ACO Practices Utilizing Notifications from CORHIO to Improve Care

Date: January 18th, 2019Category: CORHIO e-NewsletterTopics: Care Coordination, Population Health, Accountable Care, CORHIO Notifications


Colorado medical practices participating in ACOs and other value-based models are relying on Notifications of patient encounters from CORHIO to fill information gaps and provide more informed, proactive care.

Accountable Care Organizations (ACOs) are cropping up all over Colorado and taking many forms – from the established federal Medicare Shared Savings Program to state-level Medicaid Regional Accountable Entities to specialized hospital-network or commercial payer arrangements. To be successful, practices participating in ACO programs need to prove their quality via metrics. CORHIO is now sending real-time notifications of hospital visits (admit, discharges, or ER) for active patients in practices. Many of those practices are using this information for patient care management, active follow-up and to improve metrics needed for ACO success.  

From the Practice Perspective

Timothy Dudley, MD, Chief Medical Officer, Colorado Care Partners and former physician at DTC Family Health in Greenwood Village has utilized CORHIO Notifications to improve care coordination in his medical practice.

“Practices not utilizing CORHIO can be caught flat-footed when a patient shows up for a hospital follow up and the practice didn’t know they had been in the ED or admitted to the hospital,” he says. “Until a few years ago, in my former practice, we would sometimes be scrambling to get the hospital notes to get the full story.”

DTC Family Health’s EHR is also set up to receive patient results directly from CORHIO, so they receive same-day notifications of a hospital discharge as well as any labs and imaging reports performed in the ED. “As a result of this notification, the practice can reach out to the patient within two business days to complete the first part of the ‘transitions of care’ visit requirement,” he says.

Mayfair Internal Medicine is three-physician internal medicine practice in Denver that is participating in the Colorado Care Partners ACO. The practice participated in a pilot of CORHIO’s Notifications to evaluate its usefulness for practices.

“With CORHIO Notifications, we identified 31% more ED and hospital discharges,” says Tiffany Martin, Office Manager, Mayfair Internal Medicine. “Specifically, we were able to identify a young patient involved in a motor vehicle accident, suffering significant brain injuries, and were able to provide follow up care specific to her injury. We also identified an ED visit that lead to a hospital admission and amputation. Our staff was able to provide medication reconciliation, home healthcare, case management and timely follow up for this patient.”

From the ACO Perspective

In his role as Chief Medical Officer for Colorado Care Partners (a HealthONE ACO), Dr. Dudley recognized the value of CORHIO data early on. CCP receives CORHIO Notifications so they can do front-line care management. They provide CORHIO with a member file of 120,000 patients, which is matched against admission and discharge hospital and ED data in the network. Those “hits” are sent to CCP and distributed to the right Care Navigators to follow up with the practice first, then the patient directly if needed.

“Our Care Navigators use CORHIO to gather all pertinent data on high-risk patients managed by CCP,” he says. “We use CORHIO as an additional database to learn about patients that we need to know more about to close gaps in care, recognize rising risk and better manage high risk.”

CCP encourages their practices to participate in bidirectional exchange with CORHIO – meaning not only do they have access to patient data in the HIE network, but they contribute to it.  “The goal is for CCP practices to work with CORHIO at multiple levels – to be on PatientCare 360® at a minimum but also sending their care summaries in as well,” says Dudley. “We have over 20 different EMRs among our 80+ locations so it’s vital that they take advantage of CORHIO’s established interoperable network.”

Colorado Care Partners provides each of their participating practices with a scorecard, helping them understand their own practice transformation information. “We aim to help them look at their journey to the high-performing primary practices,” says Dudley. Two areas on the scorecard that CORHIO data helps with are Utilization, which looks at avoidable ER visits and successful transitions of care follow-ups and Disease Management, which looks at management of adult patient diabetes and pediatric asthma and antibiotic stewardship.