Contracting with health care organizations requires Area Agencies on Aging (AAAs) and other community-based organizations (CBOs) to move from service-based reporting to alignment with clinical outcomes and, ultimately, to demonstrate lower health care costs, via reduced hospital readmission rates or other measurements.

Providing individuals with person-centered options counseling and assessments, and connecting people with services that address social determinants of health are key functions of the Aging and Disability Networks. It is important for AAAs and other CBOs to link services like transportation, home-delivered meals, social engagement activities and participation in self-management or falls programs to the prevention of hospital/emergency department visits, reduction in health care costs and improved quality of life in order to demonstrate our value to the health care sector.

OUR STEPS TO SUCCESS

Over the last 3 years, the Maryland Living Well Center of Excellence – MAC, Inc. (LWCE), a program of the AAA, moved from paying hospitals to refer at-risk patients to evidence-based programs to contracting with 26 hospitals for a variety of services, including program licensing, training and certification of leaders, data collection/data reporting of pre/post-clinical measures and risk assessment and referral of individuals to SDOH-related services.

First, we worked with a local hospital to provide blood pressure screening at hypertension workshops. We established protocols for referral of individuals with dangerously elevated blood pressure or who had previously undiagnosed hypertension to health care providers, and for reinforcement for individuals whose hypertension was well-managed and/or those who did not have hypertension. Participants received a call-to-action “Stoplight” to encourage them to take action. 

Next, we established data-sharing agreements with our state Health Information Exchange (HIE), the Chesapeake Regional Information System for Patients (CRISP) and a local hospital. Our agreement, along with an expanded participant consent form, allows us to submit client panels to CRISP to document SDOH services and attendance/completion of evidence-based programs. Clients are matched with hospital patient records to identify hospitalizations six months prior to the services or program and six months after services/program completion. This data is used to document changes in hospital utilization and resulting cost savings.

Beginning in 2020, Maryland will be the first state to be fully at risk for the total cost of care for Medicare beneficiaries under its Total Cost of Care (TCOC) Model. CRISP is an integral component of this plan and is committed to providing meaningful data. As a result, CRISP is working with us to document the provision of nonclinical services and programs. In addition, the CRISP system can provide us with notification alerts when there is a major change in a patient’s status (such as hospitalization) and we can use the same alert system to notify providers of a patient’s need for clinical care.

As part of Maryland’s hospital-to-home initiative, we developed a process flow, known as our Hospital to Home Discharge Referral Process, for patient referral to home and community-based services and evidence-based health and wellness programs. Based on the needs identified at discharge, referrals flow across AAA departments and provision of services is documented.

We participated in the National Council on Aging’s Network Development Learning Collaborative. The collaborative was helpful in providing resources, connecting with other organizations about similar challenges, and learning from agencies that have identified sustainable revenue streams. One of the most valuable activities was using the Healthcare Cost-Savings Estimator Tool to determine Maryland’s return on investment for chronic disease self-management programs.

STEPS TO TAKE FOR SUSTAINABILITY

If your organization is not already working with hospitals and providers, reach out to them to tell about the work you do and how your services can impact their revenue streams and help them meet required quality standards. For more information on how to make the case to the health care world, see the Aging and Disability Business Institute’s library of resources here.

Implement expanded consent forms and sign business agreements with hospitals and providers so you can share information about the services and programs provided to their patients.

If you are not already working with your state HIE, reach out to see how you can work together. Fifty-six states and territories have HIEs that rapidly build capacity for exchanging health information across the health care system both within and across states. Visit their website here.