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In Care Transition Scenarios, OptimalOutcomes Require Efficient Handoffs

“Our collective ability to provide the right data, to the right people at the right time along

the complete care continuum has no longer become a nice to have – it is an imperative. “

OPEN

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As the country’s healthcare system continues down the reform path andhospitals and health systems transform from transaction to value-drivenbusiness models, there is a demographic tsunami poised to impact our caredelivery networks. In addition, the reimbursement landscape is changing, whereoutcomes and patient experiences will factor into the overall revenue equation.

Transitions in care and facilitating effective handoffs to post-acute care must bemade a priority to meet these new demands.

Ensuring that healthcare systems are

able to keep up with these dynamic

changes and continue delivering on

their missions will mean enhancing

clinical interoperability data

capabilities and closing the data gaps

that exist today, particularly within

care transition scenarios.

This seismic shift in what ails older populations combined with longer life spans means we are experiencing increased transitions from acute care settings to post-acute and home careenvironments. And while many health systems are quite capable of capturing patient datawithin their own “four walls”, delays in receiving patient data or “dropped” handoffs betweenexternal care teams directly contributes to avoidable readmissions. According to Health PolicyBrief’s “Improving Care Transitions” report, 2012, nearly one-fifth of fee-for-service Medicarebeneficiaries discharged from the hospital are readmitted within 30 days; three-quarters ofthese readmissions—costing an estimated $12 billion a year—are considered potentiallypreventable, especially with improved care transitions.

Identifying the at-risk sub-populations, critical transitions of care and responsible care givers is the necessary first step towards addressing the problem. Significant improvements can be achieved by making sure the right information gets to all the responsible care givers across the care continuum at the right time.

In Care Transition Scenarios, OptimalOutcomes Require Efficient Handoffs

• Longer life spans and aging baby boomers—will combine to double the population of Americansaged 65 years or older during the next 25 years toabout 72 million.

• By 2030, older adults will account forroughly 20% of the U.S. population.

• More than 25 percent of allAmericans and two out of everythree older Americans have multiplechronic conditions; and

Additionally, the CDC report further states that during the pastcentury, a major shift occurred in the leading causes of death forall age groups, including older adults, from infectious diseasesand acute illnesses to chronic diseases and degenerative illnesses:

• Treatment for this populationaccounts for 66% of the country’shealth care budget.

Costing an estimated$12 billion a year. ManyReadmissions are considered potentiallypreventable, especiallywith improved caretransitions.

According to Health PolicyBrief’s “Improving Care Transitions” report, 2012

DemographicTsunami

Acute care setting Post-Acute and Home-care settings

ChronicConditions

$Over 65 yrs

O

According to the CDC’s 2013 State of Aging & Health in America report:

> 65 yrs

2014 2039

72 Million

Preventable Reamissions

© 2014 ICA – The Interoperability Experts | www.ica-carealign.com | 615-866-1500

http://www.ica-carealign.com

3© 2014 ICA – The Interoperability Experts | www.ica-carealign.com | 615-866-1500

Today’s Care Delivery Environment

As we see across the US, health systems are quite collaborative with regard to implementingaccountable care and population health strategies. It’s very common for hospitals to have agreementsin place with wellness companies, disease management organizations, post-acute care providers andhome health agencies along with primary and specialty care physicians and physician managementgroups. While these collaborations are not groundbreaking, the way in which reimbursementincentives are driving alignment among all care providers is breaking new ground. Ensuring that thebest possible care is received along the care continuum, while preserving reimbursement incentivesrequires an ability to identify and eliminate discontinuity amongst care-givers during transitionsbetween care settings. Closing those gaps requires improvement to care team workflows driven by aheightened awareness of critical patient activity. Most often, promoting broad awareness of patientactivity can be accomplished through better use and sharing of existing data rather than additionallayers of complex workflow.

One common example of such a gapoccurs during the handoff betweenthird-party care teams. Whether it iselements of care being managedbetween post-acute specialty providers,disease management and wellnessprofessionals or home health carecoordinators, often the hospital/healthsystem – the “central hub” for carecoordination – is unable to connect thecare transition data in real or near realtime. Thus they lose the ability tomonitor and effectively manage carefor which it may be at financial risk.

Collaborative Care

Primary Care Practitioner

Specialist

Care Coordinator

H

Admittance

titioneracrPy CrimarP

titionere ary C

Specialist

Admi anctta

Admittance

ortdinaoorCreCa

Reimbursement

incentives are

driving alignment

among all care

providers.

Hospital is the Central Hub for Care Coordination

Closing those gaps

requires improvement to

care team workflows

driven by a heightened

awareness of critical

patient activity.



With emerging care delivery models such as ACOs, virtual integrated delivery networks andother risk-themed models, new partnerships are being formed and disparate workflows arebeing integrated. Additionally, individual entities are no longer solely responsible for just theirrole along the care continuum. With incentives aligned around the complete patient experience,all care providers have elevated responsibility to communicate and share relevant patientinformation with all appropriate care team members.

