbursement on quality of care and patient outcomes rather than volume of treatment. Both of these approaches to care delivery reduce waste and unnecessary treatments, decreasing healthcare costs (4) and improving patient outcomes and engagement (5,6). 

Orienting the workforce towards delivering patient-centered care is a matter of culture change. Health systems must be definitive in their expectations in order to fully carry out a new care model, and introducing the values behind patient-centered care should be explicitly communicated to providers. Workforce training and reeducation to pay closer attention to each patient’s particular situation and schedule may increase time spent with each patient, but overall improves the efficiency of each service line. Providers are encouraged to cut down on unnecessary testing and appointments and including preventive care treatments to prevent rehospitalizations alongside traditional treatments, saving the patient and the provider time and money.

8. Optimize provider workflow in context with the new care model

The workforce will also require reeducation to operate new technologies and workflows associated with newly established low cost-of-care settings. Office setups, electronic health records, billing, and other aspects of workflow logistics will have to be rewritten to accompany the changes from the new care model. Workforce familiarity and comfort with their workflow will make the process less frustrating for everyone involved, including the patient. 

Each workflow reinvention will need to be customized based on the previous setup and new model for each service line. For example, radiology, which is highly conducive to virtualization and work-from-home settings, will require software that enables a provider to share images and scans with patients and other members of the care team in a confidential way from an offsite server. Modifications such as this will require coordination from radiologists providing feedback about their workflow, health IT to initiate secure sharing platforms, and administrative staff to formulate authorization paperwork and reimbursement filings that apply to this new type of appointment. Surveys from the workforce to troubleshoot will be crucial in perfecting new workflows. 

Although there will certainly be a learning curve, with strong communication and cooperation from the workforce and health system administration and management, the new care model will be instituted efficiently into the everyday norm.

9. Integrate COVID-19 dashboards and reassign underutilized staff to communicate and enforce the new care model

To manage the chaos that the public health emergency brought, health systems opened communication lines that directly connected management and decision-making boards to all members of the workforce. Urgency in relaying decisions was paramount to dealing with the health crisis, and we argue it will remain crucial in implementing new care model expectations. 

With adjustments being made on the fly to respond to trouble areas, the workforce must be adequately informed to ensure a smooth transition post-COVID-19. Maintaining these lines of communication that have been so critical in treating the pandemic will facilitate execution of any changes to workflow and treatment protocols that accompany this new age in health care management.

Although expectations may be clearly communicated, health systems must ensure an enforcement group is able to assist the workforce when enacting any new changes. Reassigning underutilized staff to enforce new policies can solve this problem and help monitor the care model’s progression in each service line. These liaisons can also serve as points of connection to management for personnel to voice concerns. Preserving current staff bases and investing in their reeducation and cross-training will improve workforce engagement and facilitate any significant transitions.

“Co-opetition” to Foster Industry Partnerships that Enable Care Model Transformation

10. Revisit partnerships and advocate for interoperability

After realigning their service portfolios with a cost-reduction model, health systems must shift to a “co-opetition” model and operate through strategically aligned partners across the care continuum. With the understanding of where there are gaps in care coverage in their provider network, health systems should revisit their partnerships with external agencies to determine if there are any opportunities to negotiate or modify the agreement to match the new care model and mutually benefit both parties.  

Identify those areas across the care continuum where the health system expends more than they would if using strategic partners. In these areas, assess potential partners for cost, outcomes, and efficiency, utilizing data analytics. Where no advantageous partnerships exist, expand in-network capabilities. This process also encourages removing existing partners that cause issues in these areas. 

Partnerships are also a tool to expand coverage in areas that are in high demand. Post-acute care, particularly home care, and mental and behavioral health partnerships will be paramount in responding to pent up patient demand resulting from the pandemic. Partnerships like this will help health systems provide quality care in areas where they have little existing expertise by tapping into specialized agencies with advanced resources.

