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Evolving Health Workforce Roles in Accountable Care Organizations
Shana F. Sandberg, PhD; Clese Erikson, MPAff; and Emily D. Yunker, MPA, PMP
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Michael Pine, MD, MBA; Donald E. Fry, MD; Susan M. Nedza, MD, MBA; David G. Locke, BS; Agnes M. Reband, BS; and Gregory Pine, BA

Evolving Health Workforce Roles in Accountable Care Organizations

Shana F. Sandberg, PhD; Clese Erikson, MPAff; and Emily D. Yunker, MPA, PMP
This qualitative study draws on interviews with clinical staff to examine health workforce use within accountable care organizations and identifies common roles that support value-based care.
ABSTRACT

Objectives: New models of payment and care delivery require new roles within the healthcare workforce, yet little is known about how accountable care organizations (ACOs) leverage clinical staff to achieve the transition to value-based care. This research examines health workforce use within ACOs and identifies common roles and functions performed by staff across sites.

Study Design: Phone and in-person interviews.

Methods: Semi-structured phone interviews with clinical or administrative leaders from 17 ACOs, supplemented by in-person interviews with a wider range of clinical and administrative staff during 1- to 2-day site visits to 6 ACOs. Sites were selected based on early evidence of quality improvement or cost savings, or because they demonstrated novel use of the health workforce.

Results: Across sites, ACOs reported increased use of interprofessional healthcare teams with roles stratified by patient risk categories. New workforce resources were primarily directed at attempts to reduce overall cost of care by improving care for high-risk patients. This was achieved through hiring new workers and expanding existing workers’ roles. Fewer resources were devoted to managing care for low-risk patients, the broadest patient population in most ACOs.

Conclusions: ACOs report considerable changes in health workforce roles to meet the aims of value-based payment models, but significant differences between models remain. Due to the need to tailor care models to the needs of the local population, a single model of care is unlikely to emerge.

The American Journal of Accountable Care. 2017;5(2):9-14
As their number continues to grow, accountable care organizations (ACOs) have become a significant contributor to HHS’ goal of moving half of Medicare payments to risk-based contracts by 2018.1 Yet, to date, there have been very few studies on the manner in which ACOs impact care delivery or how overall outpatient care teams are evolving to support the implementation of value-based payment models.2 Beyond the basics of increasing care coordination and shifting the focus of care from treatment to prevention, not much is known about how providers’ roles are evolving and how the health workforce is changing under ACOs. Although there have been a few individual studies on the role of nurses3 and social workers,4 the preponderance of research on ACOs has focused on whether these models have generated savings or improved quality5-7 and sheds little light on the specifics of how care was transformed in the shift from fee-for-service to value-based reimbursement models.

In order to address this important knowledge gap, this research synthesizes the perspectives of leadership, clinicians, and other staff working in ACOs obtained from a series of semi-structured interviews and site visits to ACOs. The researchers specifically sought respondents’ views on key workforce changes introduced as a result of ACO implementation and the patient populations targeted. In doing so, this paper highlights the importance of risk stratification in making the most of limited workforce resources. Our findings focus primarily on workforce transformations for high-cost patients where we found that ACOs had focused their efforts. Such information can help inform researchers interested in the impact of ACOs on workforce use, policy makers seeking to encourage participation in value-based models, as well as ACO participants and potential participants currently evaluating their own staffing models.

METHODS

Sample

Through an environmental scan of the literature and interviews with experts in the field, the authors identified 20 ACOs that were early high performers on quality or cost savings results, or that showed evidence of novel use of the health workforce. The authors intentionally sought participants from a broad range of ACO models, including those participating in Medicare models, such as the Pioneer and shared savings ACOs, public ACOs serving vulnerable populations, and provider groups participating in accountable care contracts with commercial payers. Sites that did not include providers that shared some financial risk with at least 1 payer or did not have at least 3 months’ experience implementing their accountable care model were excluded. After e-mail outreach to all 20 sites identified, 17 agreed to phone interviews, including 5 Pioneer ACOs, 7 Shared Savings ACOs, 4 commercial ACOs, and 1 county-based Medicaid ACO (see the Table for a list of the sites).

Data Collection

Phone interviews, during which a team of 2 or 3 researchers typically interviewed 1 to 3 representatives from ACO leadership at each site, were conducted between September 2013 and June 2014 and lasted approximately 1 hour. Representatives from ACO leadership included chief executive officers, chief medical officers, and clinical leads for care management initiatives. The interview guide focused on a core set of questions, including: 1) the size and nature of the population targeted under the ACO, 2) major care delivery models and services offered, 3) clinical staff responsible for care delivery, 4) challenges encountered under ACOs, and 5) leadership’s vision for the future of care delivery under value-based payment.

