Delivering Successful Care Coordination: Creating the IT Foundation for Accountable Care

Oct. 6, 2013
Joseph M. Taylor, vice president and ACO practice leader at the Wayne,-Pa.-based FluidEdge Consulting, has produced an in-depth examination of the issues surrounding the foundation-laying for accountable care organizations. Healthcare Informatics will be publishing the complete article in a serialized form. Here is section 1, along with an introductory interview with HCI Editor-in-Chief Mark Hagland.

Joseph M. Taylor is vice president and ACO practice leader at the Wayne, Pa.-based FluidEdge Consulting firm. Taylor, who is based in Dallas, works with a total team of more than 60 healthcare consultants, where he specializes in helping senior healthcare executives to prepare for and develop accountable care organizations (ACOs). Taylor has written a highly granular article, “Delivering Successful Care Coordination,” which the editors of Healthcare Informatics have decided to publish in five segments, in order to give our readers the full benefit of its granularity. In this first section, Taylor addresses the topic, “The key elements needed to identify and stratify patient populations.” In the next couple of weeks, additional sections will address “The office and patient workflow, including integrating the role of care coordinators”;  “The expanded collaborative role among different members of the broader care team”;  “Tools to empower the care coordinator and track patient progress between visits”;  and “Reporting the outcomes needed to demonstrate success.”

HCI Editor-in-Chief Mark Hagland interviewed Taylor recently regarding this important article, and some of the overall strategic implications involved in laying the strategic and strategic IT foundations for accountable care organizations. Below are excerpts from that interview, followed by the first section of the article itself.

What made you decide to write this article?

What I was trying to get at here was trying to put into words a lot of the concepts and the things we’re talking to our ACO clients about, in terms of how to put together a successful care coordination program, in order to achieve ACO success.

Joseph M. Taylor

One of the challenges in ACO development is that the people, processes, and technology seem to be organized differently in every patient care organization, correct?

Yes. And there are four critical success factors here. The first is to incorporate, which means data integration. The second one is understanding, which is analytics and actionable information. The third one is act, which is care management, which is care coordination, and related activities. And the fourth is report, which is being able to demonstrate results. So the paper really goes into that. There are a couple of bullets focused on the workflow, the care coordination, the care team, and how to empower processes with tools. But really, I’m focusing on those four themes, with a little bit of extra detail on the “care” part.

We’re so early in the process of ACO development that it reminds me of the early history of the car, when no one knew how to drive, and there were terrible car crashes all the time. It feels as though everyone’s trying to invent fire at the same time here, in some ways.

Exactly. And you can perform these tasks in different sequences.

In the four areas you mentioned above, where are people and organizations the weakest, in general?

Lots of people have data, but they don’t always have it integrated, and can’t always turn it into actionable information. And in care management, they have a lot of talented people, but don’t have their organizations architected to support care management, or the tools needed to execute it. And in terms of documentation, even if you’re doing all the right stuff, will someone pay you for it, if you can’t document it correctly? Those are where the pain points are.

What is the core of your advice, as organizations begin to move forward in this area?

I think it’s really to plan. I think President Lincoln said something like, if I have six hours to cut down a tree, I’ll spend four hours sharpening my ax. So, put in the right plan, make it pragmatic, and deliver results and success measures along the way, so you’re not spending three years building something out. Build things incrementally, and document success along the way, and support your teams on the care delivery side and on the administrative side.

In other words, don’t try to boil the ocean?




Delivering Successful Care Coordination

By Joseph M. Taylor, FluidEdge Consulting

Care Coordination is not a new concept; however, it is being reinvented to meet the increasing demands of healthcare today. Personal physician driven, nurse executed, Care Coordination models will continue to evolve. It is the main intersection between informed care management and patient engagement within today’s new alternative payment models.  The new reimbursement models place increasing financial risk (and gain) directly on those for whom the patient is “attributed”.  Real world success or failure for Accountable Care Organizations (ACO’s), Patient Centered Medical Homes (PCMH’s) and physician-driven chronic condition and case management lies in the ability of their Care Coordinator’s to collaborate with the rest of the team and their understanding of the complexities and their relationship with their patients.

