UCHealth Integrated Network Utilizes Notifications from CORHIO to Improve Care Transitions

The network tracks hospital and emergency department visits for Medicare Shared Savings Plan population in real-time for crucial care interventions and coordination.

An estimated 32 million Americans are covered by an Accountable Care Organization (ACO)*, under different payers including commercial health plans and federal programs, such as the Medicare Shared Savings Program (MSSP). This program involves a minimum requirement of three years and incentivizes healthcare providers to improve the quality of patient care by adopting transparent quality reporting and more targeted care coordination.

The UCHealth Integrated Network is a partnership among UCHealth, CU Medicine and locations across Colorado, and the physician-led ACO includes more than 2,400 actively participating providers and 10 hospitals. UCHealth Integrated Network participates in MSSP and actively coordinates care for more than 40,000 patients in the program, using CORHIO’s Notifications as a data tool.

“We’re participating in Medicare Shared Savings Program tracking, so we receive a beneficiary list at the beginning of the year and that’s the population that we are essentially responsible for managing their care,” says Sally Nietfield, IT Program Manager for Population Health at UCHealth Integrated Network. “Our goal is to show good quality outcomes for our patients all while decreasing the total cost of care – do the best thing for the patient, health-wise as well as financially.”

Shift From Volume to Value-Based Care Starts With Data

Notifications from CORHIO are real-time alerts when a patient has been admitted to the hospital or visited an emergency department. For UCHealth Integrated Network, the CORHIO notifications provide crucial information for their care coordination process. “We send an active MSSP roster to CORHIO on a monthly basis and they send us back information on recent hospital admits or discharges.”

But just receiving the notifications from CORHIO was only one part of the puzzle. The information had to be made as meaningful as possible and reach the right person who could take action on it – preferably within an existing workflow.

“We feel like we’ve taken a unique approach to this in that we combined clinical data we had in our Epic electronic medical record with the CORHIO notification data and put it into one,” says Nietfield. “Now the care managers have the whole picture to work with.”

UCHealth takes the notifications they receive daily from CORHIO and pulls the information (admit location and date, reason for admission, diagnosis, discharge date) into a data warehouse. They then do patient matching, de-duplicating and linking up of existing data elements on that patient from Epic such as the patient’s primary care provider, last appointment, care manager contact information and general risk score.

Targeted Care Management and Coordination

The UCHealth Integrated Network’s care managers run reports in Epic directly within their existing workflow, and those reports now include the data from CORHIO. They can run two reports: one that shows all patients who were admitted or are currently in the hospital and another that shows all patients discharged. The different reports inform the action taken by the care manager.

“Our care managers need the right information to outreach to these patients,” says Nietfield. “They can contact the patient and see what they need, start working with them on medication reconciliation, an appointment with their primary care provider or maybe a new care plan or a referral to behavioral health or a specialist.”

Once they learn a patient has had an emergency or inpatient event, the care managers can review more details in PatientCare 360, particularly if the information is outside of the Epic system.

“The feedback is pretty good so far, we are tracking how many patients are being contacted following discharge and as we gain more usage, we plan to look at pre- and post-readmission data,” says Nietfield.

To learn more about Notifications from CORHIO, please visit our website.

*Source: Accountable Care at the Frontlines of a Health System: Bridging Aspiration and Reality by Ishani Ganguli, MD, MPH and  Timothy G. Ferris, MD, MPH^, https://jamanetwork.com/journals/jama/fullarticle/2666233