Problem
Accountable care organization (ACO) is an effort that focuses on support for Medicare patients, to ensure that these patients, especially the chronically ill, receive the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

Hancock Regional Health has taken on the responsibility of becoming an ACO. Part of the ACO effort is to know and understand all the care their ACO patients receive, no matter where they receive it, so they can provide support to reduce preventable hospital readmissions, for example.

When an ACO succeeds in delivering high-quality care (as in reducing hospital readmissions) and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.
Solution
One of the most effective ways that ACOs can help manage their patients is to receive an alert when one of their patients is admitted or discharged from an emergency department visit, or is transferred to another facility as a result of an ED encounter.

IHIE has partnered with HRH to send them ADT alerts for their ACO-related patients. With its network of over 100 hospitals, IHIE is able to cover most of the emergency encounters in Indiana. Once a month HRH will send IHIE their list of ACO patients, and IHIE matches those up with emergency encounters. These encounters are sent on a daily basis to the hospital IT team so that HRH can alert the specific practice associated with that patient. This notification enables the physician practice to contact that patient for follow-up support. Additionally, IHIE provides a readmissions report for patients who where readmitted to the hospital within 30 days of the original encounter.
Keywords
population health, accountable care organization, ACO, efficiency, reporting, admissions, discharge, transfers, ADT alerts, discharge and transfer alerts, care coordination, Medicare, Patient Protection and Affordable Care Act
Identifier
Eric Rush & Jeff Morin
IT
Hancock Regional Health
Clinical setting: Population Health –ADT Alerts, IT, Accountable Care Organization
Benefits
  • Provides ACOs needed information to keep track of patient population and provide timely, relevant interventions
  • Enhanced reporting that tracks 30-day hospital readmissions
  • Reports make it easy for IT and clinician collaboration within the ACO
Quotes

Our partnership with IHIE to receive information about emergency encounters for our ACO patients allows us to plow new ground to support effective collaborations between our IT staff and our clinicians to fulfill our responsibility as an ACO.

Case Study

Situation:
Accountable Care Organizations are new in their current form. One of the biggest hurdles associated with them is creating accountability that extends across a continuum of care.

Benefits:
IHIE brings its network of over 100 hospitals to help address the need for providing ACOs information on their participating patients, especially in emergency encounters (in the form of ADT alerts), to help close the accountability gap and support greater transparency.

What it Means:
Because the ADT alerts pull information from across the whole state, they provide a high value and highly impactful way to facilitate better care. By partnering with ACOs to provide these alerts and other follow-on support, IHIE can help support the success of the ACOs.