Value-based care impacts outcomes

I think that that's actually a great segue way to talk about outcomes. And in Dr. Feldman, I want to start with you here. You know, there's providers, patients themselves and families spend a lot of time trying to manage patients at home, keeping them out of the hospital every day. For a patient with multiple chronic conditions, out of the hospital is a day at home in their own beds with their families doing the things they want to do.

But, you know, hospitalizations are sometimes unavoidable. And I know that many of you probably spend a lot of time thinking about how you can work with the physicians in your practice to ensure that your members, to the best of your ability, can stay healthy at home and can stay out of the hospital or out of the E.R., if at all possible, even though sometimes it isn't avoidable.

So I would love to hear from you, Dr. Feldman, starting with you, how your organization thinks about utilization, the all-important, you know, avoidable hospitalizations, avoidable readmissions, E.R. utilization, those types of things. Certainly, we know that members who are assigned to practices that take on risk, that are value-based care arrangements, do have fewer hospitalizations. And E.R. visits.

But that takes work. That doesn't happen by accident. So I'd love to hear how your organization thinks about it.

Great. Thanks for the opportunity to answer that question. We spend a lot of time and energy trying to answer this question in practice, and it starts with access for the patients to be seen in a timely fashion. So many patients who end up in the E.R. start with the phone call to their doctor, which is followed by their full and is then followed by I guess I'll have to go to the E.R. for that problem.

And so we're constantly professionally managing physician schedules so that there's same day access and real time access that's coupled with care navigators who provide patients a hot phone line that they can reach out to a person to discuss their health conditions, and that person can reach out to the clinician in real time and make sure that the patient is seen.

So I call that access and in between care. I think that also having a robust, urgent care center, so an alternative to a high-cost center like an ER is critical because there are some patients, it doesn't matter what they show up with, they're going to be admitted by virtue of their comorbid it is on their best day they could be admitted.

And so that's just the bias of the emergency room encounters. If they can be seen in the urgent care where their charts are available in the same integrated EMR that their outpatient care is provided, where the urgent care physician has access by cell phone to the attending physician, that care can be coordinated with real time follow up the next day.

So I think it's a combination of care management, appropriate access and a robust sort of urgent care program allows for a reduction in acute E.R. visits. The challenge, once they get to the E.R., many of them are admitted. And then, you talk about reducing hospital days, and that's where the hospitalist and sniffers programs come into play. But so that that's a that's our approach.

Thank you. Dr. Bhansali, what would you add to this question?

Yeah. So I guess I can share our secret sauce, which is not really that secret because we're recording this is really thinking through how are we going to meet patients exactly where they need to be met. Primary care by far is the key tactic and gatekeeper for providing that excellent care. So the first thing we've done is taken our patients and tiered them into figuring out which patients are the highest risk, average risk and low risk, and then a cadence with their primary care doctors to ensure that they they're being engaged with whatever it is that they need.

We have created a pretty robust care management team that is remote. So these are care managers, social workers, the entire gamut where primary care doctors can engage with that group whenever that whenever they would like. We have our ICS, which we've given access for our patients, you know, walk in, access to attend. They can call the ICC and figure out exactly what the care coordination is.

And same thing with our primary care group. So today we're looking into pre acute management. So there are groups that are providing EMT or sorry, excuse me, EMT care at home and hospital at home. So we're looking to explore those solutions when a patient is potentially appropriate to go to the E.R. And so the teams would go to the patient's home, assess the condition and see if it can be managed outside of the E.R.

We're also utilizing direct admission to sniff opportunities where if it looks like the patient needs to be in a skilled nursing facility again, then we can bypass the hospital and go directly to the staff. We also have a 24/7 central nurse, Trish. So any time whenever the patient wants to call, they have the opportunity to talk to a nurse.

And there's a part of Kleist Decision Tree that helps decrease the variability of figuring out whether or not the patient should go to the ER or the urgent care or follow up with their PCP and a couple of really unique things we've done is we've created an er diversion program where our hospitalists will come down to the E.R. and engaged with the E.R. doc and have shared decision making and whether or not the patient should be admitted.

So a metric that we look at closely is treat and release rate from the emergency rooms to figure out, ah, is there an excessive amount of admission for the patients that show up in the emergency room? And the last thing we've done, and I shouldn't say the last few other things, but another key thing we've done is a room is something called a care ally.

And there are a lot of different definitions for care alone. So I can share what our care allies to is they're embedded in the clinics and they coordinate care. So they serve as social workers, care coordinators, case managers, community health workers, sort of the gamut of all four of them combined. And they are all nurses, and they work with our most our sickest patients, essentially.

So are critically ill or seriously ill patients and ensure that all the I’s are dotted T’s across essentially a bubble wrap around those patients. And the last thing we've done, I keep on saying of the sexual the mental aspect, this is the less important point is that we've created these high acuity centers. We call them the breakthrough care centers, where it is.

It is physicians that are focused essentially on the sickest patients with the highest burden of social and behavioral determinants of health. And their compensation model is not a productivity-based model. And they have every resource you can imagine. And so in these clinics, we ensure that our most complex patients are funneled to these clinics so that they can get the highest acuity of care that's needed to provide the right care for them.

So a lot of different strategies and tactics to improve patient outcomes.