3 ways to make your population health ecosystem more transparent

By Jessica Robinson

The population health ecosystem can be massive. When patients acquire more chronic conditions, their movement within the ecosystem is more active as they more frequently visit specialists, hospitals, rehabilitation therapists and skilled nursing facilities, among other providers.

The challenge for accountable care organizations (ACOs) and other clinically integrated networks (CINs) is monitoring where these high-risk patients go in the ecosystem. After all, while you're sure you deliver optimal care, there may be providers or facilities outside your preferred networks where quality, and even safety, is unknown.

CINs need visibility and transparency into patient movement through the ecosystem to ensure good outcomes, but also to protect the bottom line under value-based care reimbursement models. Managing referrals and staying updated on patient activity in the ecosystem is time-consuming. Advanced population health management technology, however, is automating not only data capture and analysis, but also patient and referral outreach. Here's how:

1. Avoid emergency surprises.  Even within integrated networks, avoidable emergency department (ED) visits and hospital readmissions are common. One study pinpointed 52 percent of admissions were avoidable, which greatly contributes to hospital and ACO costs and can trigger penalties under the Centers for Medicare and Medicaid Services' Hospital Readmission Reduction Program.

Sophisticated PHM technology, such as Bridge, can automatically alert physicians or care managers when a patient arrives in the emergency department. It can also automatically e-fax the relevant ED with physician contact information to help the patient receive needed care if the triage nurse or attending physician determines it does not require hospitalization or emergency department resources. Likewise, ACO participants are expanding after-hours, same-day or walk-in clinic availability at their facilities to help EDs divert patients to a more appropriate care venue when their complaints do not require an urgent intervention.

2. Keep patients on your radar.  Another way ACOs and CINs are better monitoring patient movement through the ecosystem is strong referral management. Integrated organizations participating in value-based care payment programs have worked to establish referral relationships with preferred providers and facilities, vetting their quality and cost performance. Although it is always up to patients where they seek care, it's in their and your best interest that they stay in your preferred network.

Once they walk out your door, the ACO may not find out where, or if, the patient received care until the organization reviews charges attributed to their beneficiary. Advanced PHM technology can be integrated with all providers and facilities in the preferred network, even if they're not directly participating in the ACO program. When the patient completes the appointment with the preferred provider, the CIN is automatically notified that the care was completed and data from the appointment is electronically transferred. This alleviates care managers from manual follow-up by phone and/or fax.

3. Communication is vital.  A third time-saving and engagement-building automation is with patient outreach. When a patient doesn't complete a referral appointment as scheduled, the care manager receives a notification. The PHM platform will then send an SMS text message, phone call or secure electronic message to the patient about the missed appointment. This outreach demonstrates to the patient that the organization cares about their health while the provider learns more about potential care obstacles, such as lack of transportation or care-plan education needs. If the patient sought care from a non-preferred provider, the care manager can obtain those records sooner and learn more to determine if the provider should be added to the preferred network.

While the population health ecosystem is large, and getting larger as more patients are using telehealth, monitoring their activity and staying updated about their care doesn't have to be a massive, time-consuming effort. Through intelligent, highly automated population health management platforms, such as Bridge, CINs can have complete transparency into their healthcare ecosystem.

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