Improving Access to Primary Care for Medicare Patients with Complex Need

Background: Healthcare spending is expected to reach 19.4% of the U.S. gross domestic product (GDP), exceeding $1.5 trillion, by 2028 (Sisko, Keehan, Poisalm, Cuckler, Smith, Madison, Rennie & Hardesty, 2019; OIG, 2019). Growth in overall healthcare spending is primarily due to the increase in the number of Medicare patients and unmanaged chronic conditions in this population (Sisko, et al., 2019). The aim of this project was to expand access to primary care by bringing chronic care management (CCM) and care coordination services to high-risk Medicare patients in their homes. The expectation was that providing home-based CCM would result in reduced Emergency Department (ED) utilization and reduced hospitalization for treatment of chronic conditions. Methods: A critical access hospital and rural health clinics in New Mexico participating in a Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) was the focus of this project. Patients were risk-stratified based on claims data to determine which patients would benefit from home-based CCM. The Readiness Assessment Checklist for home-based CCM with the accompanying workflow was used to identify gaps between the home-based CCM model and the CCM process. The checklist was completed with the population health nurse and members of the leadership team at the hospital and results were shared with their leadership team.Results: One critical access hospital with associated rural health clinics in rural New Mexico completed the Readiness Assessment Checklist. This community was a participant in an MSSP ACO and attributed patients were stratified by risk. Nursing and clinic leadership in the rural health clinics completed the checklist to determine readiness to implement home-based CCM. The Readiness Assessment Checklist was successful in identifying gaps in staffing, training, and policies for home-based CCM in this community. The community had 458 high-needs patients out of 3480 Medicare patients who would benefit from CCM at home based on their chronic disease burden, social and health needs. Conclusion: The Readiness Assessment Checklist can be used in any primary care clinic in the ACO. It includes the elements required to meet the CMS billing requirements for CCM to ensure that the nurse-led interventions are reimbursed by Medicare. The checklist also includes recommended staffing, training and policy for home-based CCM. Next steps include updating the checklist with recent developments from CMS and expanding utilization to other clinics in the ACO.