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Proactive Transition Planning for ACOs

Managing patient transitions through different levels of care will be a primary concern for ACOs.

For any organization positioning itself as an ACO, managing patients as they transition through different levels of care will be a primary concern. Each transition - from acute care to different post acute care settings and ultimately to home - represents a need for planning and an opportunity for things to go wrong. In most settings Case Managers will be the 'point of continuity' for patients, and it will be their job to ensure that all of the internal and external care givers involved have what they need to meet the patient's needs.

Importance of Managing Transitions

Transitions in a health system can be either horizontal or vertical. Horizontal transitions happen within the same level of acuity - for example different specialists within an acute care setting. Vertical transitions happen between different levels of acuity - for example acute care to LTAC to skilled nursing. Because vertical transitions usually involve a 'hand off' between providers, managing them is a much more complex process. Research bears this out. 1 in 5 older adults with complex chronic health conditions are readmitted within 30 days of hospital discharge.

Good communications is one of the single most important components to successfully managing any vertical transition. Information technology has a definite role to play in helping to foster this. All members of the health care team including patients and their family caregivers need access to key pieces of information in order to make transitions of care smooth, safe, and effective. But technology is only effective in the context of a collaborative model for managing transitions.

Where Technology Adds Value

Technology can assist transition management planning in the following ways:

  • Web based collaboration 'portals' can be used as common areas for Case Managers and providers from different institutions to 'meet' and share information regarding patients, prior to making the actual transition. Bringing the process online means that sharing can begin much earlier in the process, and therefore ensure that when the patient is transferred to the next level of care the receiving providers, as well as patient and family are fully prepared.
  • Online assessments can be used as decision support tools. "Case-Manager-centric" assessments can help ensure that the patient is placed within the right care program based on clinical criteria, and identify which providers have performed best with similar patients. "Provider-centric" assessments can help providers identify the patients best matching their own care programs and available resources, as well as identify potential risk factors and co-morbidities associated with that patient.
  • By comparing "snap shots" of the patient at the beginning and end of each stage of care, patterns can be identified that point to best practices in managing patient care and allocation of system resources.

Process Model for Managing Transitions Online

While technology can support the process, the key to transition planning is to begin the process early and to ensure that all parties have access to the same patient data. What follows is a model for managing the transition planning process online

  1. Discharge planning starts when the care plan is first established. Criteria based guidelines are used to validate what the patient's next likely transition will be.
  2. The Case Manager invites partner providers (which may be internal to the health system, external or both) to review the patient in an online, collaborative environment.
  3. Providers can apply their own criteria to the patient to determine if this is a patient they can take and whether they expect to have availability at the anticipated discharge date.
  4. The Patient’s profile is updated as care proceeds. Partner providers can continue to monitor the patient and change their status regarding their ability to take the patient.
  5. Prior to discharge, Case Manager shares partner information with patient and patient's family, who make the final decision regarding placement.
  6. At time of transfer, patient is completely known to partner provider. Transition proceeds much more smoothly as a result.
  7. Metrics gathered throughout the process are available to streamline future placements.

Conclusion

As companies move into an ACO model case management and transition planning will become increasingly important. While technology has a key role to play in this, it is equally important to put into place an operational framework that ensures that all involved parties get the information they need when they need it.

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