All older patients are not the same. The characteristics and needs of community-dwelling versus long term care (LTC) facility-dwelling individuals are different. Unsure how to manage LTC residents, particularly high-needs and frail older adults, health care payers such as managed care organizations (MCOs) and accountable care organizations (ACOs) were slow to embrace this population in the early days of value-based care.

However, as large numbers of American adults age into their seventies and eighties, this subpopulation of older adults is growing and is gaining attention. In recent years, institutional special-needs plans (I-SNPs) and ACO REACH models have shown some promise as ways to serve this distinct population. However, gaps and challenges remain, and there is a need for public policy and other actions to acknowledge and address the distinction between community- and congregate-dwelling older adults. The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) has been focusing on this issue and looking at what new value-based care models may provide solutions and enable cost-effective quality care for even the frailest and sickest older adults in whatever setting they reside.

In its recent Strategic Vision document, the Center for Medicare and Medicaid Innovation (CMMI) stressed the need for a focus on population and systems transformation, rather than setting. This is significant, as there is a growing interest in and need to serve subpopulations that are not reached by a risk-based, fee-for-service model and can’t afford or don’t have access to affordable/accessible housing. However, there are some settings that naturally lend themselves to population health initiatives to support this population, such as nursing homes and assisted living communities.

There are challenges when creating policy and payment for this subpopulation of congregate-dwelling seniors. For example, in AHCA/NCAL’s assessment, only about 50 percent of the long term care nursing home population meet the current ACO REACH High Needs criteria, thereby limiting participation even though it is a highly medically complex and frail population that would benefit from the REACH model.

According to Nisha Hammel, vice president, reimbursement policy and population health at AHCA/NCAL, “The ACO REACH model could capture the needs of this subpopulation by allowing this long-stay population to be aligned at the facility level, recognizing the role that the integrated care team plays in care coordination.” She added that AHCA/NCAL members support arrangements that offer providers an opportunity to assume greater leadership for and meaningful participation in the full care experience of residents/patients.

In keeping with other models such as the Program of All-Inclusive Care for the Elderly (PACE), I-SNPs, and IE-SNPs, the association suggests that policymakers consider the nursing facility level of care as a criterion to meet the high needs threshold. This would create pathways for this subpopulation and support the commitment of the Centers for Medicare & Medicaid Services (CMS) to promoting value-based care for vulnerable and underserved populations. 

Community- Versus Congregate-Dwelling Older Adults

Hammel observed that while various value-based care models have demonstrated successes, these programs were designed with the community-based population in mind; therefore, she said, “Our long term care providers are constantly trying to fit a square peg in a round hole. The needs and characteristics in our setting are unique.”

There are some obvious differences between these two populations. As Fred Bentley, managing director of ATI Advisory’s Post-Acute/Long Term Care and Senior Living Practice, observed, “Individuals residing in long term care settings tend to have much higher acuity, so they have more complex medical needs and more functional impairments; and there is 24/7 monitoring in the facility setting.” However, some residents may have significant challenges accessing primary care and routine care services even if there is full-time medical staff onsite.

“People in the community tend to be more independent, but they’re not without their challenges. They’re often plagued by mobility issues, chronic disease, social isolation, and transportation challenges,” said Anthony Laflen, vice president of value-based care innovation at PointClickCare. LTC residents tend to have more complex medical needs, he said, and often have cognitive issues.

While issues with many social determinants of health—such as food and/or housing insecurity—diminish when people enter congregate living, they still may have challenges such as lack of family support and feelings of loss. At the same time, some community-dwellers would benefit from moving into a congregate-living setting but can’t afford it or perceive that it is unaffordable. Laflen said, “In some states, income insecurity is off the charts.” As a result, at least some older adults may resist the decision to make such a move even as their food insecurity and isolation increase. As a result, they are sicker and have greater health care needs when they finally do make the move.
Hammel offered, “If you recognize the distinction between community- and congregate-dwelling individuals and then tailor programs accordingly, we can create policy solutions and programs to address these populations more successfully and achieve the shared goal of improved care and quality outcomes and smarter spending.”

Gaps To Be Filled

While I-SNPs, REACH ACOs, Medicare Advantage (MA) plans, and PACE programs play a key role in providing care for older adults, gaps exist that need to be filled—especially for high-needs residents of long term care facilities. Bentley said, “The biggest gap is that in contrast to I-SNPs, where you know eligibility is fairly broad if the individual lives in the long term care setting, it’s not nearly as broad for those individuals who are in a Medicare fee-for-service program.” He noted that CMS is taking steps to try and broaden criteria, but there is a need for a model that fills these gaps. “We need to be advocating for broadening the eligibility criteria,” he stressed.

“The REACH ACO model and SNPs offer an opportunity to address the unique needs of LTC populations by fostering integrated care, reducing fragmentation, and aligning incentives across providers and payers. However, to maximize the potential of these models, it is essential to address systemic gaps,” said Laflen. These, he offered, include siloed care delivery with poor communication between settings and limited integration with broader health systems; lack of continuity in transitions that can result in missed opportunities for early interventions; and gaps in reimbursement, including barriers to funding for holistic care and limited incentives for preventive care. Keith Persinger, chief operating officer at Provider Partners and chief executive officer at Provider Partners Connect Care, noted managed and value-based care programs like I-SNP and ACO High Needs REACH help address these issues by creating incentives for coordinated care management.

