From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (EKC, JO, JH); OCHIN, Inc., Portland, OR (EKC, KD, JO, RLJ, NM); Virginia Garcia Memorial Health Center, Hillsboro, OR (CA).
J Am Board Fam Med. 2021 Jan-Feb;34(1):78-88. doi: 10.3122/jabfm.2021.01.200027.
The fee-for-service reimbursement system that dominates health care throughout the United States links payment to a billable office visit with a physician or advanced practice provider. Under Oregon's Alternative Payment and Advanced Care Model (APCM), initiated in 2013, participating community health centers (CHCs) received per-member-per-month payments for empaneled Medicaid patients in lieu of standard fee-for-service Medicaid payments. With Medicaid revenue under APCM no longer tied solely to the volume of visits, the Oregon Health Authority needed a way to document the full range of care and services that CHCs were providing to their patients, including nontraditional patient encounters taking place outside of traditional face-to-face visits with a billable provider. Toward this end, program leadership defined 18 visit and nonvisit-based care activities-"Care Services That Engage Patients" (Care STEPs)-that APCM CHCs were asked to document in the electronic health record to demonstrate continued empanelment.
To describe trends in rates of traditional face-to-face office visits and Care STEPs documentation among CHCs involved in the first 3 phases of APCM implementation.
The study population included the 9 CHCs involved in the first 3 phases of APCM implementation. Using data from the electronic health record, quarterly summary rates for office visits and Care STEPs were calculated for the first 18 quarters of implementation (March 1, 2013 to June 30, 2017).
Among participating CHCs, the mean rate of face-to-face visits with billable providers declined from 635 ± 128 to 461 ± 109 visits/1000 patients/quarter (mean difference, -174; 95% CI, -255, -94). Care STEPs documentation increased from 831 ± 174 to 1017 ± 369 Care Steps/1000 patients/quarter, but the difference was not statistically significant. Care STEPs within the category of New Visit Types were documented most frequently. There were significant increases in documentation of Patient Care Coordination and Integration and a small, albeit significant, increase in Reducing Barriers to Health. There was a significant decline in the documentation of Care STEPs by physicians and advanced practice providers an increase in documentation by ancillary staff.
These findings suggest that APCM is increasing CHCs' capacity to experiment with new ways of providing care beyond the traditional face-to-face office visit with a physician or advanced practice provider. However, CHCs may choose different ways to change the delivery of care and some CHCs have implemented these changes more quickly than others. Future mixed-methods research is needed to understand barriers and facilitators to changing the delivery of care after APCM implementation.
在美国，主导医疗保健的按服务收费报销系统将支付与医生或高级执业医师的计费就诊联系起来。在俄勒冈州的替代支付和高级护理模式（APCM）下，从 2013 年开始，参与的社区卫生中心（CHC）为登记的医疗补助患者提供每位成员每月的付款，而不是标准的按服务收费的医疗补助付款。根据 APCM，医疗补助收入不再仅仅与就诊次数挂钩，俄勒冈州卫生署需要一种方法来记录 CHC 为患者提供的全方位护理和服务，包括在没有计费提供者的传统面对面就诊之外进行的非传统患者就诊。为此，项目领导层确定了 18 项就诊和非就诊护理活动 - “患者参与的护理服务”（Care STEPs） - 要求 APCM 参与的 CHC 在电子健康记录中记录这些活动，以证明继续登记。
描述参与 APCM 实施的前 3 个阶段的 CHC 中传统面对面就诊和 Care STEPs 记录的趋势。
研究人群包括参与 APCM 实施的前 3 个阶段的 9 个 CHC。使用电子健康记录中的数据，为实施的前 18 个季度计算了办公室就诊和 Care STEPs 的季度汇总率（2013 年 3 月 1 日至 2017 年 6 月 30 日）。
在参与的 CHC 中，与计费提供者进行面对面就诊的平均就诊率从 635 ± 128 下降到 461 ± 109 就诊/1000 患者/季度（平均差异，-174；95%CI，-255，-94）。Care STEPs 的记录从 831 ± 174 增加到 1017 ± 369 Care Steps/1000 患者/季度，但差异不具有统计学意义。在新就诊类型类别中记录了最频繁的 Care STEPs。患者护理协调和整合方面的记录显著增加，减少健康障碍方面的记录略有增加，但具有统计学意义。医生和高级执业医师记录的 Care STEPs 显著减少，辅助人员记录的 Care STEPs 增加。
这些发现表明，APCM 正在提高 CHC 提供超出与医生或高级执业医师进行传统面对面就诊的新护理方式的能力。然而，CHC 可能会选择不同的方式来改变护理的提供方式，并且一些 CHC 比其他 CHC 更快地实施了这些变化。需要进行未来的混合方法研究，以了解 APCM 实施后改变护理提供方式的障碍和促进因素。
