Transitions—when patients move from one care setting to another—represent a state of vulnerability for both the patient and the healthcare organization. Patients need referrals to the most appropriate provider in a timely, seamless fashion so they get the level of care they need. If patients leave the network, it could result in revenue leakage for the provider organization.

I’ve heard healthcare leaders estimate that between 20-30% of their patients ultimately leave their network during a transition of care. This renders the care team less able to ensure patients get the best possible care—and less able to track patient progress and monitor follow-up.

Plus, it means missed revenue opportunities. When patients see out-of-network ambulatory or post-acute providers, healthcare networks are unable to capture the revenue that would otherwise be associated with patient care.

There are downstream financial effects, too. When patients leave healthcare networks, providers can’t be sure patients are following their care plan, which can be costly. The risk of preventable hospital readmissions increases, for example, which can result in significant financial penalty. CMS penalized 2,610 hospitals this year for avoidable readmissions. And that means CMS will reduce payments for every Medicare patient stay—not only for those patients who are readmitted.

Fully integrated referral management with CareInMotion™ Precision Transitions of Care

Precision Transitions of Care is a component of Allscripts’ innovative CareInMotion platform, designed to address specific population health management priorities.

Precision Transitions of Care helps clinicians in three primary ways:

1 Manage referrals across the entire organization – acute-to-post-acute, acute-to-ambulatory and ambulatory-to-ambulatory – within a single workflow.

2 Direct patients to the next phase of their care, keeping them within provider networks to minimize leakage.

3 Reduce preventable readmissions, ensure care is aligned across settings and enable optimization of resources.

A powerful combination of proven Allscripts solutions is at the heart of Precision Transitions of Care, a modular solution set that can adapt to different strategies. It draws from the capabilities of Allscripts Care Management™, which facilitates 12 million annual referrals, or 27% of electronic acute/post-acute referrals in the United States. It incorporates the industry’s leading ambulatory-to-ambulatory referral management platform, par8o. It also includes Allscripts Care Director™, to help manage high-risk patients while capturing data to measure improvements in the care process and patient outcomes, and Allscripts EPSi™ for financial decision support data to optimize provider networks.

Clients see results very quickly after adopting these solutions to more closely manage their referrals. For example, a Pennsylvania medical center has been using the ambulatory referral management capabilities from Allscripts. Within 10 months, the organization reported more than 28,000 referrals, a 216% increase in referral volume. More than 61% of those referrals required follow-up action. The organization also reduced the amount of time needed to contact referrals by 93%.

To find out more about how Precision Transitions of Care can help your organization, visit our website.

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About the author

Martha Thorne, senior vice president, oversees the Population Health business unit, which provides a comprehensive portfolio of solutions to help clients coordinate care, engage patients, manage chronic diseases and achieve operational excellence. Her vision for Allscripts CareInMotionTM, a comprehensive suite of population health solutions, aligns with the healthcare industry’s evolution from fee-for-service to value-based care. Previously, Martha led the Performance & Care Logistics business unit of Allscripts, which included a suite of solutions for care coordination and management as well as post-acute care. Prior to this assignment, Martha served as Vice President for Solution Sales & Strategic Initiatives. In this role she directed strategic planning and go-to-market strategies for the Allscripts solution set and strategic partner solutions company-wide, across all venues of care.



Murray Sanderson says:

10/29/2015 at 9:47 am

Martha, thank you for articulating this industry problem so perfectly. It’s more than a problem, it’s the massive iceberg barely submerged beneath the majority of our health systems in America. Patients have certainly felt shuffled around and have long sensed the lack of coordination/collaboration. Clinicians have languished at the issue, but they just don’t have the bandwidth to solve it. Thank you for helping get the message out that there is help – there is a solution to this titanic problem. Press onward.


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