The Centers for Medicare and Medicaid Services (CMS) recently published a toolkit describing a variety of strategies Accountable Care Organizations (ACOs) use to better coordinate care for beneficiaries. The focus of this toolkit is on finding innovative solutions that allow ACOs, post-acute providers, and clinicians to work together and support diverse beneficiaries in all care settings. Many of these suggested solutions involve implementing technology that removes barriers for collaboration and helps ACOs focus on certain important care settings–like the emergency department (ED).
Get the Entire Care Team Involved
The CMS toolkit highlighted the importance of focusing on the ED as it is a known point of entry for admissions and readmissions. Participating ACOs also emphasized this importance and have implemented strategies to communicate with ED staff and engage with hospital leadership. Legacy Salmon Creek (LSC) decided to concentrate on ED traffic as part of its commitment to providing quality care and turned to technology to achieve this.
The Washington-based hospital used the Collective Platform to design new processes that included an ED readmissions algorithm, which addressed patient needs and provided alternatives to readmissions. In the first year of this customized process, LSC made over 600 referrals to primary care providers, specialists, and community providers. As a result, avoidable ED visits were reduced by 81 percent and all-cause 30-day readmissions by nearly 25 percent. This helps every member of a patient’s care team provide better support while lowering costs.
Reduce Costs Through the Use of Technology
CMS advised that, while ACOs may have different strategies for providing quality care and reducing costs, individual beneficiaries should always remain the focus. Columbia Medical Associates (CMA), a 60+ provider practice in Washington, was able to lower costs by taking a patient-centered approach to addressing inefficient emergency department (ED) utilization.
With Collective Medical, CMA has been able to accurately track and support patients visiting the ED. Patients were directed to primary care services that were more affordable for both the patient and CMA. Providers also screen for obstacles that may hinder a patient’s access to care, such as lack of transportation and direct the patient to appropriate in-house services. ACOs participating in the toolkit worked with nearby community services when social determinants of health impacted patient care.
By reducing avoidable ED utilization and admissions, CMA was able to save $6.5 million in total cost of care.
Create Collaborative SNF Networks
Many ACOs participating in the production of the toolkit emphasized the importance of coordinating care with skilled nursing facilities (SNFs). Some of these ACOs have implemented technology like Collective that alerts care managers when a beneficiary has been admitted to a SNF. Additionally, Collective Notifications can notify SNFs if beneficiaries readmit to the hospital after being discharged from the SNF. This visibility helps SNFs collaborate in real-time to potentially avoid an unnecessary readmission–and in some cases readmit the patient directly to the SNF as opposed to the hospital setting.
Marquis, which manages assisted living facilities in Oregon, California, and Nevada was able to avoid nearly $115,000 in penalties by implementing the Collective Platform across three of its Oregon-based facilities. Through the Collective Platform, Marquis was able to drop readmissions rates by 60 percent in less than six months.
Gain Real-Time Visibility with Technology
The goal of coordinated care is to ensure that patients get the best care and support possible, while avoiding unnecessary services. Collective delivers real-time information to ACOs. With Collective, ACOs know when and where beneficiaries are having medical encounters. This real-time information allows ACOs to follow up in a timely manner and to collaborate with primary care providers, behavioral health practices, home health agencies and post-acute facilities.
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