Improving transitions of care in CMS’ BPCI advanced model

CMS’ recent Bundled Payments for Care Improvement Advanced (BPCI Advanced) initiative has attracted a large number of healthcare organizations that are eager to test-drive the voluntary program starting October 1.

A sequel to the Bundled Payments for Care Improvement (BPCI) program, BPCI Advanced, which will run through Dec. 31, 2023, is centered on value: The program aims to support healthcare providers who invest in practice innovation and care redesign for the purposes of improving care coordination, boosting quality, and reducing unnecessary expenditures.

The latest model emphasizes transitions of care. Although, post-acute care (PAC) providers are not invited to apply directly, CMS refers to PAC providers throughout its description of the new model and episodes of care – underscoring the importance of skilled-nursing facilities (SNFs) and other care partners in improving care transitions.

But improving care transitions isn’t as easy as flipping a switch.

Coordinating care among multiple specialists and other team members involved in a patient’s care team may be more akin to getting cranky toddlers to play together at a birthday party. Also, EDs—a critical touchpoint for potentially avoidable readmissions from PAC providers—often lack the broad longitudinal view of bundled payment patients or even just recent discharge information. This makes the creation of bundled payment-specific ED workflows much more difficult.

The key to succeeding in an initiative like BPCI Advanced is tied to a hospital’s ability to tightly coordinate care with SNFs and other PAC providers to avoid unnecessary readmissions.

Working Well with Others

Participation in BPCI Advanced is a win-win all around when care partners can work together like a well-oiled machine to keep patients healthy after they’re discharged from the hospital.

While SNFs and other PAC providers, including home health agencies, aren’t eligible to participate in the program directly, they play an important role in hospital participants’ success in bundled-payment models.

In entering into a bundled payment program, participating hospitals will need to sit down with their SNF and PAC partners and talk about improving care transitions, and evaluate existing care-transition practices: What does the typical patient who is readmitted to the hospital from the SNF look like? What tools are being used to communicate a patient’s whereabouts at all times? What are some of the problems with existing care-coordination tools?

Smarter Tools, Greater Efficiencies

While clear communication is essential to succeeding in a BPCI model, collaboration technology can also play an important role in streamlining care transitions by offering real-time visibility and critical information at the right time.

Smart notification tools that aggregate and transmit relevant data at the point of care, for example, can push discharge summaries and other patient insights, sourced directly from hospitals, directly to SNFs, specialists, and other EDs. Such summaries include targeted, real-time, risk-based information that enables actionable insight for case managers and specialists to engage in care coordination.

To understand how these tools can potentially impact transitions, consider the COPD patient discharged from the SNF, who later presents to the ED with respiratory exacerbation from anxiety within 90 days of their SNF admission date. A SNF case manager receives an email or SMS notification informing them that patient is at the ED, at which point he or she can reach out to the patient’s case coordinator and physician simultaneously to determine that the patient’s needs are non-urgent and can handled by the SNF.

Because the SNF already knows the patient, and has their medication work-up on file, the patient doesn’t experience any gaps in care. Subsequently, the case manager doesn’t waste time conducting a whole new work-up – and the SNF and ED care manager successfully prevent an unnecessary hospital readmission.

While this is just one example of a smart notification tool at work, it’s an important one because it demonstrates the potential for the right technology to have a major impact on a hospital’s success in a bundled payment model like BPCI Advanced.

When information flows seamlessly across the care continuum, case managers are empowered to act quickly in their patients’ best interest.

The lessons learned from the BPCI Advanced “test drive” on October 1 are to be determined. But to start, healthcare organizations will benefit from an approach that encourages tighter coordination with PAC providers as they navigate the challenges of improving patient care in a value-centered world.

Benjamin Zaniello, MD, MPH, is a practicing physician and the chief medical officer at Collective Medical. Collective has built the nation’s largest network for care collaboration.

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