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

Oct. 24, 2013
In part four 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 “Tools to empower the Care Coordinator and track patient progress between visits.”

In part four 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 “Tools to empower the Care Coordinator and track patient progress between visits.”

In the previous three parts of the series, Taylor addressed  the topics “The key elements needed to identify and stratify patient populations”; “The office and patient workflow, including integrating the role of care coordinators”; and “The expanded collaboration role between different members of the broader care team.”

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

A practical observation prior to going into a more detailed discussion on “tools and vendors”: For years I have attended and spoke at industry events such as AHIP, HIMSS, CCA, ACO, Care Management, and Predictive Modeling National Summits.  These events are funded in part by vendors who show off their latest products.  Their mission is to tell you about all the great things they can do, get you to consider their product and hopefully to buy from them.  Each sales cycle they show you the latest and greatest and talk about their new partnerships.  However, when you ask about what they were selling last year and what traction it got in the market, the comments I most often hear are “well, we are focused and 100% committed to this new product” or “we have a new strategic direction that I would love to talk to you about.”  One has to wonder if last year’s latest and greatest didn’t materialize, will this year’s?

Some of this “space” is new and leading edge.  There are emerging vendors with new and exciting concepts and products which have an intriguing value proposition.  Evaluating which tool(s) and vendor(s) could potentially be leveraged by your ACO/PCMH, how they fit into your strategic plan and how they can help you improve your market position and meet your strategic goals is paramount.

Remember to venture into these waters carefully; there is some “vapor ware” out there!  Conducting a well thought out vendor selection process including detailed due diligence can help met your goals save a lot of headaches later on.  Understanding what is really available and when “it” can be delivered, and who has a successful implementation either in place or underway is critical. 

The Needed Tool to Empower the Care Coordination Process

So, you hired the perfect Care Coordinator. You updated the office visit workflow to support your care coordination process and your EMR is able to meet Stage 2 Meaningful Use requirements.  The check-in, check-out and back office staff are all on board and supporting the new process.  The Care Coordinator is trained on and has logins for the EMR system.  You believe you are ready to deliver the best care coordination in the industry.  Well, not quite yet.  Successful coordination needs to be empowered by the appropriate tools designed to integrate data, identity patients, develop patient specific care plans which engage and educate the patient, track their progress, and report the needed outcomes.  Broadly the tools fall into five (5) categories:

  • Data Integration Tools
  • Patient Identification and Stratification Tools
  • Care Planning and Coordination Tools
  • Patient Engagement Tools
  • Reporting Tools

Tool 1 – Data Integration Tools

Not many ACO’s / PCMH’s have fully integrated the data from their own EMR’s, the various payers they are contracted with, the local or statewide HIE and patient preference data.  In many cases today, two or more of the needed data sources are not connected as part of an ACO’s/PCMH’s toolset.  There are other data integration points as well.  There is a need to integrate data and meaningful information to and from the selected Care Coordination tool and all patient engagement tools and apps that are used.

There are many vendors who purport to be specialists in this type of data integration.  Experience shows that indeed, many “can” do this on paper, but few “have” done this – in any scalable way for an ACO /PCMH.  When adding the patient facing tools and applications to the integration list the vendor list gets much shorter.  In addition, getting all the disparate data “in” is only the beginning.  Converting the data into actionable information, running analytics on the data, generating data and reports that empower patient registries, patient dashboards, and patient facing applications in near real-time is a huge undertaking.  Producing the reports that show both clinical performance and financial outcomes is vital as well.  Given all these needs, we have narrowed the vendor field considerably.

Developing an end-to-end data strategy including an integration priority list based on expected clinical and financial outcomes and measures prior to vendor selection is crucial.  Once the vendor is selected, working together with the vendor on building an execution plan tied with key milestones including implementation and performance guarantees is essential.  If a vendor is in place, there is likely a need to design a data integration plan for all the new integration points and patient facing tools/applications used or about to be installed.  As you evolve your programs you need to insure the plan supports your outcomes reporting process and all metrics as well. 

Tool 2 – Patient Identification and Stratification Tools

We covered patient identification and stratification earlier.  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, these tools need to help your ACO/PCMH optimize the use of critical clinical resources that are currently in or soon to be in short supply and high demand.

Tool 3 – Care Planning and Coordination Tools

Uncovering every care improvement opportunity and managing patients with chronic disease and other high-risk populations is a huge effort. To truly provide scalable care coordination, physicians, nurses and other caregivers need tools that convert the vast amounts of data into actionable information, potential alerts and appropriate proactive, personalized patient outreach opportunities.  And of course, this information needs to be presented in a workflow friendly way.

