Preventive Measures: How Network PCPs Can Leverage Data to Identify Care Gaps

As a risk-bearing provider partner to health plans, ConcertoHealth has developed expertise in managing high-risk patients. Our patient outcomes have been powered by data collection, analysis, and application via our homegrown population health platform Patient3D, as well as our proprietary risk stratification algorithms, which were the subjects of the first two blog posts in this series. We recognize, however, that we can’t do it alone. Delivering and managing care effectively for the most vulnerable individuals requires a knowledgeable and motivated network of care providers.

Our health plan partners contract with local providers to deliver care. To remain proactive in our care management approach, Concerto Health works with our partners to design value-based quality incentive programs that seek to address gaps in care among network providers. This is done using HEDIS Measures and Medicare Stars and state quality standards, as well as partner-specific quality benchmarks. Participating in and adhering to these quality programs takes time on top of the primary care visit, and so it’s important to compensate providers appropriately for the additional effort.

Personal Engagement & Support

ConcertoHealth employs dedicated Provider Relations Representatives who engage and support health plan provider groups. These team members act as account managers as they educate provider network staff on how to access and use medical information through Patient3D tools, which offer insights to clinical and administrative staff. Representatives conduct periodic provider office visits and facilitate regional town hall meetings that bring together providers for training and knowledge-sharing sessions.

Proactive Physician’s Assistant

Through all of these initiatives, we provide patient intervention reports (PIRs) which detail chronic conditions and claims-based care gap opportunities to each provider, and encourage follow-up for the patients who need additional care. The PIR is an individualized pre-visit preparation tool that presents persisting conditions, quality of care opportunities and medication reconciliation information that may not have otherwise surfaced during a patient visit. The care gap opportunities are identified by an algorithm that considers the patient’s history of chronic diseases, laboratory results, medications and vital signs, as well as their disease progression, to call attention to conditions that have not yet been addressed this year. The quality of care opportunities include specific guidelines that enable providers to diagnose and document each patient appropriately. The medication list highlights high-cost or high-risk medications, potential side effects and adverse interactions, and any adherence challenges the patient may experience.

Representatives educate network providers and advise them on how to incorporate Patient3D into their day-to-day care delivery. We encourage PCPs to review the PIRs — which are available online — during their pre-visit preparation to identify gaps in care. The multifaceted interface allows for a detailed 360-degree view of a patient’s health record, including medical history, recent PCP and specialist visits, facility admissions and discharges, and care management interactions. When the provider addresses each care gap and submits a visit claim through their EHR, the PIR updates to show which gaps were closed — by whom and when — and which remain unaddressed. Closing these gaps helps ensure patients receive necessary preventive and chronic-condition care and helps providers achieve their quality incentive goals.

ConcertoHealth relies on network providers to adhere to existing EHR documentation and claims submission processes. Our analytics systems can indicate discrepancies between claims and documentation from the patient visit. We recommend that providers upload their progress notes through Patient3D, as an “online chart chase.” Alternatively, we enlist chart chase vendors to collect progress notes that may have been captured outside of a provider’s EMR system, to further address these care gap opportunities.

Care Performance

Often, we hear from network provider groups that they need aggregate analytics on their providers’ performance, delineating opportunities for improvement. Patient3D offers a Care Performance Dashboard that details the performance of group providers with respect to PIR closure, drawing specific attention to open care gap opportunities. The dashboard also includes advanced medical economics statistics, including:

• Acute admissions per thousand patients,
• Emergency visits per thousand patients,
• Average length of stay,
• 30-day acute readmission rate,
• Percentage of post-discharge follow-ups,
• Percentage of high-risk patients and
• Percentage of high-need, vulnerable “hot-spotter”

Providers and administrators can use this self-service tool to drill down and generate patient action lists to help initiate closing care gaps.

Optimizing Provider Workflow

Another way ConcertoHealth supports network PCPs is through eConsults. We’ve partnered with a multispecialty eConsult provider that grants remote access to specialists for clinical advice and treatment recommendations. This can help educate providers, inform their decision-making, and reduce the risk of patients not receiving specialty care. Within our organization, 85 percent of physicians found that eConsults strongly impacted a patient’s care plan, and 72 percent of consultations resulted in both physicians agreeing that the patient could be treated by the PCP. If the eConsult physician and PCP determined that the patient could benefit from an in-person visit with a local specialist, the PCP would proceed with that referral.

Additionally, ConcertoHealth is transitioning away from phone and fax authorization requests to a purely online submission process through Patient3D. An end-to-end electronic process equips network providers to submit new authorizations, check the status of existing requests, and view an authorization history submitted by all providers for specific patients. Upfront online validation allows for cleaner data capture from the providers and direct integration to the utilization management system reduces time-consuming manual data entry required for fax and phone requests.

Network providers are an integral part of our patients’ care. ConcertoHealth strongly believes in partnering with providers to deliver proactive care by empowering patients with advanced point-of-care tools.

In the next blog post in this series, we will review how ConcertoHealth medication management initiatives, supported by analytics, prevent adverse events and readmissions, ensuring the highest levels of safety for our patients.

This piece was written by Sampath Narayanan, CIO at ConcertoHealth, a provider of specialized primary care and clinical services that operates exclusively in value-based agreements.