Dr. Jayant A. Talwalkar

United States health care is moving rapidly from volume- to value-based reimbursement. An essential part of this movement will be the development of alternative payment models where a specific bundle of care (colonoscopy), episode of care (a year of care for attributed Crohn’s patients), or ongoing care of a specialty-centric patient population (patients with cirrhosis) are covered within a contract that links health outcomes, quality of care, and payment together. Gastroenterologists are slowly becoming aware of these concepts. Primary care has its patient-centered medical home and now specialists have a patient-centric specialty practice where patient populations are cared for principally by a specialty practice within a well-defined care delivery structure. Previous columns have illustrated these concepts, and this month, Meier and colleagues provide an excellent definition and example of how practices can participate in this new world order.

John I Allen, M.D., MBA, AGAF, Special Section Editor

The Patient Protection and Affordable Care Act secures access to health insurance coverage for many previously uninsured individuals, while transforming the structure of health care delivery to promote high value care that is coordinated and patient-centered.¹ The development of innovative care delivery models is a key feature of this transformation. In turn, patient-centered medical homes (PCMHs) have proliferated in number, with PCMH-related pilot and demonstration projects spanning numerous federal agencies.²

Defining the patient-centered medical home

The concept of the PCMH predates the Patient Protection and Affordable Care Act, with its origins in the American Academy of Pediatrics’ 1967 discussion of the medical home. In 2007, a joint release by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association defined the PCMH as “an approach to providing comprehensive primary care for children, youth and adults.” Furthermore, the PCMH would serve as “a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.” Several key principles underscore the PCMH model; the patient has a personal physician, and care is physician-directed at the level of the practice, oriented around the whole person, and coordinated to ensure the highest quality and safety of medical care. The PCMH facilitates enhanced access to care, and the payment structure incentivizes and compensates high-quality care delivery.³

Advent of the patient-centered specialty practice

In 2013 the National Committee for Quality Assurance (NCQA), which operates the Patient Centered Medical Home Recognition program, released a set of standards governing the recognition of the patient-centered specialty practice (PCSP).⁴ Similar to the PCMH model, the PCSP model places the patient at the center of care delivery. Key functions of the PCSP include placing the patient at the center of care, sharing of information, and coordinating across all practices (specialty and primary) for patients.⁵ The NCQA outlines six standards for PCSP recognition; these standards focus on planning, management, tracking and coordination of care, performance measurement, performance improvement, referrals, communication to patients, care access, and coordination and management for populations.⁵

Centering patient care in the specialty practice

With the release of the NCQA PCSP standards, provider groups and regulators should work to identify circumstances under which the PCSP might best operate as an effective model for the populations they serve. For example, in the case of mental illness that is both severe and persistent, the creation of a PCMH may disrupt existing patient-provider relationships, increase fragmentation of medical care, and position poorly equipped providers at the center of a care process that requires greater specialization.⁶

Drawing from this example, we suggest that select patient populations with advanced chronic liver disease may benefit from the development of patient-centered care models that operate such as a PCSP. This may include patients with compensated cirrhosis and other comorbid illnesses such as diabetes mellitus or depression, populations with active complications of portal hypertension, or patients who await or have received liver transplantation.^7,8 We suggest examining the potential value of this model in circumstances where the complexity of patient needs or the sensitivity and vulnerability of the patient circumstance may best be managed by an established, trusted, and specialized provider. In the case of patients with cirrhosis and substance abuse from alcohol, a hybrid specialty model that incorporates addiction medicine, social work, and psychiatry providers in addition to hepatologists and allied health providers may be warranted.⁷

Designing the patient-centered specialty practice for populations with cirrhosis and liver transplant recipients

Practices and providers should carefully assess the context for PCSP adoption, identifying whether the specialty care model will promote greater efficiency and quality than that realized in the absence of a PCSP model. The PCSP model should align with patient needs, considering factors such as cause of disease, disease stage, comorbidities and complications, and socioeconomic factors. Although the NCQA PCSP standards should guide model development, there are specific needs and complexities of cirrhosis and liver transplant populations that may prove highly relevant in identifying one or more ideal model designs. This may entail development of additional PCSP standards beyond what is recognized by NCQA.

