Real-time Data Improves Care Coordination, Value-Based Care

At Allegheny Health Network, providers use real-time data and analytics to follow patients throughout the healthcare system, a big step towards successful care coordination and value-based care.

Patients can easily become lost in the healthcare system. A patient moving from the emergency department to an inpatient hospital stay then to a specialist and finally following up with their primary care provider can be complicated. Follow-up care can be delayed or non-existent. But this only increases a patient’s chances of ending up back in this cycle.

Some studies have even shown that care coordination can improve cost savings up to up $296 per member per month, making it impactful to the two key elements of value-based care: improving patient outcomes and decreasing costs of care.

So Allegheny Health Network decided to implement a real-time analytics platform that has allowed the organization to deliver on its value-based care goals.  

“A nurse would come into the office in the morning and manually either go into our EHR or physically contact the different hospitals or skilled nursing facilities where we know we had patients,” Bill Johnjulio, MD, chair of Allegheny Health Network primary care institute and medical director of physician partners of western Pennsylvania told HealthITAnalytics.

“We know if we provide a better transition to care management for our patients, we have a greater chance of keeping them from repeat returns to an emergency room, a hospital, or a skilled nursing facility,” he continued.

While coordination efforts can be done manually with data searches and follow-up phone calls, this can be tedious and increases the workload for frontline staff and administrators.

But Allegheny’s new care coordination platform allows the organization to identify patients in need of follow-up care in real-time.  

“The CarePort platform takes all that manual detective work away. We have patient lists from any emergency room, skilled nursing facility, or hospital that has the admission discharge and transfer information automatically accessible to our practices in an electronic file basically the moment it happens,” Johnjulio continued.

The platform allows Allegheny to track their patients across the healthcare system. When a patient leaves one facility, their provider is notified immediately to schedule a follow-up care.  

“Patients have a much greater chance of answering a call when it’s from their practice and they have a greater chance of getting care that can prevent a repeated need for unnecessary care,” Johnjulio said. “We have a great ability to impact waste through reducing readmissions or revisits to the emergency department.”

A recently discharged patient might receive calls from the insurer, hospital, specialist, and primary care provider. But one integrated platform allows this process to be streamlined, removing a lot of confusion from the equation.  

Still, clinics streamlining follow-up care visits require an increased staffing to support these endeavors.  

“We’re increasing the proper level of staffing with nursing and health coaches,” Johnjulio said. “We’re moving to a team-based care model and introducing extended care team members to include behavioral health consultants, pharmacy, nutrition, and social work.”

This wrap-around care support is a key element to the success of value-based care.

“When you contact your patients and get them in, not only is the patient getting a benefit, but the practitioners are receiving a benefit of a higher credit or a financial reward for those visits,” pointed out Johnjulio.

Reducing unnecessarily emergency room visits or hospitalizations is a common quality metric in value-based contracting, so Allegheny is using this metric as a measure of success for the care coordination platform.

“The number one measure we’re going to be watching is the 30-day readmission rate,” emphasized Johnjulio. “We know anecdotally in other places where they’ve increased their transition of care that their readmissions went down.”

Throughout the course of 2019, Allegheny’s number of transfer-of-care visits has doubled. This demonstrates that more patients are receiving the necessary follow-up care they need after a hospitalization or emergency department visit.

“We know that when we do these transition of care visits properly, we reduce the readmissions, which is high dollars of waste. It really does fit well into a value-based agreement model,” Johnjulio noted.

An overall culture change helped Allegheny succeed in this model, he continued. The clinic brought in individuals who were trained in change management to discuss the changing workflow. Rather than enforcing new habits, the change management team worked with the staff to understand how increased patient flow would impact their responsibilities.  

“It’s a fun thing to watch when the physicians, staff, and advanced practitioners get it and start to take control,” Johnjulio concluded.  “Then we see things happening in their offices that we didn’t even think of that the providers think of to keep patients out of the hospital or engage them in medication adherence.”