Technology firm Acclivity Health has launched a new system to coordinate clinical care and support resources for seriously ill patients, initially in 38 states. The Connected Community Interoperability Framework includes a network of corporate and organizational partners that includes tech companies Axxess, Muse Healthcare and MatrixCare, as well as the National Hospice & Palliative Care Organization (NHPCO).
Members of the initiative include hospice and palliative care providers, primary care providers, health systems and accountable care organizations, health plans, pharmacies and an array of vendors in the health care space.
“In essence, we’ve now built a central nervous system working together across 38 states and 4 million patients and 2,300 partners that are sources of data,” Acclivity Health CEO Jeremy Powell said. “We’re literally pulling back the camera and looking at the full ecosystem.”
The initiative’s objectives include reducing hospital readmissions as well as emergency department visits and facilitating more seamless transitions of care between settings. The program builds cohorts for targeted referral programs using palliative indicators such as risk of death or hospitalization and the presence of psychosocial issues associated with the patient.
Interoperability is typically used to describe the ability of health care organizations’ electronic health records (EHR) systems to communicate with one another. The U.S. Centers for Medicare & Medicaid Services (CMS) requires this capability among organizations participating in value-based alternative payment models, such as direct contracting.
Nearly 75% of physicians indicated in a MatrixCare survey that they would be apt to change post-acute partners that they believe could more effectively process electronic referrals. This is up from 64% in a similar survey last year. This research also shows that 95% of respondents in the post-acute space believed that interoperability was important to their referral partners, a substantial increase from 34% in last year’s report.
The Acclivity interoperability framework is designed to acquire and share more data than traditional EHR-focused systems.
“EHR work is often only aware of the clinical transactions; it would know everything from admission through any orders and results,” Powell told Hospice News. “It doesn’t consider things like the cost of that care. It doesn’t consider information that might have reference ranges or the actual value of diagnostic results. When we think about interoperability, especially when it comes to the sickest patients among us, this framework is setting out to set its sights wider than a traditional interface.”
The framework is also designed to help measure a patient’s disease burden using a Palliative Performance Score, developed by Acclivity. This feature is intended to anticipate patients’ care needs to ensure they receive appropriate care in a timely manner.
The score measures functional decline by considering factors such as ambulatory status, activity levels, ability to self care, lucidity and evidence of disease.
The framework is designed to support improved care coordination. Care coordination is a driver of quality and a watch word among emerging value-based payment models in which hospices are newly eligible to participate, including Medicare Advantage and direct contracting reimbursement options.
Coordination is also integral to the Serious Illness Population model, but the CMS has delayed the launch of that program indefinitely, indicating that the payment system is “under review.”
“NHPCO recognizes the importance of coordination of care for people with a serious or life-threatening illness,” said Lori Bishop, Vice President of Palliative and Advanced Care at NHPCO. “We are pleased to partner with Acclivity Health’s Connected Community Interoperability Framework to help providers get an interdisciplinary view of their patients and help patients and families get the best care possible from their providers.”