In Nebraska, a Transitions-of-Care Program Has Proved Its Worth

July 29, 2014
Starting out as an ACO learning lab program, UniNet Healthcare Network in Nebraska leveraged data and analytics to identify high-risk patients. The results have been a successful transitions-of-care program and significant cost savings.

In 2010, the Omaha, Neb.-based UniNet Healthcare Network, a not-for-profit, clinically integrated network (CIN), embarked on an accountable care organization (ACO) learning lab program to develop its capabilities to accept risk-based payer contracts. A year later, the organization utilized MedVentive (now part of the San Francisco-based McKesson) to actively manage the health and financial risk of employees at Alegent Creighton Health in Omaha. Under the UniNet umbrella is Alegent Health Partners, a Medicare Shared Savings Program (MSSP) ACO participant.

Initially, UniNet sought a technology solution to allow it to better manage the cost and quality of care for its own employees and their beneficiaries. Specifically, UniNet needed a tool that would allow the CIN to explore claims data, stratify patients by risk, and identify the individuals who would most benefit from outreach and care management, according to a McKesson case study. These models of care could then be applied to promote employer-paid plans and acceptance of risk-based contracts based on the ACO model.

After creating care management models, UniNet added 22,000 ACO members to its care intervention programs. The organization wanted to use population health management to help improve its quality indicators and lower costs for populations with multiple chronic conditions. Today, UniNet’s network includes more than 2,000 physicians, specialists and advanced practice clinicians, 30 metro and rural hospitals, 10 post-acute care facilities, and four ambulatory surgery centers.

With the new technology, UniNet care managers contact members identified for outreach using the predictive risk stratification analytics in the tool. The care manager conducts a comprehensive assessment interview to identify each patient’s needs, and provides education and support through phone calls and written material. Self-management skills and follow-through with the patient’s medical care plan is emphasized.

In addition to its care management program, UniNet runs a transition-of-care program— for which it received funding from the Centers for Medicare & Medicaid Services (CMS) — for hospitalized members with high-risk scores, says Ann Oasan, UniNet’s president. Begun in 2010 in partnership with Blue Cross Blue Shield to reduce potentially preventable readmissions, the program engages high-risk members upon discharge from affiliated hospitals. UniNet discharge transition nurses use information from its population health solution to manage the care of members who are in the program, and then follow up with these patients to ensure they understand their post-discharge plans and follow-up instructions. This program has been extended to all discharged patients at Alegent Creighton Health hospitals. “The first year we focused on patients with chronic illnesses, but the second year we ran data that showed us those patients who were predicted to be high risk, so we focused on that population,” says Oasan.


In addition to putting the care coordinators into the clinics, UniNet has tried to build a “medical neighborhood”—beyond the medical home, Oasan says. To create the medical neighborhood, nurses focus on discharge transitions, social workers are added to connect patients with community resources, the CIN works closely with pharmacists to provide medication therapy management, and the services of dieticians and diabetes educators are enlisted, she says.

Ann Oasan

The medical neighborhood was a modification of UniNet’s use of patient-centered-medical-home care coordination. Goals included developing patient registries, improving clinical quality scores, and reducing waste by avoiding low-acuity emergency department visits.  What’s more, the organization developed relationships with continuing-care networks and brought in skilled nursing facilities (SNFs) while utilizing the nursing home network, which places advanced practice nurses in the SNF, to focus on keeping patients in the SNF rather than sending them to the ED.

 “It’s been a work in progress over the last year or two,” Oasan concedes. “Right now, a lot of our payers are paying fee-for-service and are keeping people out of the hospital and the ER. Unless you get paid differently, pretty soon that’s a hard sell for hospital administration. So we’re pushing our payers to move towards different ways of paying.”

According to Oasan, the organization hired nurses that were placed into its primary care clinics; 32 nurses in all were placed. The care coordinators were employed by UniNet, meaning they wouldn’t be pulled into the day-to-day nursing activities; instead, they have a population of patients that they are working with, focusing on care coordination, Oasan says. “They are looking at patients who have been admitted and have been in the ER. So they’re really focused on keeping people out of the hospital or being readmitted.”

Originally, in the transition-of-care program, after a patient got discharged, he or she might have gotten five phone calls from all different departments and people connected to UniNet. This lack of organization led to some patients getting five phone calls, while others received no calls. “But because of the ability to predict the high-risk patients for readmission, we would be able to categorize which patients got how many calls,” explains Oasan. “For example, high-risk patients might get four calls, where someone who just had a baby would get one call. We also coordinated it so all the calls would come from one place, which was very satisfying for patients because while everyone is getting at least one call, those who need more will get them,” she says. And overall, in that program, for the patients UniNet reached out to and worked with, readmissions were lowered about 30 percent, Oasan notes.

What’s more, cost savings have been as high as $6 million annually over the last three years, she says. “Our costs and usage are going down, but best of all, our high‑risk members’ risk scores are going down as their health improves,” says Oasan. “Now that we’re more experienced looking at risk, we’re focused on our 2nd year of CMS ACO members and the evolution of risk‑based payment models.”

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