Hot Topics | Taking Action in Value-Based Care

Intermountain Health’s Ambulatory Care Approach 

Health care is at a crossroads. Transformation from traditional fee-for-service payment models to value-based care (VBC) models requires a fundamental change from “sick care” to “health care.” Incentives are changing from paying for production and volume as a response to illness, to rewarding systems heading upstream to meet health needs early, to help keep people as healthy as possible, and to prioritize value. As health care organizations strive to achieve the quintuple aim of cost, quality, experience for caregivers and patients, and health equity (Nundy et al., 2022), we must be willing to courageously embrace both payment model and care delivery model changes to truly improve population health.

Years ago, the Centers for Medicare and Medicaid Services (CMS) began implementing reimbursement methodology changes based on the 2010 Affordable Care Act (Patient Protection and Affordable Care Act, 2010). Many health care systems were challenged to embrace VBC contracts and have waited to adapt, holding on to traditional fee-for-service methods and models for payment, reimbursement and care. Moody (2015) admits that hospital-centric organizations face significant challenges in this new reimbursement landscape. We must understand the role of ambulatory care (or community health care) as a foundational partner and leader for success in the value transformation journey. VBC programs in ambulatory settings can influence metrics important to hospitals like decreasing inappropriate emergency department use, reducing unnecessary hospital readmissions and reducing the burden of mental health crises on acute care settings. It is crucial to understand how to accomplish these objectives.

Intermountain Health, based in Salt Lake City, was an early adopter of integrated care delivery models and alternative payment models issued by the CMS Center for Innovation. Intermountain is a multi-state system consisting of 33 hospitals and more than 300 clinics. Success in this dynamic reimbursement landscape relies on shifting how and who provides care, with an emphasis on the right care, right time, right setting, by the right person. Preventive care and access to care are the fundamental drivers of success in VBC. Recently Intermountain has expanded its geographic footprint and now exists in eight western states and includes a health plan. Ambulatory care nurses and behavioral health leaders at Intermountain describe key areas of work that have helped the organization achieve success in the transformative journey into VBC.

Health equity and health-related social needs

The addition of health equity to the quadruple aim indicates the importance of social determinants of health in achieving improved health outcomes (Nundy et al., 2022). In this section and as recommended by The Joint Commission, the term “health-related social needs (HRSN) will be used instead of social determinants of health (SDOH) to emphasize that HRSN are a proximate cause of poor health outcomes for individual patients as opposed to SDOH, which is a term better suited for describing populations.” (The Joint Commission, 2022).

Unmet socioeconomic needs have been identified as an indicator of future health care utilization; therefore, assessing these needs is an important step in managing patients and populations. Health care delivery has evolved from a framework of cultural competence toward a need for in-depth understanding of the challenges individuals face that may prevent them from accessing care and achieving health goals. Intermountain has used a multi-pronged approach to identify and address HRSN as demonstrated by three years of work completed by the Alliance for the Determinants of Health (2023). Assessment is completed at multiple steps of the health care journey. Ambulatory care and virtual settings are ideal places for these screenings to take place as they can offer dedicated time and privacy to answer questions about access to resources and personal safety. Intermountain has worked to standardize assessment questions as well as capture ICD-10 Z codes that identify HRSNs. Such data can be used for further reporting and the capture of patient cohorts for interventions. Intermountain uses technology platforms to pinpoint local resources for patients and to direct those services to those who need them. Automated referrals for transportation and food have been built within the system to link directly to our community support partners. 

The addition of community health workers (CHWs), a non-licensed caregiver role, helps to reflect the populations served and break down health care-related cultural and access barriers (Firoi & Oyeku, 2022). Fundamentally, developing care teams and systems that ask and identify each person’s HRSN allows Intermountain to support referrals to services or community partners and thus, begin to address the root causes of barriers to health and to achieve the quintuple aim principle of reducing health inequities.

Integrated behavioral health

In 2020, Milliman published a seminal report analyzing the total health care cost for 21 million patients and a subset of high-cost patients with a focus on the impact of behavioral health conditions and treatment. The analysis found that a small minority of high-cost individuals drove most of the total health care costs. Of those high-cost patients, the majority had behavioral health conditions and yet many had zero or minimal spending on behavioral health services. The study concluded that the consideration and management of behavioral health conditions is critical in a comprehensive approach to improving outcomes while managing the total cost of care for patients and health systems. Furthermore, approaches for the integration of behavioral and physical health care have been well-studied and found to have significant implications for total cost savings (Davenport et al., 2020).

