DOTmed — March 29, 2019 —Preventing system and organizational leakage is a common goal across nearly every type of provider. It doesn’t matter if you run a massive integrated delivery system, a mid-sized ACO or a community hospital—you can’t care for your patients holistically, or as effectively, if they end up going elsewhere for care that your organization could and should have provided.
It also doesn’t matter whether you’re operating under fee-for-service or value-based care contracts, or both. Either way, there are financial repercussions from patients going somewhere else for care. This is especially true for organizations that are formally accountable for a patient’s entire care plan and outcomes.
Leakage can occur at any point in the patient’s journey, from transport to admission to discharge and beyond. Each point along the way is effectively a fork in the road—a deciding moment that determines what care they’ll receive, where they’ll receive it, and which entity will bill for and provide follow-up care.
At first glance, it might seem like this is less of a concern in the ongoing environment of consolidation. After all, if you’re the only (or one of two) health systems in the area, you can count on patients coming to you, right? Maybe.
If you can’t guide them through the journey, you can’t make best use of your resources. So, in some ways it matters even more, especially if you find your ED overutilized or if you’re implementing SDoH-related programs such as new types of non-emergency medical transport.
Quick, follow that patient
Let’s look at two patient journeys as an example.
The first patient has an emergency and calls 911. The paramedics arrive and ask the patient and his family where they want to go, specifically which hospital they prefer. The family, understandably in something of a panic, doesn’t really know. The closest one? The best one? Which even is the best one?
“Where would you go?” they ask the paramedic. And of course, they take the paramedic’s advice, a deciding moment as it means transport has determined which hospital will see that patient.
A bit later the patient arrives in the emergency room and the paramedics leave to take another call, having been unable to readily share any results of the tests they performed or the information, such as current medications, that they gathered during transport. The ER staff gets to work duplicating those efforts. The patient’s family can’t do much except hope they made the right choice.
There’s good news for the patient—he’s cleared to leave the ER, but the doctor says he should follow-up with a specialist to get a CT scan. The patient might even need surgery. But he walks out the doors with no referral, left to coordinate the next (and new-to-him) phase of his care as best he can.
Now imagine this is occurring at your organization. If the patient follows up with a specialist outside of your network, you just leaked that case right out the door by not having a clear referral process. This could be because you lacked the technology to power it, especially if you’re a large or complex organization. Either way, under certain value-based care models, you just signed up to pay for the follow-up visit, imaging tests and labs, potential surgery and post-surgical care performed at a competitor’s facilities. If you’re operating a fee-for-service model, that leakage just cost your organization thousands of dollars of lost revenue.
Of course, there are further repercussions if the patient doesn’t follow up at all, which is not uncommon. After all, he’s feeling better for the most part, aside from being completely overwhelmed by trying to figure out what steps to take and where to go. So maybe he’ll just see how he feels after a few days before deciding to make an appointment (or not).
It’s also possible that in his rush to just get home he insisted he understood his discharge instructions but forgot them by the next day. So, after he was discharged from your ED and it came time to schedule his CT scan, he didn’t know what else to do other than make an appointment with a specialist he’d heard good things about. Who also happened to be outside of your network.
How the other half lives
The second patient in this example has an established primary care physician in your network. Outreach staff regularly check in on her records and care activity, making sure she gets her annual wellness exam, mammography appointment and flu vaccine. The focus is on keeping her as healthy as possible. For the sake of the example, let’s also say the second patient has diabetes. She works to manage her condition, but, like anyone else, she isn’t always perfect.
Her provider proactively monitors her stats and gets an alert when they’re outside the target range. When that happens, a clinician follows up with a phone call to ask how she’s doing. It turns out the patient isn’t feeling well. They see her primary care physician has an opening at 2 p.m. and book an appointment. Further, her record shows she doesn’t have a car or access to public transportation. The transport center orders a ride to pick up and drop off, which at $12 is a bargain compared to multiple ED visits.
On the one occasion she does need to visit the ED (she’s fine, btw), your system’s central communications hub–something more than what many would consider a traditional transfer center–is able to route her records and information gathered during the ambulance ride to the ED so that staff don’t have to duplicate efforts. To further close the loop, clinical staff follow up with her after discharge to insure she’s feeling well and following a plan to prevent another incident or readmission. When she needs to see a specialist, the right staff person sees that need within the system and proactively connects her to the right in-network facility and ensures her transportation needs are met as well.
That’s a pretty stark contrast from the patient who was simply discharged and left to find his own way through the local healthcare jungle.
The evolving model of system-wide communications and resource management
Today’s typical transfer centers tend to focus on high-acuity cases. But just as we’re going to see a shift from fee-for-service to value-based payment models, the role of the clinically-staffed transfer center will broaden and expand to become a critical function for keeping patients well and making decisions with visibility to patients about what in-network facilities are available to them. I hear this eventuality called many things including command centers, cognitive hospitals, healthcare without walls. Even with consistent language, the definitions are inconsistent. One company will call a simple colocation strategy a command center where another refers to an integrated model where actionable data drives decision making.
Organizations that embrace this model will experience less leakage of patients and of revenue, no matter the types of contracts they have in place with payers. They’ll also likely see an uptick in patient satisfaction. After all, of the two patients described above, which one do you think is more satisfied with their experience? I’d be willing to bet it’s the one who received the right help at the right time every step of the way.
About the author: Angie Franks is the president and CEO of Central Logic, a leading innovator in transfer center software solutions. She has more than 25 years of technology leadership experience. Her areas of healthcare information technology expertise include clinical and financial information systems, enterprise resource planning, telemedicine and Software as a Service solutions.
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