Bundled Payments and the Role of Longitudinal Care

Fee-for-service pressures are pushing health systems to pursue alternative payment options for economic survival while simultaneously providing high-quality care. Bundled payment models are an attractive option because they create a powerful incentive for improving outcomes, enhancing care coordination and aligning providers behind shared performance improvement goals.

Bundled payments have proven to be a vital strategic tool for health systems just beginning the journey to value-based care. For instance, while global payments or accountable care organizations (ACOs) may require an organization-wide mobilization and assumption of risk, health systems can test the concept of bundled payments within a few service lines and scale up accordingly.

Let’s hone in on a specific capability needed for success within bundled payments – the role of longitudinal care.

Taking the Long View

Bundled payments may require participants to adjust their definition of what an episode of care means. An episode of care includes both pre-hospitalization and post-hospitalization, which are integral factors to delivering a high-quality care outcome just as much as the medical procedure or inpatient hospital stay itself.

To be successful in this concept of longitudinal care, an organization venturing into bundled payments should:

• Define and standardize processes before an inpatient admission and up to 90 days (or more) after a hospital discharge;
• Promote ownership of desired patient outcomes by all care partners along the continuum;
• Encourage overall cost reduction across all points of care;
• Invest in focused care coordination activities and resources to facilitate patient and family-focused handovers; and
• Drive appropriate use of post-acute care resources based on achieving optimal patient recovery.

Baby Steps

At first glance, managing care delivery across an entire episode may seem overwhelming. The key is to break it down and focus on incremental progress within a few key strategic areas.

• Patient and family engagement. “Patient engagement” is a hot topic of conversation. However, talking about patient and family engagement is easier than executing on this strategy. Meaningful engagement of patients, families and caretakers means educating and having timely conversations about a patient’s options, values and preferences to jointly determine care goals and make decisions. Other key aspects of engaging a patient include understanding where the patient is relative to his/her readiness for change, their environmental dynamics, as well as how personality traits can impact compliance (or their ability to successfully follow through) with a plan of care.
• Patient support and management. Organizations should implement both pre- and post-hospitalization support and management practices that directly impact patients. Examples include embedding care managers in primary care medical homes (or other practices), and hospital-based navigators or coordinators to liaise between providers and assist with care transitions. An essential piece of patient management is implementing protocols that address social determinants. This includes having the necessary data platforms and analytics in place to identify risk and appropriate level of support (e.g. transportation or nutrition assistance), as well as established partnerships and workflows in place to address care needs and overcome barriers to safe recovery.
• Partnerships and collaboration. A longitudinal approach spans across the care continuum and inherently depends on team-based care and collaboration. This involves proactive coordination between primary care providers and specialists during the pre-hospital and inpatient phases. It expands to include post-hospital services such as rehabilitative providers and non-clinical, community partners such as senior centers, meal support, and leveraging faith-based organizations and continuation of palliative care resources. It’s also worth underscoring the importance of a high-value post-acute network, including skilled nursing facilities, home health agencies, assisted living facilities, etc.

Despite its appeal as an early, less intensive test of change, bundled payment models are not without risk. There are a myriad of program options and care episodes that can be selected, as well as engagement and incentive structures that promote the right amount of change at the right pace which must be initiated before a successful implementation. Moreover, infrastructure is required to measure cross-continuum performance, and care management needs to be fully integrated into an overall program.

Beyond these success factors, there are certain cultural traits of an organization or system that promote likelihood for success. Those that are agile and adaptable, with a penchant for running multiple tests of change and intervention strategies are key to sustaining effective patient management over the course of an episode. Additionally, a robust data infrastructure and timely analytics are critical to communicating progress transparently, evaluating performance and driving improvement.

To learn more about best practices for bundles, download Ready, Risk, Reward: Keys to Success in Bundled Payments.