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How Bellin's ACO Gets Real-time Admission, Discharge Data From Outside Facilities

By Mandy Roth  
   September 03, 2019

A care coordination solution enables Bellin to better manage skilled nursing lengths of stay, reduce inappropriate use of emergency departments, and enhance transitions of care to lower costs.

Monitoring admissions and discharges of patients who receive treatment at hospitals, emergency departments (ED), and skilled nursing facilities outside of the organization are among the challenges ACOs face. The inability to manage these patients drives up the cost of care.

Bellin Health Systems, an integrated healthcare delivery system based in Green Bay, Wisconsin, has found a solution that not only provides immediate visibility into patient activities across Wisconsin and Michigan health facilities, it also has contributed to a 12% drop in inappropriate ED utilization and enables Bellin to institute transition of care protocols for 85% of patients being discharged from other facilities.

Through real-time notifications, or "pings," the care coordination platform, PatientPing, is designed to reduce the cost of healthcare by connecting providers to coordinate patient care, and has helped Bellin use the real-time notifications to address the following needs:

  1. Better manage length of stay at skilled nursing facilities
  2. Address transitions of care for patients discharged from other hospitals
  3. Identify and interact with high and inappropriate utilizers of emergency departments

How the Tool Addresses an ACO's Needs

Bellin was one of the original members of the Pioneer ACO, designed by the Centers for Medicare & Medicaid Services. Today, the health system has multiple ACO contracts, including participation in CMS' Next Generation ACO Model.

"With one exception (when Bellin was rated second)," says Chris Elfner, vice president of accountable care strategy for Bellin, "in all of our years of participation, we have been the highest quality and lowest cost ACO each year."

Using PatientPing has contributed to this success, says Elfner. "It helps us drive appropriate care for all of our patients—not just the ACO patients—by giving us real-time information on which we can act to ensure people are receiving the best and most appropriate care."

"The tool brings us into an accountable care world where we can see utilization outside of the walls of Bellin Health," he says. PatientPing notifies Bellin when its patients are seen at other hospitals, emergency departments, and skilled nursing facilities so Bellin representatives can immediately begin interacting with the patient and facility to manage care.

Historically, such information has only been available through claims data, which "typically comes 45 to 90 days too late to do anything actionable," Elfner says. And, while the electronic medical record Bellin uses has some of the necessary information, "it isn't available in a way today that gets us to the actions we're doing with [the tool]," he says.

1. Better Manage SNF Length of Stay

Bellin began using the tool in the fall of 2017 to help reduce length of stay at skilled nursing facilities, a measure that Elfin says was higher than the national average. "We wanted to understand when our people are at those facilities and engage with those organizations to manage the care together."

Because Bellin does not own any SNFs, it was difficult to monitor this aspect of patient care, Elfner says. Now, a team member is immediately notified when an admission occurs. This enables Bellin to schedule case conferences early during a patient's stay to determine whether the individual is medically ready to go home, perhaps with home health services or physical therapy, says Bellin's director of care coordination Lois Van Abel, RN, BSN, MBA, NEA-DC.

While Bellin did not disclose how length of stay has been impacted by the tool, Elfner says the savings that have resulted from this functionality alone have more than paid for the investment.

Better managing SNF length of stay plays directly into the total cost of care for individuals, resulting in savings on ACO contracts that can be shared with the insurance company, explains Elfner. "That means all of the other things that we're getting out of PatientPing are kind of gravy."

2. Address Transitions of Care at Other Facilities

Following Institute for Health Improvement guidelines, Bellin doesn’t use the term "discharge," instead substituting the expression "transitions of care." 

"Discharging means that you are abdicating your responsibility," says Van Abel. "We never give up responsibility of our patients." This philosophy drives a cultural change that dovetails with the goals of Bellin's ACOs.

Thanks to the real-time notifications, Bellin is now able to apply the same transition of care protocols practiced within its own organization to its patients leaving other facilities, says Van Abel. This includes:

  • A follow-up phone call by an RN within two days of a patient leaving a facility
  • Conducting a patient risk assessment during the call
  • Scheduling moderate- and high-risk patients for a visit with their primary care physician within three or seven days following "discharge," depending on their risk level

"In situations where we [previously] didn't even know that the patient was in-house at [another] facility, we're [now] able to see our patients in real time being transitioned out of a hospital setting, capture them as they are leaving, close that loop, and start follow-up care," says Van Abel.

From once having zero visibility, Bellin now initiates the transition of care protocol with 85% patients who are leaving facilities outside of the health system.

Not only does this improve patient care and contribute to lowering the overall cost of caring for ACO patients, Elfner says that Bellin can bill insured patients for transition of care management. "That's something insurance companies understand the value of and will pay to make sure happens because it … lowers costs," he says.

3. Curb High Emergency Department Utilization

Curbing high emergency department utilization is a challenge for many health systems and a factor that amps up the costs that ACOs are trying to control. The ability to review ED usage outside of Bellin enables providers to see a broader perspective on a patient, Van Abel says.

"Just because they're a Bellin patient doesn't mean they come to the Bellin emergency room," she says. While a patient might have been to the Bellin ED once in six months, PatientPing may indicate they've visited other EDs multiple times during the same period. "It gives you an idea very quickly of who our high utilizers are," says Van Abel.

"It's important to understand the utilization, so we can help [these patients] self-manage," she says. "Obviously, this is beneficial in an ACO world because the ED is a high-cost place of service."

Bellin offers retail care, urgent care, and digital care as alternatives.

"We need to help [patients] get to the right acute care setting so that they get the care they need in the most appropriate way," says Elfner.

A Bellin case manager reaches out to high utilizer patients to better understand what's behind their behavior of using the ED and whether its related to a social determinant of health. And, if they don't have a primary care physician, one can be assigned, says Elfner.

As a result of these initiatives, Bellin has reduced potentially avoidable ED visits from 57% in August of 2018 to 45% by February 2019, a 12% decline over six months.

The ED data has proved useful in other ways. By using diagnostic code information from the tool, Bellin determined that many inappropriate ED visits were headache-related. To address this issue, Bellin opened a headache clinic during the day, says Elfner.

The Network Behind the Tool

The "magic" behind the tool is the network PatientPing has created that enables organizations to exchange this data with each other, says Van Abel. "It's been really valuable for PatientPing to be the one going out and talking with all of the facilities, getting them on board, and being able to sell the value to them. They're the feet on the street. The more [organizations] you have on PatientPing, the more valuable it is for everybody involved."

As of August 2018, WISHIN, the Wisconsin health information exchange (HIE), also began participating in PatientPing's network.

"All of this data has been available in our HIE for years," says Elfner. "It's just that nobody was able to put it together in a way that it becomes useful to us."

Jay Desai, CEO and co-founder of Boston-based PatientPing, says  the company's network includes 1,000 hospitals, nearly 4,000 postacute care providers, and a third of the country's ACOs.

“The tool brings us into an accountable care world where we can see utilization outside of the walls of Bellin Health.”

Mandy Roth is the innovations editor at HealthLeaders.


Real-time notifications enable Bellin to monitor admissions and discharges of patients treated at facilities outside of the health system. Historically, such information has only been available through claims data.

Inappropriate use of emergency departments dropped by 12% in six months.

Bellin institutes its own transition of care protocols with 85% of its patients who are discharged from other facilities.

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