Community-wide Coordinated Care

Community-wide Coordinated Care

© 2011 Clarity Health Services 2

The typical primary care physician has 229 other physicians working in

117 practices with which care must be coordinated, equivalent to an

additional 99 physicians and 53 practices for every 100 Medicare

beneficiaries managed by the primary care physician.

Annals of Internal Medicine (2/17/09)

The Challenge: Care Coordination is Complex

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• Commitment– Commitment to serve your patients– Commitment to serve your colleagues– Commitment to share all pertinent information

• Collaboration• Narrative & Understanding• Shared Framework or Context• Develop shared practice• Routine practices become standard process

– Process can be rendered in tools and automation– Process enables measurement & improvement

• And the cycle continues – constant and incremental change

The Evolution of Coordinated Efforts within a Practice


• Local workflows & protocols• Individual & institutional relationships• Ownership and affiliations• Physical, Dental & Behavioral health domains• Local information systems• Existing Connectivity

– Shared EMR– Point to Point Connections– Secure Messaging– Local & Regional HIEs

The Context within a Community

© 2011 Clarity Health Services

• No standard communication protocol for referrals• Poor or no visibility to the complete patient record• No simple way to acknowledge receipt, scheduling, or visit status• Inordinate amount of resources focused on the revenue cycle• Latency or absence of clinical reports and notes

Current State of Affairs Between Practices

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Did they getmy referral?

Is the appointment scheduled?

Did my patientshow up?

Clinical notes?What happened to

my patient?

Was insuranceeligibility confirmed?

When will I get a report back?

What forms need to be filled out?


• Community provider directory and patient panels• Staff initiates a referral or transition

• Which patient, reason for referral, referral destination or provider• Include appropriate members of the patient’s Care Team• Attach required clinical information• Accompany with message(s) to assist coordination

• Service or Payer “processes” the referral• Verify insurance, obtain authorization, check network status• Transmit complete package to the recipient

• Recipients “receive” and “respond”• Acknowledge receipt • Request further information • Provide scheduling status and visit status• Provide results to “close the loop”

• Transitions and records archived and shared by Care Team

Starting Point – The Referral

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• Experience helping to build highly engaged integrated care communities

• Platform– Cloud based– Value-based pricing with no up front costs– Communication infrastructure– Patient Index & Provider/Practice Directories– Transaction/work-flow based with support for multiple work flows– Functions within heterogeneous IT environments– Integrates with EHRs & other Clinical Information Systems (RIS, et al)– Supports any care settings: Physical, Dental & Behavioral– Performance Measurement & Reporting

• Service infrastructure & organization to fill the gaps• Platform and Service can be adapted to support any transition and the

supporting care team

A Community needs a Partner with a Platform


• Community-wide “leadership” engaged around a common purpose• Create structure for clinical community• Align community-wide expectations around service levels and

standards of care• Adopt standards of measurement• Hold each other accountable - It’s a “public” not a “private” practice• Share your plans and promote your success

Getting Started


• Identify high-risk patients in the hospital • Coordinate the care that they receive from the inpatient side to the

outpatient side • Have a discharge program or set of activities around discharge that

include making sure the patient understands their medicines and that there's follow-up in an appropriately acute amount of time, and

• Increase emphasis on better communication with the outpatient providers during acute stay, at discharge and beyond

Use Case: Successful Post-acute Transitions

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Specialty

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Robust Community-wide Care Coordination Platform – Facilitates care transitions across all care settings– Enhances communication – Provides a shared repository of patient information

Broad-based community service– Inclusive – any one can participate– Any setting – from single providers to health systems– Any transition – from outpatient referrals to post-acute transitions

Incremental – No capital expenditure– No installation or integration is required– Monthly subscription and service fees based on activity

Provides a Basis for Meaningful Accountability….

Clarity Overview

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Health Plans/ACOs Collaborate with providers

around care decisions Manage care across a managed

care/ACO population

Clarity Service Center Eligibility verification Network Checks & authorizations SNF and ALF placement Other administrative processing

Hospitals Accept patients into

ambulatory setting Perform radiology and other

services

SNF / ALF / Home Healthcare

Collaborate with other parties on admissions

Manage interventions Provide feedback on care plans

Case Managers Monitor cases across the entire

care cycle Provide input on care decisions Review overall performance of

the care system

Other Services(PT, counseling, etc.)

Accept referrals and provide patient status

Consult with providers on treatment options and progress

Consultants/Specialists Receive and schedule referrals

visits Manage referrals to additional

specialists Maintain dialogue with

remainder of care team

PCPs Initiate referrals Review status of referrals and

confer with consultants Review radiology findings and

determine care plans

Clarity Solution: Community Wide Care Coordination

Platform


Clinically-Integrated CommunityLinked around common patients

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Imaging Center

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Documents

Community-wide Coordinated Care