Mayfair Internal Medicine Improves Patient Care, Reimbursements with CORHIO Notifications

Date: November 18th, 2019Category: CORHIO e-NewsletterTopics: Care Coordination, Transitions of Care, CORHIO Notifications


This sophisticated small practice has long-embraced technology and innovation to benefit not only their patients but also to bolster their bottom line. CORHIO Notifications is the latest innovation to make a positive impact in their operations.

In part to help with their participation in an advanced payment model (APM), Mayfair set out to improve care coordination by receiving alerts when their patients were admitted to the emergency department or hospital. In less than a year since implementing CORHIO Notifications, Mayfair has already begun to see an overall decrease in alerts. This decrease can be attributed to the practice’s care coordination efforts.

As the charts below indicate, the practice has seen a consistent decline in Notifications from CORHIO on the patients they did not know had been seen in the Emergency Department or Hospital.

 Mayfair ED Notifications

Mayfair Hospital Notifications

Statistics courtesy of Mayfair Internal Medicine, November 2019

“We’re excited about the decrease, because to us it shows our outreach is working. It means we are improving education around continuity of care, taking better care of our patients, decreasing cost and inefficiencies. This is a powerful strategy in performance-based value-added contracts,” says Tiffany Martin, who has served as Mayfair’s office manager since 2008.

In fall 2018, Mayfair joined CORHIO’s Notifications pilot program to try out new technology that sends batched or real-time notices about patient emergency department (ED) visits, hospital admissions or discharges.

“The entire CORHIO implementation team has been phenomenal, they are very supportive and knowledgeable,” Martin says of the process.

Missed Transitions of Care Opportunities

Before Notifications, any Mayfair patient who went to the ED or hospital and didn’t identify Mayfair as their primary care provider weren’t flagged in the practice’s EMR. This resulted in missed transition of care opportunities, which are important for two reasons: 1) patients who see their primary care provider after hospitalization experience decreased mortality rates, and 2) providers are reimbursed at a higher rate for visits that occur seven to 14 days after discharge.

“We’re now able to go in and look at ED and hospital discharges and reach out to patients with a phone call within two business days of discharge,” Martin says. “We’ll call and say, ‘I noticed you were in the ED, did you know you can call us first?’ Or, ‘I see you went to the ED for a UTI, do you know the difference between urgent and emergency care?’”

Notifications have also been an effective tool to improve overall care coordination, Martin says.

“We had a patient who went into the ER and was admitted to the hospital, where she ended up having a toe amputated, but we never received a discharge summary. Upon discharge, she had trouble managing her medications and was not set up with home health care services,” she says. “Because of Notifications, we were able to intervene, reconcile her medications, get her home health, and ultimately, we saved her a readmission.”

Jumping on the Bandwagon

Mayfair Internal Medicine, which serves 3,000 patients, was an early adopter of electronic medical records (EMR) systems, moving away from paper records in 2011 after electing to take advantage of funds made available by the American Reinvestment and Recovery Act.

“Our providers have always been pioneers and they’ve instilled that into our team and into the overall culture of our office,” Martin says.

Martin says their practice “jumped on the bandwagon right away,” implementing eClinicalWorks EMR and demonstrating 90 days of meaningful use within the first year of eligibility.

Through their HealthOne affiliation, Mayfair joined several pilot programs at Rose Medical Center, one of which facilitated the implementation of eClinicalWorks EMR interface to receive electronic reports from the hospital.

“Over the years, we kept learning about and joining other innovative programs. When we heard about Colorado Care Partners value-based contracts, we knew we wanted to be a part of it,” she says.

Participation in the APM opened the door for Mayfair to access additional free or low-cost resources and incentives -- including services offered by CORHIO -- to help track and report on required milestones like quality improvements.