Because the child was living with her family in public housing, CCNC contacted the municipality to have the necessary repairs made to the home and had the cockroaches removed. As a result, the child was put on the appropriate medications and can now attend school regularly, Mahoney says. Because CCNC could determine the root cause of the patient’s asthma-related distress, the state was able to save money that would have been spent treating her in a medical facility.
Danika Mills, MSW, director of care management, notes that, for every dollar invested in CCNC, the state receives $3 in value.
In terms of care quality, inpatient admissions for CCNC clients are 28% below expected admissions, and emergency room visits are 8.4% below expected, according to CCNC’s 2017 annual quality report. The nonprofit’s management of chronic diseases including diabetes and hypertension exceed five of six HEDIS benchmarks for all reporting years.
Information sharing considerations
Kristen Barlow, senior consultant at The Advisory Board, says post-acute care providers are largely “pen and paper endeavors,” meaning most don’t have access to the EHRs used by physician practices and hospitals.
That’s a “nut that hasn’t been cracked” by a lot of post-acute care providers, she says. One challenge is the financial barrier—in that EHR vendors charge for their software based on a per-user license basis and post-acute care providers can’t pay for access to all of their healthcare partners’ EHR platforms.
This is another reason CCNC’s approach of embedding care managers in hospitals and physician practices works. They have access to those providers’ EHRs, which gives the nonprofit greater insight into the patients it’s treating, says Philyaw. “It’s a win-win and, to my knowledge, we have not had a provider push back regarding payment for [EHR] access,” she says. Because CCNC works with Medicaid patients, the organization also has access to patients’ utilization history and claims data.
Soon the nonprofit will implement a platform from population health and care management software firm VirtualHealth, which will allow providers to make referrals to CCNC electronically. In addition, the platform will provide data feeds related to admissions, discharges, and transfers, medical and pharmacy claims, EHR and lab results, and risk scoring, in addition to other information types, says Adam Sabloff, founder and CEO.
Having this data in one place will increase collaboration and facilitate risk stratification, he says. While Sabloff credits health information exchanges with capturing data from some healthcare entities, these data entities don’t analyze information about patients’ hospitalizations or alert care providers that a patient needs a new medication, which he says the new platform will do.
Aine Cryts is a writer based in Boston.