Part of practicing good population health is regularly performing transition care management visits (TCMs), referred to in “Overcoming Transition of Care Management (TCM) Visit Challenges.” This visit is essentially a scheduled primary care visit that occurs within 1-2 weeks of an inpatient, observation, or skilled nursing facility discharge. This special visit, however, may force physicians to think more about what is going on in their own offices to prevent the admissions in the first place, as well as pose the questions around identifying when their patients are admitted. How do these providers handle care proactively?
Through a major push from the government for providers to use electronic health records, we see that the majority of hospitals throughout the country have Admit, Discharge, and Transfer (ADT) feeds that were created to alert providers electronically. At first this feed wasn’t welcomed by many hospitals, however, the push to value-based care requires serious continuity of care efforts. Once the ADTs have been established, the provider offices can understand when a patient is admitted so that they may be prepared for the TCM and ensure the patient gets back to baseline in the community as quick as possible.
The problem with areas that may be heavily populated with healthcare facilities and hospitals is that there lies an extreme burden on administrators to obtain all the necessary feeds to get a good picture of the hospital ADTs. In an effort to minimize that burden, many states are creating their own Health Information Exchanges (HIE), which is a mass consolidation of ADT feeds, and may vary with additional clinical information by state and solution.
There are several types of HIEs: State HIEs, Private HIEs, and Community HIEs. In time, with better interoperability, we should see more data shared across the country rather than segmented as it currently is. HIEs are growing fast. In fact, the private Health Information Exchange market has been predicted to nearly double in value by 2024. This comes as no surprise as practices still without EHRs are declining, and the need for sharing data is fast increasing.
When I was part of a large multispecialty private practice near West Palm Beach, FL, we had ADT feeds set up with every hospital within a 20-mile radius of our office. All it took was a call to each hospital’s Medical Records department, and they would usually have us fill out requisite forms. After that, we made sure our providers instructed every single patient that, “If you end up in the hospital, let them know that we are your primary care providers.” As we had a patient advocate on staff, she was in charge of receiving the ADT feeds, but even your own medical records department can handle that responsibility. Upon admittance, we would contact the patient via our Patient Portal, reminding them that upon discharge to schedule an appointment with us. Once we received notification via the ADT feed that the patient had been discharged, our staff would actively reach out to schedule their TCM appointment. If your ACO plans on designing a TCM initiative to reduce hospital admissions and boost quality care, establishing an ADT feed with your local hospitals should be at the top of the “To Do” list.
As a former administrator from a provider organization, I can tell you that without the addition of the ADT and HIE feeds, our managed care and accountable care performance would not have been the same. The continuity of care was the key to ensuring proper transitions so that our patients felt that we had a strong grasp of their healthcare and that we truly were their primary care providers.
If you’re unsure about whether you can connect to an HIE or even ADTs, speak with the service providers in your region and hospitals that your patients frequent. They’ll provide you with their specific requirements, and you can determine if you have the technology to support the interoperability. CMS has a great getting started plan to use as a checklist. If your state doesn’t have an HIE, or the local hospitals are not connected to the HIE, nor do they have an ADT feed, at least consider creating a direct feed via fax or encrypted E-mail. To practice good population health you need every advantage you can get to stay on top of your patient’s information. With a link to an HIE and a few ADT feeds, you’re off to a great start.