[{"innerBlocks":[],"name":"core\/freeform","postId":1042,"blockType":{"name":"core\/freeform","keywords":[],"attributes":{"content":{"type":"string","source":"raw"},"lock":{"type":"object"}},"providesContext":[],"usesContext":[],"selectors":[],"supports":{"className":false,"customClassName":false,"reusable":false},"styles":[],"variations":[],"apiVersion":3,"title":"Classic","description":"Use the classic WordPress editor.","category":"text"},"originalContent":"Healthcare information technology is increasingly being leveraged by Medicare accountable care organizations to coordinate and manage care.

That\u2019s the theme of a new Medicare ACO care coordination toolkit<\/a> released by the Centers for Medicare and Medicaid Services.

\u201cSome ACOs focus on facilitating the exchange of data between primary care providers and emergency departments, whereas others establish networks of post-acute care partners to support their mission of improving the quality and effectiveness of care,\u201d states the toolkit. \u201cOthers developed initiatives that focus on managing the care of individual beneficiaries, such as launching a home visit program or using information technology to streamline referrals to community organizations.\u201d

When it comes to coordinating care for beneficiaries after an emergency department visit, CMS reveals that multiple ACOs embed care managers within the ED to facilitate communication and collaboration between ED clinicians and primary care providers.

\u201cEmbedded care managers are able to access information on patients\u2019 previous health needs from the EHR to share with ED clinicians and can assist with discharge and transfer from the ED to another care setting or to the home,\u201d according to the document. \u201cEmbedded care managers also help to close information gaps if an ACO\u2019s clinicians and hospitals use EHRs that lack interoperability.\u201d

To encourage communication between ED clinicians and PCPs, ACOs have utilized electronic alert systems (e-alerts) that notify the ED clinician of a patient\u2019s attribution to an ACO and include both the PCP\u2019s contact information and a reminder to contact the PCP.

\u201cACOs pointed to the benefits of e-alert technology that is integrated into the ED\u2019s EHR, saving busy ED clinicians the time and effort of logging into another system,\u201d states the toolkit.

Also See<\/b>: How IT can help support successful ACO performance<\/a>

To support care coordination with skilled nursing facilities, the toolkit reports that some ACOs have implemented electronic tools that alert care managers when an attributed beneficiary has been admitted to a SNF, while others rely on being notified directly by the partnering SNF.

For better care coordination for beneficiaries with conditions affected by social determinants of health, some ACOs embed social risk-assessment tools into EHRs, enabling clinicians or care coordinators to screen the beneficiary at the point of care by using a standardized data collection tool.

\u201cThe clinicians and care coordinators can then review the results of the screening tool within the beneficiary\u2019s medical record,\u201d states the toolkit. \u201cACOs can also use the assessment data in the EHR to guide interventions. For instance, recognizing that beneficiaries may struggle with multiple challenges related to the social determinants of health, one ACO purchased a program that analyzes and ranks the challenges that emerged from the assessment.\u201d

According to CMS, this ranking of the challenges enables ACO staff to decide which ones to make top priority and which to address at a later date, while another ACO leverages an algorithm to sift through assessment data in the EHR and identify high-risk patients.

\u201cIn addition to capturing data on beneficiaries\u2019 challenges, information technology can also streamline referrals at the point of care and improve beneficiaries\u2019 access to partners\u2019 services,\u201d notes the toolkit. \u201cSome ACOs built tools that allow clinicians and care coordinators to use their computers to identify and make direct referrals to community partners.\u201d

As an example, CMS points to an ACO that added a link in its staff\u2019s computers to the website of a community organization focused on food security to promote direct referrals for patients who do not have reliable access to nutritious food.

\u201cAnother ACO has referral capabilities built directly into its EHR and into the same screen that displays the results of patients\u2019 risk assessments,\u201d states the toolkit. \u201cThis allows care coordinators, social workers, or physicians to review the risks flagged by the assessment and to make referrals during the same appointment.\u201d","saveContent":"Healthcare information technology is increasingly being leveraged by Medicare accountable care organizations to coordinate and manage care.

That\u2019s the theme of a new Medicare ACO care coordination toolkit<\/a> released by the Centers for Medicare and Medicaid Services.

\u201cSome ACOs focus on facilitating the exchange of data between primary care providers and emergency departments, whereas others establish networks of post-acute care partners to support their mission of improving the quality and effectiveness of care,\u201d states the toolkit. \u201cOthers developed initiatives that focus on managing the care of individual beneficiaries, such as launching a home visit program or using information technology to streamline referrals to community organizations.\u201d

When it comes to coordinating care for beneficiaries after an emergency department visit, CMS reveals that multiple ACOs embed care managers within the ED to facilitate communication and collaboration between ED clinicians and primary care providers.

\u201cEmbedded care managers are able to access information on patients\u2019 previous health needs from the EHR to share with ED clinicians and can assist with discharge and transfer from the ED to another care setting or to the home,\u201d according to the document. \u201cEmbedded care managers also help to close information gaps if an ACO\u2019s clinicians and hospitals use EHRs that lack interoperability.\u201d

To encourage communication between ED clinicians and PCPs, ACOs have utilized electronic alert systems (e-alerts) that notify the ED clinician of a patient\u2019s attribution to an ACO and include both the PCP\u2019s contact information and a reminder to contact the PCP.

\u201cACOs pointed to the benefits of e-alert technology that is integrated into the ED\u2019s EHR, saving busy ED clinicians the time and effort of logging into another system,\u201d states the toolkit.

Also See<\/b>: How IT can help support successful ACO performance<\/a>

To support care coordination with skilled nursing facilities, the toolkit reports that some ACOs have implemented electronic tools that alert care managers when an attributed beneficiary has been admitted to a SNF, while others rely on being notified directly by the partnering SNF.

For better care coordination for beneficiaries with conditions affected by social determinants of health, some ACOs embed social risk-assessment tools into EHRs, enabling clinicians or care coordinators to screen the beneficiary at the point of care by using a standardized data collection tool.

\u201cThe clinicians and care coordinators can then review the results of the screening tool within the beneficiary\u2019s medical record,\u201d states the toolkit. \u201cACOs can also use the assessment data in the EHR to guide interventions. For instance, recognizing that beneficiaries may struggle with multiple challenges related to the social determinants of health, one ACO purchased a program that analyzes and ranks the challenges that emerged from the assessment.\u201d

According to CMS, this ranking of the challenges enables ACO staff to decide which ones to make top priority and which to address at a later date, while another ACO leverages an algorithm to sift through assessment data in the EHR and identify high-risk patients.

\u201cIn addition to capturing data on beneficiaries\u2019 challenges, information technology can also streamline referrals at the point of care and improve beneficiaries\u2019 access to partners\u2019 services,\u201d notes the toolkit. \u201cSome ACOs built tools that allow clinicians and care coordinators to use their computers to identify and make direct referrals to community partners.\u201d

As an example, CMS points to an ACO that added a link in its staff\u2019s computers to the website of a community organization focused on food security to promote direct referrals for patients who do not have reliable access to nutritious food.

\u201cAnother ACO has referral capabilities built directly into its EHR and into the same screen that displays the results of patients\u2019 risk assessments,\u201d states the toolkit. \u201cThis allows care coordinators, social workers, or physicians to review the risks flagged by the assessment and to make referrals during the same appointment.\u201d","order":0,"get_parent":{},"attributes":[],"attributesType":{"content":{"type":"string","source":"raw"},"lock":{"type":"object"}},"dynamicContent":""}]

Medicare ACO care coordination toolkit highlights value of health IT

More for you