Care coordination is a pillar of accountable and value-based care—when clinicians know the current health status of patients and where they are seeking treatment, they’re better able to close gaps in treatment and keep tabs on chronically ill patients, who can rack up expensive bills.

For example, patients who experience gaps in treatment are at increased risk of hospitalization or readmission, and medical treatment that can be avoided through better coordination might represent an avoidable expense for providers who are increasingly at risk for treatment costs under value-based contracts.

The concept of value-based care, with reimbursement rates tied to quality and not just volume of services given, is certainly not new. According to NaviNet, a major vendor of financial and clinical transactions processing services, 75 percent of providers in 2014 already were participating in one or more value-based programs. The Centers for Medicare & Medicaid Services announced in early 2015 that it would tie 30 percent of Medicare payments to value-based care by the end of 2016, and said earlier this year it had already achieved that goal; the agency plans to tie 50 percent of payments to value-based care contracts by the end of 2018.

In 2014, 220 organizations participated in the Medicare Shared Savings Program and 7,000 organizations were in the Bundled Payments program, two efforts intended to reimburse providers for the value of the care they provide.

Some providers are making good progress in efforts to improve care coordination and meet the demands of value-based care.

Clinicians at Houston Methodist Hospital review their patients’ Rothman Index scores.
Clinicians at Houston Methodist Hospital review their patients’ Rothman Index scores.

Femwell Group Health, a management services organization serving 500 physicians in south Florida with billing, collections, human resources and electronic health records services, uses data exchange to ensure primary care physicians are referring babies to pediatricians, says Geeta Nayyar, MD, chief healthcare and innovation officer.

The MSO also manages appointment reminders and schedules Uber rides for patients needing transportation, creates short video clips of physicians explaining procedures for patients to view and sends newsletters out to patients.

Femwell Group Health also created a mobile app to help physicians send referrals to each other and to patients, created a text messaging system to communicate with patients and was scheduled to go live in November with telemedicine services.

Its population health management strategy also will enable it to better coordinate care with hospitals and other ancillary provider sites. While Nayyar sees care coordination as the anchor for patient engagement, there are still gaps that Femwell must work to fill, she says. “We’re aiming for a comprehensive solution like everyone else, but we’re not quite there yet.”

For instance, more education is needed for physicians to improve their bedside manner and explain issues to patients in an understandable and friendly way. Early work on the telemedicine pilot, for example, shows the need to teach physicians to look patients in the eye, and to hold the phone in a way where patients aren’t just seeing the doctor’s nose or forehead.

Collecting copious amounts of data and making it useful is crucial to the success of care coordination in any value-based care model, says Ben Quirk, chief strategy officer at CareOptimize, a Miami-based healthcare consultant. An optimal approach would enable physicians taking central roles in compiling all the data necessary for comprehensive patient care coordination, but that is not typically practical, he says.

“Physicians simply do not have the time, or inclination,” he adds. “The use of care coordinators becomes the key to keeping information flowing smoothly and used efficiently.”

Mastering the use of data to improve care, increase reimbursements, mitigate risk and monitor utilization is critical, so care coordinators balance their work between technology and patients, coordinating the data and gathering patient information until it becomes part of their daily routine. Then, Quirk adds, “an analytics platform provides physicians with information they need at the time they need it.”

Ensuring that physicians successfully transition to value-based care is challenging, he acknowledges. “Even with the use of care coordinators, a fair amount of retraining has to occur. When physicians understand that better care coordination can actually bring in revenue and promote cost savings, however, they are more inclined to realize the benefits.”

The shift to accountable and value-based care can be overwhelming, but knowing the basics can help ease the transition. In Iowa, Tim Gutshall, MD, practiced medicine for 25 years and now serves as chief medical officer at Wellmark Blue Cross and Blue Shield.

Gutshall preaches four simple strategies for improving value-based care, which Montgomery County Memorial Hospital in Red Oak, Iowa, a 25-bed critical access hospital, has adopted, says CIO Ron Kloewer. The strategies are:

  • Focus on the patient and his or her experience in four areas—preventative care, chronic care, referrals for care and transitions of care.
  • Fully use a highly functional and certified EHR that collects data across an expanded continuum, is available to all of the care team and is ready for use in analytics.
  • Surround providers with a competent support staff that is well-trained, understands the principles of population health and the new roles it brings in the expanding continuum of care.
  • Be mindful that efforts to improve population health do not start and stop at the clinic door but reach to extend an organization’s capabilities.

Rather than get caught in the minutiae of all that surrounds accountable care, value-based care and care coordination, Montgomery County Memorial decided to make sure it is implementing these four strategies successfully and created four teams for that purpose.

The project started with an analysis of critical steps to ensure that preventable care processes are working well and that patients leave the clinic with a list of engagement activities that need to be done. “This helped us see the gaps, and that’s when care coordination started to improve,” Kloewer says. “People began to come up with better ideas for care coordination, and we’ve seen that happen.”

