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.
“Hospital registration data is not always clean and we had to understand that and apply at lot of filtering. So we had to build bridges with the hospital registration team and work out improving and correcting those kinds of things as they were identified,” Thompson says. For instance, SHP had to communicate with hospital registration staff the importance of inputting the patient’s primary care provider’s name correctly in order for that patient to show up in the SHP census.
As Thompson explains, “You can easily see when you are assigned a patient on a census if they are the right one or not, but if you aren’t assigned a patient, you don’t know what you don’t know. So it took a little bit of reconciliation over a few months, looking at reports from insurance companies, and if we didn’t see this patient on the census then we need to dig a little deeper, as maybe we’re missing an insurance code and it’s not capturing the right information. Or maybe there’s a primary care physician gap on some list on the hospital side. So it was really that fine tuning that took longer than actually building the census itself,” he says.
The next step in this project was to use the patient census data to provide SHP physicians with real-time notifications about their patients. Thompson credits Dr. Nelson with devising a creative solution to adapt SHP’s existing technologies to create the real-time notifications. According to Nelson, adequate technology solutions for ACOs, and specifically ambulatory care management aspects of ACOs, are somewhat limited. As a nimble organization, SHP was able to integrate notifications from Orion Health’s HIE to TigerText, a secure text messaging application that physicians already were using, rather than purchasing a new health IT solution.
“We’re fortunate that our organization has someone like her and several other physicians who are pragmatic and understand technology and are constantly coming up with new ideas to challenge us to go down a new path with the technologies that we have,” Thompson says.
So, the SHP team integrated notifications from Orion Health’s HIE to TigerText so secure, real-time and context-rich notifications are sent to transition care managers, primary care physician-based care coordinators and primary care providers on a 24/7 basis. Thompson adds that both Orion’s and TigerText’s technologies are flexible and open, which was a key part of the success of the project.
“We’ve carefully chosen our technology partners, and really look at their openness and their ability to integrate, so we can configure and customize their systems on our own without having to use vendors or buy new technologies just to solve a particular problem,” Thompson says.
Dr. Nelson says, “Once we had that set up, I was the first test subject. And we found out we get multiple ADT messages at the same time, as I got 30 messages at 3 a.m., about one patient, notifying me that the patient was in the hospital.”
The solution was adjusted and improved so duplicate messages were filtered out and after about nine months of testing it was ready to roll out to all the primary care physicians. As a result, transition care managers, care coordinators and primary care physicians can turn on notifications to receive specific information such as patient’s name, date of birth, hospital, unit, room, admitting diagnosis and the primary care provider’s name.
The third phase of the project entailed adding the ability for primary care-based care coordinators to establish relationships with patients in the HIE by building a page within the CareConnect portal. This enables coordinators to track and monitor their patients enrolled in the ambulatory care coordination program via an efficient dashboard and they also receive notifications in real-time about their patients, Thompson says.
Vanaskie says the project has been a “lifesaver” for transition care managers as it enables them to allocate time to work with patients and clinicians rather than chasing down data and spending time on manual documentation, and also frees up time for clinicians to focus on providing quality medical care.
Ambulatory care coordinators carry a caseload of around 90 to 125 moderate to high-risk patients, making it difficult to simultaneously monitor the right patients at the right time without technology. Since implementing the solution, transition care managers are able to see 20 to 40 percent more patients per day.
And, getting back to the lower readmission rate, Vanaskie says the solution enables the care management team to quickly respond as soon as a patient registers at the ER. “At that point, the transitional team can go down to the ER and begin to look at the needs of that patient and decide whether they need to come into the hospital, or are there alternatives with our post-acute providers that we can provide services. And, we’ve been able to turn the course and get the patients in the right settings for the right treatment versus just admitting them to the hospital and then figure out what they need.”
As an example, she recalls an elderly woman in a group home who fell and was rushed to the ER due to concerns about an injury to her hip from the fall. The transition care manager received a real-time notification, and was able to see the patient at the ER and talk to the primary care physician and the care coordinator about the case. Based on the patient’s healthcare needs, the team decided an acute rehab facility was a better choice instead of the ER. “Being able to communicate with all the healthcare team about the case, we were able to give the patient the right level of care,” she says.
Vanaskie credits the success of the care management model at SHP, with both the transition care manager at hospitals and care coordinators at the primary care practices, for the lower readmission rate, but also acknowledges that technology played a key role.
She continues, “The technology platform that Faron and David have given us allows us to keep our arms around those moderate to high-risk patients. The care management team is in close communication and we couldn’t do that without technology. We’d be using telephone and voicemails, but now we get answers right away.”
And, SHP’s creative adaption of existing technologies has closed the technology gap for its ambulatory care management with very little incremental investment.