Are Caregivers the Missing Link in Value-Based Care Delivery for Seniors?
As the nation grapples with rising healthcare care costs, value-based care is a growing trend. Medicare, for example, has implemented a value-based purchasing program that ties hospital reimbursement levels to patient readmissions. If an institution has high levels of readmissions for patients who have undergone certain procedures, it will see a decrease in its Medicare payments, negatively affecting the bottom line.
So, what does this have to do with caregivers? Recent work done by Dignity Health, the Santa Barbara Foundation, the Ventura County Community Foundation, and the Hospital Association of Southern California suggests that caregivers could be one of the missing links in value-based care delivery for seniors.
On February 13, 2020, Grantmakers in Aging held a webinar to explore how the Family Caregiver Navigation project and a pilot project conducted at Dignity Health's Marian Regional Medical Center in Santa Maria, California, are transforming how healthcare systems approach caregiver support and how that is affecting high profile performance metrics like hospital readmissions and emergency department visits among older patients.
The Cost of Care is Shifting to Family Caregivers
The webinar presenters, Phylene Wiggins of the Ventura County Community Foundation and Kathleen Sullivan from Dignity Health, made a compelling case that the cost of medical care for seniors is shifting to family caregivers. They noted that healthcare systems are tending to discharge patients "sicker and quicker." As a result, family caregivers for older patients are taking on the work of managing medications, wound care, special diets, and medical equipment. Wiggins and Sullivan likened caregivers to hospital care coordinators, yet they are working without knowledge of the broader network of resources that could be helpful.
At the same time that the healthcare sector is relying on caregivers to support older patients in home settings, it often takes these people for granted. The National Academies 2016 report, Families Caring for an Aging America, noted, "Family caregivers are often marginalized in the delivery of healthcare….Paradoxically, some providers exclude them from older adults' treatment decisions and care planning, while also assuming they are able, have the knowledge and are willing to perform essential tasks."
With Person- and Family-Centered Care, Value-Based Care Is Easier to Deliver
To facilitate the shift to person- and family-centered care, Dignity Health's Marian Regional Medical Center received a grant from the Santa Barbara Foundation in 2014 to develop a community-based caregiver support collaborative and to embed a caregiver support program within a health system.
The medical center views family caregivers as patient advocates. Caregivers are given special badges to wear which inform clinicians and staff about their role on the care team. In addition, caregivers receive a portfolio with a special logo to organize paperwork and an electronic personal health record to keep track of their family member's care plan. On a quarterly basis, caregivers work with care navigators to create a CareMap. This is a visual representation of the care ecosystem which shows who cares for whom and how.
Marian Regional Medical Center also has worked with community partners and social service agencies to create a network of resources to support caregivers. An important element of the pilot project has been developing culturally-specific outreach, based on the demographics of the local population. To serve Spanish-speaking caregivers, for example, the medical center works with the Promotores Network of volunteers.
Strengthening the culture of family-centered care among clinicians is also essential. Marian Regional Medical Center educates physicians about the role played by family caregivers through its Family Medicine Residency Program. Residents participate in caregiver home visits, as well as home visits for patients receiving palliative care.
The results of the program have been compelling in terms of value-based care. Between June 2016 and March 2019, Marian Regional Medical Center evaluated care receivers' health system usage for six months prior to the start of their care and six months after the start of their care. Hospital admissions decreased 43.78% and emergency department admissions decreased 28.57%.
Caregiver Navigation Programs Offer a Clear Return on Investment and Important Community Benefits
Based on the positive results of the pilot project at Marian Regional Medical Center, the Ventura County Community Foundation and the Hospital Association of Southern California (HASC) have launched the Family Caregiver Navigation project. This is a three-year grant program for HASC affiliated hospitals that serve Ventura County residents.
The Family Caregiver Navigation initiative has created the Caregiver Navigation Toolkit – this playbook is derived from lessons learned at Marian Regional Medical Center. To create a Caregiver Navigation Program, healthcare systems are encouraged to focus on eight elements: staff, caregiver assessments, community partner identification, care planning, referrals, education, integration into health system workflows and clinical care coordination, and program monitoring.
The toolkit estimates that the yearly program cost for a Family Caregiver Navigation initiative is approximately $112,500. This expenditure would be eclipsed by the savings associated with reduced hospital readmissions and costly emergency room visits by older patients, not to mention potential increases to the bottom line through Medicare's value-based purchasing program.
As a caregiver, I for one, would have been thrilled if my Dad's healthcare providers had participated in this type of navigation program. It feels like the healthcare sector is starting to make more meaningful progress toward family-centered care and recognizing the value that family caregivers provide to patients and the healthcare system overall.