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High Utilization in the ED and Patient Leakage in the World of ACOs

: Emergency department care team

The emergency department (ED), for most people, is the easiest place to go for health care. Hospital administrators and payers have understood for a long time that patients who are seen frequently in the ED are responsible for a disproportionate amount of health care spending.

In an effort to reduce ED visits, one of the primary strategies being employed is a shift of high-utilization or high-risk patients to primary care. Traditionally, this is a complex process requiring a team of people who are not only able to identify high risk patients but also would be in a position to intervene in a timely manner, before the patient is seen in the ED.

Clinically Integrated Network Helps Identify & Track High-Risk Patients

In addition to chronic health problems, high-utilization patients also often experience challenges in their ability to access care such as transportation, financial difficulties, or poor health insurance coverage. Understandably, this difficult reality often forces these patients to look for help at the ED closest to them, regardless of facility or the facility’s relationship with their primary care provider.

Some organizations, for example Oncology practices who are participating in the Oncology Care Model (OCM), are often well-positioned to be able to identify and intervene.  Practices who have strong relationships with their local hospitals, potentially leveraging pMD's clinically integrated networkwould have the ability to not only identify these high utilization patients but also understand their relationships with other providers. By understanding where the patient is already established and also understanding important elements of their medical history, providers are then able to eliminate unnecessary tests and imaging studies, reducing the costs of, or even necessity of, an admission.

Patient Leakage a Significant Problem for ACOs

But what happens when a patient is not within this utopia of information sharing and potentially not being tracked closely? Patients who visit the ED of a facility outside of the clinically integrated network are off the radar of care coordinators and this presents a significant problem for ACOs. When an ACO patient is seen outside of the ACO, this is known in the industry as patient leakage. The problem is exacerbated if the patient has not already been identified as a high-utilizer as it’s unlikely that this patient has been assigned to a team of care coordinators.

The Solution to ACO Patient Leakage

The pMD solution to patient leakage is comprised of two layers. The first being the ability for a provider or care coordinator to receive real-time notifications when a patient is admitted to a facility where pMD is integrated. The second layer is real-time communications - the ability for providers, care coordinators, family members, and even patients themselves to communicate securely with their care team. In this way, the people who are best able to help are able to intervene as soon as possible, getting the patient to the right place of service or at the very least, the right ED.
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