But as we consider condition-related targeting, Grace Hines, RT, MBA, corporate vice president of systems integration for Sentara Healthcare, a nonprofit health system comprising 12 acute care hospitals and more than 100 sites of care throughout Virginia and northeastern North Carolina, reminds us about the interrelated nature of health problems. "As much as we know these conditions and how to control them," she says, "you've got to get the diabetic patient or the heart failure patient engaged so they can be part of the solution. Often that means you've got to delve into behavioral health issues, too … because many patients have something preventing them from doing what they know is the right thing to do."
So, although only 39% of respondents say they have or expect to have a staff person assigned to coordinate the care of patients with behavioral health conditions, those involved in care coordination should expect to encounter a range of conditions, including behavioral health.
A by-product of targeting is that a small number of patients receive the attention of care coordinators, and a great number of patients are not assigned to a care coordinator—they are on their own to coordinate care. Hines notes that Sentara has an outreach program that assigns quality assurance RNs to work with private practice physicians.
"Quality RNs work with providers to identify aspects of care that can be better managed to improve quality and costs. They explore how best to use the tools and resources of the network to impact patient engagement for the vast number of patients not assigned to a care manager," she says.
Within the acute care environment, the highest levels of clinical integration are seen with outpatient primary care and specialty care (76% and 68%, respectively). Slightly more than one-third of hospitals (36%) and health systems (38%) are clinically integrated with skilled nursing facilities, a count that is bound to increase because relationships between acute care providers and SNFs are the focus of considerable attention due to readmission penalties.
James Newbrough, president of OhioHealth's Home Care Division, says that CMS data helped OhioHealth, which operates 11 hospitals and more than 50 ambulatory sites, notice how close per-patient outpatient spending is to per-patient inpatient spending. "The largest areas [for spending] were SNF and home health," he says. "That probably was a trigger for a lot of people. The lowest-hanging fruit, the biggest opportunities we have to impact postacute spending are SNF and home health."
Michael Zeis is a research analyst for HealthLeaders Media.