Value-based Care Must Evolve to Manage Multiple Chronic Conditions

Value-based objectives are more easily met for patients with one chronic condition. However, patients living with multiple chronic conditions (MCCs) typically have a more complex clinical picture. One where the standard value-based care framework often falls short, demanding a different approach than Medicare care management programs were created to address.

According to a study by the Agency for Healthcare Research and Quality (AHRQ), the patient population affected by multimorbidity is a significant and primary focus for value-based care programs. Their findings highlight the need:

• 70.6% of total US health expenditures are for patients with MCCs
• 50% of healthcare costs are for Medicare patients with MCCs and multiple medications
• 38.5% of admitted patients had five or more MCCs

VBC must go beyond a disease-centered approach for multimorbidity

Traditional value-based care models and quality metrics tend to still operate through a disease-centered lens. This approach, rooted in practice guidelines for specific conditions, works reasonably well when an individual has one predominant illness and common goals as their provider, such as prolonged survival or stroke prevention.

Disease-centered decision-making can lead to significant challenges, however. Patients often face a treatment burden as they attempt to adhere to multiple, potentially conflicting, guidelines.

For example, managing diabetes, congestive heart failure, and COPD simultaneously can call for numerous medications, dietary restrictions, and lifestyle modifications, creating an overwhelming workload for patients. Recommendations for one condition might inadvertently exacerbate another.

A patient with both heart failure and chronic kidney disease, alternatively, may need careful fluid management strategies that can potentially defy simple, disease-specific guidelines.

Fundamentally, a disease-centered approach often fails to address what matters most to each patient, whose health priorities can vary significantly beyond mere survival. And, whose active participation is vital to provider success in any VBC or alternative payment model.

A new framework for multimorbidity patient-centeredness in value-based care

Research published in JAMA suggests an approach to value-based care for patients with multiple chronic conditions that focuses on cost, outcome, and patient-driven goals. This method defines high-value care as achieving “each patient’s highest-level health outcome goals given the workload each is willing and able to perform.”

The authors state that although advanced illness and end-of-life care tend to include patient goals and preferences, this information is “rarely translated into actual care decisions” for patients in earlier disease stages.

Figure 1 shows our interpretation of the researcher’s structure of personalization or what they call health outcome goals and workload.

Figure 1: A new framework for viewing patient-driven goals and workload.

This framework uses prognosis, clinical course, and realistic outcomes as essential for clinical decision-making and VBC planning. Most importantly, it looks at the patient’s workload and available resources—such as physical, mental, emotional, financial, time, and commitment—to determine the best plan of care for this patient, right now.

Our framework asks four questions to create an actionable, patient-centered care plan, including:

What’s desirable? This includes what the clinician and patient would like to see as health and quality of life outcomes.

What’s possible? This informs the first answer, which is based on the most typical clinical course for this patient’s collection of multiple chronic conditions, prognosis, and health scenario.

What’s probable? This is what is most likely to happen based on the clinician’s experience with this patient in the context of other patients with similar multimorbidity or based on industry-accepted research.

What’s manageable? The final question accounts for this specific patient’s available resources and capacity. It focuses on what’s probable by the possible limits this patient may experience, as well as highlights what the care team and community resources can support to help fill gaps. 

Integrating this framework into an existing workflow creates the most realistic and potentially successful care plan. This helps not only adhere to clinical standards but also orient to the patient’s goals, capabilities, and resources.

Figure 2 shows the types of patient health outcome goals and workload that researchers suggest VBC care management teams consider.

Figure 2: Patient health outcome goals and workload domains and examples. Source.

How ThoroughCare incorporates patient-driven goals and workload

The journey from a purely disease-oriented approach to honoring patient preference and moving toward a balanced approach that prioritizes patient goals-directed care can seem overwhelming and time-consuming. Emphasizing value-based goals alongside clinical and cost objectives may feel counterintuitive.  

Yet, research indicates that it “will stimulate efforts to simplify the process within the context of busy clinical workflows.”  The JAMA piece cites that, “Focusing all care on a unified set of individualized patient outcome goals, rather than on disparate disease-specific outcomes, should reduce fragmentation among, and demands on, overwhelmed clinicians while raising patient trust in, and satisfaction with, their health care.”

Incorporating patient-driven goals can be achieved by assessing disease management and Chronic Care Management protocols and workflows to ensure that there are ample opportunities to evaluate patient capacity, available resources, and workload while also facilitating shared decision-making.

ThoroughCare supports and addresses these aspects of patient-driven goals primarily through four features and modules.

1. Health Risk Assessment (HRA)

A Health Risk Assessment (HRA) is used to identify, evaluate, and manage potential health risks. It considers factors such as family history, lifestyle habits, and existing medical conditions and pinpoints specific factors that contribute to an individual's health risks. 

The HRA can be an invaluable tool, helping to ensure that payers reimburse providers adequately for high-risk patients. A 2023 KFF analysis found that 62% of Medicare Advantage beneficiaries were enrolled in products that incentivize HRA completion.

ThoroughCare’s HRA tool offers a guided workflow that covers required topics, including:

• Medical history
• Hospitalizations and surgical history
• Providers and suppliers
• Medications and allergies
• Social history
• Mental health
• Lifestyle
• Functional status and support
• Home safety
• Life planning

The platform not only provides facilitated questions that create automated documentation and billing codes, but also a visual completion bar for the overall HRA workflow, as well as for each individual topic covered.

