Essentials to Success In The CMS Direct Contracting Entity (DCE) PART 3: Care Transitions

DCEs lack insight into costly, poorly coordinated care transitions unless they can monitor the entire continuum of care.

Ensuring the proper transition of care – the movement of patients between care settings – is a crucial factor in achieving quality patient outcomes. When these are not properly managed, the results can be adverse medical events, readmissions, poor patient experience, and a higher cost of care.

The impact of care transitions on patient outcomes, the quality of care, and the patient experience is relatively the same across all populations and patient cohorts. However, for organizations who take on the risk for the total cost of care or who are in a value-based care program, such as direct contracting entities (DCE), they can experience additional negative effects. DCEs and the new geographic DCEs (GeoDCE) are the latest value-based care programs introduced by the Centers for Medicare and Medicaid Services (CMS) to help reduce the cost of care and improve patient outcomes and quality of care.

Reducing Poor Care Transitions

The transition from the acute care setting to the next, home or post-acute care, results in the most significant financial impact. A study by concluded that “poorly coordinated care transitions from the hospital to other care settings [in the U.S.] cost an estimated $12 billion to $44 billion per year.”

The study also listed five best practices in care transition to reduce poor transitions and improve patient outcomes:

  1. Comprehensive discharge planning
  2. Sending discharge summaries to outpatient providers
  3. Assessing financial barriers to filling prescriptions
  4. Using a “teach-back” method to ensure patient understanding
  5. Following up with outpatient providers

“These care transition best practices hit it right on the head,” said Mike Rawaan, Chief Strategy Officer at Post Acute Analytics. “They’re pretty intuitive, which makes it even more puzzling that our health care system largely ignores these easy steps.

“Key challenges in executing the transitions of care model are disparate technologies across health care providers, under-resourced discharge planners, and misaligned incentives. Addressing any of the three will result in positive outcomes.”

The Impacts DCEs Have on Care Transitions

Many provider organizations – hospitals and physician groups – are beginning to pay more attention to and invest in care transitions. However, the investments are not significant enough to impact, creating a big challenge for value-based care organizations, like DCEs, that signed up to manage the total cost of care but have very little control when it comes to care transitions for acute-care hospital patients.

DCEs can leverage some of the strategies accountable care organizations implemented to help with care transition. However, those solutions are very resource-intensive and don’t scale easily. Also, when not executed properly or the right relationship doesn’t exist between a DCE-participating physician and the acute-care hospital, these processes are seen as disruptions. They are quickly shut down by hospital discharge planners.

“When engaging with discharge planners, it’s critical to understand their workflow and recognize that when you ask them to do their job differently for one set of patients, you’re introducing variability into their process. Often, we end up making their jobs harder while trying to help them. You have to meet them where they are and establish a trade-off or create a process they can follow for all patients,” said Mr. Rawaan.

How AnnaTM Can Help

Most hospitals have discharge planning tools embedded into their electronic medical record systems. Yet, most only address the need to quickly and efficiently discharge a patient, leading to the demand for third-party tools to more effectively coordinate care transitions. Regardless if the billion-dollar industry evolved from these third-party tools, many don’t address fragmentation across the entire continuum of care.

This is where AnnaTM, a proprietary real-time post-acute care management platform from Post Acute Analytics, is a stand-out solution within the health care industry. AnnaTM is patient and payer agnostic allowing the discharge planner to use the platform for every patient. AnnaTM also maintains a longitudinal record of a patient’s care journey and carries a patient’s clinical profile – complete with demographics, diagnoses, procedures, lab values, vitals, and clinical notes – across all care settings, giving the care team real-time access to a patient’s complete profile. In addition to making these key data points and insights available to the entire care team, AnnaTM alerts DCE-participating physicians when their patient has a care event, such as a hospital admission or discharge from a post-acute care setting.

“One of my favorite AnnaTM alerts is the ‘home health start of care’ alert, which informs the care team that their patient was referred to home health and home health has not shown up in 48 hours,” said Mr. Rawaan.
Solving for all care transition challenges goes beyond technology. It requires people and processes to achieve optimal success. A platform like AnnaTM allows organizations to automate and streamline many tasks necessary for successful care transitions.

Click here to request a demo and explore the opportunities AnnaTM provides.

Leave a Reply