Harnessing ADT data: Transforming patient care and addressing social needs
Manifest MedEx leads the charge in California by utilizing basic health information for improved healthcare equity and outcomes.
Basic health information can provide important insight into meeting patients’ social needs, and that can support providers in meeting patients’ needs and keeping them healthier.
In fact, some of the simplest data – like notifications associated with admissions, discharges and transfers (ADT) – can provide important clues about challenges that patients may face in their homes, either on an ongoing basis or post-discharge.
ADT information typically has provided a trigger to healthcare organizations to make certain that patients can receive follow-up care at home after discharge – when factors such as lack of family support or access to medication or nutrition could jeopardize recovery. Admission and transfer data also is crucial in ensuring that everyone involved in a patient's care knows the latest status or care venue.
ADT can trigger appropriate review from healthcare organizations, when something as simple as a follow-up phone call can help streamline care coordination or meet social needs, and that can reduce costly readmissions.
Improving data sharing
In California, Manifest MedEx is ensuring the seamless exchange of health information, with an early focus on ADT data. Currently, it’s the state’s largest health data network. It helps facilitate the exchange of health information of more than 34 million Californians between 1,800 healthcare organizations, more than 125 hospitals and 13 health plans.
In addition to supporting basic data exchange, the health data utility has a bigger vision. It’s looking to achieve healthcare transformation by working with local and state partners to address health equity challenges, support population health management initiatives, and achieve goals embodied in the California Advancing and Innovating Medi-Cal (which aims to improve whole person care of those covered by the state’s Medicaid program) and the Data Exchange Framework (which is a data sharing agreement in the state to expand health information exchange).
Manifest MedEx sees early advantages in enabling the exchange of ADT information, says Mimi Hall, vice president of public health innovation, who gave an update on the program during the 2023 WEDI spring conference in mid-May.
The exchange is offering MX Notify, through which it provides real-time alerts. Other offerings that can play a supporting role in meeting social needs include MX Access, which provides information on patients’ health records, and MX Analyze, which includes population health tools to assess risk trends and prioritize patients for care management.
ADT information – although basic and already required for submission since 2021 by the Centers for Medicare & Medicaid Services – can enable continuity of care and meeting of social needs by providers, particularly federally qualified health centers, Hall says.
How ADT data helps
For example, ADTs can play a role in anticipating the rising incidences of syphilis among newborns. ADTs for a panel of pregnant women who have either been diagnosed with the disease or exposed to it – the ADTs are for patients who are presenting to emergency departments or for labor and delivery.
FQHCs in medically underserved areas also get access to ADT data from Manifest MedEx so that they’re aware of patients who had been discharged from the hospital within hours of their release.
“We want to provide increased monitoring of patients with a high number of ED visits to improve care and reduce unavoidable ED admissions,” Hall says. Awareness of this ADT information enables FQHCs to schedule appointments with patients’ primary care physicians, as well as to provide patient education on when it’s appropriate to seek care from emergency departments.
Health plans also benefit from quick access to ADT information, which they can use to prevent avoidable readmissions or redirect ED visits to more appropriate and less costly care settings, she adds.
“There are very few issues around which a number of stakeholder incentives align, but ADT serves that purpose,” Hall concludes. “Everyone across the spectrum is aligned across the purpose of the ADT,” which helps to bolster the safety net of public health.
The biggest challenge has been participation by cash- or technologically strapped public health agencies, she says. “When you only have so many resources, you don’t prioritize health data exchange. From a data perspective, a foundational health data infrastructure should be a public-private partnership to equalize access to data.”