ThoroughCare supports three ways providers can have patients participate in their HRA, including:

• Emailing a link to an online version of the HRA for patients to complete at home
• Giving a tablet to the patient in-office with the online version of the HRA
• Through a clinician-guided assessment in real-time or over the phone

Once the HRA is completed, the platform uses built-in logic to analyze patient risk factors and provide clinical recommendations from the American Academy of Family Physicians to pass along to the patients.

The platform also includes an optional Health-related Social Needs assessment from the Accountable Health Commission (AHC-HRSN). This SDOH survey can be billed during an Annual Wellness Visit (AWV) and covers five core domains:

• Living situation
• Food
• Transportation
• Utilities
• Safety

When completed as part of the initial or subsequent AWVs, the HRSN can be billed under G0136. ThoroughCare automatically documents for billing this service when requirements are met.

2. Annual Wellness Visit (AWV)

Initial and yearly AWVs provide an opportunity for providers and the care team to not only offer preventive care and close gaps in care standards, but to tailor future care in alignment with patient priorities and goals.

ThoroughCare offers an end-to-end workflow for Annual Wellness Visits. It adheres to CMS requirements, tracks all reportable activities, and simplifies claim preparation.

Clinicians can use the platform to tailor the AWC to enhance patient-directed care through optional add-on screenings, such as the HRSN and Advance Care Planning, which are geared toward patients with life-limiting illnesses.

The AWV also provides an opportunity to enroll patients into care management programs that can help them achieve their health goals through personalized care planning.

3. Motivational Interviewing (MI)

While the benefits of patient-directed outcomes in value-based care are expansive, they hinge on healthcare professionals’ ability to tap into patient motivation. 

Motivational interviewing is an evidence-based counseling style that engages patients around health issues and making positive change.

Shown to be effective in various studies, including psychotherapy and medical plan adherence, MI uses patient-specific experiences and personal goals, including strategies such as:

• Affirmations
• Open-ended questions
• Reflective listening
• Summary

ThoroughCare facilitates motivational interviewing techniques through embedded questions and workflows. Examples include:

• Providing possible patient health goals to select from or include custom objectives
• Setting SMART Goals with specific duration, frequency, and timing parameters
• Offering change-related questions with fields for custom responses, rating scales, and other lifestyle assessments
• Change-focused questions that highlight particular steps to take as interventions
• Visually connecting goals and commitments to specific health issues

4. SMART Goals

SMART goals research demonstrates their value in promoting patient-driven health by establishing clear, internally motivating, and measurable goals that align with what is most important to each individual.

SMART goals engage a patient’s desires and transform general health objectives into concrete, timely, and actionable targets.

Using SMART goals as part of care coordination can foster rapport between the care manager or clinician and the patient, which is essential for achieving both patient-centered and value-based care outcomes.

As shown in Figure 3, this type of goal setting is foundational to a bottom-up, person-centric approach to health. 

 Figure 3: Engaging Patients with SMART Goals for Chronic Care. Source.

How to know if you're meeting value-based care goals

Research suggests that value-based metrics move beyond traditional clinical outcomes and incorporate patient-reported outcomes (PROs) and patient-reported experience measures (PREMs).  

PROs include health-related quality of life (HRQoL), functional status, symptom burden, mental health measures, and attainment of treatment goals. PREMs focus on patient satisfaction, shared decision-making, communication quality, care coordination, and timeliness.

Both types of measures directly reflect the patient's perspective and touch on many of the domains suggested in Figure 2.

ThoroughCare incorporates assessments that gather PRO and PREM data, such as:

• Depression and anxiety scales – PHQ-9 and GAD-7
• Functional status via ADL (Activities of Daily Living) assessment
• PAC (Post-acute care assessment) measures
• Patient-reported pain and related symptoms

By aligning the principles of patient goals–directed care, comprehensive coordination, and a focus on meaningful outcomes with the structure and resources of Medicare care management programs, VBC models can create more effective and valuable healthcare experiences for individuals living with the complexities of multiple chronic conditions.

ThoroughCare helps providers deliver value-based care

By combining software, advisory services, and training, ThoroughCare is your partner to improve care program ROI by 10-15x. We give providers the tools and insights to run value-based care management services. 

Our software offers functionality suited to the care management needs of providers, including:

• Performance metrics and cost reporting
• Medicare care management compliance and billing
• Timely interventions
• Personalized care plans
• Data integration and interoperability 

ThoroughCare’s Clinical Advisory Team collaborates closely with healthcare organizations to enhance competency, ensure compliance, and optimize operations, enabling them to achieve their care coordination objectives. We combine this expertise with a comprehensive software platform to help providers and care management organizations follow best practices.

Key questions answered

Why are patients with multiple chronic conditions a priority for value-based care?

According to a study by the Agency for Healthcare Research and Quality (AHRQ), the patient population affected by multiple chronic conditions (MCCs) is a significant and primary focus for value-based care programs. Their findings highlight the need:

• 70.6% of total US health expenditures are for patients with MCCs
• 50% of healthcare costs are for Medicare patients with MCCs and multiple medications
• 38.5% of admitted patients had five or more MCCs

Why should value-based care models go beyond traditional disease-based care?

Value-based objectives are more easily met for patients with one chronic condition. However, patients living with multiple chronic conditions typically have a more complex clinical picture. One where the standard value-based care framework often falls short, demanding a different approach that Medicare care management programs were created to address.

Fundamentally, a disease-centered approach often fails to address what matters most to each patient, whose health priorities can vary significantly beyond mere survival. And, whose active participation is vital to provider success in any VBC or alternative payment model.