Table 1 outlines key questions providers might address when considering the development of the PCSP in this patient population. We divide these questions into three main categories: 1) understanding the context for PCSP model adoption, 2) identifying opportunities to align the PCSP model with the specific needs of the patient population, and 3) selecting a model design. Incorporating careful consideration of the questions highlighted within each of these categories can help inform practitioners on the merits of various PCSP models.

Understanding the context for patient-centered specialty practice adoption

Drawing from Alakeson et al.,⁹ we suggest that providers embarking on PCSP model adoption first consider how the quality of care and strength of patient-provider relationships for the target population will improve. The selection of an appropriate patient population is a key determinant in the answer to this question. Focusing specifically on the cirrhosis population, the PCSP may need to be directed toward a disease stage (i.e., decompensated cirrhosis) where the specialist is the most frequent and continuous point of system access. Similarly, the PCSP might yield the greatest gains in quality when access is a function of requiring specialized knowledge in the day-to-day management of care delivery (i.e., compensated liver disease or long-term post liver transplant recipients).

The case for the PCSP may be particularly strong in instances where the primary care provider lacks sufficient knowledge to appropriately manage patient care. For example, treatment of mental and behavioral health conditions that are comorbid with cirrhosis may best be suited to a specialized and established care team that has secured patient trust. Many transplant centers in the United States have explicitly created teams in this regard in the context of regulatory requirements for being a transplant program.¹⁰

Identifying opportunities to align the patient-centered specialty practice model with the specific needs of the patient population

Liver transplant and cirrhosis patients exhibit variability in the cause of disease, with genetic, social-behavioral, and other causal mechanisms operating as factors in the expression of disease. Developing a model focused on reduction in the risk of need for transplant might differ from these former two examples in target population and specialist team. A relevant example is with hospital readmissions because multiple studies to date have documented at least a 20% frequency of re-hospitalization within 30 days of index readmission.^11,12 Although disease severity indicated by Model for End Stage Liver Disease score explains a significant amount of the variability in risk for readmission, there are other factors including frailty¹³ and complications from index hospitalization14 that also contribute to 30-day readmission. The use of case management and remote monitoring strategies for patients at risk for hospital readmission is likely to be included in a PCSP focused on reducing inpatient utilization.

Variability in the social and economic context surrounding a patient’s daily life should also factor into model design. In the case of Medicaid coverage, a well-designed model might address discontinuities in specific provider and service access arising from churning in Medicaid eligibility and coverage.

Selecting a model design

Three examples of specialty care medical home designs have been described in the literature including the integrated model concept and two variants of the partnership model design. The integrated model concept provides specialty and primary care in one location, whereas the partnership models include an on-site liaison at the specialty practice, either a nurse practitioner who provides some degree of care and is able to draw from the services from an off-site primary care physician or otherwise an on-site nurse care manager who serves as an information source and advocate.⁹

We suggest that selection of model design should consider the number of specialty and primary care providers required to construct a comprehensive care team and whether there is reasonable capacity for patients to access comprehensive care in multiple settings. Providing a spectrum of services through separately located but coordinated PCSP and PCMH care models may be practical for some target populations. In other instances, multisite care programs may place an undesirable and impractical burden on patients with complex needs or low health system literacy.

As the field of PCSP model development moves forward, we suggest that providers learn from shared discussions of experience. If appropriate, innovation and shared learning should inform the development of additional standards to ensure that PCSP development for cirrhosis and transplant patients adheres to meaningful quality standards. As is clear from discussion, cirrhosis and liver transplant patients are a diverse group with a range of needs that fall across a spectrum of complexity. The development of well-structured PCSP models may require a high degree of specialization, where model adaptation acknowledges how specific disease-based needs, clinical comorbidities, and external support networks vary across groups.

