Integration and identifying riskiest patients should top ACO wish lists

By Jessica Robinson, VP of Product Management and Delivery

The holiday season is a time of family, friends, and, of course, presents. If you have children, they may have given you (or texted you) a wish list of gifts they want to receive this year.

Accountable care organizations (ACOs) and other clinically integrated networks (CINs), however, also have wish lists for the holidays. Instead of presents, the items are likely goals they hope to achieve for their organizations and their patients in 2018. In that spirit, we have pulled together a few most sought-after goals at the top of many ACOs and CINs' wish-lists this year:

1. Data integration. All ACOs have electronic health records (EHRs), but perhaps not on the same platform, which can pose time-consuming and costly data integration challenges. For population health management (PHM), data integration is essential so that providers have a comprehensive, accurate and timely perspective of their at-risk populations. Choosing a PHM platform that can be easily integrated across multiple EHR systems can help ACOs avoid an EHR integration challenge while gaining unprecedented and actionable clinical insight.

2. Hospital ADT access. Similarly, accessing the admission-discharge-transfer (ADT) data concerning patients attributed to the ACO is crucial to prevent care gaps and readmissions. Since some ACOs do not have a hospital participant within their agreement, real-time access to a community hospital's ADT system can be difficult. As a result, patients can receive duplicative or unnecessary testing in the hospital, which increases costs for your attributed patients. An integrated PHM platform that seamlessly and automatically syncs with a hospital's ADT system feed can update your ACO's providers and prevent patients from receiving wasted care.

3. Identifying at-risk patients. The first two list items and this one go hand-in-hand because without enterprise-wide, normalized and reliable data , identifying at-risk patients is not feasible. In 2018 and beyond, however, ACOs need to progress beyond tracking high-risk, high-need patient populations to those who are on the cusp of that level. Identifying those patients and intervening before an avoidable ambulance call, emergency department visit or readmission can be the competency that truly helps ACOs become high-performing CINs.

4. Telehealth. ACOs that are intent on reducing care costs and improving patient engagement in 2018 need to put telehealth on their wish list. Telehealth, whether that is through virtual visits or live text messaging , can be an immediate and effective intervention method with some of these near-high-risk patients. Telehealth also helps overcome some social determinants of health obstacles, such as transportation difficulties and disabilities that prevent patients from adhering to their prescribed care plans. The good news is Medicare reimbursement regulations surrounding telehealth are loosening, especially for ACOs, so next year is a great time to get started.

5. Transparency. Regardless of the care venue-at home or at the hospital-the patient's entire care journey needs to be transparent to ACOs. Transparency ensures that patients are not only adhering to care plans, but also that other providers are delivering care in an evidence-based, cost-effective manner. Patients, too, require transparency so that they can easily access and understand their care plan, overcome adherence obstacles and understand what they are being charged for and why.

It's not a long wish list for next year, but it could nonetheless be quite challenging to achieve in just 12 months. However, with an advanced PHM platform and properly designed care management workflows, ACOs might be checking off more wish list items by the end of 2018 than they expected.

Want to learn more about how The Garage can help you cross off all your population health management wish list goals next year and beyond? Please contact us today at info@thegaragein.com or give us a call at (407) 730-2286.