This is the third in a series Silverline POV’s focused on helping healthcare organizations, as providers of healthcare services to patients, be successful in five key areas as healthcare reimbursement models shift from fee for service to fee for value. Each one is focused on how to leverage the Salesforce platform and effectively navigate patients on their healthcare journey. These POV’s are based on my twenty years’ experience in healthcare and twelve years experience creating and operationalizing patient journeys utilizing Salesforce for large healthcare systems in Texas and Colorado at the physician group, clinically integrated network (CIN) and healthcare system levels.
Here are five areas we are exploring:
- Provider Relationship Management
- Consumer & Patient Engagement
- Ambulatory Care Coordination
- Transitions in Care
- Specialty Care Coordination
We will view these opportunities in the context of using Salesforce and leveraging Silverline’s suite of solutions and accelerators.
Ambulatory Care Coordination
Reimbursement Models are changing as a result of the ACA. Healthcare reimbursement is moving from Fee for Service to Fee for Value. Ninety percent of Medicare payments will be tied to quality or value in 2018.
|Fee for Service||Fee for Value|
|Reimbursed for line item services||Payment rewards population value: quality and efficiency|
|No incentive to increase quality of care||Quality impacts reimbursement|
|No shared financial risk||Partnerships based on shared risk|
|No incentive to produce better outcomes||Incentives aligned with outcomes|
|No incentive to collaborate||Collaboration encouraged and rewarded|
|Focused on episodic care and the acute stay||Focused on ambulatory care, navigating healthcare journeys|
These changes necessitate a change in the way healthcare organizations care for patients. It requires an active engagement between patients, their families and the healthcare organization that now has reimbursement tied to the patient’s healthcare outcomes. It is no longer enough to be reactive to acute patient episodes, but healthcare organizations must be proactive to prevent or reduce these acute episodes, thus increasing the patient’s quality of life.
The first step in developing a successful ambulatory care coordination model is to know your patients. In order to effectively manage risk (increasing shared savings and quality incentives while reducing readmissions and unnecessary care), a healthcare organization must risk stratifying patient population to identify high-risk and high-cost patients in real time. This can be done with external risk stratification tools with the risk score imported to Salesforce, but there must be a real-time nurse-driven factor that can change the patient’s risk score as needed. It’s not enough to rely on claims data, which is typically 60-120 days old.
The high-risk/high-cost patients can be assigned to active care coordination while the moderate to low risk patients can be assigned to passive care coordination. Active Care Coordination consists of assigning an RN to actively reach out to and manage the care of a patient through the PCP-defined care plans, standing order sets, and remote monitoring. Passive care coordination is accomplished through passive interaction with patients to include addressing gaps in care and monitoring for events that would increase their risk score. This can be done with assessments, documentation of barriers to care, or notifications of adverse events from a health information exchange (HIE).
Disease Management is an important component of a successful ambulatory care coordination model. Organizations can develop and implement disease-specific care plans and protocols for diseases such as asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes, hypertension (HTN). These protocols can be developed in-house or linked to protocols from respected healthcare organizations such as Cleveland Clinic, Mayo Clinic, or Geisinger.
Many of the Medicare innovation (alternative payment) models, such as Chronic Care Management (CCM) program and Medicare Shared Savings Program (MSSP) have specific requirements for reimbursement. For example, Silverline’s CCM component includes a countdown timer to satisfy the 20-minute minimum contact requirement while also providing a billing model for organizations that provide this service for PCP’s.
As mentioned above, preventative care plays an important role in increasing the quality of care while reducing the cost of care for at-risk patients. Silverline’s Preventative Care accelerator allows for the tracking of preventative care campaigns and associated referrals utilizing HEDIS measures as the framework and linking object. This allows for both the identification of eligible patients and the navigation of patients to the appropriate provider for testing and treatment in a Patient Contact Center setting through the use of outreach workflows and reminders.
The tracking of quality and compliance within these programs is critical. Each program has unique documentation standards, intervention timing, and quality indicators. Each payor, government or commercial, manages their fee for value programs differently. The ability to customize the reporting and dashboards to meet these unique requirements makes Salesforce the perfect platform for ambulatory care coordination.
In summary, Silverline, with its ambulatory care coordination solutions and accelerators, can provide a framework for managing an at-risk patient population in a fee for value model. Create active and passive care plans. Develop preventative care outreach and referral management programs to address gaps in care. Integrate your patient contact center to provide 24/7 support for your highest risk patients. Wherever you start, Silverline has the tools and the experience to help you be successful.
Download the Provider Roadmap to Success ebook to see how the five key areas come together to improve care and reduce costs.