Population Health: How the Value-Based Care Model Is Driving Better Outcomes in Geriatrics

There are four critical factors to driving the best outcomes in value-based contracts, says Nirav Vakharia, MD, Vice Chairman of Population Management and Associate Chief Quality Officer at Cleveland Clinic:

1. Know who your patients are from an attribution standpoint.
2. Establish a team-based care model with all caregivers working at the top of their license.
3. View patients holistically, incorporating their social factors.
4. Partner with community resources.

“It’s important to engage patients and patient families to define not only the care plan but quality care measures and clinical priorities,” adds Dr. Vakharia.

This model of care is being introduced throughout Cleveland Clinic, most notably in the Center for Geriatric Medicine. The center’s director, Ardeshir Hashmi, MD, and Dr. Vakharia will share their insights at Cleveland Clinic’s second annual Advanced Payment Summit, in Cleveland, Oct. 22-24, 2018.

Among the benefits they will discuss:

Geriatric patients have better access to consultations and assessments. Frailty and cognitive impairment are common among the center’s patients, average age 87. According to the Annals of Internal Medicine, patients with frailty constitute 8 percent of the nation’s Medicare population yet more than half (51 percent) of preventable spending.

“Access is important for a vulnerable population like our senior patients,” says Dr. Hashmi. “If these patients don’t have access to proper healthcare, often their only alternative is to dial 911 or go to an emergency department.”

Since late 2017, Cleveland Clinic has made strides to provide geriatric care throughout its regional medical practice. Now geriatricians are available in all nine primary care service area “hubs” at least one day a week. Patient show rates are averaging a remarkable 98 percent.

“We hope to begin seeing lower rates of hospitalization due to better access to geriatric caregivers in the community,” says Dr. Hashmi.

Integrated practice units and cross-collaboration with specialists keep care centered on each patient. In addition to access, quality of geriatric care in the community also has improved, thanks to integrated practice units (IPUs). Instead of scheduling with multiple providers on different days, patients schedule a single visit with an IPU and see their geriatrician, care coordinator, behavioral health social worker, geriatric pharmacist, physical therapist and other caregivers on the same day, in one location.

Geriatricians guide IPUs in developing a unified care plan for each patient, based on the patient’s priorities.

“We ask each patient what matters most to them,” says Dr. Hashmi. “If someone says their one goal is to breathe better so they can keep playing with their grandchildren, we’ll focus care efforts on that.”

At the end of the comprehensive visit, a care manager educates patients on medication changes, informs them of test results and prepares them for next steps.

“IPUs have improved navigation and saved time for our patients,” says Dr. Hashmi. “The concept is similar to the CMS PACE program, but moved upstream, to benefit patients long before they become candidates for skilled nursing.”

Geriatricians focus on helping patients sustain successful aging through healthy lifestyles, proactive disease prevention and earlier disease diagnosis. The sooner common geriatric conditions like cognitive impairment are diagnosed, the sooner treatments can begin to help preserve patients’ quality of life. That’s why providers have begun conducting cognitive screenings for all patients age 65 and older, not just those with signs of impairment, across all Cleveland Clinic primary care locations.

“Earlier detection and treatment allows us to prevent the use of expensive clinical biomarkers, such as MRIs, which are more common once a disease has progressed,” says Dr. Hashmi. “Through wise stewardship of resources, we can potentially save several thousands of dollars per patient.”

Supporting patients’ healthy living is equally important, he adds. And a major part of that is directly addressing social determinants of health, including transportation, and food and home security issues.

“Without these basics, patients often stop engaging in healthcare,” says Dr. Hashmi.

Technology helps geriatricians better measure frailty and cognitive impairment. A new technological tool is allowing geriatric teams to test higher levels of mental ability — measuring patients with higher cognitive reserve against their own baselines. Another tool is helping gauge frailty and its associated morbidity and mortality risks to more accurately recommend patients for home care or skilled nursing.

Virtual visits through Cleveland Clinic’s Express Care Online and eConsults are other ways technology is improving care, allowing geriatric patients to access providers without leaving home.

Learn more about the benefits of value-based care models in population health at Cleveland Clinic’s second annual Advanced Payment Summit, Oct. 22-24, 2018. The summit will bring together leaders in value-based care redesign and payment reform, from a variety of disciplines. You’ll hear insights on alternative payment models and innovative ways to reduce the costs of care while improving patient quality and experience. Register today.