To go in-depth on the entire ecosystem of successful care coordination would entail writing volumes so let’s fast forward to the state we are in today in US Healthcare.  In doing so, I will focus on five (5) key areas over the next few weeks:

> The key elements needed to identify and stratify patient populations

> The office and patient workflow, including integrating the role of Care Coordinators

> The expanded collaboration role between different members of the broader care team

> Tools to empower the Care Coordinator and track patient progress between visits

> How to report the outcomes needed to demonstrate success

The key elements needed to identify and stratify patient populations

Every day it seems a new study is released that shows the US population is living less healthy lifestyles, therefore getting “sicker” and consuming more resources than ever before.  We hear of dramatic increases in the rates of obesity, heart disease, and diabetes.  The number of individuals who have multiple chronic illnesses such as high blood pressure, high cholesterol, congestive heart failure, coronary artery disease etc. is growing.  The prevalence rates of depression, stress and stress related illness, Attention Deficient Disorder and ADHD continue to rise.

While overall life expectancy continues to improve, the population has a higher burden of illness and is worse off or “sicker” today than it was 5, 10, 25, years ago.  To meet the new levels of medical resource need today’s health care professionals require new and better ways to identify, stratify and address patient populations.  The use of 30-60 day old payer-based administrative paid claims data such as medical, pharmacy and lab events data is not sufficient or timely enough to meet patient’s care coordination and outreach needs.  Given current Electronic Medical Record (EMR) penetration and lack of interoperability between EMR’s, single system physicians and hospitals EMR only data does not provide a comprehensive view into the patient’s health care consumption. The EMR represents only a small portion of the patients total medical system usage.

Meaningful and accurate prospective outreach is absolutely necessary if we are to impact the long term medical cost increase, slow disease progression and reduce chronic condition prevalence rates – overall improving outcomes.  In addition, better use of critical resources that are currently in or soon to be in short supply and high demand is required given the looming physician shortages, especially in Primary Care.  Patient selection is evolving from fighting the known “burning fires” and addressing potential care gaps 30-60 days after the event, to an informed prospective patient selection and outreach for preventative care or early treatment.  Today’s prospective patient selection criteria and predictive measures have higher credibility than traditional paid claims based prospective stratification methods.  Armed with additional and robust data sets from EMR’s and advanced analytics, we can conduct meaningful preventive activities.  This powerful combination of new data sources and reduced data latency provides more accurate patient stratification; reduces “alert fatigue” and provides for meaningful prospective patient outreach as well.

The emerging leading edge approaches combine:

From the payer:

> Medical claims data while improving their data latency issues

> Near real time pharmacy data

> Key lab tests with their corresponding results

> Recent radiology events

> A listing of recent medical events (Physicians seen – including phone number, Hospitalization data, Urgent Care and Emergency Room usage and diagnosis)

From the ACO/PCMH and their EMR systems:

> Recent diagnosis and laboratory values

> Listing of prescribed pharmaceuticals, complete with Medication Reconciliation

> Recent radiology tests and their images

> Admission, Discharge, and Transfer (ADT)  

> Discharge Summaries information

At some point, based on each market’s evolution, EMR data from all physicians and providers, including alternative providers, will be available through the local and regional HIE’s.  Soon patient preference / social data will also be added which will enrich the understanding of patient behaviors and enhance both the predictive capabilities and patient outreach and prevention services.

The combinations of these data elements provide medical professionals new and additional needed insight and understanding about their entire patient population.  Until recently, this was not able to be provided.  Today we can have the important conversations around case selection criteria and staff allocation which are more “information enabled” than ever before.  We can evaluate with a complete and more robust understanding of who the appropriate patients are for:

> Population based “gap closure” approaches to optimize HEDIS, ACO, STARs, PQRS etc. measures and Medicare/Commercial payer performance rankings and reimbursements

> Patients who need Medication Therapy Management, poly-pharmacy management, and specialty pharmacy management

> At-risk populations suited for health promotion and health education approaches and coaching,

> Patients who would be served best by single and multi-chronic condition management, with corresponding potential treatment opportunities to focus the Care Coordinator’s efforts and conversation with their patients

> Patient populations who need discharge planning and readmission avoidance planning (starting at the date of admission)

> Patients best served by case and intensive case management

> Those who need end of life care.

Given these new powerful methods, tools and data sources ACO’s and PCMH’s can evaluate and define their “right balance” between both traditional and prospective case selection based on their staffing ratios and contractual provisions.  Leveraging all the above, we can quickly and more accurately identify the critical situations that need to be addressed right away, those who have a high probability of near term high medical resource consumption and those who are best served by campaign and population management approaches, thus optimizing the use of constrained medical resources. 

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