In April, Jeff Hurst discussed how Cerner’s Clinically Driven Revenue Cycle captures charges automatically as a by-product of quality documentation, providing all the intricate information needed later for appropriate billing. In this blog, he talks about how integrated technology allows for more coordinated care management and a healthy revenue stream.
Disjointed data and processes make it extremely difficult to have one comprehensive picture of a patient, let alone a patient population. It also limits clinicians and financial staff from making the best decisions at the right time to deliver optimal outcomes with accurate and timely payment. For these reasons, clinical and financial alignment is essential.
Fortunately, today’s challenges with disparate data present an opportunity to optimize care delivery and revenue streams. Organizations that do this well will not only achieve healthier clinical and financial outcomes, but will also be well positioned to manage their populations today and tomorrow.
Health systems increasingly see care management as critical to responding to value-based reimbursement. As a primary component of a care management strategy, acute case management solutions can advance care coordination across venues through five main areas: appropriateness of care and setting, efficiency of care, transition of care, a focus on cost and connectivity.
A critical component of acute case management is determining appropriateness of care and the appropriateness of facility setting – especially when it comes to the transition of care from an ambulatory setting into the inpatient care setting. Does the patient need to be admitted, and what level of care is the best fit? Based on the review of patient records and medical necessity, what care plan does the patient require?
Today, there are a lot of discussions about how we transition from having a relationship with a patient within a single episode of care to how we have a broader relationship with that patient across the continuum.
When we consider health and wellness, whole person care and the health of that individual over an extended period, what we're really talking about is building a relationship with that person that's based on trust, understanding, knowledge and awareness. When clinicians can establish a lasting relationship with that person over an extended period, they incorporate health and wellness initiatives at the appropriate point and time – ideally early in the care process, to keep that person well and away from an episode of care in a high-cost setting.
In this way, the shift to quality and care management can help proactively manage the complete health care delivery chain over the course of a person’s entire life. Providers must think in terms of population health management as opposed to individual patient management – and work together to keep the person healthy – or risk revenue.
Statistics tell us that a length of stay (LOS) that is longer or shorter than average is associated with increased risk of readmission and that a focus on efficiency leads to decreased LOS, 30-day readmissions and fewer deaths after admission.
When it comes to efficiency of care, reducing unnecessary LOS means providing the patient with a positive, comprehensive experience in the hospital and effectively transitioning the patient to the next level of care.
The more integrated health care systems are, from both a clinical and financial standpoint, the more opportunities there are to aggregate and evaluate data. By looking across the entire data spectrum, providers can understand what's going on with a patient from a whole person care perspective – this means going beyond their clinical condition and looking at the care they’ve received and any previous clinical diagnoses. This allows the current provider to get a better understanding of a patient’s clinical profile, which in turn means better care guidance and care efficiencies.
When acute case managers understand the patient from a whole person care perspective, they can make thoughtful and evidence-based recommendations that impact clinical and financial outcomes.
When a patient is transitioned from one care setting to another, it’s crucial that we’re making sure they understand their care plan, medication and how to reach their primary care physician or their sub-specialist. This is so that, first, we are helping them get the care they need, and second, so that they don't ultimately deteriorate and end up getting readmitted to the hospital.
Often, when a patient is discharged from the hospital and their socio-economic status is such that they are unable to follow up with their primary care physician or to purchase necessary medications, they are not going to continue down the recommended clinical care path.
Consider evidence-based medicine. Evidence is based on intelligence and intelligence is based on data, so the more providers have access to a broad spectrum of data, the better they can trust evidence-based decision making. A lot of what drives evidence-based protocols are clinical factors, so that integration between the clinical side of the system and the financial side of the system can allow clinicians to add socio-economic data. This is critical information, because patients with the same clinical profile could require a different path in terms of care management, care coordination and access to care.
By integrating clinical data with financial data and the socio-economic profile of a patient, acute case managers are empowered to advance value-based care strategies for the hospital, securely transitioning patients to lower levels of care for improved quality.
From a health system perspective, if we can focus on delivering the appropriate level of care in the appropriate setting at the appropriate time, we’ll create several opportunities to reduce costs. The more we can drive out waste from inefficient or ineffective expenses, the more value we’ll create – not just for the individual consumer or the individual health system, but for the entire industry.
Pressure to control prices combined with the growing need to control the cost of treating patients with multiple chronic conditions, will lead health systems to seek solutions that allow for more holistic care management—proactively managing care across the community for a population with certain risks, chronic conditions, complications and high utilization.
Acute case managers play a critical role in cost-effective care and need tools to coordinate and facilitate a single care plan with effective care management services across all venues.
Organizations can benefit from the connection between clinical documentation and the business office. Having a focus on pre-authorization in advance of care delivered and medical necessity – both in terms of the care that's delivered and the care that is documented – ultimately flows through to the business office which leads to appropriateness of payment, and reduces non-payments and delayed payments.
The patient’s experience begins and ends with revenue cycle processes, from the time an appointment is scheduled, to registration, to when a statement is submitted for payment. While quality of care and improved health outcomes remain top of mind, a person’s first and final impression of the care experience is important and will impact overall satisfaction.
For this reason, the provider’s responsibility does not stop at discharge. Clinicians must appropriately identify the condition of the patient, treat the patient, and effectively transition the patient with relevant information so that caregivers are better equipped to continue care for that patient throughout the continuum.
With clinicals and financials on a single system, tracking patient throughput and utilization can help you spot unfavorable trend lines, such as patient satisfaction scores where reimbursement is attached, and proactively implement process and system changes to streamline those processes.
Health care systems today can do well financially by doing good. We've progressed down a path where there is increased connectivity between the care that's delivered and the outcomes that are achieved. In a value-based, pay-for-performance model, a health system’s finances are tied to those outcomes.
Driving continued efficiencies can help lower costs and improve the overall financial vitality of the health system, which in turn means the health system can expand its mission and serve a broader patient population. This can lead to improved health and wellness outcomes not just for the patient, but for the broader community.
All roads lead to an effective care management strategy – one that uses clinical information to drive financial outcomes – to advance care coordination across venues and help optimize your business and the health of your population.
Cerner will speak on Holistic Care Management: Connecting Care Across the Continuum on Monday, June 26, 12:30 p.m. and Tuesday, June 27, 12:15 p.m. EDT in the Cerner booth #523 at HFMA National Institute (ANI). Schedule a private meeting at ANI.
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