Applying Care Coordination Technology to Meet the Quadruple Aim of Health Care

^{By Edan Stanley}

Researchers estimate that poor care coordination can result in up to $45 billion worth of avoidable expenses in a year. Lissy Hu, MD, founder and CEO, CarePort, discussed the importance of collaboration between providers, main issues with care coordination, and shares how CarePort (a care coordination software technology platform, a part of WellSky) facilitates collaboration through a large network and real-time patient tracking.

Can you tell us more about the work CarePort does and the populations it serves, and what sets it apart from other organizations?

CarePort is a technology that connects hospitals as well as post-acute care providers. Think of care settings like nursing homes, home health agencies, hospice, long-term acute, dialysis, community-based organizations, and mental health providers.

These are all types of care that patients need after a hospital stay, and we continue to track those patients through this post-discharge period to ensure that they are getting appropriate and high-quality care. What makes us unique in the market is that we have providers that are connected to us across the continuum at a huge scale.

We are in over a thousand hospitals. We work with over a hundred thousand post-discharge providers, and an estimated 20 million referrals go through our system, serving about a third of patients coming out of US hospitals.

In a fragmented market like post-acute care, it is very difficult reach large scale. We have been successful in doing so and now, anyone who joins our care coordination platform gets the benefit of being able to coordinate care with all the other members on our platform.

If you are a hospital and you want to send your patient to a nursing home in one of the 43 states in which we have customers, it is easy for you to do so because the nursing home is already connected to our platform. It is in our system every single day, collaborating with other care providers on these transitions.

What are some of the most common care coordination problems faced by patients, providers, and payers, and what role does new technology play in addressing these challenges?

Both providers and payers move to accomplish the quadruple aim: better outcomes, lower cost, improved patient experience, and the fourth—what made it go from triple to quadruple—is improved provider experience.

One of the areas that payers and providers are looking at is how we can better collaborate to accomplish that quadruple aim. You want to be able to do so in a way that does not disrupt the clinical or provider workflow.

I think health plans know that there are so many barriers to asking the provider to log into another platform. We all hear about portal fatigue. There are a hundred portals that each health plan wants a provider to log into to do something, and we shift that concept on its head.

As a company, we work with payers and explain that we are software technology of significant scale across the entire continuum. These providers are in our system, collaborating every single day on patients as they are transitioning across different care settings, and we would like to bring you, as a payer, into the loop.

If you know that one of your patients, for example, could benefit from a complex care management program or a multiple medication management program, then let us bring health plan context to the provider. At the point of, for example, hospital discharge, the provider knows that that patient is eligible for that service, and they can make a referral.

It is about aligning payers and providers and ensuring that we bring the health plan into the care coordination loop that we've already established.

What is the importance of locating and tracking patients after discharge for payers, and how can real-time notifications ensure proper billing?

The post-discharge period is hugely important in terms of the overall cost and outcomes that patients face.

For example, what we know from the literature is that many patients, something like 40% of patients who get referred to home health, do not receive home health within 7 or 14 days of discharge. You have a very sick patient who is going out into the community, and there may be no touchpoint with them for two whole weeks.

What happens in those cases is patients, understandably, go back to the emergency department. This is not great for the patient and, from a health system, as well as population health and payer perspective, is a high-cost event.

Being able to track your patients—knowing when they have been discharged, knowing if they're receiving any of that follow-up care, and getting alerted if that patient is not getting the follow-up—as well as having that real-time data is important to being able to manage this post-discharge period where time is of the essence.

That's where I think payers can fall short in terms of their reliance on health care claims data. NCQA and HEDIS measures recognize that and have addressed it with their new transitions of care measure which is going to be measuring providers in terms of their ability to arrange follow-up care for patients who are discharged from the hospital.

That has been finalized and a lot of payers are now paying attention to it. As part of that transitions of care measure, what's going to be tracked from a health plan perspective is whether the health plan knew that there was an inpatient admission.

Did the health plan know that there was discharge information, and, as a result, did the health plan ensure that those patients after the discharge received a visit, some type of patient engagement, whether it is an office visit, a visit to the home, or telehealth within 30 days of discharge?

Those are some of the areas that people are looking at in terms of the future of how health plans are going to be measured. It is increasingly going beyond what the claims data can show.

Where do you think the future of care coordination is heading?

I think the future of care coordination is heading towards settings of care that are increasingly outside of what we consider traditional health care settings. It is the patient's home and the services that they receive there.

As a care coordinator, you need to be able to stitch all that information together. That means being able to connect with traditional providers such as hospitals, as well as with non-traditional medical providers such as community-based organizations that are involved in the non-medical aspects of the patient's health.

In terms of whole-person health, those are the types of care settings, so we're going to need to be able to bring all that information together. And you need that information in real-time so that you can manage these patients so that they're getting the right care at the right time with the right resources.

That is what CarePort is trying to do, better enable that ability. We have done the hardest part, which is stitching together a disparate network of traditional providers, such as hospitals, as well as non-traditional ones like community- and home-based organizations, as well as post-acute providers.

Is there anything that you’d like to add?

It is an exciting time for payers and providers as that line continues to blur, and we think about new ways for payers and providers to collaborate. The health plans that are going to be successful in the future are the ones in which we understand how to collaborate with our providers.

Collaborating with them is not just because it's the right thing to do for the patient, but because that is how you can deliver better outcomes at lower cost with a better patient experience and lower provider abrasion, which is the quadruple aim.