Medicare ACO care coordination toolkit highlights value of health IT

Healthcare information technology is increasingly being leveraged by Medicare accountable care organizations to coordinate and manage care.

That’s the theme of a new Medicare ACO care coordination toolkit released by the Centers for Medicare and Medicaid Services.

“Some ACOs focus on facilitating the exchange of data between primary care providers and emergency departments, whereas others establish networks of post-acute care partners to support their mission of improving the quality and effectiveness of care,” states the toolkit. “Others developed initiatives that focus on managing the care of individual beneficiaries, such as launching a home visit program or using information technology to streamline referrals to community organizations.”

When it comes to coordinating care for beneficiaries after an emergency department visit, CMS reveals that multiple ACOs embed care managers within the ED to facilitate communication and collaboration between ED clinicians and primary care providers.

“Embedded care managers are able to access information on patients’ previous health needs from the EHR to share with ED clinicians and can assist with discharge and transfer from the ED to another care setting or to the home,” according to the document. “Embedded care managers also help to close information gaps if an ACO’s clinicians and hospitals use EHRs that lack interoperability.”

To encourage communication between ED clinicians and PCPs, ACOs have utilized electronic alert systems (e-alerts) that notify the ED clinician of a patient’s attribution to an ACO and include both the PCP’s contact information and a reminder to contact the PCP.

“ACOs pointed to the benefits of e-alert technology that is integrated into the ED’s EHR, saving busy ED clinicians the time and effort of logging into another system,” states the toolkit.

Also See: How IT can help support successful ACO performance

To support care coordination with skilled nursing facilities, the toolkit reports that some ACOs have implemented electronic tools that alert care managers when an attributed beneficiary has been admitted to a SNF, while others rely on being notified directly by the partnering SNF.

For better care coordination for beneficiaries with conditions affected by social determinants of health, some ACOs embed social risk-assessment tools into EHRs, enabling clinicians or care coordinators to screen the beneficiary at the point of care by using a standardized data collection tool.

“The clinicians and care coordinators can then review the results of the screening tool within the beneficiary’s medical record,” states the toolkit. “ACOs can also use the assessment data in the EHR to guide interventions. For instance, recognizing that beneficiaries may struggle with multiple challenges related to the social determinants of health, one ACO purchased a program that analyzes and ranks the challenges that emerged from the assessment.”

According to CMS, this ranking of the challenges enables ACO staff to decide which ones to make top priority and which to address at a later date, while another ACO leverages an algorithm to sift through assessment data in the EHR and identify high-risk patients.

“In addition to capturing data on beneficiaries’ challenges, information technology can also streamline referrals at the point of care and improve beneficiaries’ access to partners’ services,” notes the toolkit. “Some ACOs built tools that allow clinicians and care coordinators to use their computers to identify and make direct referrals to community partners.”

As an example, CMS points to an ACO that added a link in its staff’s computers to the website of a community organization focused on food security to promote direct referrals for patients who do not have reliable access to nutritious food.

“Another ACO has referral capabilities built directly into its EHR and into the same screen that displays the results of patients’ risk assessments,” states the toolkit. “This allows care coordinators, social workers, or physicians to review the risks flagged by the assessment and to make referrals during the same appointment.”