In order to gain a richer understanding of the use of this workforce under new care delivery models, we selected 6 of the 17 ACOs for in-person site visits. These sites were selected based on the discovery of multiple initiatives during the phone call that warranted further study. During site visits, which lasted 1 to 2 days and took place between January and October 2014, 2 researchers conducted individual and group interviews together with a wide range of staff, from ACO leadership as described above, to medical directors at practice sites, to frontline providers. Providers varied by site, but included physicians, nurse practitioners, registered nurses, social workers, pharmacists, and community health workers. At some sites, administrative staff overseeing quality metrics and data management were also interviewed. During most of the site visits, we visited

multiple practice locations participating in the ACOs. In all, more than 50 interviews were conducted by phone or in person.

Analysis

Research followed an inductive process designed to generate insights from the themes that emerged during the interviews. Researchers took detailed notes for all interviews in which they participated, whether in-person or by phone. The research team met regularly during the study period to review notes and discuss emerging themes. Once themes were established, 2 researchers independently reviewed and coded the transcripts.

The study design was reviewed and approved by the Association of American Medical Colleges’ affiliated independent institutional review board, the American Institutes for Research in Washington, DC. 

RESULTS

The phone interviews and site visits revealed that all of the organizations were using earlier quality improvement initiatives as a starting point for their ACOs, but participation in an ACO provided an opportunity to renew or expand such efforts. Most of the earlier efforts were funded by grants or participation in demonstration projects where sustainable funding was uncertain. ACO leadership generally set the organizationwide vision and provided some budgetary and administrative support, but let individual practices make the specific staffing decisions, often leading to variation from site to site (and even between providers at the same site) within an organization. Although ACO leaders sometimes expressed frustration that shared savings

limited their ability to fully invest in workforce redesign, the potential for downstream savings did nonetheless prompt some ACOs to expand existing care coordination efforts and engage in additional practice redesign that had a significant impact on workforce roles.

Across sites, respondents reported increased use of interprofessional healthcare teams. At individual sites, this was accomplished through hiring new workers (eg, additional care coordinators) and/or expanding existing workers’ roles (eg, using pharmacists to perform medication reconciliation and improve adherence). The addition of new workers and expansion of roles tended to be concentrated around care for the highest-cost patients in recognition of the potential to significantly lower the cost of care through enhanced care coordination. All sites reported using risk-stratification techniques to identify the patients at highest risk of hospitalization and directed increased services to these patients. However, the sites varied in their exact methods for stratification as well as the number of tiers and percentage of patients in each.

The Figure depicts a model of the way that patients were generally stratified by level of risk within ACOs and the corresponding care management strategies that were the focus of new or expanded workforce roles. The 3 levels of the pyramid represent (from top to bottom) high-risk, moderate- (or “rising”) risk, and low-risk patients. To the right of the pyramid are listed the workforce roles and care management strategies that are generally applied to patients at each level. It is important to note that, although we depict a static model, the exact workforce put in place at each site varied, and in practice, 1 care management strategy—such as addressing behavioral health needs—may actually apply to patients in more than 1 tier.

High-Risk Patients

The healthcare workers who were most commonly assigned to manage high-risk patients across ACOs were care coordinators or case managers, roles that were typically filled by registered nurses (RNs) or social workers at the sites participating in this study. All sites reported using someone in this coordination role, although the titles varied. Most ACOs embedded them in at least some of their primary care practices, 5 primarily used centralized care coordinators for either telephonic or face-to-face care, and a few used a hybrid approach because not all practices had the patient volume to support an on-site person. The primary duties of this role included communicating with other care team members and the patient to ensure that the provider’s recommended care plan was put into place, that any gaps in care were met, and that appropriate follow-up appointments and tests were scheduled as needed.

Although the number of patients assigned to each care coordinator varied by ACO, there was general agreement among different ACOs that 1 care coordinator or case manager could actively manage somewhere between 100 to 150 high-risk patients. Those assigned to a larger population of patients tended to have patients at different risk levels, not all of whom required the same level of care management (for example, some case managers were assigned 1000 to 1500 patients, but only 5% to 10% of them had health needs so significant as to require active case management). Some care coordinators expressed a preference for lower patient-to-provider ratios to improve efficacy in addressing individual patient needs; however, not all programs had sufficient funds to support this.

Four sites developed separate clinics devoted to intensive outpatient care management services—sometimes referred to as “ambulatory ICUs [intensive care units]”—that were specifically designed to intervene and break the cycle of repeated hospitalizations for high-risk patients or those with complex chronic diseases. These clinics were quite resource-intensive and had much lower patient-to-provider ratios than general primary care practices, allowing providers to devote more time and more frequent follow-up visits to these high-need patients. These intensive outpatient clinics were staffed by a 0.25 full-time equivalent (FTE) or 0.5 FTE physician, and supported by other team members such as 1 FTE nurse practitioner (NP) and 1 FTE social worker, per 125 to 200 patients. They also included additional team members, such as addiction and behavioral health specialists, geriatricians, dieticians, pharmacists, and patient navigators, to meet specific needs.

 
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