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The Cleveland Clinic: leveraging CarePort to achieve BPCI-A success

Identifying, tracking and managing patients affiliated with bundled payment episodes is the only way to succeed under BPCI programs, but doing so is difficult and time-consuming without the right data and tools. CarePort recently hosted a webinar with the Cleveland Clinic to discuss challenges they faced when using only their EHR for bundles management – and why they turned to CarePort as the sole source of truth for all BPCI activity. Joining us from Cleveland Clinic were Jessica Marzulli, Program Manager, Center for Connected Care and Hannah Thomas, Project Manager, Payment Innovation Team.

Bundles Management Challenges

The Cleveland Clinic initiated its participation in BPCI in 2013 with BPCI Classic. When BPCI Advanced was introduced in 2018, the health system moved forward with COPD, asthma, bronchitis and orthopedics bundles across many of its northeast Ohio hospitals. Though its BPCI-A approach was similar to that of BPCI Classic, the health system encountered challenges identifying COPD, asthma and bronchitis bundle patients, and in standardizing and tracking post-acute utilization.

BPCI-A Patient Attribution

Leveraging only its EMR, the Cleveland Clinic’s active BPCI-A patient rosters were historically pieced together from multiple data sources with significant manual input. It was difficult for their multidisciplinary hospital teams to, in real-time, understand the patients for which they were accountable, and to achieve visibility into SNF utilization to identify higher risk patients that may require additional support.

Post-Discharge Visibility

50 to 60 percent of the Cleveland Clinic’s COPD, asthma and bronchitis BPCI-A patients do not receive their primary care from the Cleveland Clinic, which posed a significant challenge for the Cleveland Clinic when relying on its EMR for bundles management. With minimal access to real-time medical records and patient history, and no established care coordination relationship between the Cleveland Clinic and some patients, the Cleveland Clinic lacked visibility into patients’ utilization and transitions post-discharge. Regardless of the patient’s PCP, however, further barriers remained in identifying a patient’s care external to Cleveland Clinic, such as when patients presented at an ED or admitted to another hospital system.

Post-Acute Utilization

Because just over 20% of their COPD, asthma and bronchitis patients had SNF utilization during their care episode, the Cleveland Clinic identified SNF utilization as an opportunity to optimize post-acute utilization and improve patient outcomes within its BPCI program. Despite population health initiatives already in place to monitor SNF utilization, in-hospital care coordinators lacked a means to identify active BPCI-A patients and provide them with extra support in their home – a potential key to avoiding a SNF stay. 

CarePort as a Source of Truth for BPCI

Realizing the need for streamlined BPCI-A patient identification – and without a comprehensive solution to do so within its EMR – the Cleveland Clinic leveraged CarePort to achieve the following:

  • A real-time BPCI-A patient roster: Comprised of patients at high risk of readmission, and in need of additional support services, as identified by the hospital.
  • One “source of truth”: Any team – whether the hospital working team, care coordination, SNF partners or post-acute connected care entities – could see the same data, patient attributions and tracking mechanisms. This real-time information eliminated providers’ reliance on spreadsheets and manual inputs.
  • Ability to “follow” active bundle patients: CarePort provided the Cleveland Clinic with increased visibility into BPCI-A patients’ care transitions during the 90-day bundle period.
  • Clear 90-day start and end date for care coordination: All providers tracking BPCI-A patients can better understand when an episode is going to expire, and also have access to the number of active BPCI-A patients at any given time. Immediately following the 90-day time frame, a patient’s BPCI-A attribution is automatically removed from his or her chart.


More than 150 Cleveland Clinic SNF partners are currently utilizing CarePort; in fact, for a SNF to be part of the Cleveland Clinic’s ACO Waiver Network or its SNF Connected Care Network, it is a requirement that they use CarePort Connect and CarePort Insight. Because of enhanced data and improved care coordination efforts gained through the platform, SNFs retrieve further insights – in a quick and efficient manner – regarding Cleveland Clinic patients, such as high-risk values and bundles attributions. Leveraging national benchmarks of COPD patients, the Cleveland Clinic has also educated skilled nursing facility partners regarding expectations, goals of care and length of stay targets.

Using the CarePort platform, the Cleveland Clinic can identify and track SNF readmission and length of stay performance for bundled patients. This increased visibility allows the Cleveland Clinic to understand a SNF’s ability to provide high-quality care for COPD patients. For the Cleveland Clinic’s primary care and specialty care coordination teams, real-time data and notifications have also reduced the “black hole” of post-acute care – informing them if their patient is discharged, or presents at either a Cleveland Clinic or another CarePort partner hospital – so that they can conduct the necessary follow-up in real-time.


With BPCI-A Model Year 4 just around the corner, a dynamically generated roster – combined with post-discharge monitoring – can provide your organization with reduced readmissions the ability to succeed in value-based care arrangements. Reach out to CarePort to learn more.

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