It’s not hard to imagine that disparate entities coming together to form new integrated careteams bring with them an assortment of EHR capabilities and processes for managing care. It’s at these junctions of care management and information technologies where data gapvulnerabilities exist.

Identifying and understanding where and why these gaps reside is the first crucial step indeveloping an effective care transition interoperability strategy.

How and Where Patient Information Flows in the Care Environment(s)

Through the process of identifying data gap vulnerability inflection points, a clearer picturedevelops regarding how patient data flows throughout the integrated care delivery model.Additionally, it is equally important to understand how workflow among the various care teammembers takes place:

• Can certain tasks be automated?

• If not, can information technology solutions be deployed to enhance productivity and proficiency?

• Are there unnecessary points of duplication where redundancies can be reduced?

3. Implementing solutions that address care team workflow issues

ICA’s CareAlign Connect

Direct messaging and

SmartAlerts

notifications services

address workflow

integration, alerting

and data gap issues.

Data GapVulnerabilities

Working with Upper Peninsula Health Plan (UPHP)unearthed three key elements in designing effectivestrategies for transitions of care interoperability:

1. Identifying data gap vulnerabilities

2. Recognizing how and where patient information flows between care environments

Care Management

+New

Technologies

H

N



Hospital/Long Term Care/ACO Complex Care Continuum Scenario

The graphic below illustrates a complex environment where a health system is connecting an acute care provider, post-acutelong term care facility, a care coordination team, a disease management organization and home health coordinators.

The “Care Coaches” working for the ACO are responsible for ensuring seamless patient transitions from the Acute to Post-Acute settings and from Post-Acute to Home. In this scenario, the health system identified two critical issues that were impacting the patient experience and ultimately outcomes:

1. The case management tool used by the Care Coaches received a daily extract from the hospital’s EMR system so the

coaches knew when a patient was admitted or discharged (although somewhat delayed), but the data did not include the

discharge information the coaches needed to coordinate with long-term care facilities or to follow up with the patients.

2. The Care Coaches had no visibility to when a patient was transitioned from Post-Acute to a home setting or to the

discharge instructions from the Post-Acute care facility.

With SmartAlerts, the coaches are notified in real-time as their patients are admitted and discharged from the hospital. The discharge alert messages includes specified content related to the event as well as the discharge-to location enabling the coaches to effectively engage with the LTC facility staff, coordinating care plans and arranging for patient visits both inthe LTC facility as well as in the home setting if needed.

Figure 1: Complex Care Coordination Scenario

HL7 Feed to theCareAlign platform

Patient Discharged

Daily Digest or real-timeAdmit/Discharge alert for

member population

Digest of memberpopulation activity at

Acute Care facility

Post-Acute contributingHL7 feed into CareAlign

Platform

SmartAlerts Flow

Patient’sHome

Acute CareInpatient EMR

(Siemens, Cerner)Patient Admit and

Discharge

Post-Acute(Home Health, Skilled

Nursing Facility, Long TermAcute/Custodial Care,

Nursing Home, Acute IP, Rehab)

PCP(Any Direct

Access)

• Patient Dashboard• Task Mgmt• Analytics

1

3

4

5

Care CoordinationTools

Care Coaches/Coordinators

MessageSent

MessageSent

MessageSent

Patient’sHome

Care AlignSmartAlerts

2



In this scenario, the ACO is also the Payer. The Care Managers at the ACO were contractually

obligated to meet certain requirements for “Special Needs Plans” as defined by CMS. In thiscase, the Care Managers only view to any of their special-needs patients being seen at anemergency room was a weekly ED Utilization report they received from the local hospitals.

A simple SmartAlerts discharge notification alert with patient demographic data andhospital location was all that was needed to significantly improve the timeliness of theirpatient follow-up contacts.

Without SmartAlertsImplementation

With SmartAlertsImplementation

Memberto ED

ContactMember

WeeklyUtilization

Review by CM

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8

Memberto ED

ContactMember

ED Admit &Discharge Alerts

sent to CM

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8

4 CM aware of patient up to 6 days sooner4 Alert for members are directed to

assigned CMs inbox

Figure 2: Simple Notification Alert Results

Simply bringing

the right care givers

into the process at

the right time can

make a significant

difference.

Payer/ACO ScenarioThere are many less complex, but no less critical scenarios. Effective transitions in care require the efficient and timely handoff ofprimary responsibility for patient care. Simply notifying the care manager that a patient they are responsible for is leaving thehospital or long term care facility allows them to engage with the patient in a timely and efficient manner. This diagram shows theimprovement that was achieved with active alerting based on real time events vs. delayed notification intuited from claims data.

Even a simple notification can have significant impact of patient health.


A Life SavedUpper Peninsula Health Plan’s (UPHP1) care managers are able to engage patients and providers at the moment of thepatient’s hospital admission thanks to SmartAlerts’ notifications.

