Question

please read questions and the bottom of the case study and post resources as well please or it wont count

Gordon D. Brown

A large psychiatric specialty group practice in a metropolitan area provides a range of psychiatric services. Since its formation in the 1980s, the practice has grown rapidly and has thrived as a result of the development of managed care plans, including the state Medicaid program that follows a carve-out model for behavioral health services. The psychiatric group is made up of highly respected psychiatrists, who carry out extensive translational research and develop evidence-based protocols that are highly respected. They are also skilled at applying clinical guidelines to inform and transform their clinical practice.

Several psychiatrists are concerned about the long-term effect of federally mandated accountable care organizations (ACOs). The mandate identifies 65 performance measures that the standard ACO must meet under the Medicare Shared Savings Program. These measures span five quality domains: patient experience of care, care coordination, patient safety, preventive health, and at-risk population/frail elderly health. The only behavioral health measure mandated is in the preventive health domain—a measure for depression screening.

Some leaders of the group believe that mental and behavioral health is a highly specialized area and that the practice's clinical volume will not change significantly. They do not support developing an ACO strategy and have resolved to take a wait-and-see approach. They point out that managed care was promoted in the 1970s by the federal government and then went away as a general policy. Other leaders, including the practice CEO, believe that ACOs do present a long-term threat but also provide an opportunity for the group to transform itself into one that is information driven.

Evidence-Based Strategy

The practice organized a multidisciplinary team to explore an ACO strategy. The team comprises two psychiatrists, one psychiatric nurse, the CEO, and a healthcare management intern. The team agrees that it will entertain all ideas and proposals, as well as research the literature to bring the best explicit information and experiential knowledge to the deliberation. Relevant literature topics include ACO basics, knowledge management, disruptive innovation, and managed care organizations’ limited acceptance and success since the 1980s.

The management intern, Marjorie, is interested in the medical-offset effect and its potential as a strategic asset. She presents to the team 30 years of critically reviewed research on the concept, including closed clinical trials. Studies on medical-offset measure the impact of providing effective behavioral health services on the utilization of medical care, including physician consults and visits to the emergency department. Marjorie is impressed by the extensive studies that include a wide range of populations and conditions, including Medicaid patients and chronic care diagnoses. The findings consistently demonstrate a savings of 10 to 20 percent through reductions in medical care utilization, particularly specialized services.

The psychiatrists meet these studies with skepticism. Although they think the science behind the research is valid, they reason that the practice's specialty is mental health and not prevention or behavioral health; thus, the studies are not relevant to what they do.

In a brainstorming session, the team explores alternative strategies for how the practice might add value to the ACOs that are developing in the area. The first strategy is to embed specialty psychiatric knowledge into the ACO's decision support system. The second strategy is to develop formal affiliations with as many ACOs as possible to capture their referrals for specialty care. The third strategy is to extend the practice's decision support protocols to address prevention, early detection, and aggressive management of behavioral health issues. This last idea is suggested by the psychiatric nurse, who points out that the nursing staff and social workers have considerable, but underused, expertise in behavioral health. The psychiatrists on the team worry that developing behavioral health decision support protocols would result in a loss of status for the psychiatrists and thus would be strongly opposed. They note that the specialty practice of psychiatry is the core competency of the group and that the proposed strategy would result in a loss of prestige and reputation for the practice.

After considerable discussion and debate, the team agrees to respect and maintain the existing culture and practice of the psychiatrists but to pursue a broader strategy to better position the group for the future. They begin to develop a full proposal for the third strategy.

Please read the above case study. Afterwards, create a strategy to leverage the knowledge base of the practice against the value of knowledge in the developing ACOs. Consider the following guidelines and questions for this exercise:
•    What change will be made in who accesses knowledge generated by the practice and how it will be used?
•    What are the implications of each on the structure of the clinical process and on the information system that supports the process?
•    What kind of organizational structure would be formed with the ACO?
•    What are the implications of collaborating with more than one ACO?
•    Should the psychiatric group serve as the focal organization for developing an ACO?
•    What value would be brought to the ACO, and how would it be assessed?

Answer 1

****Please please please LIKE THIS ANSWER, so that I can get a small benefit, Please****

What change will be made in who accesses knowledge generated by the practice and how it will be used?

The clinical guidelines and protocols developed by the group could be embedded within the clinical decision support system of the ACO, however it is configured. The strategy envisioned by the psych practice is to structure the ACO around knowledge and how knowledge adds value to the ACO, instead of designing around an institutional structure, which has a managerial rather than a clinical logic

What are the implications of each on the structure of the clinical process and on the information system that supports the process?