Frequent users of the emergency department now see a care coordinator who communicates with health coaches, and ER nurses are given access to information to help them communicate with a patient’s care team, which includes primary care physicians, medical assistants, care managers and specialty clinics.

Now, the hospital is tackling additional issues such as referral management, and care teams are expanding their scope to better manage transitions to long-term care and home health. Care manager nurses make visits to patients in the hospital and at home to be certain that medication reconciliation is accurate and patients understand what medications do and how to take them appropriately.

The patient portal not only facilitates communication with patients but communication across Montgomery County Memorial’s entire care team, and interactions with patients are put in the EHR for team members to reference.

The disease registry within the EHR also plays a role in managing diabetes, hypertension and COPD, and analytics helps to identify patients on more than one registry. The hospital also has access to insurance claims information that can be analyzed to identify patients at risk, and it is a member of the Nebraska Health Information Initiative, which is a regional health information exchange. “That HIE is vital for us to get a broader picture of the patient,” Kloewer says.

Further, Montgomery County is rather big for a critical access hospital, with 360 employees, 50,000 outpatient visits annually and $45 million in net patient services revenue, he notes.

Three years ago, St. Joseph Hospital in Nashua, NH, used its own employees to learn how to do accountable care, supported with analytics, as it joined a Pioneer ACO in concert with Dartmouth-Hitchcock Medical Center. St. Joseph then contracted with vendor MedeAnalytics to build a data warehouse, which enables the provider to do deeper analyses.

Through a third-party administrator, the 203-bed facility each May had been getting feedback on how to achieve better outcomes, says Richard Boehler, MD, president and CEO. “But that’s just telling me what I should have done the previous year.”

So the hospital bought software to track healthcare utilization patterns of employees, their use of generic and brand-name medications, and their visits to the ER, as it seeks to lower its own costs and improve care coordination among its employees—while also learning more about accountable care.

The tracking software works well, Boehler says. The analytics program supported by MedeAnalytics also can identify patients who are not filling medications, getting screening tests or following up on lab results, he notes. “We are proactively managing things instead of just waiting for them to happen.”

This year, employee spending on healthcare is 10 percent lower than in 2015, and a year earlier costs were flat, “which is an accomplishment of its own,” Boehler says. “What we put in place here works.” Now, he adds, “we can influence outcomes with patients, having learned from our employees.”

In early 2017, St. Joseph Hospital hopes to get the data it needs from Optum to aid its transition to value-based care.

Based on its positive results with employees’ coordinated care, the hospital has since reached out into the community, Boehler says. For example, two winters ago, there seemed to be a blizzard every other week, and care coordinators reached out to vulnerable patients to ensure they had enough medications and food.

The benefits of better care coordination cannot be overestimated, Boehler believes. “Because of care coordination, I can go to my board and say, ‘I’m a couple million dollars ahead on healthcare costs for my employees compared to last year.’ There aren’t a lot of people who can say that.”

Overall, there are significant care coordination efforts across the nation, and progress is being made, says Michael Mytych, principal at Health Information Consulting in Menomonee Falls, Wis. But real challenges remain.

Providers want data from insurers to run risk stratification analyses, and identify and engage the highest risk patients. But not all payers are accommodating requests for data.

Combining electronic health records data—such as body mass index, hemoglobin levels, screenings, medications and problem lists—with insurance data can enhance knowledge about high-risk patients, but some EHR vendors do that job better than others, and none excel, Mytych notes.

Consultants, he adds, can help providers aggregate data from multiple sources to better understand where patients are getting treatment. “We can see ZIP Codes where patients have gone, and providers are surprised when they see this.”

On the flip side, Mytych has had organizations contract for assistance that clearly had not done much homework about care coordination. One congestive heart management program, for instance, had one physician to care for 2,000 patients.

While claims data telling providers where patients have gone is valuable, the data becomes even more important when it can be exchanged with other physicians through health information exchanges, which enhance care coordination. For patients, better coordination enabled by using HIEs can help them stay in their insurance network and save money. The problem is, there aren’t that many high-performing HIEs across the nation, Mytych says.

Fortunately, there are national interoperability initiatives under way, says Mytych, who highlights efforts of the Carequality HIE initiative of the Sequoia Project, a coalition of payers, providers and vendors.

Despite progress in interoperability and care coordination, about 30 percent of physicians still work primarily off paper, according to a September 2016 report from SK&A-Quintiles. The report also notes that two-thirds of physician offices have adopted EHRs.

So, that’s more evidence of progress, yet many in the industry continue to grapple with how many patients they can track, whether they can exchange data within their network and whether they can exchange data outside their network, Mytych says. “We still have challenges with these.”

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