GENERATIONS – Journal of the American Society on Aging

New Strategies for Condition Management Within Value-Based Care By Robert Fields

Managing chronic conditions must involve behavior change, new data sources, and new clinical roles.

I ncreasing costs and poor national outcomes have forced stakeholders such as government, health systems, and providers to redirect their efforts toward value-based care. Health systems, previously a loose mix of employed and affiliated medical staff, are organizing into Accountable Care Organizations (ACO)—networks of hospitals, medical practices, and other providers of health services focused on managing populations to reduce care costs, while improving the quality of care. As a result, new strategies, such as partner- ing with community-based organizations (CBO) to manage social determinants of health—not routinely part of delivery systems or condition- management programs—are emerging as neces- sary steps to achieve population-health goals. ACOs and other value-based models have forced an upstream approach to managing populations in order to avoid downstream costs. The renewed focus on primary and sec- ondary prevention is a welcome approach in a system that has historically concentrated on dis-

ease-specific care, which provides most of its interventions long after the diagnosis of illness and-or its complications have manifested. As ACOs take on increasing risk and quality metrics, and outcomes become a key part of the strategy, they must adapt condition-management programs to include new technologies and new insights into behavior change, as well as to expand part- nerships with community organizations that can reduce barriers for older adults and help them achieve better health. Education is at the core of all condition-manage- ment programs. While most frontline providers use Electronic Medical Record (EMR)–based education, the most effective models employ a more individualized approach tailoring this edu- cation to the person’s needs and health literacy levels. Such programs often use baseline assess- ments to match the appropriate education to the Key Elements of Condition-Management Programs

abstract Accountable Care Organizations are an increasingly common value-based care model emphasizing quality and outcomes. This shift has forced providers to think creatively about managing chronic conditions to avoid complications, poor outcomes, and increased costs. New technologies in self-management and remote monitoring and strategies to promote behavior change can drive clinical outcomes. Recognizing the relationship between social determinants of health and achieving clinical goals has encouraged stronger relationships between delivery systems and community-based organi­ zations to foster better healthcare decisions | key words : Accountable Care Organizations, value-based care, social determinants of health, patient education, technology

24 | Spring 2019

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