One suggestion for moving forward is to focus early efforts narrowly on small and highly complex patient groups where the expected value of PCSP is large. This may entail beginning with patient groups whose clinical complexity may otherwise disqualify them from participation in traditional patient-centered care model demonstrations and evaluations. An ideal target population would be patients with decompensated cirrhosis who are ineligible for liver transplantation on the basis of multimorbidity. In addition, specialty providers might consider partnering with state agencies or patient groups in the development, testing, and funding of such programs. These partnerships may help to identify target patient populations with potential to benefit from participation in demonstration projects that innovate through the use of new PCSP model designs.

References

1. Sheen, E., Dorn, S.D., Brill, J.V., et al. Health care reform and the road ahead for gastroenterology. Clin Gastroenterol Hepatol. 2012;10:1062-5.

2. Agency for Healthcare Research and Quality. PCMH activities across federal agencies (Table 1). Available at: http://www.pcmh.ahrq.gov/sites/default/files/attachments/federal-pcmh-activities-table-1.pdf. Accessed May 13, 2015.

3. AAP, AAFP, ACP, and AOA. Joint principles of the patient-centered medical home, March 2007. Available at: http://www.acponline.org/running_practice/delivery_and_payment_models/pcmh/demonstrations/jointprinc_05_17.pdf. Accessed November 24, 2015.

4. Huang, X. Rosenthal, M.B. Transforming specialty practice–the patient-centered medical neighborhood. N Engl J Med. 2014;370:1376-9.

5. National Committee of Quality Assurance. Patient-centered specialty practice recognition: white paper. 2013. Available at: http://www.ncqa.org/Portals/0/Newsroom/2013/PCSP%20Launch/PCSPR%202013%20White%20Paper%203.26.13%20formatted.pdf. Accessed November 24, 2015.

6. National Committee of Quality Assurance. Patient-centered specialty practice frequently asked questions. Available at: http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredSpecialtyPracticePCSP/PatientCenteredSpecialtyPracticeFAQs.aspx Accessed June 4, 2015.

6. Kanwal, F. Coordinating care in patients with cirrhosis. Clin Gastroenterol Hepatol. 2013;11:859-61.

7. Fortune, B.E., Golus, A., Barsky, C.L., et al. Linking a hepatology clinical service line to quality improvement. Clin Gastroenterol Hepatol. 2015;13:1391-5.

8. Alakeson, V., Frank, R.G., Katz, R.E. Specialty care medical homes for people with severe, persistent mental disorders. Health Affairs. 2010;29:867-73.

9. Talwalkar, J.A. Potential impacts of the Affordable Care Act on the clinical practice of hepatology. Hepatology. 2014;59:1681-7.

9. Volk, M.L., Tocco, R.S., Bazick, J., et al. Hospital readmissions among patients with decompensated cirrhosis. Am J Gastroenterol. 2012;107:247-52.

10. Berman, K., Tandra, S., Forssell, K., et al. Incidence and predictors of 30-day readmission among patients hospitalized for advanced liver disease. Clin Gastroenterol Hepatol. 2011;9:254-9.

11. Tapper, E.B., Finkelstein, D., Mittleman, M.A., et al. Standard assessments of frailty are validated predictors of mortality in hospitalized patients with cirrhosis. Hepatology. 2015;62:584-90.

12. Eappen, S., Lane, B.H., Rosenberg, B., et al. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013;309:1599-606.

Dr. Meier, Dr. Shah, and Dr. Talwalkar are in the department of health care policy and research, department of health sciences research; Dr. Talwalkar is also in the division of gastroenterology and hepatology and the William von Liebig Center for Transplantation and Regenerative Medicine; Mayo Clinic, Rochester, Minn.

United States health care is moving rapidly from volume- to value-based reimbursement. An essential part of this movement will be the development of alternative payment models where a specific bundle of care (colonoscopy), episode of care (a year of care for attributed Crohn’s patients), or ongoing care of a specialty-centric patient population (patients with cirrhosis) are covered within a contract that links health outcomes, quality of care, and payment together. Gastroenterologists are slowly becoming aware of these concepts. Primary care has its patient-centered medical home and now specialists have a patient-centric specialty practice where patient populations are cared for principally by a specialty practice within a well-defined care delivery structure. Previous columns have illustrated these concepts, and this month, Meier and colleagues provide an excellent definition and example of how practices can participate in this new world order.

