Improve ACO And Post-Acute-Care Provider Collaboration Through Interoperability
By Aric Agmon, Executive Vice President and President, MatrixCare CCRC Solutions
Nearly 40 percent of Medicare beneficiaries are discharged from a hospital to a post-acute care setting, which means the communication and data sharing between these two institutions is crucial, considering as many as 19 percent of those beneficiaries are readmitted within 30 days.
Those readmissions impact accountable care organizations’ (ACOs) and senior care organizations’ revenue in several ways. If rates are too high, the hospital participant(s) in the ACO could receive an avoidable readmission penalty from the Centers for Medicare and Medicaid Services, which can be as much as 3 percent of their Medicare payments. Readmissions also increase costs, decreasing the potential bundled payment for the ACO if it participates in a risk-bearing payment program, such as the Medicare Shared Savings Program (MSSP).
For senior care organizations, a larger 30-day readmission rate than peer organizations could mean that there will be fewer referrals from ACOs and other partners in the care continuum and an increased difficulty in marketing the organization’s clinical performance. If the senior care organization is contracted to receive a portion of the shared bundled payment under an ACO program, higher readmission rates could translate to a reduced share of the revenue.
In these value-based payment scenarios, improving care transitions, communication and data access between hospitals and post-acute providers is possible today through technology that supports interoperability between EHR systems. Interoperability enables accurate and HIPAA-compliant data exchange and safe and secure communication to reduce avoidable readmissions, improve outcomes and increase resident satisfaction.
Improving Transitions Of Care Crucial For Better Outcomes
Avoiding readmissions and improving quality performance starts with care transitions. For example, as many as 60 percent of medication errors occur during care transitions, which is why seamless and accurate information exchange between an ACO’s hospitals and post-acute facilities can help identify errors, such as dosage disparities and possible drug-drug interactions. Comprehensive medication reconciliation ensures no current medications that were prescribed before or during the inpatient stay are omitted unless ordered by a physician.
A challenge facing many senior care organizations and other post-acute care facilities, however, is that they rarely use the same EHR as the referral hospital. As a response, many forward-looking organizations are implementing EHR systems designed for their specific post-acute care environment with HIE tools that integrate directly in real-time with the EHR used by the hospital or physician’s practice, such as the most popular systems: Epic, Cerner, McKesson, Greenway and Allscripts.
Through this interoperable HIE technology, which should support HL7 and CCD standards, organizations can retrieve clinical documents and deliver secure messages to the hospital or practice-based providers through DIRECT protocols. Once interoperability is achieved, providers and administrators in the post-acute or senior care facility will have a consolidated view of residents’ medical history and medications to identify potential complications, decrease recovery time and build resident trust.
Quality Improvement Requires Enterprise-Wide Data Analysis
Tracking avoidable readmissions is only one of many care-quality metrics that ACOs need to monitor where post-acute facilities play an integral role. Senior care and other post-acute care organizations should also track other relevant quality measures to share with care-continuum partners. For example, there are 33 care-quality measures in the MSSP, including numerous involving screenings and managing chronic conditions that could fall to providers within or associated with the post-acute facilities.
Enterprise-wide data combined with information accessed through the HIE or other types of communication with care partners builds the foundation for quality analysis. This interoperability between systems is especially an advantage when residents are spread out on more than one campus and transition from multiple unaffiliated hospitals. Organizational leaders still require a comprehensive, holistic view of performance, regardless of the multiple data inputs.
That is why once the data is compiled, the senior care organization’s EHR system should offer analytic tools for timely reporting or dashboards that give providers and administrators in these organizations an immediate snapshot of quality performance. Assessments should offer insight into ACO requested metrics, but also any quality measures the organization wants to follow, such as those on the MDS or QI/QM reports.
Accountable Partners Connected Through Interoperable Systems
Even for senior care organizations with mostly private-pay populations without plans to partner with an ACO, monitoring quality is important for marketing to prospective residents and generating referrals from community providers, existing residents and their families.
More importantly, tracking performance on evidence-based quality measures also helps improve the vibrant longevity, outcomes and quality-of-life for all residents, regardless of their payment method or if they are part of an ACO patient population. Implementing certified long-term and post-acute care EHR technology is a good first step toward achieving both the goals of the ACO, but also internal quality and business goals.
For maximum impact with less effort, the chosen technology should also integrate data from outside providers as well as enterprise-wide financial, operational and scheduling information. This comprehensive view can deliver the intelligence post-acute and senior care organization leaders need to drive changes that truly improve clinical outcomes and increase resident satisfaction.
About The Author
Aric Agmon is Executive Vice President and President, MatrixCare CCRC Solutions.