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Community-based Care Coordination in a Multi-EHR Ecosystem

By Paul Black  
   August 01, 2017

Good care coordination strategies can help healthcare organizations survive the shift to value-based care. Learn how one hospital successfully overhauled care management and how open and interoperable systems help deliver truly connected care.

Closed IT systems lock data into “silos.” These systems make it difficult to share patient data with one another, and they hinder care teams that need complete, real-time information about patients at their fingertips.

More than ever before, payment and delivery system reform is requiring tighter collaboration across fragmented settings. As risk-based financial models become more common, the industry is focused on breaking down data silos and creating more open, connected communities of health.

The real world has changed for the good; there are many more acute, ambulatory and community-based organizations that are digitized today than there were at the beginning of this decade. There is not a single geography nor country where all caregivers and patients communicate and transact on a single integrated patient record.

Organizations that can effectively manage patients across care settings – and among different healthcare systems – will survive the industry’s shift to value-based care. A good, comprehensive care coordination strategy is the foundation for increased access, appropriate cost and higher quality of care across the continuum in today’s environment.

How one hospital successfully overhauled care management

Like many healthcare organizations, Massachusetts-based Holyoke Medical Center participates in Centers for Medicare & Medicaid (CMS) value-based programs, including Medicare Shared Savings Program (MSSP) and Model 2 Bundled Payments for Care Improvement (BPCI) Program. Holyoke Medical Center recognized the need for a new approach to successfully participate in these programs and redesigned its entire care management function.

“One of the challenges we had was that our outpatient and inpatient case management efforts were disconnected. Departments couldn’t see what the others were doing, so we risk loss of continuity of care,” Director of Transitional Care Management Michael Ipekdjian RN, BSN, PHRN said in a recent case study. “To accomplish quality care across the continuum, you can’t have these siloes.”

Unfortunately, disconnected systems contribute to gaps in communication, which can lead to gaps in care. Beyond potential risk for the patient, it can cause organizations to lose out on shared savings and bundled payments, too. 

Holyoke Medical Center set goals for its effort to revamp care management: 1) provide superior transitional care management services, 2) improve clinical outcomes, 3) sustain reduced readmission rates and 4) improve utilization of appropriate services.

Its new structure includes an inpatient Case Management department, outpatient Community Navigation department and a Patient Call Center to engage patients post-discharge. Once all teams reported into the same leadership, Holyoke deployed a platform to encompass discharge planning, utilization management and evidence-based care plans.

Holyoke Medical Center operationalized a significant amount of technology in just six months.With a more unified structure – and technology that supports this approach – it provides smoother transitions for patients and closes gaps for better patient care.

As a result, Holyoke achieved its goals. For example, superior transitional care management services boosted its Press Ganey care transition score from 54.4% to 60.4% and reduced its readmission rate from .9 to .8 in just six months.

Vision for the future: Open, interoperable and connected

Until patients can go anywhere, anytime and know the provider is up to date, our job is not done. Technology must have two key attributes to achieve this; it must be open and interoperable. The result of the open-plus-interoperable equation is a connected community.

An open platform enables a world of possibilities and potential for healthcare. Core systems that are open help providers to extend and scale functionality – so they can meet the specific needs of their community. They can easily integrate proprietary software or plug in new applications from the industry’s most creative innovators.

When we add true vendor-agnostic interoperability, we enable providers to exchange data with any system – accessible in the provider’s home system. Of course, it’s important to also limit the “firehose” effect by organizing the information and making it actionable for clinicians.

Until we reach the post-silo era, clinicians lack the full picture for optimal decision-making and patients will suffer from this lack of access. But innovators, such as Holyoke Medical Center, show us that an integrated, unified approach to care management is possible – that open and interoperable systems lead us beyond data silos to a truly connected community of health.

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