Provider Networks’ Role in Expanding Patient Choice

Guest post by Cheri Bankston, RN, MSN, director of clinical advisory services, Curaspan.

Cheri Bankston
Cheri Bankston

When determining a discharge plan, hospitals must provide a list of home health agencies (HHAs) or skilled nursing facilities (SNFs) that are available to care for the patient; this comes as part of the Conditions of Participation (CoPs) for Discharge Planning. In the case of a HHA, the provider must be able to serve the patient in the area where the patient resides, or in the case of a SNF, the area requested by the patient.

Acute care providers have been struggling on how to set up a high-quality provider network to support patient choice as we move from volume to value. Provider networks aim to gather more information to assist beneficiaries with selecting a high-quality post-acute provider. CMS has not outlined any specific criterion that deems a provider “high quality,” but the end goal is to provide the patient more information on quality performance and resource use at the time they are making a decision Through the Center for Medicaid and Medicare Services’ (CMS) Star Rating program, discharge planners or case managers working for hospitals are able to highlight those provider networks that will best fit the needs of the patient. The networks are able to counsel patients about their available choices, while more importantly upholding the patient’s right to choose.

Under the Affordable Care Act’s value-based purchasing initiative, hospitals are at financial risk for the outcomes of care its patients receive from post-acute care providers, leading hospitals to work towards establishing high-quality provider networks. For many, upholding the standard of Medicare policy – patient freedom of choice – is challenged by potential financial incentives and penalties for the bottom line – the quality of care provided to the patient after discharge impacts the reimbursement levels for hospitals and ACOs. Although provider networks may appear to narrow patient choice, they actually create a set of higher quality post-acute providers that improve patient outcomes without impeding access to care.

Payers have been using “provider networks” for years, but being applied to hospitals is a brand new concept. An ACO’s success depends on using a provider network that has a demonstrated history of high quality of care outcomes. For example, SNFs that have a high rate of patients going to emergency rooms and not being admitted must be evaluated to determine the variance from other providers with the same level of care and fewer emergency room visits. Quality outcomes and patient satisfaction are going to drive the definition of provider networks.

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The Right Prescription for Effective Population Health Management, Improved Outcomes

Guest post by Diane D. Homan, MD and Adam Lokeh, MD.

As the healthcare industry unwraps the next phase of population health management (PHM), providers are increasingly embracing its promise to drive success with healthcare’s triple aim of improving population health, enhancing patient experiences and reducing costs. It’s a 180-degree shift in thinking for many providers who have been conditioned to long-standing fee-for-service models, one that will require a coordinated care effort and an advanced technological infrastructure to support decision-making based on the latest industry evidence.

As regulatory initiatives, such as meaningful use and value-based purchasing converge to up the ante on improved outcomes, the proactive premise of PHM will be critical to success. A foundational component to effective implementation of a PHM model is a clinical decision support (CDS) strategy that drives standardization of care based on best practices.

For Rush-Copley Medical Center, the first step in this process was deployment of evidence-based order sets and a complete clinical content management solution— ProVation Order Sets, powered by UpToDate Decision Support. The decision to leverage evidence-based order sets at the point of care has proven advantageous on many fronts, from supporting recent responses to public health crises to raising the bar on outcomes improvement and laying a foundation of accountability across the continuum.

Reducing Variation for Improved Response

Getting clinicians on the same page and helping them to adopt industry best practices in their day-to-day workflows is certainly a key element in bending the quality curve, but ensuring that variations are minimized in a public health crisis is absolutely critical to success.

A 210-bed hospital serving the greater Fox Valley region of Illinois, including the state’s second largest city, Aurora, Rush-Copley uncovered an outbreak of tuberculosis (TB) in late 2009 following two admissions over the course of two months. In cooperation with the Kane County Health Department, an investigation traced the outbreak back to a homeless shelter, which, in turn, presented a considerable challenge to containing the outbreak as the population was highly transient.

With evidence-based order sets and an advanced clinical content management solution already deployed to address standardization of care, the clinical team was able to quickly deploy a point-of-care strategy for identifying at-risk patients, apply isolation management tactics and develop collaborative efforts throughout the community to minimize exposure. The strategy was three-fold: 1) contain the epidemic, 2) provide highest quality treatment based on industry best practices and 3) avoid duplication of services.

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