Recently, I met with colleagues at USAging to discuss C-TAC’s Core Principles for Models with Serious Illness Populations. C-TAC has a dynamic and fruitful relationship with USAging, and we highly value the insights and knowledge of our USAging colleagues. C-TAC partners with USAging on various projects designed to support and expand the critical role that Area Agencies on Aging play in providing support and services to individuals with serious illness. USAging is a membership organization that represents the nation’s Area Agencies on Aging and Title VI Native American Aging Programs, local leaders devoted to helping older adults and people with disabilities live with optimal health, well-being, independence, and dignity in their homes and communities.
I spoke with Sandy Markwood, CEO of USAging. Sandy turned to two of her colleagues, Amy Gotwals, Chief of Public Policy and External Affairs, and Marisa Scala-Foley, Director of the Aging and Disability Business Institute, during the conversation for details and anecdotes, some of which are included below.
Brian Lindberg: As you know, C-TAC developed these core principles to share with CMS and CMMI on the critical issues related to a payment model or package of care for people with serious illness. These core principles are what everybody should be thinking about when they’re trying to provide care for people with serious illness. I would like to get your reaction to these principles to understand how you see them dovetailing with the mission and activities of USAging.
Sandy Markwood: Thank you so much, Brian, for the opportunity to read and reflect on C-TAC’s principles. They are great core principles, and I think this discussion will highlight the ways that our members and other community-based organizations (CBOs) bring these principles to life in the work they do to support patients and families.
Principle 1. Care is person- and family-centered, improving quality of life.
Principle 2. Care is inclusive – reducing inequities and disparities and removing barriers to access and to quality care.
Sandy: These two principles are foundational to the work of our members, Area Agencies on Aging. We assess each person’s needs from a holistic perspective. In other words, if somebody is calling in and they need a meal, they’re hungry. We recognize that there are probably other needs that are there too and try to determine what those are and how to help address them. For example, from a care transitions perspective, somebody’s coming home from the hospital with a whole bag of new medicines. They’re coming home to an empty refrigerator or the food in the refrigerator is spoiled because they’ve been in the hospital. They’ve got medications inappropriately sitting on their windowsill. They have no transportation to their follow-up medical appointments arranged. AAAs provide the in-depth assessment needed to identify those needs, then determine which ones the AAA, its providers, or other CBOs can meet in order to help that person transition home safely. AAAs also involve family or other caregivers in this process, so that they are part of the assessment and the solution.
Brian: Would you please talk a little bit about how you address health equity, because that is certainly part of this second principle.
Sandy: AAAs are grounded in serving people with the greatest social and economic needs. There is a whole list of factors they use to target those most in need of services, including an individual’s level of need for in-home care, their income, recognizing racial or cultural disparities, limited English proficiency—all those different issues that can be barriers to people being able to access needed health care and community-based services. In addition, AAAs are cognizant of the need to provide services in a culturally competent and culturally sensitive manner. It means having people who are delivering those services come from the neighborhood, come from the community so that they reflect the people they’re serving. That’s critical to building trust with the care recipient and trust with their families.
Brian: How are USAging and its members addressing social determinants of health and health equity?
Sandy: We believe that networks of AAAs and CBOs provide a critical pathway to help promote health equity. We have a grant from The John A. Hartford Foundation to work with AAAs and other CBOs on ways to build more equitable networks to ensure that underserved or underrepresented populations are represented as part of the healthcare and CBO networks being built around the country to improve access to care and support.
Brian: Assessment is so important, let’s turn to Principle 3: Each person’s physical, social, psychological, and spiritual needs are assessed on an ongoing and standardized basis.
Sandy: Regarding Principle 3, the difference between a medical assessment and a social assessment is the scope and reach. A community-based assessment allows you have a chance to look at the person in their home, which is where most health happens. You talk to them, meet their family and their pets, find out if they have grandchildren, and as a result, you get a better sense of what their whole life is all about and what they care about— not just the results of their medical tests. You get that balanced approach of who a person is, what their needs are, and how to address their needs. You also get a sense of who their caregivers are and what support systems they have in place so that you can fill in the gaps and augment those with community-based services. That’s the beauty of ensuring that community-based services are part of any care plan. They’re not just an add-on, they are integral to what the care plan is, especially for someone with serious illness.
Principle 4. A care plan is developed, using shared decision-making, based on those needs and the person’s individual goals and preferences.
Sandy: This sounds good, but sometimes in a medical situation, people don’t listen to patients or their family caregivers because of time or other constraints, they just want to check the box and move on. If you really want to get into shared decision-making, that requires a conversation. It’s not a check the box and it’s not somebody at the computer who is typing in your information and doesn’t even have a chance to even look at you. The success of the care plan depends on how the decision-making is carried out—how much it involves the person and their family.