In 2000, Intermountain developed and implemented an integrated mental and physical health care program within primary care called Mental Health Integration (MHI), which led to better clinical outcomes and lower costs. MHI is a team-based approach with care managers, mental health specialists and primary care providers, which creates and implements individualized care plans with patients and families. Through standardized case identification and shared decision-making, complexity and necessary team care support is determined so that optimal behavioral health care can be provided. In 2016, a study published in JAMA found MHI reduced emergency room visits by 23%, hospital admissions by 10.6% and led to an average of $115 savings per patient per year (Reiss-Brennan et al., 2016).

In addition to MHI, Intermountain recognized a need to build additional pathways to continue to promote greater access to mental health services in efficient and cost-effective ways. In 2022, Intermountain launched the Collaborative Care Model (CoCM), which is a specific type of integrated care treating common mental health conditions, such as depression and anxiety, for a specific patient population. The model utilizes a registry, measurement-based practice and treat-to-target goals. In over 100 randomized controlled trials, CoCM leads to better patient outcomes, better patient and provider satisfaction, improved functioning and reductions in health care costs (AIMS Center Advancing Integrated Mental Health Solutions, 2023). Although early in implementation, the program has led to reductions in standard scores for depression (PHQ-9) and anxiety (GAD-7) while achieving average length of treatment of only 52 days as compared to 614 days for usual standard of care (Garrison et al., 2016). Intermountain is committed to the integration of behavioral health in primary care as part of a comprehensive approach to meeting behavioral health needs while reducing the total cost of health care.

Care management and virtual teams

Intermountain is divided into three distinct geographic regions (Canyons, Desert and Peaks) with care management critical for caring for populations and improving health outcomes in each one. Reimagining a care team model for primary care has led to an evolution of care management at Intermountain. The tenet of care management is to stratify and support the highest-risk patients outside of a hospital setting to prevent readmissions or overutilization of resources. Nurse care managers at Intermountain traditionally worked on-site in primary care clinics, performing care management duties mixed with clinic nurse tasks that often decreased the priority or standard approach to care management. In 2019 Intermountain created Castell, a subsidiary organization, dedicated to achieving quality outcomes with our patients in value-based contracts to positively affect population health. Care manager FTEs were moved out of clinics and into a virtual space. Castell developed a risk prediction model to identify patients who would benefit from care management. The model employs indicators of various diagnoses, measures of utilization, HRSN, demographic information and patient trends in medical expense over the previous year. By using a predictive model, we identify patients upstream of their health deteriorating, and intervene accordingly. Care managers work with other team members to meet identified needs and coordinate with primary care to communicate and facilitate these needs. Castell care managers are National Committee for Quality Assurance-accredited for complex care management and can help manage higher-risk patient panels and meet more needs for this population. 

Virtual teams have a unique opportunity for care management innovation. For example, Intermountain developed the triage and transitions RN team used in the Peaks Region. This virtual team of 10 RNs support 42 primary care clinics in Colorado and Montana. As the title implies, these nurses are responsible for performing phone triage and transitional care management (TCM) services. 
Benefits of this model include efficient distribution of work, improved patient safety and system standardization. With a minimal number of RN FTEs, Intermountain can effectively flex the workload in the event of time-off requests or employee turnover. Triage calls that are potential medical emergencies are performed with warm handoffs and minimal wait times. Not all clinics in the region have an RN on staff, and thus standardization with the triage and transitions team has ensured that the high-risk, high-impact activities of triage and TCM outreach are done with consistency. 

The combination of triage and TCM responsibilities appear misaligned, but complement each other. RNs on the triage and transitions team split their days between triage and TCM outreach to create a balanced workload. Additionally, the same nurse who performed telephone triage and referred the patient to the emergency department may perform TCM outreach post-discharge, improving continuity of care. Patients have responded positively to this model and nurses appreciate seeing the direct impact of their work.

Outpatient care models, roles

In 2011, the Intermountain Medical Group focused its primary care model on the patient-centered medical home model. This model provided the foundation and organization needed to transform our primary care teams. This transition also moved us toward a more focused team-based care model. But primary care practices continue to face common challenges: panels/schedules are full, making it difficult to add new patients and capacity is insufficient to meet the patient demand for care, resulting in poor access. Physicians and advanced practice providers are spending too much time on electronic medical records and office work creating dissatisfaction. 

The development of team-based care started with the addition of RN care management and a medical assistant (MA) role, called a health advocate. The RN is focused on patients with chronic conditions such as diabetes, hypertension and depression, helping with follow-up care and patient education. These RNs also provide some clinical assessment in addition to some triage and wound care. The health advocate completes pre-visit planning and outreach to patients to assist with closing care gaps, with a focus on preventive procedures such as cancer screenings or vaccines. 

