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.