Care Coordination Q&A with Hoangmai Pham

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Dr. Hoangmai Pham, CMS
Dr. Hoangmai Pham, CMS

Hoangmai Pham, MD, MPH serves as Chief Innovation Officer for the Center for Medicare and Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS). In this role, she is responsible for overseeing implementation of the Medicare and CHIP Reauthorization Act, and strategic and operational planning for the Center. Previously, she served as Director of the CMMI’s Seamless Care Models Group, where she was responsible for the design and implementation of payment and care delivery models on accountable care organizations and advanced primary care.

Q. In April 2016, CMS launched the Comprehensive Primary Care Plus (CPC+) model to transform and improve how primary care is delivered and paid for in America. Tell us a bit about this initiative and how it relates to home health services for Medicare beneficiaries.

CPC+ is a primary care initiative targeted chiefly at independent primary care practices, which involves a novel payment arrangement and care delivery model. On the payment side, CPC+ offers practices a monthly per capita payment to cover care management costs, as well as a primary care payment intended to incentivize comprehensive care. Additional performance bonuses are awarded to practices based on their meeting performance-based metrics for utilization and quality. On the care delivery side, we are being more prescriptive than in some other CMMI models about how practices prioritize their work. We want to steer them to particular types of work like improving care coordination, access, and shared decision making. We set milestones for the practices each year in these high-priority domains, which escalate in difficulty. The initiative’s relationship to home health is similar to its relationship with urgent care and preventive services. Home health falls into the universe of total care for which we want practices to feel responsible. They need to make sure patients are getting the services they need and not the ones they don’t need.

Q. What are some other CMS innovations that potentially could help older Americans maintain their health and continue to live independently in their home environment?

We have a range of initiatives sponsored by CMMI that focus on these goals, as well as the Medicare Shared Savings Program, which is a permanent program focused on accountable care organizations. Some examples include our Accountable Care Organizations initiative and our Accountable Health Communities model in which we are working with community-based social service organizations to coordinate patient care with clinicians. One of our main goals is to find different approaches for improving care coordination, which lead to better outcomes and the ability for beneficiaries to continue living at home as long as possible. One way we are doing this is by conducting our Independence at Home Demonstration, which tests the effectiveness of delivering comprehensive primary care in the home setting to beneficiaries with multiple chronic conditions.

Q. What role do you see the Quality Improvement Organization (QIO) Program playing as CMS continues to expand its home health initiatives?

I think that QIOs would be great at spreading what we have learned to other practices. They also could give us intelligence about what is happening in their local communities and inform us about opportunities they see for CMMI to develop new programs or refine current ones.

Q. You’re also a member of the Health Care Payment Learning & Action Network’s Population-Based Payment Work Group. What are your work group’s next steps coming out of the LAN event that took place in April 2016?

The work group is continuing to develop and publish recommendations. So far, we have published two papers — one on financial benchmarking and one on quality measurement. Now we are working on one about data sharing.

Q. Anything else you would like QIO News readers to know? 

We are experimenting with finding different possibilities for home health models. For example, under our Next Generation ACO Model, patients will be able to get a certain number of home health visits reimbursed by Medicare during the immediate post-discharge period. Any additional ideas that QIO News readers have for home health models may be submitted to us via the QIO Program office.

Update on Home Health Compare

Information provided by CMS’ Division of Chronic and Post Acute Care

Q: CMS recently convened an expert panel of stakeholders to gather feedback on Home Health Compare. Based on that review, what steps will CMS be taking to enhance the website and its ratings system?

The technical expert panel (TEP) met from May 2-3, 2016 to review trend data from the Home Health Quality of Patient Care (QoPC) Star Rating. During a productive and collaborative discussion, TEP members had several suggestions for additional monitoring analytics, potential revisions to the way ratings are calculated, and the data sources included in the rating methodology. In addition, panel members recommended enhancements to the display of the ratings on Home Health Compare and provision of additional educational materials. One of the recommendations was for CMS to explore the best ways of identifying patients for whom maintenance of function, as opposed to improvement, is an appropriate goal. In addition, members recommended that CMS develop information that may be useful for consumers when selecting a provider. Based on TEP feedback, CMS intends to conduct the recommended analysis, including exploration of longer-term data sources and options for measuring maintenance of function, and to reconvene the TEP for a teleconference for further discussion. The TEP also recommended that CMS identify new ways of presenting the information on Home Health Compare to make the information more accessible to consumers and agencies, such as plain language information for provider review reports, and adding information about the relative nature of star ratings. CMS is reviewing the static text and website search functionality at this time and identifying next steps to enact these changes.

Q: What features and benefits of Home Health Compare should QIN-QIOs and other CMS Quality Networks highlight when working with providers or beneficiaries on care coordination, cardiac health and other clinical quality improvement activities?

There are two types of measures featured on Home Health Compare: process measures and outcome measures. Process of care measures show how often home health agencies gave recommended care or treatments that research shows get the best results for most patients. QIN-QIOs may want to emphasize the process measures that specifically address cardiac issues, such as addressing heart failure symptoms, as well as care coordination, including timely initiation of care and drug education on all medications provided to patients and caregivers. These items are derived from the Outcome and Assessment Information Set (OASIS) item set. There are also outcome of care measures that show the results of care given by the home health agency. Outcome measures of care coordination include Medicare claims-based measures of utilization, such as acute care hospitalizations, emergency department use and readmission during the first 30 days of home health.