Care coordination: This is a multi-faceted area. This includes not only care coordination but access to specialists, the exchange of clinical information among caregivers and access to clinical knowledge. All of these elements are essential to quality, efficiency and patient satisfaction. The main premise being of how integrating all these five quality domains can help move the health system in a cohesive direction, along with the ACO’s ability to continuously adapt and adopt ongoing change. One should consider both patient-centered and knowledge-based systems to be integrated into their organization. This could be, but not limited to adding access to specialist and adding an evaluation process for further evolution as healthcare is constantly changing and bringing along with it new challenges.

Patient Safety: ACO’s without the presence of a hospital or clinician setting would not include the patient-safety metric to be used for a measure of performance. Many things should be addressed when dealing with patient safety. One on the forefront would be the possibility of obscured data coming from a “payers” data. This can be misrepresented or poorly related. A strong approach would be measuring data that is more integrated, patient centered and wellness oriented to include preventive health and focusing on the demographic area that are more specific to the ACO.

Preventive Health: A commonly missed question in most facilities lies in that of assessing for depression. Most “subjective data” gathered from patients excludes this type of screening. In the recent past, a lot of research has been given for depression screening as we know this a base that with early detection, can prohibit many of other issues arising with the patient. These things can be non-compliance of medical treatment. Many insurance companies are leading more to preventative care, as we know this can decrease the cost of later treatment. In saying this, one must have a data set that specifically addressed these issues. Many physicians/organization uses a protocol screening based on a person’s lifestyle. Most insurance companies cover a yearly preventive care at no cost. This is when knowledge-based clinical decision-making should be used to support this type of transformation. Based upon the literature, on the depression screening process is heavily scrutinized. However, we use different metrics to facilate early detection of things such as high blood pressure, risk for colon cancer, smoking cessation (if needed) etcetera. If one could form a clinical team, along with IT) to form an interrelationship with a metric system, you could go from ACO-based prevention to a patient-based prevention.

At-risk population/frail elderly health: This is directly tied to the previous domain, prevention. Studies have shown, that with the aging population, comes an increase in comorbidities and acute age-related illnesses becoming chronic. With preventive measures being taken as in early detection and health maintenance, this will help the configuration of ACO’s and how they might be changed on patients overall health status, thus increasing more effective treatments

What kind of organizational structure would be formed with the ACO? What are the implications of collaborating with more than one ACO? Should the psychiatric group serve as the focal organization for developing an ACO?

The organizational structure that ACO would form would be that of a formal organization but also serve an extension of the other structures within the health system, again helping to tailor the care to the individual. With the ACO system, as an organizational member, one would add value by inputting into the superstructure using their unique knowledge based on quality outcomes, safety and efficiency. This would instill the members being supported and reimbursed based on their added contribution. “The key to holding such a structure together is how members’ value is assessed and reimbursed.” One can not expect the traditional fee-for-service logic but on some other form of higher reimbursement due to overall patient satisfaction and outcomes.

What value would be brought to the ACO, and how would it be assessed?

The value of the ACO would present as the utilization of medical services will be reduced. This is due to the aggressively treated behavioral aspect being treated. As with many measures and assessment, historic data would prove to be efficient. Also, comparison with utilization rates of comparable institutions along with the evidence from scientific clinical trials. ACO would be paid on a capitation or bundled-bases, which would incentivize its members to increase quality outcomes, increase efficiency, decreased amounts of co-morbidities associated as a result of the increase of preventative services, and overall optimized performance.

References: (APA)

Lowell, K. H., & Bertko, J. (2010). The Accountable Care Organization (ACO) model: building blocks for success. The Journal of ambulatory care management, 33(1), 81-88.

Colla, C. H., Lewis, V. A., Kao, L. S., O’Malley, A. J., Chang, C. H., & Fisher, E. S. (2016). Association between Medicare accountable care organization implementation and spending among clinically vulnerable beneficiaries. JAMA internal medicine, 176(8), 1167-1175.

Koury, C., Iannaccone, L., Strunk, A., Udelson, A., Boaz, A., Cianci, C., ... & Keale, M. (2014). The accountable care organization summit: a white paper on findings, outcomes, and challenges. Hospital topics, 92(2), 44-57.

****Please please please LIKE THIS ANSWER, so that I can get a small benefit, Please****