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How an ACO is Bridging Functionality Gaps for Effective Care Coordination

April 16, 2015
by John Morrissey
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To succeed as an accountable care organization (ACO), care coordination has to be planned and executed well with a big assist from healthcare IT. And that’s a challenge, because care coordination and care delivery are hardly the same from an IT perspective, according to a highly successful ACO with its own care management subsidiary.

Montefiore Medical Center, Bronx, N.Y., whose Medicare Pioneer ACO earned $48 million and kept $28 million in savings the first two years of the federal program, presented its experience-backed views at the Healthcare Information and Management Systems Society (HIMSS) conference in Chicago on functionality gaps that have to be bridged for effective care coordination. The medical center comprises eight acute care hospitals, 22 community primary care centers, a home care agency and a nursing home.
The past 10 years of IT development have centered on bringing computer power and communications capabilities to the physicians, nurse practitioners, pharmacists and others making up the delivery of healthcare. Moving to an ACO model adds significant new monitoring, shepherding and social problem solving to the mix, and an electronic health record (EHR) isn’t focused on those functional requirements, said David Kim, a consultant with Encore, a Quintiles Company, and adviser to Montefiore.
“Care coordination workflows are just different,” Kim said. “They have different people doing different things. Some tasks are more administrative in focus, and some are more advanced and clinical in nature. So being able to get tasks to the right person to perform the work is key, and [also] being able to manage that.” EHRs may have the functional ability for those objectives, “but the workflows have to be designed according to what care coordination is.”
A complex operational environment is required to support multiple risk-based based programs and lines of business, said Anne Meara, Montefiore’s associate vice president for network management. The ACO includes behavioral health services, social work functions and a range of other support for individuals beyond traditional clinical services--and beyond what an EHR primarily is meant to do.
Care coordination activity and its work requirements also are much more variable than the more static work flows built for doctors and nurses, said Kim. Care coordination is harder to pin down because there are so many ways to plan these functions. That challenge begs for “a flexible tool that can adjust and modify those workflows and those rules,” he said. “In a hospital, you get sick, you enter the hospital in the ED, you get admitted to the inpatient unit--that’s relatively well known. It’s not like that’s necessarily going to change. It’s less of a moving target from an IT perspective.”
Montefiore has pioneered its own IT solutions to the proliferating coordination requirements since it established an independent practice association and dedicated care management organization to facilitate risk contracts in 1996, Kim said. Starting with 12 registered nurses, it now has 600 RNs in care management. The capacity helps support shared risk and full capitation operations covering a population of 345,000 in 2015, with estimated revenue of more than $2 billion.
Besides the IT requirements for care coordination, population health management requires robust data analytics, Meara said. For example, dicing the data has unearthed 8 percent of the covered population that accounts for 55 percent of the organization’s spending and who need a focus of attention.
But analytics alone will not be able to identify the underlying drivers behind complicated conditions such as diabetes, she said. About 12 percent of the population Montefiore cares for has diabetes, “and that’s good to know, but there’s a next level down from the analytics.”  Social determinants of ill health such as mental illness, unstable housing and stress over ability to pay bills “are all things that get in the way of people taking care of their health,” said Meara. 
Based on results of more than 4,000 assessments of high-risk patients conducted at Montefiore, a substance abuser has 89 percent higher costs than average. For a mental health diagnosis, it’s 38 percent higher, and financial distress adds 25 percent. First they have to be isolated, and then the care coordination team can get to work.