Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

An Accountable Care Model for the ED

1/8/2015 12:28:01 PM | 1 comments

In Tuesday's post, Gail Silver, MD, discussed the evolving role of the emergency department (ED) within the Acute Care Continuum. As an urgent care provider, she was concerned about the number of highly acute patients presenting to her practice when they clearly needed emergency care. She noted that in addition to providing life-saving care, EDs also offer care coordination services that connect high-risk patients with needed follow-up and community resources.
 
As an emergency physician, I strongly agree that EDs can and should play a pivotal role in facilitating transitions of care — and ultimately in breaking the cycle of repeated ED visits and hospitalizations that underserved patients often experience. I feel fortunate that my state (Oregon) is pioneering an approach that could serve as a blueprint for coordinated care programs nationwide.
 
In addition to serving as regional director of my practice's Oregon/Washington region, I’m also chief medical officer of Achitrave Health, our county’s coordinated care organization (CCO). In this post, I’ll share how our CCO and ED are working together to help patients, as well as some benefits and limitations of this approach. 

Oregon’s Unique System

CCOs grew out of the Oregon Health Plan (OHP), our state Medicaid program. OHP has been around since 1993 and was one of the first rationed-benefit plans in the country. It’s chief champion was John Kitzhaber, a former emergency physician who went on to serve as a state senator and is now our state’s governor.
 
OHP initially expanded basic healthcare coverage to all Oregonians living below the poverty line — about 120,000 people in all. In 2008, the state further expanded coverage on a lottery basis. And of course, passage of the Affordable Care Act prompted yet another expansion in 2014.
 
In Roseburg, where 30 percent of ED visits were previously self-paid, this latest expansion has given our reimbursements a significant boost. Of course, that money has to come from somewhere, and with an estimated 400,000 additional Medicaid patients expected to enroll by 2022, promoting health and preventing waste and fragmentation have become crucial.
 
That’s where CCOs come in. A CCO is a group of primary care, specialist, mental health and (sometimes) dental providers who work together to coordinate care for OHP patients in a certain region. Care focuses on population health management, particularly preventative care and the management of chronic illness. CCOs go beyond traditional managed care by working to address the socioeconomic causes underlying health disparities (e.g., arranging transportation, securing safe housing and connecting patients with resources such as adult foster care).
 
The CCO program is funded by a five-year, $1.9 billion grant that is contingent on the state’s achievement of certain cost and quality benchmarks. Each regional CCO receives capitated payments per member, and high performing regions share in cost savings. (In this way, it's very similar to the ACO program being piloted by Centers for Medicare and Medicaid.)
 
Architrave Health, the Douglas County CCO, is jointly owned by Mercy Medical Center Roseburg and the Douglas County Independent Practice Association. A centerpiece of the program is the Umpqua Regional Medical Center, a CCO-funded community clinic that provides comprehensive primary care for both scheduled and walk-in patients.

CCOs and Emergency Care

As an emergency physician, I feel that one of the best things about the CCO model is the built-in transition management it provides for our most vulnerable patients. ED "frequent fliers" have been the focus of many of the program’s early management efforts. Preliminary results have been promising: in 2013, ED visits among Oregon Medicaid patients decreased by 17 percent and chronic disease-related hospitalizations were down 32 percent.
 
While transition planning hasn't traditionally been a function of the ED, I think it’s important for emergency providers to accept it as part of our evolving role. Emergency physicians have perhaps the best vantage point on the Acute Care Continuum when it comes to identifying patients who are at-risk for treatment failure. As safety net providers, we see people in crisis and hear their stories. We encounter situations where a simple ride to the pharmacy or dialysis center could have averted a costly health crisis. And we also see a fair number of patients coming into the ED for prescription refills because they can’t get an appointment with a primary care provider.
 
To better serve these high-risk patients, Architrave is piloting a coordinated transition team that includes a physician medical director, RN, LPN and two staff members. When a high-risk OHP patient presents to the ED, the doctor obtains consent and makes a referral to the team. (It’s as simple as sending an email from the EHR.) Team members then reach out by phone, text message or email to help the patient navigate the healthcare system. They schedule needed follow-up appointments with community partners or through URMC. They also give reminder calls and coordinate community services such as transportation.

Keys to Success

So what are the building blocks of a successful ED transitions program? I think it’s easy to overgeneralize, because every hospital serves a unique patient population, and every community has different resources.
 
Here in Douglas County, which is pretty self-contained, we definitely benefit from the existing relationships between the hospital and local providers. Because they trust us, they’re often willing to be flexible when the transition team calls for an urgent follow-up appointment. We’re also lucky to be partnered (via Architrave) with a strong, well-contracted IPA.
 
That being said, here are three areas where we’re really focusing our efforts:
  • Access. In the past, there was no real incentive for providers to see OHP patients. However, via the transition team, our CCO is now in a position to "reward" accessible providers with increased referrals.
  • EHR integration. Seventy-eight percent of Architrave providers are on the same system, which greatly enhances collaboration and continuity of care.
  • Physician leadership. As CMO at Architrave, one of my goals has been to extend CEP America’s emphasis on data and transparency to our primary and specialty care partners. This can be a big cultural shift for outpatient providers, many of whom are uncomfortable with having their performance data on display. So it's important that I help them see the benefits both for patients and for their own practices. (I have a bit of leverage here, because ultimately our CCO funding is contingent on performance.)

Risks and Rewards

Our care transitions program isn’t without risks. For one thing, it’s expensive — the annual budget is in the seven figures. We’re also navigating the murky waters of HIPAA compliance. And occasionally, we run into the awkward situation where a referred patient isn’t actually covered under OHP.
 
While the pilot program is fairly new, I do believe it’ll pay dividends for patients and for our hospital down the road — notably in the form of more appropriate ED utilization and fewer readmissions. In addition, our experience so far suggests that the transitions team is a great patient satisfier. Coordination often means lower out-of-pocket costs and fewer doctor visits. And for many patients, our team members are the first people to offer a listening ear and long-term solutions to their problems.

The Future

Architrave is currently collecting data on 17 measures identified by Oregon as performance targets. This will help us gauge our success in "closing the healthcare gap." I hope to post again once we’ve had a chance to see the program’s impact on clinical outcomes, quality, patient satisfaction and revenue.
 
One of my great hopes is that we’ll develop some best practices that can be applied by EDs across the country. Maybe down the road, transition management will become a service line we can offer our hospital clients, just like emergency medicine and anesthesia. Certainly some great lessons are being learned.

[Image credit: "Telehealth - older man and nurse using blood pressure" by Tunstall licensed under CC BY 2.0]


Comments
True McMahan
Dr. Fox speaks from a very knowledgeable and experienced background. This CCO idea is at the forefront and is pivotal to successful participation in any acute care continuum. The challenge remains in rural and suburban environments where the complexities of single practice competing with the melting pot of various ACO's and HMOs create strong cross currents and dichotomies. Also, antithesis and just as unsavory is a single system that leaves no room for competitive innovation. However no one can argue that local conditions prevail, and each individual site needs and transitions of care models will undoubtably be different. Thank you Dr. Fox for some very enlightening ideas.
1/9/2015 10:06:54 AM