How Real-Time Data Can Support ACOs to Achieve Value-Based Care Goals

As the shift to value-based care (VBC) continues healthcare providers have encountered challenges meeting the required goals. For US providers hoping to comply with the Centers for Medicare & Medicaid Services (CMS) mandate that all Medicare beneficiaries be covered by value-based care models by 2030, the need to be successful in VBC arrangements  will become increasingly urgent over the next several years.

This was the case for Pathways Health Partners, an accountable care organization (ACO) in Florida that works with more than 280 providers across multiple clinical specialties. They were struggling to ensure access to patient records in real time, which was necessary for improved care delivery and care coordination across their network. By leveraging technology for real-time visibility into patient activity across care settings, Pathways was able to achieve key value-based care goals. Learn how they did it.

Lack of Visibility into Patient Data Impacts Network Performance

Without access to current data about patient health encounters or health status changes, providers cannot support care coordination or effective decision-making for their patients. For large provider networks like Pathways Health Partners, this is an obstacle to improving care delivery. “Ensuring access to patient records in real time, regardless of where patient care is delivered, was an ongoing hurdle for our organization,” said Ricardo Matos, CIO at Pathways. “It was a significant limitation with regard to our providers making timely, informed care decisions.”

Pathways had explored accessing data in a variety of ways, which included registration and payer activity information from data clearinghouses. However, this data can be delayed by days, weeks, or even months – when it’s already too late to support proactive interventions to prevent a hospitalization, or timely follow up after a patient is discharged to home or a post-acute care setting like a skilled nursing facility (SNF).

Better informed care decisions can also lead to improvements in key performance indictors like readmission rates, unplanned admissions for patients with multiple chronic conditions, and SNF length of stay for risk-bearing providers. For this reason, it was of critical importance for Pathways to find a better data source and way to disseminate critical patient data across the network.

Leveraging Technology to Improve Care Collaboration

For value-based care goals to be fully realized, Pathways needed a system that provided prompt access to patient data regardless of where care was delivered to solve the visibility. They began partnering with PointClickCare to leverage technology solutions that could increase care coordination across their network of care providers by dispatching notifications of hospital admissions, discharges, and transfers (ADT) and other real-time patient data.

Knowing a patient has been hospitalized is the first indication for care teams to take action. Using this technology, Pathways Health Partners could provide clinicians with ADT notifications in order to coordinate with primary care providers more quickly and seamlessly. This made it much easier to realize its mission to provide timely, coordinated care for patients and to support ACO guideline compliance.

In addition, this ADT data was layered with clinical data like lab work, transition care management information, and discharge documentation, which fully integrated into the organization’s population health data dashboard. Having easy access to this patient data made it much easier for providers to coordinate care and follow up with patients for better outcomes.

More Effective Care Delivery, Health Equity, and Cost Savings

The real-time notifications sent directly to provider workflows helped patients in the Pathways network get into treatment faster, regardless of socioeconomic status or other barriers to care access. Providers can connect with patients and deliver critical care faster, leading to better outcomes and reduced costs with equitable access across the network. 

With access to a growing volume of patient data, Pathways Health Partners was also able to introduce new methods to connect and inform care while allowing for closer monitoring between short and long-term care. The notifications trigger faster access to care, from SNFs, hospice, and home care. By making outside services available to the patient, including at SNFs or long-term care facilities, Pathways reduced costs for hospital readmissions.

“We’ve achieved a near 100% response rate to inquiries on payer activity, an impressive success,” Matos reported. “And as an ACO, we continually gain broader insights into the populations we serve. These more timely and broader insights are shared with primary care providers to support informed care decisions for their patients and mitigate readmission risks.”

To realize value-based care goals like improving outcomes at a lower cost, streamlining workflows for providers, and delivering care more equitably, organizations need to have the technology infrastructure and solutions to support fast, secure data exchange for effective care delivery. For organizations working to optimize strategies to improve cost-effectiveness in operations, real-time patient notifications are a requirement for improved care delivery and increased savings. For more firsthand details about how Pathways Health Partners leveraged PointClickCare technology to realize their value-based care goals, check out this interview with CIO Ricardo Matos on Healthcare IT News.