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For years, a gap in communication existed between a physician-owned medical group in New York and local post-acute care settings.
CareMount Medical, an outpatient practice with a primary care base that offers hospital capabilities such as urgent care, found it difficult to keep tabs on Medicare patients after they were discharged and transitioned to a post-acute care setting. Once they left for post-acute care, CareMount primary care providers just waited for Medicare patients to show up at their regular doctor visits again, according to Richard Morel, deputy chief medical officer at CareMount, based in Mount Kisco, N.Y.
The lack of communication was something Morel and CareMount CIO Nicholas Korchinski set out to change in early 2018. They decided to establish a preferred provider network of skilled nursing facilities (SNFs). CareMount now contracts with 23 local SNFs, and Morel said creating a tight community and developing new metrics have already improved communication between CareMount and post-acute care settings. Korchinski is also working to enhance communication with care management technology.
"We had to change some of the culture of the skilled nursing facilities that we were working with," Morel said. "They certainly felt an obligation to try to make sure their patients had appropriate follow-up, but notifying the primary care provider, making sure they had the appointment [and] getting a timely discharge summary over [were] not part of their standard workflow."
Post-acute care provider network enhances communication
CareMount Medical focused on better communication with post-acute care settings as part of its transition from a Medicare Shared Savings Program Track 1 Accountable Care Organization to a Next Generation ACO Model under the managed care subsidiary CareMount ACO in January 2018.
Richard MorelDeputy chief medical officer, CareMount Medical
The Next Generation ACO Model is supported by the Centers for Medicare and Medicaid Services and focuses on Medicare patients -- a vulnerable population that is often not well enough to go directly home after a hospitalization. The initiative was designed for healthcare organizations "experienced in coordinating care for populations of patients," according to the CMS website.
CareMount ACO -- now one of 51 Next Generation ACOs in the country -- takes on higher financial risks and rewards than it did under the Shared Savings Program, which prompted it to better analyze its spending. If CareMount exceeds its projected Medicare spending in a given year, it will have to make up the difference.
CareMount's analysis of spending from prior years showed that about 20% of CareMount's contracted $325 million of Medicare money went to post-acute care settings, according to Morel. CareMount also discovered patients were discharged to more than 200 different SNFs that varied in quality of care, cost, length of stay and hospital readmission rates on the first day of discharge.
The CareMount team decided to tackle the large amount of Medicare spending in post-acute care through the creation of a preferred provider network. CareMount selected the top 25 SNFs in the area for patient volume and formed preferred provider contracts with the 23 that wanted to participate. The SNFs in CareMount's preferred provider network share the risk and reward for Next Generation ACO patients by being held to certain metrics, such as length of stay and readmission rates.
"If they hit those targets, they would have a return on some of that shared risk," Morel said.
Contracting with the SNFs helped CareMount establish a better bridge of communication between the two care settings. The SNFs now alert CareMount when they receive a Next Generation ACO admission or when a patient is discharged. They also send a discharge summary to CareMount for a patient's electronic health record, which can be useful for the primary care provider.
Once CareMount is notified of a patient discharge, the medical group's care management team will call the patient within 48 hours to schedule a follow-up appointment with the primary care provider.
CareMount also employs a handful of discharge coordinators, who work out of CareMount Medical's highest discharge facilities and are there to explain to patients how the preferred provider network works.
"That communication, we believe, is going to lead to superior care," Morel said.
A care management platform
Today, most of the communication between CareMount and the SNFs happens by email or phone calls, and Korchinski is working to change that. The medical group is using an analytics and care management platform from Arcadia.io, as well as the Salesforce Health Cloud, to create a more transparent and instant communication network.
"We have made a series of what I think are strategic purchases that provide us the opportunity to extend the knowledge and understanding that's collected within the EHR and move it to the mobile platform of a discharge coordinator or a social worker in these other areas of care," he said.
CareMount uses the Arcadia platform as a data warehouse to bring together claims data from patient Medicare files, EHR data and care management data. Integrating all of this data together enables CareMount to monitor the performance of its 23 preferred provider partners.
"How they're doing on length of stay, notification of admissions, readmissions -- we monitor them on that," Morel said. "We meet with them quarterly to go over their metrics, and they're financially accountable for some of those metrics."
The Arcadia platform also monitors post-discharge phone calls and patient follow-up appointments.
CareMount plans to use both the Salesforce and Arcadia platforms to connect to the preferred SNFs and continuously monitor Next Generation ACO patients moving between the two systems, Korchinski said.
Rather than an email, SNFs will then be able to send a notification to CareMount's care management team electronically upon patient admission, directly adding the patient to a care manager's worklist. The care manager would then keep tabs on the patient, paying attention to the length of stay and patient care. Upon discharge, the patient's status would automatically change, and the care manager would move the patient into a new workflow.
"We believe that we have an opportunity of truly managing the patient through the cycle by driving workflow-based best practices that allow the care manager to ensure that they're moving to the right next step in the process," Korchinski said.