John I Allen, M.D., MBA, AGAF, Special Section Editor

The Patient Protection and Affordable Care Act secures access to health insurance coverage for many previously uninsured individuals, while transforming the structure of health care delivery to promote high value care that is coordinated and patient-centered.¹ The development of innovative care delivery models is a key feature of this transformation. In turn, patient-centered medical homes (PCMHs) have proliferated in number, with PCMH-related pilot and demonstration projects spanning numerous federal agencies.²

Defining the patient-centered medical home

The concept of the PCMH predates the Patient Protection and Affordable Care Act, with its origins in the American Academy of Pediatrics’ 1967 discussion of the medical home. In 2007, a joint release by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association defined the PCMH as “an approach to providing comprehensive primary care for children, youth and adults.” Furthermore, the PCMH would serve as “a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.” Several key principles underscore the PCMH model; the patient has a personal physician, and care is physician-directed at the level of the practice, oriented around the whole person, and coordinated to ensure the highest quality and safety of medical care. The PCMH facilitates enhanced access to care, and the payment structure incentivizes and compensates high-quality care delivery.³

Advent of the patient-centered specialty practice

In 2013 the National Committee for Quality Assurance (NCQA), which operates the Patient Centered Medical Home Recognition program, released a set of standards governing the recognition of the patient-centered specialty practice (PCSP).⁴ Similar to the PCMH model, the PCSP model places the patient at the center of care delivery. Key functions of the PCSP include placing the patient at the center of care, sharing of information, and coordinating across all practices (specialty and primary) for patients.⁵ The NCQA outlines six standards for PCSP recognition; these standards focus on planning, management, tracking and coordination of care, performance measurement, performance improvement, referrals, communication to patients, care access, and coordination and management for populations.⁵

Centering patient care in the specialty practice

With the release of the NCQA PCSP standards, provider groups and regulators should work to identify circumstances under which the PCSP might best operate as an effective model for the populations they serve. For example, in the case of mental illness that is both severe and persistent, the creation of a PCMH may disrupt existing patient-provider relationships, increase fragmentation of medical care, and position poorly equipped providers at the center of a care process that requires greater specialization.⁶

Drawing from this example, we suggest that select patient populations with advanced chronic liver disease may benefit from the development of patient-centered care models that operate such as a PCSP. This may include patients with compensated cirrhosis and other comorbid illnesses such as diabetes mellitus or depression, populations with active complications of portal hypertension, or patients who await or have received liver transplantation.^7,8 We suggest examining the potential value of this model in circumstances where the complexity of patient needs or the sensitivity and vulnerability of the patient circumstance may best be managed by an established, trusted, and specialized provider. In the case of patients with cirrhosis and substance abuse from alcohol, a hybrid specialty model that incorporates addiction medicine, social work, and psychiatry providers in addition to hepatologists and allied health providers may be warranted.⁷

Designing the patient-centered specialty practice for populations with cirrhosis and liver transplant recipients

Practices and providers should carefully assess the context for PCSP adoption, identifying whether the specialty care model will promote greater efficiency and quality than that realized in the absence of a PCSP model. The PCSP model should align with patient needs, considering factors such as cause of disease, disease stage, comorbidities and complications, and socioeconomic factors. Although the NCQA PCSP standards should guide model development, there are specific needs and complexities of cirrhosis and liver transplant populations that may prove highly relevant in identifying one or more ideal model designs. This may entail development of additional PCSP standards beyond what is recognized by NCQA.

Table 1 outlines key questions providers might address when considering the development of the PCSP in this patient population. We divide these questions into three main categories: 1) understanding the context for PCSP model adoption, 2) identifying opportunities to align the PCSP model with the specific needs of the patient population, and 3) selecting a model design. Incorporating careful consideration of the questions highlighted within each of these categories can help inform practitioners on the merits of various PCSP models.

