Delivering Successful Care Coordination: Creating the IT Foundation for Accountable Care (Part Two)

Oct. 7, 2013
In part two of a five-part series on creating the IT foundation for accountable care, Joseph M. Taylor, vice president and ACO practice leader at the Wayne, Pa.-based FluidEdge Consulting firm, addresses the topic of “The Office and Patient Workflow, Including Integrating the Role of Care Coordinators.”

Last week, HCI Editor-in-Chief Mark Hagland interviewed Joseph M. Taylor, 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 the first section of the article, which followed Hagland’s interview with him, Taylor addressed the topic, “The key elements needed to identify and stratify patient populations.” In the second section, published here, Taylor addresses the topic, “The Office and Patient Workflow, Including the Role of Care Coordinators.” The remaining sections will be publishing in the coming days.

Joseph M. Taylor

The Office and Patient Workflow, Including Integrating the Role of Care Coordinators

An ACO patient may be assigned to a “Personal Physician” on the existence of only one office visit over the last 12 or even 24 months.  Generally, today a physician sees an “Attributed Member” or patient only when the patient reaches out and makes an appointment with that physician.  Many EMR’s are not loaded with full health history and the payer data is likely contained in a different system than the EMR if the physician is provided the payer data at all.  The Personal Physician may be provided a monthly patient “roster”.  Due to lack of process and staffing constraints prospective patient outreach is seldom undertaken.  In the meantime, life happens between those office visits.  The patient could have had no other health care interactions or they could have been to the ER, Urgent Care Center or even hospitalized.  The patient could have seen other doctors, been prescribed new medication and/or stopped taking existing medications.  They could have switched jobs, insurance companies or changed their diet and exercise habits.

On the payer side the scenario works something like this - After a 9 hour day of work, a 30-60 minute commute, and discussing the day’s events with loved ones, the “member” sees a letter in the mail in-between the car payment and the electric bill.  This letter describes “Friendly Commercial Insurance Company’s” care management programs that are “available” to use.  When the phone rings later that night during their favorite TV show or the next morning at work where co-workers may be able to overhear, the member is excited to answer the call.  The member can’t wait to discuss with some distant nurse that they never met before their entire health history and listen to the nurse’s predefined 45 minute script and questionnaire.  They are eager to improve their lifestyle and make significant changes right away.  After a few calls over the next few months which get missed and rescheduled, they achieve long term behavior change and significant improvement to their health status. 

Okay, so I may sound a bit jaded; however, neither of these two scenarios are far from the truth, and yet we wonder why things are the way they are. 

So what do we do?  We have to learn, embrace and understand the past and improve the current methods.  Successful physician driven, nurse executed, Care Coordination needs to understand today’s care management approach reality and incorporate the promise of tomorrow.  Today’s Care Coordination needs to change the paradigm or we will be destined to continue to achieve today’s results. 

It isn’t as difficult as it may seem to improve on today’s payer-based nurse call, member mailing care management approaches.  After identifying and stratifying the patient population (with the more robust and timely data sources discussed earlier), we have to leverage the greatest factor we have available to us today and empower it.  This greatest factor and largely underutilized factor by health plans is the physician/patient relationship.  In a physician driven, nurse executed Care Coordination environment, workflow and integration happen something like this:

The Personal Physician is alerted (in their EMR or from nightly payer reports) that their ACO attributed patient had an ER admission last night for a given diagnosis.  The Personal Physician sees that this is a patient who hasn’t been in the office for 6 months and who previously was not part of the ACO contact with the payer.  However the patient is now part of an ACO relationship and now falls under their new enhanced Care Coordination program.  The physician instructs their staff to call the patient and set an appointment for the patient to visit the doctor within the next 3 days.  At the visit, the patient’s Personal Physician evaluates the patient, looks at the combined payer and EMR data and the associated analytics in their dashboard.  They decide that the patient needs to focus on several things and tells the patient that while checking out from the visit, they will need to set up an office visit with the doctor’s Care Coordinator. 

At the Care Coordinator’s appointment; together, the Care Coordinator and patient review the doctor’s orders, talk about problems, barriers, interventions and goals.  Together they design a more detailed care plan for the patient to work on until the next appointment.  It includes achievable near term and longer term tasks and goals.  They review current medication and work with a staff pharmacist to optimize the medication list and cost.

The first few visits are in person, at the office and more frequent based on needs identified in the discussion with patient, lab values, analytics and confirmed treatment opportunities.  Over time as goals are met the frequency decreases. Later the visits leverage “telemedicine”.  Visits happen “in person”, but over the internet utilizing the latest technology.

If the Care Coordinator sees that the patient is continually non-compliant over a time period and their health status is not improving or perhaps getting worse, the Care Coordinator “refers” the patient back to their Personal Physician.  The Personal Physician conducts a visit where together the patient, doctor and Care Coordinator reset the care plan and discuss how to stay committed to achieving the goals.  The Care Coordinator also leverages behavioral health specialists and community resources as needed.

