Succeeding with Value-Based Care

Value-Based Care

March 27, 2024
Two doctors reviewing analytics of their patient communication

Key points:

  1. ACO REACH requires providers to capture and document sensitive information such as social determinants of health (SDoH), sexual orientation, and gender identity (SOGI) ─ a task that can potentially discomfort staff and patients alike.
  2. Enduring success entails influencing patient behavior outside of the care setting, e.g., increasing Medicare Annual Wellness Visits (AWVs), increasing post discharge follow up and minimizing preventable readmissions.
  3. Rising AI chatbot adoption increases sensitive data capture and patient engagement. Integration with the EMR/EHR further reduces the data entry burden on staff.

Participation in value-based payments is growing. Propelled by recent industry trends, McKinsey & Company estimates that value-based care (VBC) lives will increase from 80 million to 100 million in 2022 to 130 million to 160 million in 2027. This expansion requires health systems to upgrade and develop new risk-bearing capabilities.

The days of ignoring value-based contracts are fast disappearing. To succeed, primary care in the United States, which has become significantly more complex for providers and patients, is:

  1. Increasing focus on health-related social needs known as Social Determinants of Health (SDoH) — defined by the Centers for Disease Control and Prevention (CDC) as "non-medical factors that influence health outcomes," such as the conditions under which people live and work, along with wider forces shaping daily life such as racism and climate change;
  2. Engaging disadvantaged populations through increased safety net provider participation and strengthened access to timely, high-quality healthcare services; and
  3. Initiating proactive outreach that includes care coordination and relationships with specialty providers to support whole-person care.

Success Factor No. 1: Capturing Social Determinants of Health and Gender Identity Data

Over the last 13+ years, implementation as well as compensation from accountable care organizations (ACOs) and other value-based initiatives in general had lagged, occurring unevenly across the nation. Historically, value-based payment models played too small a part in a provider’s reimbursement portfolio to influence the needed operational changes and funding to be successful.

With the U.S. at a pivotal inflection point in an unsustainable healthcare cost structure, the growth of value-based care is now dramatically shifting the healthcare landscape. Regulatory measures increasingly focus on outcomes.  In January 2023, under the Biden administration, CMS announced a plan to enroll 13.2 million Medicare beneficiaries in three accountable care models in 2023 and a goal of getting 100% of traditional Medicare recipients enrolled in an accountable care relationship by 2030.

One of the models, ACO REACH, requires providers to capture patient SDoH data and to develop and implement a robust health equity plan to measurably reduce health disparities for their population. Starting in 2024, these providers must capture Sexual Orientation and Gender Identity (SOGI) data.

Chatbots are ideal for capturing SDoH and SOGI data

Advancing health equity for the rising self-identifying lesbian, gay, bisexual, transgender, and queer (LGBTQ+) population begins with identification. The Interoperability Standards Advisory Committee defines the standard patient demographics information providers need to capture and report. Many barriers persist in collecting this data including political and regulatory discrimination, patient/practitioner hesitancy, and a lack of best practices for SOGI data collection.

Electronic health records may not allow for capture of SDoH data or accurate documentation of gender identity, gender pronouns, or chosen names can lead to stigmatizing experiences, such as misgendering or deadnaming.

Identifying and implementing a culturally sensitive way to capture this information is critical. Social gender minority patients reported significantly greater satisfaction when SOGI information was collected nonverbally compared with verbally. Based on this patient preference finding and others, hospitals and health systems must act in meaningful ways to identify the best mode of data collection. Efforts must include providing a respectful, safe and welcoming place in which patients feel comfortable sharing their SOGI information.

Leveraging a chatbot is one culturally sensitive solution to incorporate SOGI data collection within the workflow.  Not only does the digital tool align with the patient’s preference for nonverbal data collection, it also integrates capture of the LGBTQ+ individual’s preferred name. This action and more help to create a welcoming environment to make the patient feel more inclusive and trustful upon arriving for care.

Capturing SOGI data is more than simply checking off a box to meet regulatory requirements. It is an important variable in developing the patient’s care plan. Ergo, supportive healthcare professionals play a profound role in helping make healthcare more gender-affirming and reduce bias. Clinicians and staff must strive to avoid assuming whether an individual is a cisgender male or cisgender female based on their appearance.