Understanding the context for patient-centered specialty practice adoption

Drawing from Alakeson et al.,⁹ we suggest that providers embarking on PCSP model adoption first consider how the quality of care and strength of patient-provider relationships for the target population will improve. The selection of an appropriate patient population is a key determinant in the answer to this question. Focusing specifically on the cirrhosis population, the PCSP may need to be directed toward a disease stage (i.e., decompensated cirrhosis) where the specialist is the most frequent and continuous point of system access. Similarly, the PCSP might yield the greatest gains in quality when access is a function of requiring specialized knowledge in the day-to-day management of care delivery (i.e., compensated liver disease or long-term post liver transplant recipients).

The case for the PCSP may be particularly strong in instances where the primary care provider lacks sufficient knowledge to appropriately manage patient care. For example, treatment of mental and behavioral health conditions that are comorbid with cirrhosis may best be suited to a specialized and established care team that has secured patient trust. Many transplant centers in the United States have explicitly created teams in this regard in the context of regulatory requirements for being a transplant program.¹⁰

Identifying opportunities to align the patient-centered specialty practice model with the specific needs of the patient population

Liver transplant and cirrhosis patients exhibit variability in the cause of disease, with genetic, social-behavioral, and other causal mechanisms operating as factors in the expression of disease. Developing a model focused on reduction in the risk of need for transplant might differ from these former two examples in target population and specialist team. A relevant example is with hospital readmissions because multiple studies to date have documented at least a 20% frequency of re-hospitalization within 30 days of index readmission.^11,12 Although disease severity indicated by Model for End Stage Liver Disease score explains a significant amount of the variability in risk for readmission, there are other factors including frailty¹³ and complications from index hospitalization14 that also contribute to 30-day readmission. The use of case management and remote monitoring strategies for patients at risk for hospital readmission is likely to be included in a PCSP focused on reducing inpatient utilization.

Variability in the social and economic context surrounding a patient’s daily life should also factor into model design. In the case of Medicaid coverage, a well-designed model might address discontinuities in specific provider and service access arising from churning in Medicaid eligibility and coverage.

Selecting a model design

Three examples of specialty care medical home designs have been described in the literature including the integrated model concept and two variants of the partnership model design. The integrated model concept provides specialty and primary care in one location, whereas the partnership models include an on-site liaison at the specialty practice, either a nurse practitioner who provides some degree of care and is able to draw from the services from an off-site primary care physician or otherwise an on-site nurse care manager who serves as an information source and advocate.⁹

We suggest that selection of model design should consider the number of specialty and primary care providers required to construct a comprehensive care team and whether there is reasonable capacity for patients to access comprehensive care in multiple settings. Providing a spectrum of services through separately located but coordinated PCSP and PCMH care models may be practical for some target populations. In other instances, multisite care programs may place an undesirable and impractical burden on patients with complex needs or low health system literacy.

As the field of PCSP model development moves forward, we suggest that providers learn from shared discussions of experience. If appropriate, innovation and shared learning should inform the development of additional standards to ensure that PCSP development for cirrhosis and transplant patients adheres to meaningful quality standards. As is clear from discussion, cirrhosis and liver transplant patients are a diverse group with a range of needs that fall across a spectrum of complexity. The development of well-structured PCSP models may require a high degree of specialization, where model adaptation acknowledges how specific disease-based needs, clinical comorbidities, and external support networks vary across groups.

One suggestion for moving forward is to focus early efforts narrowly on small and highly complex patient groups where the expected value of PCSP is large. This may entail beginning with patient groups whose clinical complexity may otherwise disqualify them from participation in traditional patient-centered care model demonstrations and evaluations. An ideal target population would be patients with decompensated cirrhosis who are ineligible for liver transplantation on the basis of multimorbidity. In addition, specialty providers might consider partnering with state agencies or patient groups in the development, testing, and funding of such programs. These partnerships may help to identify target patient populations with potential to benefit from participation in demonstration projects that innovate through the use of new PCSP model designs.

