Frequently Asked Questions
- How does Obamacare address Care Coordination?
“Obamacare” or the Affordable Care Act (www.hhs.gov/healthcare/rights) was signed into law on March 23, 2010. This healthcare reform law emphasizes payment for value instead of volume…a key part of effective health care delivery is care coordination.
Post-hospitalization care can no longer be fragmented. Instead, it must be integrated and linked to performance and quality outcomes through care coordination activities. ACA supports two new models in health policy— patient-centered medical home (PCMH) and Accountable Care Organizations (ACOs)—that aim to provide such needed integration. Such models provide an opportunity to increase the effectiveness of care coordination (American Academy of Family Physicians et al., 2007). The shift to value-based care is evident in a new McKesson study, which shows that reimbursement based on value outcomes will comprise two-thirds of payments by 2020 (Becker’s Hospital Review: McKesson: New Reimbursement Models to Eclipse Fee-for-Service by 2020). HAS will work within these models to facilitate value outcomes.
- What is Care Coordination?
Care Coordination is the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care service.” (McDonald et al., 2007). The focus is on individuals with chronic conditions at risk for adverse events and expensive care, and bridge gaps in the current healthcare system by:
- identifying their medical, social, and emotional issues and needs that put them at risk for adverse events and evaluating ongoing care gaps;
- addressing those needs via education in self-care, optimization of post-discharge care, and integration of fragmented care;
- establishing authority for each aspect of care, including the extent and duration of the provider/caregiver responsibility;
- streamlining the flow of information between care providers and patient and family caregivers to ensure coordination and continuity;
- monitoring patients for progress and early signs of problems; and
- facilitating transfers to alternate levels of care if required.
(Source: (National Quality Forum. 2010). Preferred practices and performance measures for measuring and reporting care coordination: A consensus report. Washington, DC: Author).
(Source: Chen A, Brown R, Archibald N, Aliotta S, Fox PD. Best practices in coordinated care. March 22, 2000 [Accessed: January 30, 2006]; Available here.)
“Care Coordination programs hold the promise of raising the quality of health care, improving health outcomes, and reducing the need for costly hospitalizations and medical care.” ( See full report,)
- What is Transitional Care Management (TCM)?
TCM, a subset of care coordination, refers to the movement of patients between health care settings (e.g., hospital to assisted living or home), providers (generalist to specialist), or different levels of care within the same location to accommodate any change in their health and needs. TCM uses experienced providers who develop a comprehensive care plan from current information about the patient’s treatment goals, preferences, and medical status. The focus is on logistical arrangements and coordination among the health providers involved in the transition. Patient and family education is key throughout the transition, as such patients typically have complex problems that require intense medical decision-making during transitions. (http://www.aafp.org/dam/AAFP/documents/practice_management/payment/TCMFAQ.pdf). Three requirements are:
(1) Employed during a patient’s transition to the outpatient setting or home after discharging from higher levels of care;
(2) Responsibility for patient care should be assumed by the healthcare provider immediately after discharge without gaps in care;
(3) Patients have medical and/or psychosocial problems that require moderate or high complexity medical decision making.
The TCM period is 30-days, and begins on the patient’s hospital discharge date and continues for the next 29 days. (HHS, CMS). Three components must be fulfilled during this period: an interactive contact; a face-to-face visit; and certain non-face-to-face services.
- What is the Patient-Centered Medical Home (PCMH)?
Primary care providers who coordinate care among all of a patient’s doctors and other care providers, allow better access through expanded hours and online support, and work in teams to manage chronic conditions are considered PCMH. They can receive official recognition by NCQA. PCMH focuses on self-management of the patient with the support of their primary care physicians, an interdisciplinary care team, and advanced health IT to track and coordinate their care. The key features are:
- patient-centered care, focused on the whole person and their needs, values and preferences
- comprehensive care provided by a team of physicians, advanced practice nurses, nursing assistants, pharmacists, social workers and others, to meet their unique prevention, wellness, and chronic care needs.
- coordinated care across health care system including hospitals home health care and community services, especially during transitions.
- enhanced access to care, to meet both urgent and non-urgent needs, 24/7 phone and electronic access to care team.
- systems based approach to safety and quality, including performance measurement and quality improvement, response to patient satisfaction, population-based health care delivery.
- What is Telemedicine?
Telemedicine is a remote healthcare delivery system. It allows access to care for people that find it hard to attend in-person healthcare due to time, mobility or transportation limitations. It enables this vulnerable population to receive critical and life-saving treatment regardless of socioeconomic issues or available providers within their insurance network. It can improve key health status indicators within a state, and improves documentation and verification. It is important to identify and monitor the effect on indicators, especially hospital readmissions and medication compliance.
Michigan Medicare has coverage for telemedicine (or telehealth), and have enacted laws mandating coverage under private health plans (in 2012). If a health insurance policy covers “physician services” then there is no basis to deny a telehealth-provided covered physician service.
What is a Health Coach?
An Integrative Health Coach works in a dynamic partnership with clients to help them achieve and sustain optimal health and vitality. Our clients are living with conditions like cancer, heart and lung disease, cancer and diabetes. Since most of these conditions are affected by lifestyle choices, research has shown that health coaches help such clients with lifestyle behavior change within a holistic framework of health. Significant improvements in dietary, exercise and weight management, and medication compliance behaviors were found in these studies. The key elements to success were goal setting, motivational interviewing (which is part of health coaching), and collaboration with health care providers (Olsen JM, Nesbitt BJ).
Integrative health coaches work with the Wheel of Health, developed by Duke Integrative Medicine, to examine the areas that influence their health. The areas include: relationships, personal/professional development, exercise, environment, spirituality, nutrition, and mind-body connection. Health coaches empower clients by building on their strengths in any of these areas so they can achieve the change they desire. Together, they design a care plan that allows the client to work at their own pace. The process takes time, sometimes up to six months with weekly face-to-face meetings or teleconferencing.