Achieving value-based care goals remains a daunting challenge for many providers, who are also doing their best to provide equitable care. Pathways Health Partners, a responsible care organization that works with more than 280 providers across multiple clinical specialties, works with organizations to address these issues.
PROBLEM
“Ensuring access to patient records in real time, no matter where patient care is delivered, is a constant obstacle to our organization,” said Ricardo Matos, CIO at Pathways. we”. “It’s a significant limitation for our providers to make timely, informed care decisions.
“And we know from experience working with partners over the years that trying to find discharge documents is the least favorite task of any practice manager,” he continued.
However, without real-time access to patient data, providers in the network are limited in understanding more fully the interventions that could make the greatest impact.
“We also need more immediate healthcare data to improve reporting quality metrics and meet the Centers for Medicare & Medicaid Services requirement that all Medicare beneficiaries are eligible,” he explains. covered under value-based care models by 2030”.
PROPOSE
Pathways ACO has contacted IT provider Audacious Inquiry, a PointClickCare Company, for assistance.
“For value-based care goals to be fully realized, Pathways needs a system that provides rapid access to patient data regardless of where care is provided,” said Matos. . “PointClickCare’s healthcare technology platform can address our challenge of having limited access to real-time patient records.
He added: “The system provides each patient’s clinician with notifications about admissions and other real-time patient data. “This is information that has never existed in a fee-for-service environment.”
With this technology, Pathways Health Partners is able to provide individual patients’ clinicians with readmission notice for faster and more seamless coordination with primary care providers.
MEET CHALLENGES ONLY
With the new platform, Pathways easily fulfills its mission of providing care to patients and works with doctors who have been community doctors for decades to follow ACO guidelines. .
Matos notes: “Knowing a patient is in the hospital is the first sign to act. “Pathways Health Partners classifies this data with transition care management and does not require patient discharge documentation.
“PointClickCare’s healthcare technology platform also provides lab results, which are then fully integrated into the organization’s population health data dashboard,” he continued. “As a result, healthcare providers have been able to significantly reduce readmission rates.”
RESULT
Since Pathways became an ACO in 2013, there have been significant changes to the type of data available to members. Previous data aggregation efforts include relationships with data clearing centers to gather detailed details about subscription activity and payers. Hospitalization notifications and other real-time patient data are the latest addition in the data journey.
“We achieved a response rate of close to 100% on questions about payer activity, an impressive success,” Matos reported. “And as ACOs, we continually gain deeper insights into the populations we serve. These deeper and more timely insights are shared with service providers. primary care to support informed care decisions for their patients and reduce the risk of re-hospitalization.
“With the growing volume of accessible, real-time data, we’ve also introduced new ways to connect and inform care,” he added. “The result is reduced readmission costs, by providing those outsourced services to patients, including in skilled nursing or long-term care facilities.”
TIPS FOR OTHER PEOPLE
Matos advises that, first and foremost, providers should ensure that they have the right infrastructure and resources in place to deliver value-based care to their patients.
He continued: “For organizations working to optimize strategies to improve operational cost effectiveness, real-time patient notification is a must. “Providers should prioritize clinical data exchange.
“Ultimately, these types of notifications help patients get treatment faster,” he said. “Regardless of a patient’s condition, regardless of their socioeconomic status, real-time notifications allow providers to connect with patients and deliver critical care. weight faster.”
Additionally, the announcements allow for closer monitoring between short-term and long-term care, he noted.
In addition to analytics, these notifications enable faster access to care, from skilled nursing facilities, hospices and home care, he concludes. all those resources equitably”.
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Healthcare IT News is a publication of HIMSS Media.
