The PHA 2020 Innovation Summit & Capital Caucus Innovation Showcase Webinar Roundup: Gaps in Adopting Value-Based Care
As the silver tsunami, the 10,000 Americans who age into Medicare each day, pushes the healthcare costs tipping point, payers are placing more accountability with the provider community to manage cost and outcomes. The older patient tends to be sicker, with a higher medical complexity profile, chronic disease and multiple comorbidities, driving up costs.
Healthcare systems look to technology as a way to facilitate and improve post-acute care communication, and therefore reduce readmissions and improve patient outcomes. During the Population Health Association’s 2020 Innovation Summit & Capital Caucus, we held a panel discussion with one organization that’s experienced success operationalizing and scaling its adoption of value-based care.
During the virtual chat, we spoke with Sarah Reffitt, Medical Social Worker with IU Health, and Anthony Sorkin, Medical Director for IU Health ACO and Health Plan, who was recognized as Modern Healthcare’s Top 25 Innovators - 2020. We discussed how their ACO works to improve and increase communication with post-acute providers moving forward, especially during the pandemic, as more seniors with chronic conditions transition from their healthcare system to post-acute care — 20% of which end up in skilled nursing facilities (SNFs).
Watch the video below for the full conversation or read the blog below for the highlights of our discussion.
The Challenges Hospital Systems Face Without a Value-Based Care Model
With over 150,000 patients passing through the IU Health system, playing an active role in patients’ post-acute journey requires real-time communications with the over 300 skilled nursing facilities utilized. A few years ago, when Dr. Anthony Sorkin began his role as Medical Director for IU Health ACO and Health Plan, he wanted to find a way to stay involved with patient care, so they could reduce readmissions for this particularly vulnerable population.
“We would get a report on the claims data for our patients, sometimes six to nine months after they were sent to a nursing home, as well as reports on readmissions and length of stay. It didn’t make sense that we did not have a way to electronically look into the post-acute settings," Sorkin says.
Compounding the complexity, each SNF across the system utilized a different EMR and some were still using pencil and paper, plus they exhibited a wide range of care delivery. IU Health wanted a higher level of engagement and decided to leverage Olio, a software solution that helps to simplify communication and scale how they work with different post-acute care providers across the continuum of care.
“Not only were we looking at a way to track medical components, but I also needed a way to track social components well,” says Sarah Reffitt, Medical Social Worker with IU Health. “Working with the different facilities and my own patients, it was really difficult to keep track of what was going on before Olio.”
Before, Reffitt says facility turnover, large geographic areas and variability amongst providers meant she constantly had to try and track down information — not only for IU Health, but for patient’s families. “I had to rely on somebody remembering to let me know the patient was a population health patient,” she says.
In addition to building rapport with post-acute facilities, Reffitt spends time with patients’ families to understand their expectations, goals and focal areas for their loved one’s post-acute care. “Now, I put a note in Olio so the facility and post-acute care manager know that information, and the family feels like we have closed the loop.”
Tracking the Patient Journey with Ease and Customizable Options
Olio provides IU Health a tool to extend beyond their organization and reach the vast post-acute network. “We needed to know where our patients are – to have vision across the entire spectrum of care,” Sorkin says. “I cannot reiterate enough how valuable it is for my role in monitoring the post-acute space.”
To improve their coordinated care efforts, Sorkin uses Olio dashboard filters, which help sort patient information and check the status of patients. “We can see who is currently sitting at each individual SNF and where they are in their journey. As soon as they hit a length of stay of 14 to 16 days, we can start engaging in a conversation with whoever’s managing the patient at the SNF.
“The more communication you have with providers at the bedside, the better the outcomes for the patient. There are less questions about what is the next step or what is coming next for the patient.”
He says increased communication proves quite valuable to all parties involved in the process. “We are working toward getting the patient discharged, and hooking them directly back into the primary care loop,” Sorkin says. “Getting them back to a steady state is something I don’t think our system spent enough time working on.
“By setting the filters, the primary care providers can see those patients who are getting ready to be discharged, and make sure the home health and DME (durable medical equipment) are set up.”
Reffitt typically transitions patients from inpatient to SNF, and finds the dashboard’s functionality allows her to easily queue up patients and tag them to the facility that will be receiving them next. “I can focus on patients building by building, and have conversations about admission and treatment,” she says.
Enhanced communication helps identify needs that can get missed during the transition of care. Sometimes SNFs or home health agencies aren't properly prepared. The patient ends up coming back to acute care, typically within the first few days, according to the data.
“It’s big that we can cue things up from our inpatient team to the receiving SNF care manager,” Reffitt says. “Sometimes, I’m working with an admission liaison, not a nurse, case manager or social worker who will have the first family meeting. Yet, these people see the same information in Olio. It reduces the barrier that comes from a well-meaning facility liaison, who won’t be the one seeing the patient in the room, especially with the isolation we are facing now.”
Improving Patient Outcomes in Value-Based Care
Olio provides a patient card, where providers can dig in and understand through a simple format what’s historically occurred during their care. The dashboard includes graphs populated from patient data, such as weight and blood pressure, as well as important documents, notes and escalations.
“The graphs are a really simple indicator of improvement or decline happening with the patients. No matter who is monitoring the patient, with whatever lens or background, they can observe visually what is happening with the patient,” Reffitt says. “We sometimes saw the chart climb rapidly, and were able to get the medical director in to see the patient and make changes.”
“As we dug through claims and looked at patients who were being readmitted from SNFs, there were avoidable encounters that, if we had known about them earlier, we could have stopped the activity,” Sorkin says. “So we designed questions, basically stop-and-watch questions, that were populated on Olio. We could track graphically to see how patients were doing.”
Sorkin adds that in addition to improving and increasing communication, Olio acts as an early warning system to avoid some of these utilizations, such as returns to the emergency department. Instead of using the ER as a triage service, IU Health can utilize Oilo to upload pictures or facilitate a patient consultation directly for care and management.
The escalation feature, created for the post-acute user, allows providers to raise their hands proactively to receive support. IU Health currently responds to skilled nursing facilities’ escalations in under three minutes.
“The escalation feature is a good way for us to know who needs our attention first,” Reffitt says. “The feature also works in reverse. If we need something urgently, we can alert the facilities for an immediate response.”
Sorkin believes the escalation feature helps patient care through the ability to understand a patient's needs and answer that need quickly. “We can bring the health system directly into the patient's room at the bedside, get an understanding of what’s happening, and put the care provider at ease,” he says.
Results of Implementing Technology to Improve Value-Based Care Efforts
In addition to increased communication, broader patient care and efficient coordination, IU Health saw results early on operationally as a result of the Olio pilot program. The program initially included three hospitals and 32 SNFs. Today, IUH’s 15 adult care hospitals use the software solution to engage with 144 SNFs to ensure optimal care coordination.
“It certainly brought down our length of stay,” Sorkin says. “Readmissions are a big piece for our system. Our average readmission spend is about $17,500 (per patient). When you look at the number of patients we have at-risk going through the post-acute space, we saw a 45% decrease (in readmissions). That’s a significant number, and it is even lower now, as we have grown into this process.”
Beyond improved patient outcomes, monetary benefits and enhanced relationships with post-acute facilities, Reffitt believes the platform helps patient advocacy. “It’s huge for me to be able to advocate for families,” she says. “I can send a quick note and say I did my part, and let the entire team of people help the family member know what your concerns were, because your patient matters to me.”