Value-based payment arrangements that move toward risk require all practices, whether in a government or commercial APM, to improve quality and reduce cost. The Clinical Practice Transformation category outlines key factors for working toward practice transformation. Practices should be able to assess their clinical/operational capabilities prior to APM participation participating in an APM. Review the following questions and responses to determine your practice’s readiness.
Does your practice know how episodes are defined or the retrospective/prospective methodology for patient assignment in an APM?
|If yes||Your practice can identify which patients contribute to results in an APM and target plans to appropriately manage that patient population.|
|If no||If your practice does not understand how patient assignments are made, your practice will lack insight on which patients contribute to results in this APM. Consider options for resolution prior to APM participation.|
|If unsure||Investigate how episodes are defined. Additionally, understand if retrospective or prospective attribution rules apply to an APM prior to APM participation.|
Access to Care
Does your practice have a patient access strategy?
|If yes||Appropriate access points that provide optimal care for existing patients maximize financial, clinical and cost outcomes in an APM.|
|If no||Inefficient appointment times and the inability to see urgent-need patients may lead to lower patient and financial outcomes. Consider options for resolution prior to APM participation.|
|If unsure||Determine if your practice has an access policy for existing vs. new patients to ensure patient care is optimized throughout the practice prior to APM participation.|
Does your practice participate in alternative access-to-care options inclusive of, but not limited to, telemedicine, virtual platforms and patient portals?
|If yes||Alternative access initiatives will serve patient needs to reduce ED visits and unnecessary hospitalizations and unplanned re-admissions in an APM.|
|If no||If your practice does not provide alternative access options, this may preclude participation in certain APMs. Consider options for resolution prior to APM participation.|
|If unsure||Strategize for the alternative access options that are right for your practice prior to APM participation.|
Does your practice have a process that actively engages patients in their care plan?
|If yes||Care planning that supports self-care and engages patients will promote adherence to treatment plans and a more successful APM experience for your practice.|
|If no||Patients that do not follow their care plan may be likely candidates for ED visits, unnecessary hospitalizations and unplanned readmissions. Consider options for resolution prior to APM participation.|
|If unsure||Without certainty around the patient-caregiver decision making process, your practice may not have the right care model processes for success in an APM environment.Consider options to incorporate patient engagement in your practice’s care planning strategy prior to APM participation.|
Does your practice have effective processes and the necessary personnel to ensure the appropriate level of documentation?
|If yes||The essential element of proper documentation helps risk-adjust outcomes so that your practice can be accurately assessed compared to the APM’s performance benchmark.|
|If no||If documentation processes are not in place, your practice’s outcomes may not be properly risk-adjusted, skewing results when compared to benchmarks. This could impact your practice’s success within an APM setting. Consider options for resolution prior to APM participation.|
|If unsure||Ensure complete documentation occurs, proper processes are in place and the right resources are available to appropriately segment your practice’s population prior to APM participation.|
Can your practice define its high-risk patients?
|If yes||Understanding your practice’s high-risk patients and associated determinants of health will improve the chance of implementing targeted plans to improve quality outcomes and control high costs.|
|If no||Poor results are more likely without the ability to identify and manage high-risk patient populations which could impede success within an APM environment. Consider options for resolution prior to APM participation.|
|If unsure||Uncertainty on the definition of high-risk patients in your practice could mean that your practice is not ready for successful APM participation. Readiness should be considered prior to APM participation.|
Does your practice’s care model promote team-based care delivery that can follow the patient along the continuum of care?
|If yes||Your practice may operate in an efficient state that can manage patients in different care settings within an APM.|
|If no||If the right care model is not in place, success in an APM could be difficult because care coordination is the operational force that improves quality and reduces cost. Consider options for resolution prior to APM participation.|
|If unsure||Revisit your current care coordination practices and determine if opportunities exist for improvement prior to APM participation.|
Does your practice establish patient follow-up procedures to improve coordination in different care settings?
|If yes||Setting patient follow-up procedures and coordinating the transition of care is pivotal to APM success as the patient moves along the continuum of care.|
|If no||Your practice may not be successful in planning and managing the care of the patients served by your practice. Consider options for resolution prior to APM participation.|
|If unsure||Consider patient follow-up procedures that can drive efficient processes through care transitions, reducing the cost of care for the patient and ensuring appropriate care access prior to APM participation.|
Is your practice positioned to perform well on the quality measures identified within this APM?
|If yes||This APM may provide a positive financial opportunity if your quality scores are well-positioned and your practice has a performance improvement plan to evaluate and address changing measures that may occur as a result of APM participation.|
|If no||This APM may not provide a positive financial opportunity if your practice’s performance with quality measures is not adequate without an improvement plan in place. Consider options for resolution prior to APM participation.|
|If unsure||Pull prior-year quality scores tracked internally or reported externally for a baseline understanding of your performance with the quality measures tracked within this APM to determine next steps.|
Review additional details on quality measures through the Cardiovascular Specialty Measure Set.
Does your practice know the benchmarks against which it will be compared?
|If yes||Update internal reports in a timely manner to track performance against applicable APM-specific benchmarks for insights into improving patient outcomes and incentive recognition, if appropriate.|
|If no||Unintended consequences may occur if your practice is not tracking the correct benchmark. Consider options for resolution prior to APM participation.|
|If unsure||Benchmarks vary by APM and/or submission method. Research which benchmarks your practice will be subject to prior to APM participation.|