Values in Care

    Value-Based Care

    Where faith-informed care meets value-based payment

    Value-based care (VBC) pays clinicians and systems for outcomes, not just visits. The same conversations that honor a patient's tradition (advance care planning, symptom relief, family presence) are often the conversations that close VBC quality gaps. This page links each model to the practices it supports, with primary-source citations.

    PENDING REVIEW
    Source-cited · independent clinician review in progress · coverage dashboard

    For patients & families

    VBC models reward teams who actually listen: to your goals, your faith, and your family. Knowing which model your care team is in helps you ask for the services it covers.

    For clinicians & systems

    Faith-aligned practices (early ACP, family meetings, symptom-focused review) track closely with the workflows ACO REACH, MSSP, HOPE, and TEAM reward. This is a documented alignment, not a measured causal effect on any specific program's metrics.

    Visual evidence map

    Model performance windows

    Source: CMS / CMS Innovation Center model pages. Each bar's start year and (where applicable) end year are parsed from the model's published performance window.

    Evidenced practice → outcome linkages

    No evidenced practice → payment-model linkages are published yet. A cell fills only when an authoritative CMS/CMMI source states the relationship directly. Directional relevance is shown as alignment on each practice card instead.

    Home & community-based value-based care

    Performance windows for CMS / CMMI models that pay for care delivered in the home or community. Years parsed from each model's published page.

    1. GUIDE
      GUIDE 20242032 · Active
    2. KCC
      KCC 20222027 · Active
    3. TEAM
      TEAM 20262030 · Active
    4. CCBHC
      CCBHC 20172027 · Active
    5. MCP
      MCP 20242025 · Ended
    6. HHVBP
      HHVBP 20232027 · Active
    20172032

    Confidence timeline of evidenced linkages

    No evidenced practice → outcome citations are published yet, so the timeline has no points to plot. Points appear only when an authoritative CMS/CMMI source states the relationship directly.

    The Expanded Home Health Value-Based Purchasing Model applies nationally, adjusting Medicare payments to home-health agencies based on quality.

    Where most serious-illness life actually happens.

    Home- and community-based VBC models translate values into payment for the setting most patients prefer. The band below is drawn directly from vbcModels; every metric card below it is cited to a primary CMS or CMMI source.

    Home & community-based value-based care

    Performance windows for CMS / CMMI models that pay for care delivered in the home or community. Years parsed from each model's published page.

    1. GUIDE
      GUIDE 20242032 · Active
    2. KCC
      KCC 20222027 · Active
    3. TEAM
      TEAM 20262030 · Active
    4. CCBHC
      CCBHC 20172027 · Active
    5. MCP
      MCP 20242025 · Ended
    6. HHVBP
      HHVBP 20232027 · Active
    20172032

    Confidence & weight legend

    The exact weights used by the Practice → Outcome Strength matrix. Display-only, never inferred from page context.

    • Verified1.00Primary-source statements from CMS, WHO, NIST, FDA, ISO, or a tradition's own authority on our allow-list.
    • Peer-reviewed0.85Indexed in PubMed, Cochrane, or a recognized academic publisher with editorial oversight.
    • Expert-consensus0.65Statements from professional bodies (e.g. CAPC, NHPCO, CHAI) representing consensus practice, not yet primary-trial evidence.
    • Emerging0.40Pilot or early-evidence claims under active editorial review; clearly labeled and never used alone for a clinical recommendation.

    Methodology notes (cited)

    Home Health Value-Based Purchasing performance scores combine OASIS, claims-based, and HHCAHPS measures into a Total Performance Score that adjusts Medicare payment for all certified home-health agencies.

    When an AI-derived signal informs any displayed metric, it is governed by the NIST AI Risk Management Framework functions: govern, map, measure, manage.

    • Home Health Value-Based Purchasing — national scope

      The Expanded HHVBP Model applies to all Medicare-certified home health agencies nationwide; CY 2023 was the first performance year, with payment adjustments beginning CY 2025.

    CMS / CMMI models

    Hospice Outcomes & Patient Evaluation (HOPE)

    CMS · Oct 2025 → ongoing

    Active

    Eligibility: All Medicare-certified hospices (replaces HIS).

    Key levers

    • Admission assessment plus up to two HOPE Update Visits
    • Pain and non-pain symptom impact follow-up
    • Assessment-based hospice quality reporting

    Guiding an Improved Dementia Experience Model (GUIDE)

    CMMI · Jul 2024 → Jun 2032

    Active

    Eligibility: Medicare-enrolled providers serving FFS beneficiaries with dementia and their unpaid caregivers.

    Key levers

    • PBPM care management payment
    • Mandatory 24/7 access line
    • Up to $2,500/yr respite for caregivers
    • Health equity adjustment

    Practices supporting this model

    ACO Realizing Equity, Access, and Community Health (ACO REACH)

    CMMI · 2023 → 2026

    Sunsetting

    Eligibility: Provider-led ACOs with strong primary care and equity-focused designs.

    Key levers

    • Capitated or partially-capitated payment
    • Mandatory health equity plan
    • Benefit enhancements (e.g. SNF 3-day waiver)

    Practices supporting this model

    Medicare Shared Savings Program (MSSP)

    CMS · 2012 → ongoing

    Active

    Eligibility: ACOs participating in MSSP BASIC or ENHANCED tracks.

    Key levers

    • Shared savings/losses against benchmark
    • Advance Investment Payments (AIP) for new low-revenue ACOs
    • Quality scoring via APP

    Practices supporting this model

    Kidney Care Choices (KCC)

    CMMI · 2022 → 2027

    Active

    Eligibility: Nephrologists and dialysis facilities caring for CKD stage 4-5 and ESRD patients.

    Key levers

    • Capitated payments for CKD/ESRD care
    • Transplant access remains a model goal; the separate Kidney Transplant Bonus ended for transplants beginning performance year 2026
    • Coordinated care and patient education for late-stage CKD and ESRD

    Practices supporting this model

    Transforming Episode Accountability Model (TEAM)

    CMMI · Jan 2026 → Dec 2030

    Active

    Eligibility: Selected acute-care hospitals (mandatory in chosen CBSAs) for five surgical episodes.

    Key levers

    • 30-day episode-based payment
    • Required referral to primary care after discharge
    • Health-equity plan and stratified reporting

    Practices supporting this model

    Certified Community Behavioral Health Clinics (CCBHC)

    SAMHSA / CMS · 2017 → ongoing (Medicaid demo expanding)

    Active

    Eligibility: Clinics certified to deliver a defined scope of mental-health and SUD services, including 24/7 crisis care.

    Key levers

    • Prospective payment system tied to scope of service
    • Required care coordination with primary care
    • Mandatory 24/7 crisis services

    Making Care Primary (MCP)

    CMMI · Jul 2024 → Jun 2025

    Ended

    Eligibility: Primary-care organizations in eight participating states; three progressive tracks.

    Key levers

    • Historical design: care-management fees with progressive tracks
    • Historical design: behavioral-health integration
    • Historical design: community-based organization partnerships

    Practices supporting this model

    Expanded Home Health Value-Based Purchasing Model (HHVBP)

    CMS · 2023 → ongoing

    Active

    Eligibility: All Medicare-certified home health agencies in the 50 states, DC, and territories.

    Key levers

    • Payment adjustment based on quality performance
    • Total Performance Score across OASIS, claims, and HHCAHPS measures
    • Annual published performance reports

    Reference guide only. Model details change frequently. Confirm eligibility, dates, and benefit specifics with the linked CMS page before operational decisions. Not legal, financial, or clinical advice.