Medical Home Network (MHN) isn’t new to care coordination. For 14 years, the Chicago-based accountable care organization (ACO) has focused on bringing care coordination into the primary care office, using community health workers to provide whole-person care. But now, as a part of the ACO REACH Model, MHN looks forward to a future free from the constraints of fee-for-service and focused on health equity and social determinants of health.
“MHN has a model that they developed in Chicago almost 20 years ago, which really revolved around embedded care coordinators who are unlicensed and care managers who are licensed, either LCSWs or RNs,” according to Abigail DeVries, MD, market medical director for MHN, who is spearheading the organization participation in ACO REACH.
Being part of ACO REACH, a designation Medical Home Network REACH ACO got in September of 2022, will be a game-changer, DeVries told PatientEngagementHIT in an interview. The transition to value-based care generally frees up clinics to do more work on health equity and community health, she noted, and that’s even more true in fully capitated models like ACO REACH.
CMS launched the ACO REACH (Realizing Equity, Access, and Community Health) model in February 2022 as a replacement for the Global and Professional Direct Contracting model. The agency said ACO REACH will promote health equity and address health disparities while centering provider-led organizations.
That’s a big benefit to an organization like Medical Home Network REACH ACO, which is ready for capitation, DeVries said. When an organization participates in a capitated value-based care model, it enjoys more freedom to innovate in community-based care. An organization like Medical Home Network REACH ACO participating in ACO REACH will be totally focused on outcomes, DeVries said, and less on fee-for-service.
“It incentivizes us to look at the whole person and think about what are the drivers, what are all the reasons—behavioral health, physical as well as social health—that are causing patients to have excess utilization,” she explained. “Then it allows us to do things a little differently, so it allows us to provide care coordination and care management services.”
Medical Home Network REACH ACO already has a model for that office-based care management, DeVries added. The federally qualified health centers (FQHCs) MHN has partnered with embed their own care coordinators and community health workers, which pays dividends in patient engagement and building trust.
DeVries said clinics will use Medical Home Network REACH ACO’s health risk assessment, which screens for social determinants of health as well as healthcare utilization patterns and behavioral health conditions. From there, MHN will use its proprietary artificial intelligence (AI) model to combine those social determinants with claims data to enroll a certain number of higher-risk patients into high-risk care management, DeVries outlined.
That’s actually one key area of the ACO REACH model that’s excited DeVries: it’s potential to promote health equity.
“The REACH model, in particular, was clearly designed with health centers in mind and getting more providers who take care of disadvantaged patients into these models, and more of these patients into these models so they can benefit from them,” DeVries noted.
Value-based care is difficult, and some industry experts have lamented that FQHCs and other safety-net clinics are disadvantaged in practice transformation, likely because they have fewer resources. DeVries indicated that something like the ACO REACH model is a key solution to ensure traditionally marginalized patients—who mostly visit FQHCs or else get their care from high-acuity settings like the emergency department—would be left behind.
But that emphasis on traditionally underserved groups is made evident through certain parameters that participants must hit as part of ACO REACH. For one thing, Medical Home Network REACH ACO must report on its health equity data as part of its participation in the model.
“Our health centers have collected it for decades, and now we’re being measured on first reporting, but then also what are our disparities looking like and what are we going to do about it,” DeVries said. “Again, just measuring something starts making you think about it a little bit more.”
Moreover, that health equity benchmark adjustment is going to help level the playing field, she stated. SDOH and health equity work is expensive, especially in the constraints of fee-for-service and even low-risk value-based care arrangements. The most underserved haven’t been able to benefit from the potential of value-based care simply because the funding hasn’t been there.
“The big thing is the health equity benchmark adjustment, and that is going to be dollars up front that we can use, again, to push the health centers to focus on some of these issues,” DeVries explained. “It’s a nice way to level the playing field and make sure that the investment is being made in these populations that have, again, not had these models before.”
DeVries indicated that the ACO REACH model will allow the wiggle room her organization needs while streamlining value-based care reporting efforts. That’s because the quality measures that ACO REACH calls for directly align with the overall mission of reducing unnecessary healthcare utilization.
“One of the nice things about REACH is that, if you do well on the quality measures, your utilization is probably going to also be good,” DeVries pointed out. “It’s nice that those are lined up, as opposed to doing HEDIS measures over here and then worrying about utilization.”
“Not that we don’t want to also do well on preventive care and things like that, but it just helps align the model,” she added. “Then we also are able to keep the primary care provider in the loop about what’s happening through some feeds that go from our system to the EHR, so that the primary care team is looped in.
Participating in the ACO REACH model simply made sense for the organization, DeVries suggested, because it serves as a complement to the other community health work that the organization has long been a part of.
In October 2022, MHN partnered with Chicago Fire Department Community Paramedics to pilot the use of paramedics for community care management. Paramedics will check in with high-risk patients up to four times, serving as an extra set of eyes and ears in the community to make sure patients’ health needs are met.
A separate $250,000 grant from the Health Resources and Services Administration (HRSA) will help MHN train unlicensed folks as community health workers to support maternal health coaching efforts. These community health workers will be part of the care team, helping to coach during pregnancy and offering support post-partum.
The organization’s experience in value-based care is what has allowed it to innovate in these areas, DeVries pointed out
“In a capitated model, that’s not something that’s typically billable,” she concluded. “But if we can prove that there’s an ROI, then we can just deploy it and don’t have to worry about the billing. I think, again, that’s so exciting, that value-based care is just doing things that work.”
Source: PatientEngagement Hit