Principle 5. Care is provided by a qualified core interdisciplinary team, with additional team members as needed.
Brian: I am happy to report to our readers that in many communities around the country, AAA staff members are already part of cross-sector care teams.
Sandy: Absolutely! AAAs interact with all sorts of health care professionals on these teams to ensure that the services and supports that people need to remain living safely and independently in their homes are present and that their care goals and medical goals are achieved. Brian, we’ve learned that there are two key aspects to creating successful interdisciplinary teams: one is you have to be invited to the table and your voice needs to be respected. The second is you have to know and respect each other’s worlds. By that, I mean having healthcare providers and payers who understand the value that CBOs can bring to the table and, vice versa, that the CBOs understand the issues that providers and payers have to deal with, such as quality metrics or compliance issues or how services happen within the healthcare setting.
Brian: Excellent, let’s move to Principle 6. Care is accessible 24/7 (using technology as appropriate) and available throughout the continuum of a serious illness (including in the home when applicable).
Sandy: This principle brings to mind an important caveat: the limits of technology. We know that using technology in service delivery can be beneficial, especially in the context of the pandemic, but it’s important to acknowledge that it is just one component of care and that it has limitations. For example, technology doesn’t check to see what’s in a person’s refrigerator. Technology doesn’t check to see where the to scatter rugs are when a person has just arrived home from having a hip replacement. So, it needs to be a blending of technology and hands-on, eyes-on care and support.
Regarding the services that people need over the course of a serious illness, often needs increase and the complexity of care increases, and more community-based services may be needed. Medical transportation is a good example: at the beginning of a serious illness, a van comes, and a person can walk out to the van and get in it. As their illness progresses, their mobility may be impaired, and the person may need a more expensive and complex transportation method, such as a van with a wheelchair lift. Later, they may need a van with a stretcher to be able to go a facility to get their needed care. There is a progression of services needed, and the cost of those services escalates. We need to ensure that we can meet that person’s needs at any point in that serious illness and ensure that that person can remain at home.
Principle 7. Care is comprehensive, coordinated, with seamless transitions, and with integration of clinical and community-based services and support for the person and family caregiver(s).
Brian: You addressed some of this under Principle 5 when you talked about AAAs and Native American aging programs along with other CBOs being part of the core interdisciplinary team.
Sandy: Yes, and this integration of clinical and community-based services means that all members of the care team are respected, and their voices are heard. It means a respected role at the table rather than just a referral without funding attached or input desired.
Principle 8. Payment is value-based, available to qualified organizations of any size, and includes risk adjustment, upfront investment, accountability, standardized metrics, and quality improvement, and covers both clinical and social services.
Brian: Hasn’t there been a great deal of growth and change in the last five or ten years in terms of the contracts and these other aspects of payment and accountability for AAAs and CBOs?
Sandy: Absolutely. The growth in our network has been incredible in the past decade and I am so proud of the advancements we’ve made, but of course, there’s still room to grow knowledge and capacity in our ranks–and in healthcare systems! The bottom line is, that we need to make it work, all of us because improving the cooperation between these systems is in the best interest of consumers, patients, and caregivers.
USAging conducted a survey and found in 2017, that about 38% of the CBOs who responded to our survey indicated that they had contracts with healthcare entities, and by 2021, that was up to around 44% of the survey respondents. We often hear from healthcare providers and payers that they believe CBOs aren’t ready to accept risk. But what we saw even between 2020 and 2021, the proportion of CBOs that indicated that they were being paid under models that were value-based or capitated increased —about 30% of the CEOs with contracts indicated that under at least one of their contracts, they were being paid on a per member per month basis or under some other form of capitation.
Brian: What about payment for the social services side of the equation—both services and organizational capacity, as opposed to clinical services?
Sandy: We haven’t made enough of an investment in social services systems—in their services, their workforce, and the infrastructure that supports them. As an example, AAAs and other CBOs are having to work with antiquated legacy technology systems that may or may not work to integrate with health care partners – making the sharing of critical data between the systems difficult. Upgrading AAA technology systems takes investment. For healthcare and social services to work together we need to solve technology and other barriers. We know that the social determinants of health are a major driver of health and quality of life. We need to look at the social services delivery piece of addressing the social determinants of health as a specialty and pay for it as a specialty, just like we would any other medical specialist, like cardiology or pediatrics. Social services are an essential part of the system of care that can address the holistic needs of people with complex care needs. So, as a nation we need to invest in AAAs and other CBOs, equipping them with the resources they need to provide services to people living with serious illness and others who need support in order to live with optimal health at home and in the community.
Notes: Brian Lindberg serves as C-TAC’s Senior Public Policy Advisor, and the Core Principles align with the evidence-based 4th edition of the National Consensus Project Clinical Practice Guidelines.
