When hospitals communicate with primary care physicians, good things can happen for patients and their doctors.
Data is not the same as information. Physicians often tell us they want greater insight into their patients’ health care experiences, not necessarily more data – unfiltered records, often crowded with unhelpful “noise” – but deeper and more actionable insights that provide meaning for their medical practices and their patients’ health care journeys.
Physicians have shared stories over the years about how a simple alert sent by a hospital to the right medical practice, at the right time, letting the physician know the patient had been treated in the hospital, changed the course of their patient’s outcome. These notifications are a key tool in both improving care and earning significant value-based care savings. This is the power of admit, discharge, and transfer (ADT) notifications, real-time alerts from hospitals to a patient’s physicians and care coordinators.
A patient’s primary care provider (PCP) is often unaware that their patient has been evaluated in the emergency department (ED) or admitted to a hospital. That’s because it’s rare that a patient’s PCP is on staff or already connected to the hospital’s records. It’s also a real missed opportunity for the PCP to follow up and ensure the patient has the care they need while in the hospital as well as after they are discharged and trying to recover at home. Lack of information and proper transitional care management (TCM) can lead to patients being readmitted to the hospital or unnecessary ED recurrence, both of which need to be avoided in a value-based care model.
How can ADTs be a powerful tool for your own practice? A leading network of independent primary care organizations in California is showing how it’s done.
Aledade is the largest network of independent primary care organizations in the country, helping primary care practices, community health centers (CHCs), Federally Qualified Health Centers (FQHCs), and health clinics deliver care. Together with 1,500+ practices in 46 states and the District of Columbia, Aledade manages more than 150 value-based contracts and is responsible for two million patient lives under medical management. Since launching in California in 2020, California Aledade (CAledade) has experienced 10 times growth with 181 practices and six Accountable Care Organizations (ACOs), representing 240,000 lives and $3.25 billion in medical spend under management (MSUM).
For any practice to succeed in value-based care, shared health information to coordinate care is key. Clinicians and care teams need to be updated on changes in the status of their patients so that the right care can be provided at the right time. Aledade has relied on ADT notifications to enable physicians to see when a patient has visited the ED or been discharged from the hospital to their home. This triggers a whole chain of action including timely post-discharge follow-up to reduce ED readmissions and decrease the number of patients going back to the ED unnecessarily.
To get more ADTs in California specifically, Aledade joined Manifest MedEx, a statewide nonprofit health information organization in 2020. As of 2023, 35 of CAledade’s practices are participants, representing almost 60,000 patients, and $780 million in MSUM. Connecting to a health data network reduces the burden for each of the practices to contract to receive ADTs from the local hospitals in their area and ensures they are receiving ADTs across the statewide network.
For Aledade, around one in seven TCM follow-ups prevent hospitalization, which saves approximately $15,000 in medical spending per admit. In 2022 alone, ADTs from the health information organization in California triggered approximately 2,000 TCM visit follow-ups with Aledade clinicians and 2,400 ED follow-ups, resulting in an estimated $4.2 million in savings while improving the quality of life and clinical outcomes for their patients.
The case study is compelling. Prior to utilizing ADTs, many practices within the Aledade network were not receiving timely notifications when patients were discharged from the hospital. Data from two anonymized practices from 2020–2022 showed a 33% and 37% increase in transitional care management after integrating ADTs into their workflows. This correlated to a 29.2% and 20.8% decrease in ED readmissions per 1,000 patients for both practices over three years, equating to a combined 393 lives and a total potential savings of approximately $5.8 million.
ADTs stand as a beacon of possibility for modern primary care practices. Beyond merely streamlining administrative processes, these notifications can deliver on both financial outcomes for practices and patient well-being. They are valuable, actionable information, not just data.
As primary care practices continue to evolve, leveraging ADT notifications is one of the simpler ways to shift to a value-based care future. As seen with Aledade, real-time updates enable care teams to orchestrate seamless transitions between care settings, fostering continuity and coordination in patient care. This continuity not only improves patient satisfaction, but also contributes substantially to better health outcomes.
When delivered by health data networks, ADTs can epitomize the intersection of efficiency and quality in health care. As we embrace these innovations, let us remember that their true power lies not just in the data they convey, but also in the lives they positively impact.
Gavin White is market president of Aledade. Erica Galvez is CEO of Manifest MedEx, California’s largest nonprofit health information organization. Before joining MX, Galvez led the health information exchange efforts at Aledade and also led the Office of the National Coordinator for Health IT’s Interoperability Portfolio.