By the start of the third quarter of 2019, there were nearly 1,600 existing public and private accountable care organization (ACO) contracts throughout the U.S., covering almost 44 million lives. For these organizations to ultimately be successful, one of the key elements will be to coordinate team-based care. To date, however, putting timely information on patient care in the hands of the most appropriate providers to deliver it has proven challenging.
In Sioux Falls, S.D., Avera Health is a full-spectrum regional healthcare family providing services to a population of nearly 1 million people. Avera participates in several Medicare Shared Savings Program (MSSP) ACOs, one of which is Prairie View Care Organization ACO. Candice Friestad, DNP, assistant vice president, clinical informatics, at Avera Health, recently spoke to Healthcare Innovation about core ACO challenges, the IT elements needed to connect care team members within an ACO, and how efficient communication leads to better patient experience and an increased ROI of an accountable care model of care. Below are excerpts of that discussion.
Broadly, can you describe your MSSP ACO journey? What have been the biggest lessons learned?
The bulk of our work is in a five-state area, but our e-telehealth services cover more than 23 states now. We are headquartered in Sioux Falls, and if you look around our region—at some of our regional facilities and our long-term care facilities—we cover a span of close to 500 miles, and a lot of that [area] is rural. Looking at the ACO opportunity, we had to figure out how we could cover all the [patient] lives and not lose money. So we ended up starting small, with a few different ACOs [that had] smaller footprints. We started one that had 20,000 covered lives, and then a second that had between 30,000 and 4,000 covered lives.
Two years ago, we decided to condense those separate ACOs into a large risk-based ACO. We live in a bit of a competitive marketplace in that we have another healthcare system that competes for those lives, but that [health system] doesn’t have an ACO. With our risk-based ACO, as we started to [think] more about how to minimizes costs, we looked closer at immunizations, and we started making sure our physicians were documenting appropriately.
We also have a few long-term care facilities that are [rated] 3 stars or higher. As a risk-based ACO, one thing we can do to help the revenue stream of our hospitals is that if a patient comes into the ER and meets certain criteria, we can skip the three-day hospital stay requirement [that was mandated by CMS] before you actually entered into a nursing home. [CMS’ skilled nursing facility, or SNF, 3-day rule waiver allows eligible SNFs that have partnered with an ACO to bill Medicare for certain patients’ care, even if they haven’t had a prior consecutive three-day inpatient hospital stay before being admitted].
So we could then care for patients [who go] from an urgent care clinic or ER directly to an SNF as long as that facility is 3 stars or higher. We have put that in place with some strict communication tools that enable this to happen. For one, we have a secure texting platform from [healthcare communications company] Voalte deployed throughout our whole footprint. So, for example, if a primary care physician has a patient in a rural area, and we have a hospitalist versioning of [this situation] in one of our larger facilities, that hospital can securely text to the primary care physician in the smaller rural facility to say he or she is sending the patient home—assuming they aren’t going to a SNF— and you can expect to see them within a week. So we can make sure we are staying in touch with the patient if they’re part of our ACO footprint.
Care coordination and ACO success seems to go hand-in-hand. Can you detail the IT elements needed to connect case managers, social workers, providers, pharmacists and others at the ACO and throughout the system’s other facilities?
[Several years ago], our nurses in one of our large facilities told us they were tired of carrying a pager in addition to a wireless phone; they said it felt like a toolbelt on them. We looked out in the marketplace, and didn’t find a lot outside of Voalte, so we started working on deploying that tool [in our largest] facility first. That included alarm integration, cardiac monitors, and integration with our nurse call system and with our EHR. We [eventually] realized that this is a great [option] to securely text or call, so we built a directory around that.
One example of [how this is leveraged] would be a nurse who is doing a home care visit. That nurse can quickly look on the directory and securely communicate about the patient. We have also integrated an HL7 ADT [feed] so that it’s easy for a physician to look online to see where the patient is [located] at Avera, which room they are in, and also be able to see who are the nurses, pharmacists, social workers, case managers, and others attached to the patient. This way, I can have a quick discussion with any of those people about the patient’s needs.
How are analytics being leveraged?
The first low-hanging fruit [items] we did with this communication tool were around discharge and length-of-stay. With this tool, whenever the patient has a discharge order, it sends that information to the same smartphone, to each the pharmacist, nurse, case manager, social worker, and [others] on the care team. The tool blasts [the data] out all at once with discharge details, so then we can work on getting the patients out sooner.
We also have a dashboard that allows us to see when the patient’s last immunization was, their last diagnosis, what their problems are, [enabling us] to follow-up. So if they are due for [a treatment], we can get them into the clinic or see them using our home care system. We also have a nurse navigators making phone calls to check in. And we can do virtual visits with American Well’s telehealth platform.
What are some core ACO challenges Avera still needs to overcome?
By 2022, 20 percent of the U.S. population will be over 65 years old. In that same year, there will be a need for [more than] 1 billion more nurses than what we’re able to educate. So those two sobering stats, from a demographic perspective, are very telling as to why we got into the ACO journey to begin with. How do we deal with the healthcare dilemmas we have right now given that the infrastructure is not what it is in Canada or the U.K.? So we are trying to figure out the best landscape and how much government help we are going to get. We have to figure out how to survive for the next 100 years while delivering great care at a decent cost, and also maintain the number of great professionals we have working for us.
