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The Financial Upside of Enhanced Care Transitions


For doctors to capitalize on value-based care, they need to take an active role in ensuring smooth care transitions. New software can help.

doctor with patient

The results of a recent study presented at the Society of Hospital Medicine’s Annual Meeting reveal that an email-based care transition bundle not only improved communication but patient care as well.

The key word in that sentence is "transition," and Clay Ackerly, MD, chief clinical officer for naviHealth, a post-acute care management company, says it’s a critical aspect of the healthcare equation today.

“Care transitions is one of the top patient safety and overall value-based care areas of focus,” Ackerly says.

And while hospitals were the focus of interest around care transitions about a decade ago, physicians today have a bit more skin in the game.

New Lens and Light

Ackerly explains that in the mid- to late 2000s, the problem of preventable readmissions received increased attention. At the same time, hospitals were saddled with readmission penalties in the form of the Medicare Spending Per Beneficiary measure that considered the cost of an overall episode of care. If the actual cost of care was higher than the national benchmark, the hospital would be penalized.

“This is now translating more for the physician,” Ackerly explains.

When Medicare came out with a mandatory bundle payment program called CJR, comprehensive care for joint replacement, it was a mandatory bundled payment. That risk sat with the hospital, not the physician. However, more and more hospitals are now contracting with physicians as part of this bundle.

“The more efficient a physician is, the more they think about quality, the more likely they are to have an upside financial benefit as part of those bundles,” Ackerly says. “And then there’s the pay-for-performance programs that are increasingly looking at the costs of the care episode. And whenever you talk about episodes, you have to worry about care transitions.”

Major Role

Ackerly believes that physicians play a major role where care transitions are concerned.

“If they don’t seize this opportunity, it’s a lost opportunity,” he says. “They’re ceding ground to other providers to be a real quarterback for the care of patients.”

And caring for patients, Ackerly says, means spending the time to understand your patient. Engaging the patient. Making phone calls. And giving the patient continued engagement across the care episode.

“This can be done without fancy technology by picking up the phone and talking to other subspecialists,” Ackerly admits. “But that’s not efficient. This is a complicated world with many different silos of care. So, how do we make this process more efficient?”

Ackerly says it’s imperative for physicians to know the needs of their patients, know the quality and the availability of providers in the community, and make sure the patients’ needs are met. If too much service is provided, that’s wasteful and potentially harmful. And if physicians under provide service and the patient isn’t getting what they need, then they have poorer outcomes, lower patient satisfaction, less functional improvement, higher risk of readmission to the hospital, and financial penalties.

Technology can address all those care transition issues.

Data and Communication

Ackerly explains that technology can help scan data and create efficient support for providers. What does this patient really need? What’s really going on with the patient?

“Decision support tools can help,” he says.

Then when you try to transition that patient from one provider to another, how are you getting that information? How do you make sure that patient is then connected to the next provider and connected to you?

“Technology can play a very helpful role in making care transitions more efficient, and more effective ultimately,” Ackerly says.

And not just by gathering and sharing data, but through enhanced communication as well. According to the study results presented at the Society of Hospital Medicine Annual Meeting, a bundle that connected inpatient and outpatient care providers in a single, HIPAA-compliant communication loop resulted in a 17% improvement in seven-day scheduled follow-up appointments.

“With care coordination software physicians can follow a patient electronically and with human touch across an entire episode of care,” he explains. “It does bring a higher level of engagement and clarity to the care episode that can end up reducing anxiety and help with care planning for both providers and the patient.”

But at the end of the day, Ackerly stresses, people are where the magic happens. Caring, knowledgeable clinical and non-clinical staff are needed to hold the hand of the patient when necessary, and to help get them from point A to point B. Technology is only part of the equation.

“People alone can’t do the job nearly as well as the patients need,” he says. “That’s why giving them the technology, the tools, to help patients have safer transitions is so crucial.”

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