ACO’s real-time data helps providers give targeted care

Pathways Health Partners’ efforts are reducing readmission rates, offering insights into discharge data and accelerating treatment.

A three-part data sharing strategy empowers Pathways' effort to get information to clinicians.

Pathways Health Partners, an Accountable Care Organization based in the Central Florida region, is helping healthcare providers expand access to value-based care.

The organization currently works with more than 280 providers across multiple clinical specialties. Pathways supports its providers by enabling more immediate access to patient records, connected care platforms and new technological advancements.

In its work with providers, the ACO recognized the growing need for real-time notifications and access to patient information to advance value-based care goals. Lack of timely patient information sharing, regardless of where care is delivered, is a widely recognized gap in the healthcare ecosystem. It was also a key impetus for e-notification requirements within the CMS Interoperability and Patient Access Rule.

To expand the ACO’s data receipt and sharing capabilities for providers, it pursued three strategies – connecting to a national data exchange, providing real-time access to encounter notifications and discharge documents, and enabling mobile device push notifications. A standards-based notifications system was used to support these initiatives, resulting in further improvements in patient outcomes for Pathways providers.

National Data Exchange

Whether managing chronic pain or a recent surgical episode, having real-time access to patient data to treat patients and understand what interventions make the greatest impact is a keystone of the ACO’s successful work with provider partners and across its regional network.

Pathways recently launched PointClickCare’s clinical document retrieval system, which provides patients’ individual clinicians with notifications of hospital admissions and other real-time patient data — information that never existed in the fee-for-service environment.

Through the network, Pathways-participating physicians have immediate access to patient discharge documents, including continuity of care documents (CCDs) and summaries. This real-time access to data has resulted in more immediate interventions and reduced readmissions, according to comparisons of the ACO’s benchmarking data in 2019 to its performance rate in 2021.

The organization has corrected its 30-day readmission rate and will continue to improve through unified access to three of the nation’s largest clinical data exchange networks. The reduction in its readmission rate has even proven true for patients residing in skilled nursing and long-term care facilities.

Discharge data insights

Trying to locate discharge documents is any practice manager’s least favorite task. By providing immediate access to these documents and data, Pathways quickly coordinates with primary care providers to follow best-practice guidelines for quality, cost-effective care.

Since Pathways became an ACO in 2013, there have been substantial changes in the types of data available to its members. Discharge data is the latest addition in the data journey. Previous data aggregation efforts included relationships with data clearinghouses to gather granular detail on registration and payer activity. The ACO achieved a near 100 percent response rate to inquiries on payer activity.

As an ACO, the organization continually gains broader insights into the populations it serves. And it shares those insights with primary care providers to support more informed decisions for their patients. With a growing volume of accessible real-time data, the ACO also introduced new methods to connect and inform care.

Push notifications accelerate treatment

Doctors receive messages from Pathways through a mobile application. Push notifications make the latest data available immediately to hospitalists, nurse practitioners and nurses. This alerts the clinicians that they need to check on a patient right away. Ultimately, these notifications get patients into treatment faster.

Regardless of a patient’s condition or socioeconomic status, Pathways works with providers to make services and providers available. For example, notifications enable for closer monitoring between short-term and long-term care. They also trigger faster access to care, from SNF, hospice and home care, making all resources available to people equitably.

Knowing that a patient is in the hospital is the first indication for the Pathways team to take action. It layers admission data with transition care management before patient discharge documentation is even produced or received. Lab results are also fully integrated into the organization’s population health data dashboard.

In-home visits are cost-effective

Finally, Pathways’ region has limited access to urgent care, which results in high volumes of costly emergency department visits. To point patients in a different direction and support more cost-effective care, the ACO takes urgent care services directly to the patients.

Depending on the severity of a patient’s case, a Pathways Health Partners clinician can personally visit a patient who needs care. The staff then schedules a follow-up visit with a primary care physician within 72 hours. These innovative interventions and additional touchpoints contribute to better health outcomes for patients, providers and the ACO.

Ricardo Matos is CIO for Pathways Health Partners and is a leader in orchestrating transformative business strategy through data-driven decisions. He has served as CIO, CTO and managed care advisor for several Florida-based healthcare organizations.

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