In short, Kristen Ratcliff McGovern, partner at Sirona Strategies, said, “The largest gap remaining is the permanent availability of an accountable care model for high-needs beneficiaries in long term care settings, as I-SNPs and Medicare Advantage will not be the right fit for every provider and beneficiary. This could look like a permanent ACO model that is designed after the ACO REACH High-Needs Track.”

Need for New Models

To help create meaningful and realistic value-based care participation options for long term and post-acute care providers, especially those with high-needs populations, AHCA/NCAL and the National Association of ACOs convened a roundtable of stakeholders, including LTC providers, ACO leaders, patient advocacy groups, payers, and others. They agreed on several recommendations to help CMS improve existing value-based arrangements and develop future model concepts that would enable providers to engage within broader accountable care arrangements.

To find better ways to create meaningful participation options in ACOs for long term and post-acute care (LTPAC) providers, the group recommends:

• Alignment/participation options for beneficiaries residing in LTC facilities, which includes recognizing needing nursing facility level of care is a participation criteria in and of itself.
• Financial methodology changes.
• Quality measurement.
• Data.

The roundtable group agreed on several concepts that would be key for future model concepts and key principles that CMS should adopt for developing a voluntary episode-based payment model specifically for SNF providers. These concepts included:

• Addressing persistent and unresolved health care delivery system problems.
• Delivering improved patient outcomes while reducing unnecessary health care costs.
• Assurance of scalability.
• Meaningful risk and reward for participants within the ACO.
• Alignment with the CMMI strategic vision.
• A sense of predictability and stability.

The group stressed the need for a voluntary model with adequate non-financial incentives to spur participation and prioritize data sharing.

Laflen suggested the need for specialized care models that address chronic conditions, frailty, and polypharmacy. At the same time, for any value-based care models to be effective, accurate and current data will be essential, which presents a challenge and an opportunity. Laflen explained, “We need to continue to lead the charge on getting and using more robust data to make coverage decisions and identify issues such as spikes or dips in readmissions.”

In addition, AHCA/NCAL is advocating for recognition from policy makers that I-SNPs in particular are smaller, location-specific, and highly specialized Medicare Advantage plans for medically complex congregate dwelling residents. This means these plans may need to be treated differently from large national MA plans focused on community dwelling seniors who do not have the same challenges.

Advocating with Policymakers

There is still much uncertainty about how the new Administration will approach oversight of LTPAC and the move to value-based care. As with any change of leadership, there are important opportunities for AHCA/NCAL members to educate new representatives and others about this care setting and the need for appropriate models of care. It is key for them to make their voice heard and offer guidance and resources as policymakers work on these issues.

McGovern noted, “Long term and post-acute care providers have been largely left out of the discussion around value-based care and post-acute care. Members should continue to elevate these priorities and highlight the important role they play in value-based care. To date, some of the most significant cost savings and care improvements realized by community-based ACOs and other episodic payment and delivery system reform models have been generated by intentional and targeted post-acute care partnerships.”

Bentley said, “I think there is a compelling argument that there is an opportunity for increased cost-effectiveness and reduced waste in the care of high-needs patients. If we can reduce emergency room visits and lower hospitalizations, as well as do a better job of managing chronic diseases, by extending coverage to more long term care residents, it has great potential.”

Laflen said, “If I had 10 minutes in an elevator with a policymaker, I would say, ‘Let’s put our dollars into a methodology that drives improved outcomes for the patient and reductions in spending. These are the two things I focus on. If we can stop people from going to the emergency room or hospital—and we can with a value-based care model specific to our high-needs long term care population—this meets both of those goals.’” He added, “With the average hospitalization cost at about $15,300, preventing that admission results in significant quantifiable savings. We can create programs that not only save the federal government money but enable facilities to provide excellent care and promote optimal quality of life for residents.”

Persinger agreed that the cost-savings aspect of any new or revised value-based care models is likely to resonate with policymakers. “They’re looking at ways to reduce the total cost of care, including for Medicare. Of course, the goal of delivering better care to residents is obviously what everyone wants and should aim to accomplish. Better coordinated care creates higher quality care and reduces the total cost of care.” He suggested the value of sharing data with policymakers that shows the benefits of nursing home care for residents, where and how you are accomplishing cost savings, and where a different value-based care model might present opportunities for greater savings and/or improved care coordination.

The key is to continue to be part of the dialogue and discussion. AHCA/NCAL and other organizations are leading the way, but they need input and support from their members. Robert Zorowitz, MD, MBA, CMD, regional vice president, health services, Northeast region, Humana, said, “We don’t know what’s going to happen in the coming months, but the people at CMS are thoughtful and serious about ways to improve care, and CMMI has tried a variety of demonstration projects. We need to keep advocating for the changes we believe will benefit our patients and our facilities, and we are fortunate to have leaders at our professional organizations to guide our efforts.”

Joanne Kaldy is a freelance writer and communications consultant based in New Orleans.​