Here is a true story that illustrates implicit bias in a care setting. Accompanied by a family member, a patient arrived at urgent care. The healthcare staff attending the patient did not question their SOGI. Instead, as part of the health evaluation, the provider ordered a pregnancy test. This triggered a conversation revealing that pregnancy was not an option since the patient identified as trans.

Social determinant data is also sensitive information to capture face-to-face.  In addition, having office staff capture this data creates an uncomfortable situation when the patient does share a SDoH barrier with a person solely responsible for capturing the data, not acting on it. A better approach would be to use a chatbot to capture the information prior to the visit and then to escalate the need to a resource who can reach out and help the patient reduce the barrier(s) identified.

Success Factor No 2: Increasing Annual Medicare Wellness Visits (AWV) and Closing Gaps in Care

At least 45% of U.S. deaths have been attributed to modifiable risk factors. Routine health screening ─ including the Medicare annual wellness visit (AWV) ─ is key to reducing healthcare burdens. Though AWVs have been around for more than a decade, the government-sponsored visit is emerging as an important element in promoting overall patient health and well-being, a needed new AWV billing source for providers to generate revenue, and an effective way to identify and close gaps in care and drive healthier behaviors.

According to the American Medical Association, there is some confusion about what distinguishes a traditional physical exam from the Medicare annual wellness visit. The AWV focuses on wellness and prevention. Whereas the traditional physical exam is just that: A hands-on full examination of a person’s health and vitals and includes tests of any symptoms suggesting a serious condition.

CMS offers the AWV at no cost to the Medicare patient. The visit does not require a physician. A 2021 study of the value of the AWV reported that though patients were up to date with 80% of the recommended clinical preventive services three months after the visit, few patients (only 0.5%) were up to date with all the recommended clinical preventive services.

Since value-based care is all about keeping people well, the Medicare annual wellness visit is crucial in keeping the age 65+ population healthy and reducing preventable readmissions. The AWV is a valuable vehicle to drive value-based incentives and outcomes with accountable care.

A chatbot helps promote AWVs in two ways:

  1. Proactively reaching out to patients to increase the number of patients who complete the visit.  Data shows that only 10% to 25% of patients schedule an annual wellness visit. Since providers rely on these visits to detect and address most gaps in care, managing only patient-initiated visits is unlikely to achieve performance targets.
  2. Reducing staff time by using a chatbot to capture data needed for a Health Risk Assessment – critical data that helps personalize the plan developed for the patient.  The Affordable Care Act authorized AWV for Medicare beneficiaries as well as Health Risk Assessment (HRA) completion in 2010.  HRAs identify health behaviors and risk factors unique to the patient and are intended to be self-reported.  The patient can complete the HRA before or part of the AWV. Since the HRA can be self-reported, it lends itself to the aid of a self-service chatbot that a patient can easily use. These digital experiences can be personalized to a provider’s needs and extend more time during the wellness visit to focus on the patient.

AllianceChicago uses chatbots to improve population health

Chatbots are an effective outreach tool to increase a healthcare organization’s gaps in care performance. Case in point: AllianceChicago and its partner federally qualified health center (FQHC) in New York, Settlement Health, developed an outreach initiative to close gaps in care and keep their patients healthy. Their partnership deployed QliqSOFT Quincy chatbots to engage patients who needed it the most and had some of the highest risks of disparities in health outcomes. Results and success factors included:

  • SDoH screening: Of patients who responded to the screening questions, 69% identified a need for SDoH assistance.
  • Higher quality care: Thirty-three percent of patients requested additional support reducing SDoH barriers such as scheduling services such as mammograms, colonoscopies, and office visits for well-child checks, underscoring the challenges patients face in care coordination.
  • Patient engagement: On a five-point rating scale, most patient respondents who engaged with the chatbot indicated a 5/5, preferring to connect with their care team using chatbots. Needed preventive services were subsequently completed by many patients.