As Intermountain has progressed in the journey toward value and with the development of Castell, these team roles have evolved and are now managed externally. This allows care management to be entirely focused on the highest-risk patients and not involved in daily clinical tasks. As the team-based care evolution continues, Intermountain understands the value of a clinic RN role within care teams, as they can perform nurse visits by protocol, help with annual wellness visits and some acute visits, thereby promoting same-day access. RNs carry out this work independently and allow for increased access to primary care clinicians (Wagner et al., 2017). Intermountain also has seen the addition of ambulatory care-trained pharmacists to support medication education and titration. Behavioral health providers support the psychosocial needs of patients, demonstrating how strong and coordinated care teams are fundamental to a successful care delivery in VBC reimbursement models.

Creating value 

Continuity and communication across health systems (from acute to ambulatory) are the foundation of excellent care. In ambulatory settings, great work can be done to screen, identify, connect and support patients with HRSN that affect their health. Strong teams with diverse caregiver roles are key to successfully supporting the transition to a value-based system. We need to be creative and dynamic to reap the rewards of a truly health-focused system that engenders the healthiest lives possible for our patients. 
 

References

AIMS Center Advancing Integrated Mental Health Solutions. (2023). Collaborative care. University of Washington, Psychiatry & Behavioral Sciences Division of Population Health. https://aims.uw.edu/collaborative-care 

Alliance for the Determinants of Health. (2023). https://alliancefordeterminantsofhealth.org/ 

Davenport, S., Gray T. J., Melek, S. (2020). How do individuals with behavioral health conditions contribute to physical and total healthcare spending? Milliman Research Report. https://www.milliman.com/-/media/milliman/pdfs/articles/milliman-high-cost-patient-study-2020.ashx

Fiori, K. P., & Oyeku, S. O. (2022). Addressing racial, ethnic, and socioeconomic differences in real-world practice. Pediatrics, 150(6). https://doi.org/10.1542/peds.2022-058243 

Garrison, G. M., Angstman, K. B., O’Connor, S. S., Williams, M. D., & Lineberry, T. W. (2016). Time to remission for depression with collaborative care management in primary care. Journal of the American Board of Family Medicine, 29(1), 10-17. https://doi.org/10.3122/jabfm.2016.01.150128

James, B. (2016). Association of Integrated Team-Based Care with Health Care Quality, Utilization, and Cost. JAMA, 316(8), 826-834. https://doi.org/10.1001/jama.2016.11232

Moody, S. (2015). Look before you leap: Shared risk programs and considerations for health systems. Milliman Healthcare Reform Briefing Paper. Milliman. 

Nundy, S., Cooper, L. A., & Mate, K. S. (2022). The quintuple aim for health care improvement: A new imperative to advance health equity. JAMA, 327(6), 521-522. https://doi.org/10.1001/jama.2021.25181 

Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, 124 Stat. 119 (2010). https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf 

Reiss-Brennan, B., Brunisholz, K. D., Dredge, C., Briot, P., Grazier, K., Wilcox, A., Savitz, L., & James, B. (2016). Association of integrated team-based care with health care quality, utilization, and cost. JAMA, 316(8), 826-834. https://doi.org/10.1001/jama.2016.11232 

The Joint Commission. (2022). New requirements to reduce health care disparities - the Joint Commission. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_disparities_july2022-6-20-2022.pdf 

Wagner, E. H., Flinter, M., Hsu, C., Cromp, D., Austin, B. T., Etz, R., Crabtree, B. F., & Ladden, M. D. (2017). Effective team-based primary care: observations from innovative practices. BMC Family Practice, 18(1), 13. https://doi.org/10.1186/s12875-017-0590-8

ABOUT THE AUTHORS

Malia Davis, MSN, APRN, ANP-C, chief nursing officer, ambulatory services, Peaks Region Intermountain Health, Broomfield, Colo.

Tammer Attallah, MSW, LCSW, executive clinical director, behavioral health clinical program, Intermountain Health, Salt Lake City.

Barry Boyce, MSN, RN, ACM-RN, Castell senior director of ambulatory and community care management, Intermountain Health, Salt Lake City.

Lauren Burnell, MBA, BSN, RN, CCM, director of nursing, ambulatory services, Peaks Region Intermountain Health, Broomfield, Colo.

Keyona Cole, MS, RN, FNP-BC, chief nursing officer, Desert Region Intermountain Health, Las Vegas.
Rebecca Holt, MA, RN, executive nurse director, ambulatory care, Desert Region Intermountain Health, Las Vegas.

Michele Lower, RN, MSN, executive nurse director, medical group, Canyons Region Intermountain Health, Salt Lake City.

Perry M. Gee, PhD, RN, NEA-BC, FAAN, nurse scientist and associate professor of research, Intermountain Health, Salt Lake City.