The future of value-based care programs will likely focus on greater integration of care, as nursing homes and other providers in the health care continuum discover the benefits of more thoughtful discharges – less focused on swiftness and more on moving patients through a continuum of care – in order to close costly gaps in care.

That’s the view shared by panelists for a discussion about the future of value-based care at Skilled Nursing News’ recent CLINICAL conference in Bonita Springs, Florida.

Closing the gaps will take resources not seen at the federal and state level before, and collaboration and trust between legislators, operators and clinical staff in other care settings, said Dr. Robert Russell, chief medical officer at Indiana-based Majestic Care. Existing programs are already moving toward integration, with the Transforming Episode Accountability Model (TEAM) model offering a bundled payment option that follows patients through episodes of care.

“We’re all integrated, whether we like it or not, and that’s where the focus is going to have to be on future innovation, to prevent those gaps [from care transitions]. We’ve siloed everything so much that that’s why the gaps have hurt,” said Russell.

The TEAM model is expected to launch in January 2026. TEAM is a forced bundled payment model with the hospital at the helm.

While new value-based programs are created to bridge such gaps, it’s imperative that the Centers for Medicare & Medicaid Services (CMS) is ready to keep up with what they’re putting out there, said Dr. Taimur Mirza, chief medical officer with ArchCare in New York. For Russell, adequate resources to ensure new program success and a united front from the skilled nursing sector is another must.

“We may be financial competitors, but we’re neighbors … we have to get past that barrier to show we are the societal stop gap measure,” said Russell. “You want us to really, truly impact these people? You have to give us the resources, and we have to work together.”

Settled guidance from CMS

Mirza’s advice to CMS: have set rules and guidance in place prior to a program’s launch.

ArchCare already participates in the Guiding an Improved Dementia Experience (GUIDE) model and is actively enrolling participants after going live in July, but it was hard to get that program off the ground with the agency changing the rules and reimbursement rates daily.

GUIDE provides wraparound services for those caring for dementia patients – respite care in a nursing home is considered a service under GUIDE, along with home and community-based services like Meals on Wheels.

“One thing that we can offer them that really gets caregivers on board is the respite care portion of it,” Mirza said of GUIDE. “When they’re really basically burnt out from taking care of their dementia loved one, they can put them inside one of our nursing homes and just take a little break. It’s the most challenging thing you can do, to take care of somebody with dementia.”

In comparison to TEAM, in which ArchCare will also participate, Accountable Care Organizations (ACOs) are voluntary bundle programs, with the task of caring for residents with five conditions, three of which are orthopedic-related, one for hip fractures, knee replacements and spinal procedures, and another for major bowel surgery and Covid.

ArchCare has been working with the Hospital for Special Surgery (HSS) on three of those conditions for the last four years which lines them up nicely to participate in TEAM. In those years, patient satisfaction has reached more than 90%, 30-day hospital readmissions are below 5%, and average length of stay is between five and 10 days for those conditions, Mirza said.

If there’s enough patient volume with HSS, profit sharing would be a natural ask for ArchCare. One challenge Mirza foresees with TEAM is in the aftermath of a major bowel procedure, within one of the five categories covered in TEAM. Timing is unpredictable for recovery; days in the hospital, days in the nursing home and days at home can vary here.

“We’re trying to get ahead of the curve with this, but when it does go live and hospitals are forced to do these five conditions, I think we’re in a very good place where we can take on the risk for them, but also maybe share some of those rewards,” said Mirza.

Hospital partners will lead TEAM

Chicago-based Ignite Medical Resorts Chief Clinical Officer John McFarlane echoed Mirza’s thoughts regarding staying ahead of the curve on TEAM, being in constant communication with hospital partners and taking credit for services done well.

“When it comes to TEAM and those conditions, putting forth data that’s valuable to the hospital systems, I think, is crucial,” said McFarlane. Going beyond the form typically sent for the five conditions and also including diagnoses groups that shows what the operator is doing with these patients ahead of TEAM going into place is something Ignite has focused on in the meantime.

Operators can show their utility prior to the launch of TEAM, Russell said, if a facility has a robust orthopedic program or if there’s data showing quality care for the five TEAM diagnoses. In terms of ancillaries, offering a home health network that’s either in-house or as a partner to keep these patients out of the hospital will help an operator easily become part of the TEAM model.

Ultimately, it’s a balancing act to take on new value-based care models, with Medicare Advantage causing huge administrative backlogs and opening up yet another gap in most cases between the cost of care and reimbursement under MA contracts. But, partnerships with other care settings and existing data on specialized care services will help determine the right fit.