Aledade Delaware ACO developed a population health management tool to more effectively coordinate care.
Organization Type: Other
Model Type: Transitional Care Model (TCM)
While emergency departments (ED) and hospitals are an integral part of the health care system, unnecessary ED and hospital utilization, as well as avoidable hospital readmissions, are significant challenges. As the foundation of an efficient and effective health care system, comprehensive care coordination by primary care physicians (PCPs) can help reduce excessive care, repeated tests and procedures and high rates of ED and hospital utilization. However, to do so, the primary care practices in the ACO need to be informed of the full spectrum of their patients’ care. This includes care delivered outside of their practice, and particularly when patients are admitted to or discharged from a care facility.
What We Tried
To give primary care physicians information on their patients’ care beyond the four walls of their practices, Aledade connected them to the Delaware Health Information Network (DHIN), the state’s health information exchange. The ACO did this by integrating practices’ electronic health record, practice management and scheduling systems with the DHIN via the Aledade App, Aledade’s population health management tool. The ACO practices can now receive admission, discharge, and transfer (ADT) notifications in real time. This means primary care physicians will be notified right away if their patient is admitted, discharged, or transferred from a care facility. Now when an ACO patient receives care from another provider, their primary care physician can engage with the patient or the other provider to more effectively coordinate care.
Once the primary care provider is alerted that their patient has been admitted to another care setting, the primary care provider can speak with the hospital/ER doc to send medical history, labs, etc. Once the primary care provider is alerted that the patient has been discharged or transferred from the hospital, then he or she can follow up with the patient, check up on him or her post-discharge, and bring the patient into the practice to follow up. Armed with real-time patient data, ACO practices are able to provide more timely follow-up with their patients during transitions of care – an important determinant of hospital readmission rates.
When a practice receives a patient admission, discharge, or transfer notification, they can contact the patient to establish a transition of care management plan. This allows for timelier, better-coordinated care, helps identify opportunities for early intervention, ensures that patients understand their discharge instructions and how to effectively transition to recovery, helps prevent unnecessary readmissions, and assists with medication reconciliation, thereby avoiding adverse medication interactions. The physicians in Aledade’s Delaware ACO have used the DHIN’s real time patient care notifications, via the Aledade App, to great effect.
In 2015, the Aledade Delaware ACO’s first performance year, the results included (as compared to 2014 measures):
-Emergency department visits were reduced by 5.9 percent
-Emergency department visits that led to hospitalizations were reduced by 8.1 percent
-30-day all-cause readmissions per 1,000 discharges were reduced by 11.4 percent
Aledade’s Delaware ACO has already tripled the number of Transitional Care Management (TCM) visits it conducted in 2015 compared to 2014.
Emergency department doctors often cite lack of access to patients’ medical history as a challenge to providing effective, personalized care. With ADT notifications and bidirectional data sharing, primary care physicians can also push patient histories to EDs to provide comprehensive patient medical information at the point of care. As of April 2016, Aledade is in the process of giving ACO partner physicians in Delaware this capability.
All health care providers should make patient data safely available in a timely manner to other health care providers to ensure health care is coordinated effectively.