The use of a patient specific and overall attributed population “dashboard” that functions as a care coordination workflow engine is the cornerstone tool.  The tool should guide the understanding and documentation of problems, potential gaps and barriers.  It needs to enable the care coordination process by easily directing the appropriate patient interventions.  It needs to help in establishing the patient’s goals, the development and delivery of patient centric care plans (print and “e”), and assist in developing all the other actions designed to achieve better patient outcomes. From this single care management platform, all stakeholders involved in care delivery across the ACO/PCMH need to be able to easily view the “riskiest patients” and identify all potential clinical gaps (sorted by priority and specialty) that require immediate intervention.  The tool needs to increase the capacity of the care coordinator.   A truly integrated system will take advantage of every point of patient contact – even a patient-initiated phone call to the office staff – to identify, record and implement care improvement opportunities.

This capability needs to be in desktop, tablet and mobile form.  In addition, it needs to be able to “feed” (if not produce on its own) the outcomes measurement tools.  This technology needs to enhance the patient experience and understanding of how to best manage their condition.  Most importantly, the tool can NOT come in between the physician or Care Coordinator / patient experience.

Tool 4 – Patient Engagement Tools

It is clear that currently there exists a large gap of knowledge of the actual patient activity and behavior in between office visits.  This gap is one of the largest points of failure in the care management process.  In person, care coordination visits have educated the patients, patient centric care plans have been developed and the appropriate materials have been provided, but now it is up to the patient and their resolution for follow through.  For the most part no one in the care coordination team really knows what is happening with the patient in between the office visits, until now.  That is exactly what the tools in the Patient Engagement space are designed to address.

However, the space is growing and can be confusing.  On line portals, smartphone and tablet apps, patient notification and surveys tools….  The list goes on and on.  The marketplace is filled with vendors who offer solutions and cutting edge products that respond to various aspects of patient care and management.  Many of these tools are directed to a single condition or use case.  Understanding who can offer what, evaluating each of these tools and then establishing bi-directional integration between all of them and your core systems is a daunting task. 

Tools designed to “close the loop” between patients and their physicians and care coordinator are paramount to drive higher patient adherence and improve outcomes.  These tools can focus on pre-visit education and health history tracking while checking in at the office.  They can be leveraged by the physician as part of the patient counseling process during the appointment.  They can be used with the Care Coordination and even to schedule follow-up care. 

Perhaps the most exciting use case for patient engagement tools is empowering the ongoing understanding and reinforcement of the patient centric care plans developed and agreed to in the care coordination process.  To be effective for the entire attributed patient population these tools need to:

  • Be accessible online and by smartphone
  • Allow patients to view and add to their health data (with an audit trail)
  • Include preventative care reminders and wellness programs
  • Support achieving Meaningful Use Stage 2 & 3 and optimal HEDIS, Stars, ACO, PQRS, CAHPS etc., scores
  • Integrate with an incentives platform and include programs to encourage participation in wellness and healthy lifestyle activities

To meet the needs of the high risk patients who are working with your care coordinator, these tools need to:

  • Provide the patient’s personalized care plans, and access to both targeted and general educational materials
  • Remind patients of their daily tasks, medication compliance and self-management activities
  • Integrate with remote monitoring devices used to support self-management
  • Connect to an incentives platform and programs, as well as online communities
  • Update in real time for the patient, care manager and physician to view
  • Track the patients progress toward meeting their goals and report back to the care coordinator the results to enable earlier intervention and ongoing support
  • Integrate into your care coordination platform and available mobility to support access  across different care settings

Leveraging one of the few vendors who have a comprehensive solution in this space can be a real game changer in terms of effectiveness and outcome based reporting.

Tool 5 – Reporting Tools

Reporting is one of the areas where a “reverse engineering approach” can be of great assistance.  Knowing and understanding, in advance, the measures that will be used to demonstrate your effectiveness and your financial payments is the best place to start.  From there determine the sub measures needed to support and/or track the effectiveness measures.  Evaluate the data needed to support those measures and insure your data integration strategy and data inputs support the ability to report out what is needed.  Some essential components to a reporting system include the ability to deliver:

  • Standard reporting packages for process, quality and outcomes measures that meet the needs of CMS and each of the contracted commercial payers
  • Care Coordination reporting including patient engagement rates, process and effectiveness measures
  • Patient specific and population based reporting including clinical values improvement, health status measures and patient satisfaction
  • Cost and Utilization reporting
  • Financial and network contracting effectiveness and leakage reporting and
  • “Leading” financial indicators so you can avoid unpleasant surprises, can adjust your programs and approach, detect trends and opportunities to reduce costs, increase efficiencies, and manage risk before it is too late.

Part five of this five-part series will address the topic, “Reporting the outcomes needed to demonstrate success.”

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