Success Factor No. 3: Reducing Readmissions

The ACO REACH model intends to improve outcomes by focusing on several types of readmissions, which all vary depending on the ACO entity type that the organization selects as outlined in the ACO REACH PY 2024 Quality Measurement Methodology document:

  1. Risk-Standardized All-Condition Readmission (ACR) measures how many hospital stays result in a readmission within 30 days after patient discharge.
  2. All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions (UAMCC) measures unplanned hospital admissions among Medicare FFS beneficiaries who are 66 years of age or older with multiple chronic conditions.
  3. Days at Home for Patients with Complex, Chronic Conditions (DAH) measures the number of days that adults with complex, chronic diseases spend at home or in community settings (excludes acute and post-acute care settings).
  4. Timely Follow-Up After Acute Exacerbations of Chronic Conditions (TFU) is defined as the percentage of acute events related to one of six chronic conditions where follow-up care was received within the time frame recommended by clinical practice guidelines in a non-emergency outpatient setting. Acute events are those that require either an emergency department visit or hospitalization. The six chronic conditions include hypertension, asthma, heart failure, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and diabetes. This measure will apply to Standard and New Entrant ACOs only. It was new in the performance year 2022.

Each of the four ACO entities faces challenges that increase the demand for care coordination staff to proactively manage care transitions. This too, can be helped by chatbots. Today, many organizations have staff calling patients. The combination of fewer people answering the phone and healthcare staff shortages limit their ability to scale outreach to the level needed for success:

  • 75% of Americans never answer calls to their wireless phone if they do not recognize the number. This lack of consumer trust in voice calling is driving strong demand for branded calling: 78% of survey respondents are more willing to answer the phone if the caller ID displays the logo and name of a brand they recognize.
  • By 2025, McKinsey estimates the United States may face a shortage of 200,000 to 450,000 nurses available for direct patient care, equating to a 10 to 20 percent gap.

Another option is to integrate chatbots into the transitions of care outreach.   For example, each of these six chronic conditions - hypertension, asthma, heart failure, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and diabetes  - have specific follow up appointment targets.  The condition-specific chatbots can be triggered by an ADT feed or a staff member to send to all patients discharge with that condition the day after discharge to reinforce self-care instructions, ensure the patient has filled their prescriptions and scheduled a follow up appointment within the target timeframe. Any answers of concern can be automatically escalated to the call center to address much more cost effectively than staff can attempt to contact and influence by calling every patient. Patients who do not respond can automatically receive follow-up communications.

Virtua Health digitizes patient communication enterprise-wide

Virtua Health, a large nonprofit community health system with multiple acute and non-acute facilities across southern New Jersey and Philadelphia, launched six distinct service lines supported by QliqSOFT as virtual care programs in 2022.  For the COVID-19 Inpatient Remote Patient Monitoring Program, Virtua reported a 32% relative reduction in hospital readmissions; 97% of patients felt more comfortable knowing a nurse was checking on them; and 92% would recommend it to others.

Virtua deployed virtual visits and secure patient texting to help care teams improve their provider-patient communication. Staff who used the Quincy chatbot quickly redirected patients to the appropriate services within Virtua’s larger healthcare community, resulting in more streamlined service offerings for both patients and staff.  The QliqSOFT browser-based platform enabled video consultations and traditional telephone calls directly with the patient. Chatbots were utilized to augment technologies in use by live agents.

As evidenced by our customer successes, proactive digital patient engagement can set up organizations pursuing value-based care for success. Our QliqSOFT platform captures real-time data for reporting and augments staff outreach to expand population health initiatives at scale. By partnering with QliqSOFT, ACO REACH leaders are assured of growing and succeeding digitally to support their mission of reducing the cost of care while improving quality and outcomes.  

Are You Pursuing a Value-Based Care Agreement?

QliqSOFT’s customer success team can help with…

  • Automating Patient Outreach
  • Closing Gaps in Care
  • Managing Transitions in Care
  • Promoting Annual Wellness Visits
  • And more
The Author
Bobbi Weber

Bobbi is a lifelong learner who is passionate about enabling healthcare transformation. She has 20+ years of healthcare experience in care delivery, consulting, healthcare IT, and market strategy.

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