Insurance Stories The Keystone Effect of Data Integration in Healthcare Coordination

Implementation and evaluation of digital projects requires that both system factors and non-system factors be taken into consideration. Invariably, it is the non-system, human variables that present the most substantive challenges to communications and information management staff. The staff responsible for the information management technology supporting the Affordable Care Act foresaw and prepared for a variety of issues that could arise during system upgrades. As a result, most of the issues that could limit the capacity to fully report on the project were headed off. Yet, measurement depends on the availability of accurate, comprehensive, and timely data -- all factors vulnerable to the remaining issues.

The non-system human aspects of the healthcare program implementation and evaluation posed several challenges to the program designers and evaluators. Case management is optional for healthcare plan members, but participation is strongly encouraged as fosters a number of strong benefits. Coordination of care is facilitated through case management. The capacity of members to take an active role in managing their health condition is enhanced by case management. Also strengthened by case management is the ability to stay on top of the health status of members and recognition that timely interventions are needed. Members who decline case management may unwittingly diminish the quality of care they receive. A thorough review of the case manager workflow indicated that some steps may impact the clinical activities and interventions that can be taken by care staff.

Quality of care is also diminished when members cannot be reached by telephone for follow up care. The primary reasons that members cannot be reached by phone, especially for follow up contact, are incorrect phone numbers or an unwillingness to return phone calls. Post-discharge contact with members is pivotal to the provision of support and patient care. Routine care is also enhanced by the ability to contact members as needed to identify potential barriers to care and to devise solutions to address any barriers.

Issues related to communication are not limited to members: providers can be lax in their responsiveness to requests for information. Efficacious care management requires good communication among the Plan stakeholders. While patient communication is a high priority for providers, responding to requests from the Plan may seem like a lower priority.

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A solid first step was to create a master list of patients with particular health needs (CHF) that would be updated at six months, and then every month thereafter. Oversight of the master list will be accomplished by the quality informatics team, the project manager, and the case management supervisors. Automated data collection will be monitored and analyzed regularly, with overall data submission scheduled by the quality informatics team. Case managers will conduct education outreach to those who refuse case management. Moreover, case managers will mine all available resources (PCP office, admitting hospital, pharmacy, providers) for current contact information. Follow-up letters will be sent out and a third-party vendor will pursue contact with patients who have refused case management. Responses from providers will be pursued more aggressively through both phone calls and faxes in order to obtain needed information. Overall workflow procedures and practices will be reviewed by a quality work team in order to create greater efficiency.
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Results and Findings

The overall rate of echocardiogram test results remains low at 49. Of the 226 echocardiogram tests conducted, only 21.7% were submitted. Of the total number of plan members, only 5 with L. VEF of less than 40% were reviewed. The total care plan developed for HF members during the project year stood at 19.9% (45 out of 226), with the care plan goals achieved for 28 out of the 45, or 62.2%.

Section 4

Analysis of Results or Findings

Emphasis will be placed on completing care plans and empowering members to achieve more goals. The low completion rate of care plans for patients diagnosed with CHF is associated with the extant barriers, many of which are being addressed. All fo the members for whom an echocardiogram was received and whose L. VEF was less than 40% were prescribed beta blockers. At issue is the concern that the number of electrocardiograms records received does not reflect the number of tests conducted. The rate of hospital admission for members diagnosed with heart failure was reduced in 2013 from 2012 numbers. A 1% reduction goal was achieved as the rate of reduction stood at 3.98% in 2013, reflecting a drop from 11.06% to 7.1%. The positive reduction in hospital inpatient admission rate cannot be attributed to specific interventions at this time, as the practice does not include a control group. Moreover, data from population and disease management effects have not been factored into the admission reduction rates.

Section 5

Action Plan Details

CCIP reports will be regularly mailed to providers and will include the following: heart failure admission rates, echocardiogram tests, care plan goals, and beta blocker utilization rates. Patients diagnosed with heart failure will utilize claims from PCPS or provider specialists, excluding lab and radiology claims. The plan will…