Care Coordination & The ACO Model: Filling the Gap with Real-Time Home Care Data
By Robert Herzog
In this age of dueling pressures—to reduce healthcare costs and improve quality of care—a critical question remains: how can Accountable Care Organizations (ACOs) deliver on the promise of providing high-value, high-quality care?
Since its creation under the Affordable Care Act, the ACO model has sought to accomplish one primary goal: to seamlessly coordinate care across a patient population. The ACO builds on the efforts of the Patient Centered Medical Home model, (a team-based, physician-led model that seeks to enhance the role of primary care to provide coordinated, continuous care), by incentivizing providers to work across silos and collaborate as teams to optimally align resources and facilitate care for patients in both ambulatory and non-ambulatory care settings.
Today under the ACO structure, proactivity on the part of providers is rewarded. ACOs essentially act as “enforcers” of care coordination, ensuring that patient care is planned, outcomes and clinical measures are carefully tracked, and resources are constantly assessed.
However, closely monitoring patients across multiple providers and settings can be a challenge—one that new technologies are solving. The management of patients who are elderly and frail or who have multiple chronic conditions is especially complicated, given the complex needs and services these populations require.
Why is Better Care Coordination Necessary?
Studies indicate that every year between $25 and $45 billion is spent across the U.S. on avoidable complications and hospital readmissions resulting directly from the limitations of current care coordination information and communication systems (Burton, 2012).
According to the Agency for Healthcare Research and Quality (AHRQ, 2009), 90% of readmissions within 30 days are unplanned and likely the result of a break in the clinical process. Poor care coordination and continuity may be to blame – only half of re-hospitalized patients see a physician prior to readmission. Studies also show nearly 20% of Medicare discharges are followed by an adverse event within 30 days, which are related to medication two-thirds of the time (AHRQ).
Other trends, including the growing aging population, are also positioning coordinated care as a high priority for ACOs and the healthcare system at large. According to AARP, 90% of seniors and boomers desire to age-in-place in their own homes – proving that the need to monitor high-risk patients across multiple settings, including the home, will only continue to grow (Farber & Shinkle, 2011).
The Home: The Missing Piece of the Coordinated Care Puzzle
The ACO’s role in enhancing care coordination is crucial, helping to ameliorate information breakdowns. Yet focus has centered on coordinating care while patients are in the provider’s office or at the hospital, ignoring the most critical setting: the patient’s home. While the majority of events in a patient’s life occur at home, the home has usually been a “black box,” leaving the care coordination process incomplete.
But now, new care management technologies are solving the serious, costly problem for managers, providers, payers, patients, and families stemming from the inability to obtain timely and critical data about the status of patients at home. Today new tools are transforming the home into a powerful real-time stream of actionable data, which helps alert providers to significant changes in time to avoid serious deterioration. This type of early intervention lowers cost by reducing the use of higher cost facilities and services, and helps hospitals avoid the major Medicare penalties for excess readmissions.
How Real-Time Home Care Data is Closing the Gap
Here are three ways real-time homecare data is closing the gap and completing the puzzle needed for high-value, high-quality coordinated care in the ACO model:
1. Reducing repeat readmissions and utilization of high-cost services:
Actionable data from the home is key to reducing emergency room visits and preventable hospital readmissions, especially for a high-risk population of seniors and individuals with chronic conditions. The majority of preventable events are due to a failure to attend to significant changes in health status, across clinical (e.g., weight, blood pressure) and behavioral (e.g., combativeness, depression) measures, and lapses in medication adherence. Real-time monitoring of care and health status can identify symptoms as they happen, notifying providers and enabling intervention, which reduces acute care visits and the need for readmission to hospital. Tools that uniquely integrate in-home clinical and behavioral information also help providers determine who is at risk for readmission, offering hospitals protection from expensive Medicare penalties and allowing for more effective care coordination
2. Providing a 360-degree view of patient care:
Real-time care information from a patient’s home provides a comprehensive picture of care, helping providers treat conditions in a complete fashion, rather than in a fragmented manner over time. Unlike telecare systems of previous generations, today’s in-home health data systems can record not only vital signs like blood pressure and weight, but also provide insight into the factors and actions that lead to these readings. For example, a two-pound weight gain within 48 hours can be significant for a congestive heart failure patient, but provides little help in determining the best course of treatment. However, receiving an instantaneous alert about this rapid change combined with dietary patterns, a medication intake calendar, and an activity log, helps providers adjust the plan of care and offer customized treatment.
Viewing objective data over a period of a day, week, or month also enables providers to recognize patterns of decline and spot emerging problems earlier. While in-home caregivers may not notice or report small day-to-day changes, a digital patient care record helps visualize these patterns over the long term. For example, a professional caregiver can see that a client with dementia has significant changes in sleeping patterns, which can affect their behavior and mood throughout the day.
Additionally, reviewing the information in the patient’s digital care record allows providers to assess the current level of care. This real-time data captures changes in clinical status that may indicate the need for a transition to a higher or lower level of care.
3. Connecting disparate “silos” through digital communication and information sharing:
A huge factor in the re-hospitalization of elderly Medicare patients is the serious lack of communication across “information silos” that have formed among various healthcare providers involved in patient care. Real-time data generated from within the home promotes collaboration among the care team, allowing multiple parties to stay informed about a patient’s condition. Providers, including physicians, insurance caseworkers, nurses, and family caregivers can simultaneously work to collectively make decisions concerning patient care. Reviewing the information in the patient’s digital care record allows providers to assess the current level of care. This real-time data captures changes in clinical status that may indicate the need for a transition to a higher or lower level of care.
Summary
The key objective of the ACO is to reduce costs while improving care. New technologies will be critical to successfully enabling information sharing among providers. Real-time data from patient’s homes is an essential component to complete patient monitoring within the ACO model – one that has major implications in terms of preventing adverse events, cost saving, and improving the quality of care.
Robert Herzog is founder and CEO of eCaring. For several years he was deeply involved in the home and extended care of his mother Grace, which gave him an understanding of the problems eCaring is designed to solve. He has been a pioneer in applying new technologies to business ventures, working as a senior executive with startup companies such as Motionbox, Diva, ON2 Corp, Softcom, Granite Films and City Winery, major corporations including JPMorgan Chase, Cahners Communications, and the Sarnoff Research Center, and not-for-profits including New Jersey Appleseed and Ecotrust. In public service, he was the creator and director of New York City’s Energy Office and also taught public school. Robert is also an author and filmmaker. He graduated from Williams College and has a Master’s from the New School. He may be contacted at Robert@ecaring.com or 855-832-2746.
References
Agency for Healthcare Research and Quality (AHRQ). Adverse events after hospital discharge. Patient Safety Primer. Retrieved June 24, 2014, from http://psnet.ahrq.gov/primer.aspx?primerID=11. Updated October 2012.
Agency for Healthcare Research and Quality (AHRQ). (2009, June). 5. Studies of rehospitalizations: Reducing avoideable hospital readmissions. Rockville, MD: AHRQ. Retrived June 24, 2014, from http://www.ahrq.gov/professionals/systems/hospital/red/readmissions/readslide5.html
Burton, R. (2012, September 13). Health policy brief: Care transitions. Health Affairs. Retrived June 24, 2014, from http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76
Farber, N, & Shinkle, D. (2011, December). Aging in place: A state survey of livability policies and practices. Washington, DC: AARP Public Policy Institute. Retrieved June 24, 2014, from http://assets.aarp.org/rgcenter/ppi/liv-com/aging-in-place-2011-full.pdf