By: James G. Uberti, MD, MPH and Kris Gorman Surber, MBA, PC
“Coming together is the beginning. Keeping together is progress. Working together is a success.”
Accountable Care Organizations (ACOs) are defined by the Centers for Medicare and Medicaid Services (CMS) as groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high-quality care to their patients. A key element of success for ACOs and/or Clinically Integrated Networks (CINs) like SoNE HEALTH is the collaboration between our primary care providers, our medical and surgical specialists, and our hospitals. When healthcare is rendered with our high-quality, cost-efficient SoNE HEALTH network, our attributed patients receive optimal care, at the best site, at the right time, for the best value.
Maintaining focus on prevention for our well patients, while identifying our most at-risk and medically complex patients, is a key to successfully ensuring that the lives for which we are responsible receive necessary services and prompt follow up, whether in their homes, in clinics, in emergency departments, in the hospital or in post-acute settings. Managing our patients across the continuum of health care, all in sociodemographic settings, is enhanced when our SoNE HEALTH providers can work and collaborate together. We are truly stronger together and our patients do better!
SoNE HEALTH is developing processes and tools to enhance collaboration and coordinated care which include:
Surprisingly, global understanding of an organization’s “network” is not as easy as one might think. Hence, “at your fingertips” access to network directories, both hard copy and electronic, otherwise is critical.
Referral Management Systems
High-performing networks are supported by referral management systems that efficiently identify network participants’ access and availability at the point of service so referral coordinators can easily connect patients with in-network providers and practices in real-time.
Providing meaningful and actionable data to understand utilization patterns and trends assists tactical teams with practice, provider, and member education to help better facilitate patient engagement and continuity of care throughout the delivery system. Further, establishing metrics to observe trends over time will enable focused improvement opportunities.
Comprehensive communications for all stakeholders: patients, providers, and practices will improve awareness and knowledge of the network’s service capabilities as well as support the process and tools that lead to continuity of care.
Health systems, practices, providers, and patients face many complexities to today’s environment. Providing the necessary support to all stakeholders is critical to optimizing patient engagement and continuity of care within a system. While many of these processes and tools appear to be routine, they require concerted long-term commitments from leaders across the SoNE HEALTH network to implement the sustainable change necessary to realize improvements. The changes will not happen overnight but organizations willing to stay the course will realize benefits.
James G. Uberti, MD, MPH is the Medical Director at SoNE HEALTH
Kris Gorman Surber, MBA, RD is the Executive Director at Advanced Orthopedics New England, PC