Clinically Integrated Network Improves Care Coordination

The Challenge

Saint Alphonsus Health Alliance is a Clinically Integrated Network (CIN) whose strategy is to tightly align physicians, hospitals, and payers to provide better access to care, combined with better clinical quality and controlled costs.

Across the continuum of care they serve, the Alliance found themselves navigating a lack of visibility into patient records during and after skilled nursing stays. This challenge led to communication gaps and difficulties in coordinating care transitions.

Michael Twomey, MD, Executive Medical Director for Saint Alphonsus Health Alliance, shares, “As a family medicine provider, it was a real struggle to access patient records when they were discharged from skilled nursing facilities. I often had no visibility into their medications, the course of treatment, or the thought process behind the care they received.”

This challenge contributed to longer patient stays and hindered timely care transitions. The Alliance saw an opportunity to overcome these barriers by enhancing care collaboration across the continuum and implementing the right tools to ensure better visibility into critical patient information.

The Solution

PointClickCare’s Value Based Care for ACOs offers real-time insights to support high-quality coordinated care across managed populations. This solution offers risk-bearing providers and accountable care organizations (ACOs), including CINs like the Alliance, the ability to track and manage high-risk transitioning patients. It also allows them to proactively prioritize, collaborate, and intervene to address changing patient needs, providing real-time patient activity alerts.

Additionally, real-time encounter alerts and smart access to clinical documents maximize impact of care management programs for higher risk patient groups. This improves quality of care, reduces excess utilization, and prevents avoidable readmissions.

With timely data and insights supporting workflows tied to quality measure performance, Value Based Care for ACOs can also help reduce duplicative services and costs, helping to meet quality benchmarks and improve financial outcomes.

The Outcome

Saint Alphonsus Health Alliance now utilizes Value Based Care for ACOs to coordinate care across the continuum, bridging gaps in access to records and communication. “Now, with PointClickCare, our team can guide providers to deliver excellent care to our members, while our social workers use it to identify specific patients that require outreach or support,” says Twomey.

As a result, explains Twomey, “I’ve seen our hospital follow-up after discharge numbers improve year-over-year. We were able to improve our Star Ratings by 10% with our Medicare Advantage Plans.”

He adds, “I think the best part about my job is being able to give providers the information that they need on a timely basis. If we can’t do that as a healthcare network, we’re really failing at what we do.” With PointClickCare, “I feel really confident that we’re able to do that at this time.”

Learn More

If you’re interested in implementing Value Based Care for ACOs to help your organization achieve results like those experienced by Saint Alphonsus Health Alliance, contact our team for more details.