Geriatric Specialty Care is currently in Category 2D of the APM Framework and we are preparing for a transition to 3A. Our current efforts include a CCM program that has seen steady growth month over month with increased quality outcomes.
Geriatric Specialty Care has recently signed an agreement to join an ACO in Northern Nevada as their Transitional Care/Frail Elderly provider group. We believe the ACO payment model is structured to provide the right incentives to support our care delivery model. We are committed to participating and sharing our lessons with others to help achieve the LAN’s payment reform goals.
Geriatric Specialty Care will support our ACO and its payment model in five areas:
1. Transitional Care Management – See 100% of patients on discharge, reconcile their medications when they transition, keep return to acutes below 8%.
2. Chronic Care Management – Meet requirements on 300 patients per month (28% of population) and to update and review 68% of all care plans monthly.
3. Advanced Care Planning – Have 100% of our patients receive Advanced Care Planning on a yearly basis.
4. Illness Burden – Better capture Illness Burden via HCC’s.
5. Scope of Work – Educate and allow all clinicians (CMA, CNA, RN, LPN, LCSW, APRN, PA-C, MD, DO) to perform at the top of their scope/ability. It is a community collaboration effort.
Using Primary Care Payment Models as a Catalyst for Improvement – Journal of the American Medical Doctors Association, May 2017