Chronic care services, including kidney services and diabetes treatment, often incur high costs due to the consistency of treatment. These fields should also be explored through partnerships to cut out waste and yield better outcomes. 

To really achieve a mutually beneficial “co-opetition” model, there must be well-organized communication between the partner agency and the health system providers. In the true spirit of virtualization, this is where interoperability makes a substantial difference. Using interoperability regulation and the latest advances in information transfer between different electronic health record systems allows for easier transitions of care for both patients and providers.

Interoperability application programming interfaces (APIs) ensure there is effective and safe coordination of care between partners and in-network providers, which will significantly decrease administrative stress and facilitate secure transitions of care in addition to added capabilities with remote monitoring devices on the rise. Most notably, The 21st Century Cures Act supports a patient’s ability to easily access their electronic health record as well as championing nationwide interoperability (7). As Ensuring there is effective coordination of care through interoperable electronic health records which each of a health system’s partners will significantly decrease administrative stress on providers and make transitions of care between providers much easier and more secure for patients. 

Advocating for Payer Support of Virtualization

11. Leverage payment parity for telehealth from payers

Continuous monitoring should become a regular occurrence once a new care model has been adequately introduced to address and recognize any deficiencies and gather successful data and feedback. Records of cost-reduction, higher patient outcomes, and stimulated patient and workforce engagement should be kept as evidence for investors and management. This information is also useful to leverage better telemedicine service coverage from payers.

Congress has introduced limited telehealth reimbursement legislation in response to its growing demand during the public health emergency, but many fear that these policies will not be upheld after the pandemic, even though it is predicted that patients will continue to demand virtual services. Therefore, health systems, especially those with improved metrics due to virtualization, should use their numbers as evidence for payment parity for telehealth services.

In a value-based reimbursement model, health systems with data showing improved care delivery will have higher reimbursement rates, but without plans that reimburse telehealth, the services that led to that improved care delivery are not covered. Once payers are presented with enough evidence showing how telehealth contributes significantly to quality of care and positive outcomes during and post-COVID-19, health plans will more likely begin to include more telemedicine reimbursement policies, thereby potentially increasing health system revenue. Including the data from studies on telehealth-improved access for populations affected by social determinants of health can also be a useful tool to show how telehealth specifically impacts a health system’s unique patient base compared to others.

Health systems that undergo successful care model transformation should freely share their successful results with payers as well as other health systems, encouraging industry-wide virtualization and bolstering the case for telehealth reimbursement. In fact, consortiums such as the Alliance for Connected Care exist with a public call for data to support concerted efforts.

 Troubleshooting and Responding to Feedback

12. Collect data on patient experience through post-care surveys

Data analytics and feedback are major themes to integrate into new care models. More than ever, patients are showing drastic changes in their care delivery expectations, and in order to remain relevant and ensure care model transformation is successful, health systems must be open to receiving feedback from their consumers. Including surveys on accessibility and care quality in post-care follow-ups and discharge materials will provide patients an opportunity to share their experiences, making them feel heard and considered, while health systems receive much-needed critiques to improve the care model further.

REFERENCES

3. Frequently Asked Questions: Telephonic Services as a Form of Telehealth. Manatt. Accessed August 24, 2020

4. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-239. doi:10.3122/jabfm.2011.03.100170

5. Priorities in Focus - Person- and Family-Centered Care | Agency for Health Research and Quality. Accessed August 26, 2020. https://www.ahrq.gov/workingforquality/reports/priorities-infocus/priorities-in-focus-person-family-centeredcare.html

6. Kuehn BM. Patient-Centered Care Model Demands Better PhysicianPatient Communication. JAMA. 2012;307(5):441-442. doi:10.1001/jama.2012.46

7. Bonamici S. H.R.34 - 114th Congress (2015-2016): 21st Century Cures Act. Published December 13, 2016. Accessed August 31, 2020. https://www.congress.gov/bill/114th-congress/house-bill/34

8. Nalebuff, B. and Brandenburger, A. Co-Opetition