Scottsdale Health Partners (SHP), a physician-led clinical integration network, was formed in 2012 and has quickly grown to 700 physicians serving 35,000 patients throughout the greater Scottsdale, Arizona community. SHP consists of 115 primary care physicians and the balance are specialists from a wide variety of specialties. SHP also participates in the Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) program. As an organization with a strong focus on transforming healthcare delivery in the Scottsdale area, bridging the gap between patients admitted to local hospitals and their primary care physicians is a critical component of SHP’s Care Management Program.
As a result of a data-driven, multidisciplinary initiative, SHP has streamlined its care coordination program using health IT solutions, so that care coordinators monitor patients in real-time and see more patients per day, ensuring proper transition care. And, more impressively, SHP has made some remarkable enterprise-wide achievements with reducing hospital readmission rates among its patients—SHP’s all-payer readmission rate is now below 9 percent, compared to the Arizona state average of 15 percent. For its innovative approach to avoid unnecessary patient hospital admissions, the editors of Healthcare Informatics have named the team at Scottsdale Health Partners the No. 2 winning team in the HCI 2016 Innovator Awards program.
“A lot of the success we’ve had around reducing readmission rates is because we’re able to notify the primary care physician in real time and tell them what’s going on with their patients in the hospital. As a result, patients get in to see their primary care physician within the right timeframes and the right follow-up is planned, which helps keep them out of the hospital,” Tiffany Nelson, M.D., chief strategy officer at SHP, says.
And while care coordination is primarily a clinical function, SHP leadership found that the system was only as good as the data supporting it. Currently four SHP-employed transition care managers are responsible for patients in three Scottsdale hospitals in the Honor Health system as well as a post-acute facility, and SHP also has an additional 15 care coordinators working with the primary care physicians. As SHP initially began building and developing its care management program, leadership recognized that there were a lack of appropriate tools available in the health IT market designed specifically for ambulatory care management professionals.
(left to right): Tiffany Nelson, M.D.; Faron Thompson; Karen Vanaskie; James Whitfill, M.D.
“The biggest complaint that our primary care providers had was that they didn’t even know that patients were in the hospital. There was a lot of difficulty getting their chart summaries and any information from the hospital. Typically, if physicians got a discharge summary, it was faxed and delayed. It’s a problem that’s pretty common and we realized we needed to provide physicians real-time information,” Dr. Nelson says.
In addition, reliance on hospital legacy systems led to cumbersome paper documentation and other manual processes, frustrating care managers and impacting efficiency. In order to obtain appropriate information about patients, care management staff were using three or four different health information technology systems, “taking anywhere from 30 to 45 minutes to get information about any one patient,” Nelson notes.
“The hospital legacy system also wasn’t able to identify all of the SHP patients that our transition care managers needed to be seeing, either because the primary care provider’s name wasn’t spelled correctly or it didn’t have updated insurance information. We wanted our transition care managers to just look in SHP CareConnect (SHP’s health information exchange portal) to get the most pertinent information,” Nelson says. “So our first big challenge was how do we provide that information through a better portal than what the hospital offers, and the second was, how do we identify that a patient is in the hospital and who exactly are the transition care managers supposed to see? So, our team had to build a real-time patient census.”
Back in July 2014, SHP set to work on building its own patient census using its health information exchange (HIE) solution, Orion Health’s Healthier Populations Solutions. David Baker, director of enterprise architecture at SHP, says building the initial census was relatively straightforward, but it was the subsequent filtering of the data coming in to ensure the census was accurate that proved to the biggest challenge.
“Once we started digging down, we started seeing nuances to the data coming in and we had to work with Karen [Vanaskie, a registered nurse and the care management program director] and her team to see what was going on with the data. We needed to understand if we were getting old data from months prior because of internal processes on the hospital side or because of the current processes resending data over and over again,” Baker says. “There was some data falling off and some data showing up that shouldn’t have been there, so we had to work with Karen and her team to really fine tune the filtering to make sure the census was accurate.”
Faron Thompson, SHP chief operating officer, adds that one challenge with hospital-generated ADT (Admit, Transfer, Discharge) messages is that the system can typically generate dozens of messages for the same admission or event.