References

1. Sheen, E., Dorn, S.D., Brill, J.V., et al. Health care reform and the road ahead for gastroenterology. Clin Gastroenterol Hepatol. 2012;10:1062-5.

2. Agency for Healthcare Research and Quality. PCMH activities across federal agencies (Table 1). Available at: http://www.pcmh.ahrq.gov/sites/default/files/attachments/federal-pcmh-activities-table-1.pdf. Accessed May 13, 2015.

3. AAP, AAFP, ACP, and AOA. Joint principles of the patient-centered medical home, March 2007. Available at: http://www.acponline.org/running_practice/delivery_and_payment_models/pcmh/demonstrations/jointprinc_05_17.pdf. Accessed November 24, 2015.

4. Huang, X. Rosenthal, M.B. Transforming specialty practice–the patient-centered medical neighborhood. N Engl J Med. 2014;370:1376-9.

5. National Committee of Quality Assurance. Patient-centered specialty practice recognition: white paper. 2013. Available at: http://www.ncqa.org/Portals/0/Newsroom/2013/PCSP%20Launch/PCSPR%202013%20White%20Paper%203.26.13%20formatted.pdf. Accessed November 24, 2015.

6. National Committee of Quality Assurance. Patient-centered specialty practice frequently asked questions. Available at: http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredSpecialtyPracticePCSP/PatientCenteredSpecialtyPracticeFAQs.aspx Accessed June 4, 2015.

6. Kanwal, F. Coordinating care in patients with cirrhosis. Clin Gastroenterol Hepatol. 2013;11:859-61.

7. Fortune, B.E., Golus, A., Barsky, C.L., et al. Linking a hepatology clinical service line to quality improvement. Clin Gastroenterol Hepatol. 2015;13:1391-5.

8. Alakeson, V., Frank, R.G., Katz, R.E. Specialty care medical homes for people with severe, persistent mental disorders. Health Affairs. 2010;29:867-73.

9. Talwalkar, J.A. Potential impacts of the Affordable Care Act on the clinical practice of hepatology. Hepatology. 2014;59:1681-7.

9. Volk, M.L., Tocco, R.S., Bazick, J., et al. Hospital readmissions among patients with decompensated cirrhosis. Am J Gastroenterol. 2012;107:247-52.

10. Berman, K., Tandra, S., Forssell, K., et al. Incidence and predictors of 30-day readmission among patients hospitalized for advanced liver disease. Clin Gastroenterol Hepatol. 2011;9:254-9.

11. Tapper, E.B., Finkelstein, D., Mittleman, M.A., et al. Standard assessments of frailty are validated predictors of mortality in hospitalized patients with cirrhosis. Hepatology. 2015;62:584-90.

12. Eappen, S., Lane, B.H., Rosenberg, B., et al. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013;309:1599-606.

Dr. Meier, Dr. Shah, and Dr. Talwalkar are in the department of health care policy and research, department of health sciences research; Dr. Talwalkar is also in the division of gastroenterology and hepatology and the William von Liebig Center for Transplantation and Regenerative Medicine; Mayo Clinic, Rochester, Minn.

United States health care is moving rapidly from volume- to value-based reimbursement. An essential part of this movement will be the development of alternative payment models where a specific bundle of care (colonoscopy), episode of care (a year of care for attributed Crohn’s patients), or ongoing care of a specialty-centric patient population (patients with cirrhosis) are covered within a contract that links health outcomes, quality of care, and payment together. Gastroenterologists are slowly becoming aware of these concepts. Primary care has its patient-centered medical home and now specialists have a patient-centric specialty practice where patient populations are cared for principally by a specialty practice within a well-defined care delivery structure. Previous columns have illustrated these concepts, and this month, Meier and colleagues provide an excellent definition and example of how practices can participate in this new world order.

