Track 3: Using Quality Improvement Frameworks to Optimize Care Delivery and Gain Financial Benefits
In our last few blogs, we’ve been looking at CMS’ new Making Care Primary (MCP) model, which aims to have Medicaid advance value-based care at the primary care level through better coordination of care.
Participating in MCP is voluntary, but the implication is clear: CMS isn’t deviating from a path toward value-based care anytime soon, and aligning primary care delivery with the model’s objectives can only help payers prepare for a future of healthcare that prioritizes member outcomes, quality of service, and caring for the whole person over the sheer volume of services provided.
Previous posts have covered how a care management platform is key to success with Tracks 1 and 2 of MCP.
- Track 1 focused on building infrastructure to support a value-based care approach.
- Track 2 focuses on advancing efficiency and coordination for overall member well-being, addressing and integrating behavioral health, and making the first steps away from a fee-for-service (FFS) payment model.
Here’s a look at participation requirements for Track 3, plus tips on selecting the right healthcare management solution for supporting value-based care and the MCP model.
Quality Improvement Frameworks for the MCP Model
According to CMS, “[Track 3] participants will expand upon the requirements of Tracks 1 and 2 by using quality improvement frameworks to optimize and improve workflows, address silos to improve care integration, develop social services and specialty care partnerships, and deepen connections to community resources.”
Essentially, by Track 3, it’s expected that participating plan providers (and those looking to advance care ahead of time) should have the following:
- Intelligent workflows in place to continually streamline care-related processes, tasks, and case management.
- Data interoperability and shared data and insights capabilities across the entire care continuum. [Learn why a solution that transforms data into formats that meet the HL7® FHIR® standard is the right choice for payers who want speed, accuracy, and simplicity.]
- Whole-person care coordination enabled.
- Connected partnerships that support programs and services related to closing care gaps and improving health equity (a plan and tools in place to address SDOH).
A Shift in Payment Methods with Outcome-Based Financial Incentives
Take note: In addition to expecting value-based care proficiency by Track 3, payment for primary care will shift to fully prospective, population-based payment. Greater financial rewards will be tied to improved patient outcomes, CMS says.
Track 3 financial goals and requirements
Care Management
- Targeted Care Management: Build on care management programs by offering individualized care plans for high-risk patients
- Chronic Condition Management: Expand self-management services to include group education and linkages to community supports
Care Integration
- Specialty Care Integration: Establish enhanced relationships with specialty care partners through time-limited co-management relationships (CMS clarifies that this new service is intended to support ongoing communication and collaboration regarding a shared patient who needs primary and specialty care but may temporarily require more intense collaboration to stabilize a chronic condition)
- Behavioral Health (BH) Integration: Optimize behavioral health-specific workflows using a quality improvement framework
Community Connection
- Health-Related Social Needs Screening and Referral: Optimize social service referral workflows using a quality improvement framework
- Supporting Whole-Person Care through Community Supports and Service Navigation: Strengthen partnerships with social service providers and optimize the use of community health worker/outreach staff with shared lived experiences using a quality improvement framework
Why the Right Medical Management Platform is Integral to Track 3
It’s important to remember that at this tier of MCP, payment shifts to a prospective model, with additional financial incentives tied to care outcomes. As reinforced by the track’s requirements, that will depend on quality improvement, seamless care coordination, and strong relationships between primary and specialty providers, behavioral health professionals, and community health workers.
Payers will need to find the medical management technology that supports population health management as well as individual care planning.
Specifically, MCP model participants will need a healthcare management platform that supports care management, disease management, utilization management, care coordination, LTSS, behavioral health, home health, utilization management, SDOH efforts, and data interoperability and management.
6 Reasons Why MCP Model Medicaid Plans Should Consider HELIOS
1. Data interoperability and access. Complete, accurate FHIR®-compatible data that’s accessible to all involved in a member’s care is the foundation of well-coordinated treatment. A platform that centralizes member health data will strengthen collaboration between specialists and primary care, aiding in the co-management of people with complex needs.
2. Quality reporting functionality. Look for both pre-built and customizable quality reporting dashboards to streamline quality improvement efforts. Remember, for Track 3 you’ll need to use quality improvement frameworks to optimize workflows and care integration, and to ensure you’re meeting members’ needs. [See some key features related to reporting for Medicaid plans here.]
3. Behavioral health integration and workflows. Addressing behavioral health is a critical facet of whole-person care. A care management platform with the following capabilities can bridge common gaps in meeting primary care member needs:
- Out-of-the-box, industry-standard assessments and screening tools
- Workflows and communication pathways with portals for providers and care managers to strengthen collaboration among providers and guide individualized care planning
- Telehealth capabilities for increased engagement and communication, especially for remote members
4. Chronic care management. Again, chronic care management depends on seamless data sharing to align primary care and specialty providers around the same member information. Beyond that, other platform capabilities that specifically support better management of chronic care include:
- Automated alerts that update all care team members on hospitalizations, emergency department visits, referrals, follow-ups, re-admissions, home care planning, and discharge planning
- Member engagement tools (see below) to keep people motivated on goals and care plan adherence
5. Built-in telehealth and engagement tools. Look for a platform with tools that motivate people to participate in their health – a key pillar of value-based care:
An integrated education library, with resources that can be tailored to literacy level and preferred learning style
Multiple channels for communication (e.g., SMS, email, video conferencing)
Interactive member portal
6. Social determinants of health (SDOH) support. Factors like unsafe housing, food insecurity, lack of transportation, and social isolation can negatively affect clinical health. To make it easier to connect primary care patients with needed resources, look for:
- Ability to proactively identify members with SDOH needs (e.g., targeted screenings, auto-generated flags)
- Integrations with community partners to quickly and reliably connect patients with resources to address SDOH
- Closed-loop reporting to notify care teams when community resources are utilized
Nearly 90% configurable out of the box, HELIOS supports all the population health management needs listed above – and more. It’s known for speedy implementation, fast adoption thanks to an intuitive user experience, and the flexibility to scale for population changes and new user bases. Schedule a call with a VirtualHealth team member today to learn more. Bring your specific questions – we’ll help you understand how HELIOS can power value-based care delivery for your member populations.