Patient “John’s” life was likely saved as a result of one such care manager’s intervention. John was very sick when he arrivedat the hospital. As he was being admitted, the SmartAlerts system was notifying John’s assigned care manager at UPHP,who was familiar with his case, medical history, medications, and other relevant information.

The attending physician couldn’t explain John’s symptoms and had noted that he might not make it through the night.John’s care manager was able to quickly intervene, revealing that John had omitted a critical detail in his medications listwhich led the physician to provide the right treatment that ultimately saved John’s life.

Dollars and SenseAll the various stakeholders in the Care Continuum have a vested financial interest in ensuring that patientsreceive the right treatment and post-discharge care the first time, preventing unnecessary readmissions.These readmissions are a burden on the entire healthcare system, tying up resources, capital, and patientsin wasteful activities.

For hospitals, the unnecessary readmissions have a direct impact on their revenue resulting from governmentand private payer penalties and denied reimbursements. Post-Acute care facilities not only face similarfinancial risks, but also face a reduction in directed patients where they are seen as potentially impacting theoverall patient outcome through quality issues.

The advent of ACOs and disease management organizations is a direct response to address some of these carecontinuum gaps. However, they are overhead to the overall health system financial picture so they mustbe operated efficiently to minimize the impact on the bottom line while optimizing patient outcome.

The average cost of an unnecessary readmission is estimated to be more than $11,000. 2 It’s hard toquantify exactly how many readmission events are being prevented, but over time the ACO anddisease management activities can return significant value to both the hospitals and payers.

The UPHP StoryUPHP is currently managing about 450 high-value patients as part of CMS’s sponsored Special Needs Plans (SNP). SNP planmembers are a defined population of high risk patients for which UPHP provides transitions of care support, engaging withthe hospitals, patients and primary care providers. UPHP currently operates with 1 care manager per 100-150 patients. They have recently contracted to provide similar levels of transition support for a much larger (9,000+) population ofMedicaid/Medicare Dual-Eligible patients with a contract value in excess of $200M/year. UPHP simply can’t scale up theirexisting processes that much and is anticipating that effective alerting automation will provide significant efficiency gainsallowing them to increase the ratios without an impact on the quality of services they provide.

According to Dennis Smith, UPHP’s president and CEO, over time, savings from the care coordination activities fueled bySmartAlerts’ timely notifications will be observable in trends in UPHP’s overall cost-per-patient and cost of readmissions.


The average cost

of an unnecessary

readmission is

estimated to be

more than$11,000 .

UPHP is anticipating that effective alerting automation will provide significant efficiency gainsallowing them to increase the ratios without an impact on the quality of services they provide.

2The Healthcare cost utilization project

Readmission

1Upper Peninsula Health Plan provides care management services for Medicaid/Medicare recipients in upstate Michigan.


Addressing Workflow IssuesPrior to implementing a technology strategy, the third critical piece of the puzzle is to understand the ways in which workflows will be impacted by the proposed solution.

Conclusion


Examples of where ICA is closing the data gaps in care transitions:

Mission Point ACO: Upper Peninsula Health Plan:

Make sure the implementation takes into consideration the following factors:

ICA is implementing both our CareAlign Connect andSmartAlerts solutions to address data gaps betweencare coordination teams, post-acute care facilities,home health coordinators and the health system.

ICA is implementing both the Connect and SmartAlerts

solutions to provide insights into Medicaid member emergency

room visits as well providing the ability to coordinate care with

plan members following hospital discharge.

Technology alone

cannot solve issues.

Solutions must be

combination of

people, process

and technology.

1. Does it provide care team members information in ways they need to receive it?

2. Will the delivery of the information allow care teams to make smart, timely care decisions and enhance the patient experience?

3. Does the information delivered aid in the workflow process? (too much information at thewrong time can be as bad as too little.)

4. Does the solution provide enhanced reporting to all care team members allowing them to improve their processes over time?

The stakes have never been higher with regard to implementing effective technology solutions to better manage bothclinical and financial outcomes. With healthcare reform in full swing and a reimbursement environment that places greateremphasis on outcomes and patient satisfaction, healthcare providers are being asked to do more with less.

As we tend to an aging demographic who present with more complicated and chronic conditions, our collective ability toprovide the right data, to the right people at the right time along the complete care continuum has no longer become anice to have – it is an imperative. Identifying and effectively addressing data gap vulnerabilities at care transition momentsmust be taken on with vigor and focus if we are to comprehensively improve care outcomes over the long haul and avoidcostly, unnecessary patient remittance.

SolutionsICA works with hospitals, health systems, HIEs, and payers across the country to identify and solve many caretransition data interoperability challenges. Through our CareAlign Interoperability Platform, our CareAlign Connect –Direct Messaging solution and our SmartAlerts – Real Time Notifications capabilities, ICA provides the vendor-neutralinteroperability solutions that are impacting and helping improve clinical and financial outcomes.

Conclusion

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