John I Allen, M.D., MBA, AGAF, Special Section Editor

The Patient Protection and Affordable Care Act secures access to health insurance coverage for many previously uninsured individuals, while transforming the structure of health care delivery to promote high value care that is coordinated and patient-centered.¹ The development of innovative care delivery models is a key feature of this transformation. In turn, patient-centered medical homes (PCMHs) have proliferated in number, with PCMH-related pilot and demonstration projects spanning numerous federal agencies.²

Defining the patient-centered medical home

The concept of the PCMH predates the Patient Protection and Affordable Care Act, with its origins in the American Academy of Pediatrics’ 1967 discussion of the medical home. In 2007, a joint release by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association defined the PCMH as “an approach to providing comprehensive primary care for children, youth and adults.” Furthermore, the PCMH would serve as “a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.” Several key principles underscore the PCMH model; the patient has a personal physician, and care is physician-directed at the level of the practice, oriented around the whole person, and coordinated to ensure the highest quality and safety of medical care. The PCMH facilitates enhanced access to care, and the payment structure incentivizes and compensates high-quality care delivery.³

Advent of the patient-centered specialty practice

In 2013 the National Committee for Quality Assurance (NCQA), which operates the Patient Centered Medical Home Recognition program, released a set of standards governing the recognition of the patient-centered specialty practice (PCSP).⁴ Similar to the PCMH model, the PCSP model places the patient at the center of care delivery. Key functions of the PCSP include placing the patient at the center of care, sharing of information, and coordinating across all practices (specialty and primary) for patients.⁵ The NCQA outlines six standards for PCSP recognition; these standards focus on planning, management, tracking and coordination of care, performance measurement, performance improvement, referrals, communication to patients, care access, and coordination and management for populations.⁵

Centering patient care in the specialty practice

With the release of the NCQA PCSP standards, provider groups and regulators should work to identify circumstances under which the PCSP might best operate as an effective model for the populations they serve. For example, in the case of mental illness that is both severe and persistent, the creation of a PCMH may disrupt existing patient-provider relationships, increase fragmentation of medical care, and position poorly equipped providers at the center of a care process that requires greater specialization.⁶

Drawing from this example, we suggest that select patient populations with advanced chronic liver disease may benefit from the development of patient-centered care models that operate such as a PCSP. This may include patients with compensated cirrhosis and other comorbid illnesses such as diabetes mellitus or depression, populations with active complications of portal hypertension, or patients who await or have received liver transplantation.^7,8 We suggest examining the potential value of this model in circumstances where the complexity of patient needs or the sensitivity and vulnerability of the patient circumstance may best be managed by an established, trusted, and specialized provider. In the case of patients with cirrhosis and substance abuse from alcohol, a hybrid specialty model that incorporates addiction medicine, social work, and psychiatry providers in addition to hepatologists and allied health providers may be warranted.⁷

Designing the patient-centered specialty practice for populations with cirrhosis and liver transplant recipients

Practices and providers should carefully assess the context for PCSP adoption, identifying whether the specialty care model will promote greater efficiency and quality than that realized in the absence of a PCSP model. The PCSP model should align with patient needs, considering factors such as cause of disease, disease stage, comorbidities and complications, and socioeconomic factors. Although the NCQA PCSP standards should guide model development, there are specific needs and complexities of cirrhosis and liver transplant populations that may prove highly relevant in identifying one or more ideal model designs. This may entail development of additional PCSP standards beyond what is recognized by NCQA.

Table 1 outlines key questions providers might address when considering the development of the PCSP in this patient population. We divide these questions into three main categories: 1) understanding the context for PCSP model adoption, 2) identifying opportunities to align the PCSP model with the specific needs of the patient population, and 3) selecting a model design. Incorporating careful consideration of the questions highlighted within each of these categories can help inform practitioners on the merits of various PCSP models.

