ACOs Restructure Healthcare Staffing for High-Risk Patients

June 19, 2017 - To successfully lower healthcare costs while improving care quality, accountable care organizations (ACOs) have restructured their healthcare staffing models to provide additional support to high-risk patients, a recent American Journal of Accountable Care study revealed.

ACOs redesigned staffing models by hiring new workers (eg, care coordinators and social service navigators) and by expanding the roles of existing staff (eg, medical assistants and pharmacists), researchers from George Washington University, National Committee for Quality Assurance, and Physician Assistant Education Association found based on interviews with 17 ACO leaders.

The additional or expanded roles primarily centered around high-risk patient populations, while healthcare staffing models for low-risk and moderate-risk patient groups largely stayed the same.

“In primary care, these new roles are mainly focused on the small but significant high-risk population to maximize the potential to improve quality and lower cost,” the study stated. “However, each organization is taking a slightly different approach, which results in differences among sites in the particular personnel used, as well as in specific provider-to-patient ratios.”

Each ACO developed its own healthcare staffing model for each patient risk group because ACO leadership permitted individual departments or practices to make staffing decisions.

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The interviews revealed that the potential of earning shared savings limited the organization’s ability to fully invest in healthcare staffing redesigns, but the possibility of downstream savings allowed some ACOs to start practice transformations.

Therefore, ACO leadership tended to provide some financial and administrative support practice transformations but generally left the work to individual practices.

Despite healthcare staffing model variations by ACO and practice, researchers revealed that most ACOs focused on restructuring the workforce around high-risk patient populations.

For the high-risk patient group, all ACOs reported hiring care coordinators or case managers. The roles were usually filled by registered nurses or social workers and they worked in primary care practices.

Although 5 out of 17 ACOs stated that they use centralized care coordinators or case managers for either telephonic or in-person care because not all practices had sufficient patient volume to support an on-site staff member.

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The main responsibilities of care coordinators and case managers were to communicate with care team members and the patient to ensure treatment adherence and identify care gaps. They also scheduled appropriate follow-up appointments and tests.

The ACOs agreed that care coordinators or case managers could actively manage between 100 and 150 high-risk patients. Those tending to patients across the risk levels tended to have between 1,000 to 1,500 patients, but only 5 to 10 percent required high-need case management.

Despite care coordinators or case managers managing at least 100 patients, they expressed concerns about the greater patient-to-provider ratios. They reported that they prefer lower ratios to enhance efficacy in meeting individual patient needs.

However, their ACOs did not have the budget to accommodate the healthcare staffing demand.

In addition to care coordinators or case managers, four ACOs established separate clinics for intensive outpatient care management services. The organizations designed the clinics to “intervene and break the cycle of repeated hospitalizations for high-risk patients or those with complex chronic diseases.”

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Compared to primary care practices, the clinics were more resource-intensive and maintained lower patient-to-provider ratios, giving providers more time and resources to focus on high-risk patient populations.

The clinicians generally included 0.25 full-time equivalent (FTE) or 0.5 FTE physicians per 125 to 200 patients and one FTE nurse practitioner and one FTE social worker for the same patient grouping. They also contained care team support members to meet specific patient needs, such as addiction and behavioral health specialists, geriatricians, dieticians, pharmacists, and patient navigators.

To realize greater healthcare cost savings for high-risk patient groups, most of the ACOs (11 out of 17 organizations) invested in additional services to address social determinants of health. By targeting social determinants of health, the ACOs aimed to reduce expensive, avoidable hospitalizations and emergency department visits.

The ACOs invested in additional services beyond traditional primary care, such as assistance with housing, transportation, public health services, and home care. They used social workers, social service navigators, or community health workers to connect patients with the appropriate resources.

Seven out of the 11 ACOs implementing the initiatives also reported providing personnel for performing home visits for the frail elderly group or for patients with conditions that limited their ability to go into a clinic. Pilot waiver programs or additional resources from ACO leadership supported the physicians, nurse practitioners, registered nurses, social workers, and emergency medical technicians assigned to the programs.

Another six ACOs stated that they were implementing a project to improve coordination across home health agencies and visiting nurse associations to ensure patient adherence to treatment plans at home.

While the healthcare staffing models for high-risk patient groups saw the greatest changes after ACO implementation, the organizations did slightly modify staffing for moderate- and low-risk patients. The healthcare employment models saw the following changes:

• Some ACOs stated they invested in modest care coordination (2 ACOs) or nurse-led wellness protocols for moderate-risk patients (8 ACOs), such as smoking cessation or dieting and exercising coaching

• 8 ACOs employed pharmacists for moderate- and high-risk patient populations to review medications, pinpoint medication adherence strategies, and resolve potential interactions

• Most ACOs reported implementing enhanced access to behavioral health services for moderate- and high-risk patient groups, including individual or group therapy, psychiatric medication management, and alcohol and drug treatment, led by master’s-level behavioral health specialists

• Increased use of medical assistants, licensed practical nurses, licensed vocational nurses, and registered nurses to search the EHR for risk factors among low-risk patients

• Some ACOs improved low-risk patient staffing models by using existing staff to direct specialist referrals to high-quality, cost-efficient providers or those who send patient data back to primary care providers (3 ACOs)

ACOs may be searching for the most appropriate healthcare staffing model to support healthcare cost reduction and care quality improvement efforts. However, researchers concluded that providers have yet to find the magic model to realize ACO goals.

“One of the biggest takeaways from the research was that there was no ‘single model’ of care, distribution of positions, or provider-to-patient ratios that worked equally well for all sites,” they stated. “Rather, sites tailored the composition of their teams according to the needs of the local patient population and provider availability.”

They added, “Factors affecting the local health workforce, such as nearby nursing or other training programs, professional licensure restrictions, or costs related to the local labor market, also played a role.”