We are continuing our review of the Office of Inspector General (OIG) study on the seven strategies that 20 high-performing accountable care organizations (ACOs) used to generate impactful results. Today we are discussing strategy four: managing hospitalizations. The largest portion of fee-for-service Medicare spending is hospitalizations, and proper management can lead to expedited treatment that reduces admissions before they occur and helps prevent readmissions later. In this post, we will cover the challenges and fundamental steps they used that offer the perfect blueprint for other ACOs to follow suit.
The Challenge of Incentive
Joanne M. Chiedi, the Acting Inspector General of the Department of Health and Human Services (DHHS), identified that hospitals are among the hardest to engage when it comes to cost-cutting tactics. Their reimbursement is chiefly based on their number of admissions, however, many have limited insight on how repayment works in the value-based care landscape and how easy campaigns are to implement. The strategies Chiedi determined from the study to manage hospitalizations are:
- Expand access to primary care services
- Target emergency room utilizers
- Improve care coordination within hospitals and at the point of discharge
Primary Care Access
A significant way these ACOs reduce the number of avoidable hospitalizations is by expanding traditional access to primary care. Allowing more time for Medicare patients to be seen after regular business hours makes it more likely these patients will take advantage of primary care offerings. Most of the ACOs expanded their primary care availability; several extend their appointment times to evenings and weekends, intentionally leaving appointments open for patients with urgent needs, and guaranteeing next-day appointments for people who went to the emergency room but were not admitted to the hospital.
That additional access expands beyond in-person care. Select ACOs have primary care physicians that are available by phone for beneficiaries to call and advise whether they need to go to the emergency room with the symptoms they are experiencing. These phone calls are designed to inform patients about alternatives, like urgent care clinics, that are far less expensive in comparison to hospital admittance. One ACO has a 24-hour hotline to triage beneficiaries and send them to the appropriate care based on their circumstances.
Targeting ER Utilizers
Since reducing emergency department (ED) overutilization is a standard initiative we help our clients perform, we hear many patient stories and personal accounts of what causes their overuse. Some are plausible, but many have clear solutions. One of the ways ACOs get to the root of their overutilization is by having a simple conversation. Several ACOs have providers ask frequent utilizers directly why they are becoming regulars. Social determinants of health (SDoH) can play a part in overutilization, and providers who discuss these with patients can tailor solutions for them based on their needs. A portion of the ACOs said that patients went to the emergency room to see providers instead of making an appointment.
“…one ACO identified a beneficiary who had 30 emergency room visits in a year; by offering a standing weekly appointment with a primary care physician, the ACO reduced the number of emergency room visits to two the next year. “
A simple standing appointment was the solution that allowed a patient to find a regular primary care physician and avoid further overutilization of emergency services.
Improving Care Coordination
Coordinating care with hospitals that are not part of an ACO proved a challenge for many of the organizations in the study based on their limitations. Communication, scheduling, and the ability to monitor patients more closely are all benefits of having hospitals within an ACO network, specifically for the use of hospitalists (physicians that work exclusively in the hospital setting). Hospitalists help tremendously with the management of both the care and cost of patient services for these ACOs.
While ACOs with hospitals have an advantage, many that do not are able to place team members in them to keep an eye on patients. These ACOs dispatch staff members to manage beneficiaries, help with clinical rounds, monitor their length of stay, and advise them on their plans for discharge. One of the ACOs immediately sends medical records to outside hospitals if specific patients are in the emergency room or admitted to prevent duplicate services.
The detailed coordination displayed by these ACOs extends beyond the discharge of patients. ACO staff within hospitals make sure that beneficiaries have a means of transportation lined up for follow-up appointments, educate them on medication use and symptoms, and secure their medical equipment. A major initiative that these ACOs employ is medication reconciliation, or making sure a provider can see whether prescriptions are refilled and picked up in the claims data. An ACO involved pharmacists in addressing medication non-compliance with patients, while another created an initiative for medication reconciliation post-discharge. Patients who have many prescriptions automatically receive a 30-day supply upon leaving the hospital. The initiative reduces the burden on the patient of remembering to fill and pick them up. The ACO saw drops in both medication errors and readmission rates.
Follow-up appointments are also a major focus after a patient is in the hospital. Touching base to confirm beneficiaries are following their post-discharge plan, are not experiencing new symptoms, and are transitioning well work together to reduce readmission. Two ways that select ACOs ensure patients have follow-up visits with their primary care physicians are:
- Scheduling appointments for the patients shortly after they are released from the hospital.
- Creating a specific quality measure for fulfilled primary care visits; one ACO set theirs for 14 days after a patient is released.
Notably, one ACO was vigilant about scheduling follow-up appointments within one week of discharge and were thorough in their transitional care efforts. In their chronic heart failure (CHF, or congestive heart failure) patients, they experienced a 50% reduction in their readmission rates.
Hospital stays are expensive, but the right care coordination is invaluable. Join us next time for the fifth strategy as Lightbeam Senior Advisor, Maha Salah-Ud-Din, discusses how these ACOs used expert approaches to manage skilled nursing and home healthcare.
The full study can be found at https://oig.hhs.gov/oei/reports/oei-02-15-00451.asp
Read more from Sean Henson, the Vice President of Operations at Lightbeam.