Play by Play

Perspectives from leaders in the field of complex care.

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This blog post highlights how skilled nursing facilities are switching over to the new Patient Driven Payment Model — a payment system that removes therapy minutes as the basis for payment and enhances payment accuracy for therapy, nursing, and ancillary services by making reimbursement dependent on a wide range of clinical characteristics.
This blog post features a conversation with Lauran Hardin, Senior Advisor of Partnerships and Technical Assistance at Camden Coalition, who explores the use of asset mapping to build stronger ecosystems of care, address the root causes of repeated hospital utilization, and improve care delivery for individuals with complex health and social needs.
The challenge of managing Medicare patients with multiple health conditions is familiar to most providers. According to recent data from the Centers for Medicare and Medicaid Services (CMS), two-thirds of Medicare patients have two or more chronic conditions. Establishing treatment guidelines for every condition and for every patient is challenging for a multitude of reasons. A recent study estimated that 37 percent of the average family physician’s time is spent on chronic care, with the balance on acute or preventive care. For Medicare patients, it may be even higher.
For frail older adults with complex care needs, an inpatient hospital stay is destabilizing and often marks the beginning of a decline in functioning. For these older adults and their families, the post-hospital period is a risky, confusing, and stressful time. Providers, payers, hospitals and health systems should look for ways to innovate their care delivery models and to manage and improve care for their patients.
The time constraints of the typical primary care practice often do not allow providers to take a comprehensive look at all of their patients’ needs each year. Getting to the bottom of the checklist of preventive screenings and evaluating all ongoing chronic care needs simply takes time. Enabling office staff to assist in this work, under the direction of the supervising provider, presents a tremendous opportunity to create a patient-centered and comprehensive care plan that matches each patient’s unique needs and desires.