Understanding the context for patient-centered specialty practice adoption

Drawing from Alakeson et al.,⁹ we suggest that providers embarking on PCSP model adoption first consider how the quality of care and strength of patient-provider relationships for the target population will improve. The selection of an appropriate patient population is a key determinant in the answer to this question. Focusing specifically on the cirrhosis population, the PCSP may need to be directed toward a disease stage (i.e., decompensated cirrhosis) where the specialist is the most frequent and continuous point of system access. Similarly, the PCSP might yield the greatest gains in quality when access is a function of requiring specialized knowledge in the day-to-day management of care delivery (i.e., compensated liver disease or long-term post liver transplant recipients).

The case for the PCSP may be particularly strong in instances where the primary care provider lacks sufficient knowledge to appropriately manage patient care. For example, treatment of mental and behavioral health conditions that are comorbid with cirrhosis may best be suited to a specialized and established care team that has secured patient trust. Many transplant centers in the United States have explicitly created teams in this regard in the context of regulatory requirements for being a transplant program.¹⁰

Identifying opportunities to align the patient-centered specialty practice model with the specific needs of the patient population

Liver transplant and cirrhosis patients exhibit variability in the cause of disease, with genetic, social-behavioral, and other causal mechanisms operating as factors in the expression of disease. Developing a model focused on reduction in the risk of need for transplant might differ from these former two examples in target population and specialist team. A relevant example is with hospital readmissions because multiple studies to date have documented at least a 20% frequency of re-hospitalization within 30 days of index readmission.^11,12 Although disease severity indicated by Model for End Stage Liver Disease score explains a significant amount of the variability in risk for readmission, there are other factors including frailty¹³ and complications from index hospitalization14 that also contribute to 30-day readmission. The use of case management and remote monitoring strategies for patients at risk for hospital readmission is likely to be included in a PCSP focused on reducing inpatient utilization.

Variability in the social and economic context surrounding a patient’s daily life should also factor into model design. In the case of Medicaid coverage, a well-designed model might address discontinuities in specific provider and service access arising from churning in Medicaid eligibility and coverage.

Selecting a model design

Three examples of specialty care medical home designs have been described in the literature including the integrated model concept and two variants of the partnership model design. The integrated model concept provides specialty and primary care in one location, whereas the partnership models include an on-site liaison at the specialty practice, either a nurse practitioner who provides some degree of care and is able to draw from the services from an off-site primary care physician or otherwise an on-site nurse care manager who serves as an information source and advocate.⁹

We suggest that selection of model design should consider the number of specialty and primary care providers required to construct a comprehensive care team and whether there is reasonable capacity for patients to access comprehensive care in multiple settings. Providing a spectrum of services through separately located but coordinated PCSP and PCMH care models may be practical for some target populations. In other instances, multisite care programs may place an undesirable and impractical burden on patients with complex needs or low health system literacy.

As the field of PCSP model development moves forward, we suggest that providers learn from shared discussions of experience. If appropriate, innovation and shared learning should inform the development of additional standards to ensure that PCSP development for cirrhosis and transplant patients adheres to meaningful quality standards. As is clear from discussion, cirrhosis and liver transplant patients are a diverse group with a range of needs that fall across a spectrum of complexity. The development of well-structured PCSP models may require a high degree of specialization, where model adaptation acknowledges how specific disease-based needs, clinical comorbidities, and external support networks vary across groups.

One suggestion for moving forward is to focus early efforts narrowly on small and highly complex patient groups where the expected value of PCSP is large. This may entail beginning with patient groups whose clinical complexity may otherwise disqualify them from participation in traditional patient-centered care model demonstrations and evaluations. An ideal target population would be patients with decompensated cirrhosis who are ineligible for liver transplantation on the basis of multimorbidity. In addition, specialty providers might consider partnering with state agencies or patient groups in the development, testing, and funding of such programs. These partnerships may help to identify target patient populations with potential to benefit from participation in demonstration projects that innovate through the use of new PCSP model designs.

References

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Dr. Meier, Dr. Shah, and Dr. Talwalkar are in the department of health care policy and research, department of health sciences research; Dr. Talwalkar is also in the division of gastroenterology and hepatology and the William von Liebig Center for Transplantation and Regenerative Medicine; Mayo Clinic, Rochester, Minn.