Avoiding the Goldilocks Conundrum: What information should ACOs leverage to optimize care management efforts?

Across the country, there are more than 500 Accountable Care Organizations (ACOs) seeking to
implement and sustain value-based care programs. To receive maximum reimbursements, ACOs
must meet cost and quality metrics surrounding population health, as well as patient and family

To meet these requirements, many providers focus on sharing pertinent clinical information.
Unfortunately, it is easy to get caught up in what I have deemed the “Goldilocks” or “the porridge
is too hot, the porridge is too cold” conundrum. Copious amounts of information are saved in the
EMR, all of which are important for providers caring for their patients. When patients transfer to a
post-acute provider, the entire medical record for their hospital stay is often printed and shared;
this poses a challenge for accepting providers to find and review key pieces of information
relevant to the patient’s transitional care plan.

Meaningful Use (MU) requirements began in 2009 and have become invaluable to documenting
and leveraging the information contained in a patient’s medical record. EMRs created the ability to
capture, trend, and benchmark significantly more information, while investing less time and effort
in manually documenting and correlating clinical data. However, to satisfy these requirements and
implement new electronic systems, providers banded together with similar providers. Because
workflows and data requirements may be similar from one hospital to another, or one Skilled
Nursing Facility (SNF) to another, these providers began using similar electronic systems as their
peers - but not across the industry. This led to an immense challenge in creating an interoperable
system that delivers better value to patient and providers.

The unintended consequence of operating different electronic systems at various points along the
care continuum is the creation of silos throughout healthcare. Each level of care or type of
provider uses different terms and workflows, which track various types of data points. Each care
setting created enhancements and data structures that supported their operations, optimized
revenue, and increased key quality metrics specific to the type of care they provide. While this is
great for the individual provider, it does not always benefit the patient.

These siloes create significant challenges as healthcare organizations attempt to compare and
share patient data, a key component of effective care coordination. Each provider now has their
own dialect of the same language; translation and normalization are required to ensure that data
is interpreted and utilized correctly.

Care Management Standardization: Finding the Perfect Porridge and Breaking Down Silos

This proves especially challenging for Accountable Care Organizations (ACOs), as it relates to
effectively managing the care of their populations. ACOs are specifically designed to better
coordinate care across settings. However, because each system captures relevant data in their
own dialect, care managers often manually correlate the relevant data. This is frequently
maintained on a lengthy spreadsheet, which is not an ideal or long-term, scalable solution.

Aside from the data inconsistencies inherent to a manual process, this practice proves difficult in
reviewing operational data for process improvement. There is little to no quality control over how
care managers are coordinating care across a patient population. Often, care managers are
encouraged to “do their best” to maintain lines of communication with their patients and
coordinate care to keep them out of the hospital and thriving in the community. They utilize their
clinical assessment skills to triage patient needs and direct their efforts.

Initial results by ACOs have proved to be successful by demonstrating savings. However, there are
still many challenges that need to be addressed. Due to the lack of data, the cause and effect of
specific interventions is impossible to correlate. As the likelihood of duplicating tasks is increased,
this leads to a process that is ripe for human error - with significant financial implications.

Instead of asking care managers to sift through large pools of data and work off spreadsheets,
ACOs should work towards relevant data aggregation, streamlining processes, and automating
low-value activities. For example, ACOs generate significant savings by meeting preventive
quality metrics. Care managers help patients schedule preventive screenings such as
mammograms and colonoscopies, promoting early detection and treatment of diseases. However,
there are manual inefficiencies that make this task difficult to track and often resource-intensive.

Standardizing care management practices and codifying responses in discrete fields allows
providers to better understand the gains of their care management efforts. Since more care does
not equate to better care, this is a key step in understanding what care protocols lead to the best
outcome with the lowest cost.

Capturing the Right Information to Enhance Care Management Efforts

Implementing tools that capture both clinical and social needs empower providers to more
effectively care for their patients. This also provides actionable data regarding why care decisions
are being made and which are leading to the most desireable results.

To improve care delivery for patients, ACOs must better understand and improve upon their
current processes. By capturing information on length of stay and services at post-discharge
settings, ACOs can utilize the power of data to benchmark progress towards quality and cost
metrics. Additional data on readmissions, physician follow up, and education that is captured in
discrete fields further solidifies these data-driven process improvements.

Developing robust care management processes that capture these differences while translating
the information into a common language focused on the patient is not simple. However, taking
steps to create a structure to simplify and understand care management process will pay off for
both patients and ACOs as they take on additional risk.

Accountable Care Organizations play important roles in helping patients remain healthy in the
community by encouraging them to take proactive responsibility for their care. Creating unity in
our fragmented system is a challenge, but care management helps patients navigate this complex
maze and promotes a happier and healthier society. By creating alignment amongst providers and
putting patients at the center of their care, ACOs are primed to find the perfect “porridge” and
help drive the long-term change that is necessary to achieve Quadruple Aim goals within the
healthcare system.

As the Vice President of Clinical Services, Lyndsey Lord, MBA, BSN, RN brings over 15 years of experience in clinical practice, healthcare operations, case management, patient throughput, and healthcare IT strategy to her current role at CipherHealth. Prior to joining CipherHealth, Lyndsey worked with healthcare providers to implement alternative payment models, such as BPCI, and supported clinical care redesign efforts to promote success within value-based healthcare programs. 

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