Our Thinking


Helping you manage patients after they walk out the door

By Jessica Robinson

Perhaps the biggest risk accountable care organizations (ACOs) and other integrated organizations face to their care quality and financial performance is what happens when their patients walk out the door. Inside an ACO's own walls, monitoring where patients go, who is treating them and what type of care they receive is relatively transparent through the electronic health record (EHR) - and seamlessly analyzed through The Garage's population health management platform, Bridge.

However, after patients receive a referral or are transitioned to another level of care, such as a skilled nursing facility, specialty hospital or home health, it can be time-consuming and costly to track care activity and outcomes.

The Garage is helping our clients manage this care outside their four walls with several new product updates to Bridge. Here's a rundown of the major highlights:

  • Referral management. Our referral management module update will help our clients identify preferred practices, hospitals and ancillary providers in their network to ensure seamless data-sharing and communication. Once identified, our clients will be able to better monitor patient activity after referrals to record care delivered, or to determine why the patient didn't complete the visit or why the patient received care from another provider.

    Another important element of referral management is to help these other members of the ACO's population health management ecosystem participate in the shared savings earned from this collaboration. This update is particularly crucial to participants in Medicare's Next Generation ACO program who have already established shared savings agreements with providers in their network.

  • New network utilization reports. Similarly, recognizing how important network care utilization is to ACO care quality and financial performance, we developed a higher-level report for our clients so they can measure the impact of referrals to ancillary providers in their communities. With our new report, users can quickly determine how many days of service patients receive from local skilled nursing facilities, hospitals, or home health providers. By quickly comparing organizations, ACOs can identify high utilizers and inquire with those organizations' administrators about length of stay or service and manage their behaviors.
  • Campaign management: Helping patients engage in their care is just as important, if not more important, to ACO performance as the care they receive from other providers. That's part of the reason why our campaign management module update allows clients to automatically send and track emails to patients concerning preventive care such as wellness visits, flu shots or annual vaccines as well as other reminders. For example, if an ACO refers a patient to a preferred physician and does not receive an appointment confirmation within a designated timeframe, they can send a reminder email to encourage patient adherence to the provider's recommendation. They can also send targeted messages to high-risk or near-risk patients about care access opportunities, such as office after-hours availability, so the patient is reminded to avoid accessing the emergency department for non-emergency care.

Those are just a few highlights of our updates from the first half of this year. Stay tuned this summer and in the second half of 2018 for news about our Garage 5.0 update, which will include new artificial intelligence functionality and automated browser updates.

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