In this model, initial patient engagement is much higher than in payer-based programs.  This is because the patient’s Personal Physician, their chosen and trusted health care professional, told the patient to set up the visit with the Care Coordinator at the conclusion of the office visit.  In addition, the office visit workflow drives setting up the initial Care Coordination visit as the office staff is also aware of the patients need’s and doctor’s request.  The staff sets up the appointment as part of the checkout process with the patient and provides reminder prompts to ensure the appointment is not forgotten, much like we do in dental care today.

As the Personal Physician explains the role of the Care Coordinator and how they are an extension of the doctor, the Care Coordinator quickly gains credibility from the patient. They are seen as part of the doctor’s integrated team. 

The Care Coordinator builds additional trust with the patient through the office visits and in person interactions.  Actual behavior modification over time is more easily observed from the in person visits and the use of technologies that incent and measure behavior modification and goal completion.  In addition, while working with the payer as part of the ACO/PCMH contracting process, plan designs for all ACO and PCMH patients are enhanced to include the reduction in monthly healthcare contributions based upon positive lifestyle changes, reduced risk behavior and/or improved medication compliance (e.g. if you regularly attend a gym, or if you stop smoking member/patient monthly payroll deductions are reduced).  Technology is leveraged to streamline costs and save time for both the patient and ACO team

The Care Coordinator supports the doctor and their entire ACO/PCMH patient load.  Their role and involvement is adjusted by the patient’s health status, severity, reported clinical alerts and prospective medical resource utilization, optimizing the use of this valuable medical resource. 

High level ACO/PCMH office visit roles are:

  • Front Office
    • Health history and medication list electronically entered / updated
    • Eligibility and benefits retrieved
    • Personal Health Record retrieved
    • Patient responsibility estimated
    • Collect any outstanding balance
  • Intake Nurse
    • Take vitals and confirm reason for visit
    • Confirm patient data in EMR and patient 360 view
    • Review medication list and compliance with patient and update as needed
    • Review other physicians and providers seen and facility usage and update as needed
    • Review and confirm analytic results  from risk reduction and potential treatment opportunities presented by the system
  • Physician
    • Daily “High Alert” patients presented
    • Review Summarized Medical History presented for ACO patients (including: real time payer data, pharmacy, labs, images, EMR and HIE data)
    • Review, confirm, and address risk reduction and potential treatment opportunities presented by the system (with bidirectional interface)
    • Perform Medication Reconciliation as needed
    • Review Medication Therapy Management (MTM) results presented, Rx programs, submit prescription to pharmacy (e-Rx)
    • Referral to Care Coordination with patient agreement to instructions and/or Specialists as needed
  • ACO/PCMH Care Coordinator
    • Daily “High Alert” patients presented
    • Design Medical Home / ACO patient Care Plan (including problems, barriers, interventions and near term and longer term goals)
    • Educate patient and provide appropriate tools, micro incentives and literature
    • Conduct Medication Therapy Management (MTM) (if no pharmacist is available)
    • Schedule follow-up appointments
    • Review patient progress reports between visits and conduct outreach call as needed
    • Provide referrals as needed (back to PCP, specialist, behavioral health, community resources, etc.)
    • Conduct population management and campaign management
  • Patient Check Out
    • Submit claim (including attachments)
    • Adjudicated claims in real-time (incentives earned)
    • Collect outstanding balance (co-pay, member liability estimate,  or previous visit)
    • Provide patient materials as instructed by doctor and/or care coordinator
    • Schedule follow-up appointment with care coordinator, PCP and/or Specialist
    • Submit referral if needed
    • Trigger follow up reminders
  • Billing – workflow based on system used and EMR, patient Management Tool integration

Part Three of this five-part article series will address the topic, “The Expanded Collaboration Role Between Different Members of the Broader Care Team.”

Sponsored Recommendations

Healthcare Rankings Report

Adapting in Healthcare: Key Insights and Strategies from Leading Systems As healthcare marketers navigate changes in a volatile industry, they know one thing is certain: we've...

Healthcare Reputation Industry Trends

Navigating the Tipping Point: Strategies for Reputation Management in a Volatile Healthcare Environment As healthcare marketers navigate changes in a volatile industry, they can...

Clinical Evaluation: An AI Assistant for Primary Care

The AAFP's clinical evaluation offers a detailed analysis of how an innovative AI solution can help relieve physicians' administrative burden and aid them in improving health ...

From Chaos to Clarity: How AI Is Making Sense of Clinical Documentation

From Chaos to Clarity dives deep into how AI Is making sense of disorganized patient data and turning it into evidence-based diagnosis suggestions that physicians can trust, leading...