Deja Vu. Have we met in the hospital recently? How collaboration and engagement reduce readmissions and ED recidivism.

In a recent Association for Community Affiliated Plans (ACAP) webinar, CipherHealth highlighted strategies for health plans to collaborate with providers and engage with members to improve outcomes such as readmission and ED recidivism rates for complex beneficiaries. Presenters included Friso Van Reesema, VP of Managed Care Sales; Liz Lagone, VP of Government Initiatives; Jordan Swift, VP of Managed Care; and Alyson Farrell, Account Executive, Managed Care.

The webinar applied learnings discussed in ACAP’s 2018 webinar focused on engaging complex populations, taking it a step further to highlight different ways to collaborate with provider partners and better engage complex beneficiaries, especially during a care transition.

The Challenges of Care Transitions
As Farrell discussed, members face many challenges as they transition from one care setting to the next and many providers don’t always have the resources to support psychosocial needs like transportation, nutrition, or education. Although health plans may have these resources, close collaborations with providers is crucial as it will impact the timing of engagement and relevance of messaging. As important as this collaboration is, there’s the risk for miscommunication gaps, which can lead to members becoming overwhelmed and difficult to engage.

Ineffective transitions can negatively impact member outcomes, which in turn creates financial burdens throughout the healthcare ecosystem. Farrell shared her experience as both a care manager and caregiver where poor communication and transitions resulted not only in poor experiences but also led to avoidable readmissions and unnecessary emotional and physical pain for members and their families.

There are many people involved with care transitions, including the acute care provider, health plan, primary or specialty care physician, and possibly even community-based resources of post-acute care. All of these entities must collaborate and communicate with each other, and directly with their members, to achieve the best possible outcome: a safe transition of care.

Swift pointed out that many of the challenges members face extend beyond clinical concerns to include social determinants of health (SDOH). It is imperative that members receive the support necessary to address these conditions, such as housing instability or food insecurity, that can affect health outcomes and lead to higher medical costs.

Strategies to Deliver Effective Care Transitions
During the webinar, the presenters highlighted many ways in which health plans can deliver effective transitions of care. One of the most cost-effective strategies is timely post-discharge follow up. When performed within 48 hours post-discharge, health plans can identify members who are at risk of readmissions or who may need additional clinical or socio-economic support. For example, many of the follow up programs CipherHealth supports show that transportation is one of the biggest issues members face – even though many plans offer the resources to alleviate these issues. Swift shared, “Medicaid members have more than double the rate of emergency department visits, and more than double the rate of no-shows to clinic appointments.” As such, there is a significant opportunity to better manage this population and coordinate their care.

Taking a collaborative approach is seen as a key component of a health plan’s ability to improve care transitions. Van Reesema highlights three steps to success:

    • 1. Identify the right people at the right time who are experiencing a transition and are ready to engage


    • 2. Engage them with the right message at the right time


    3. Collaborate with providers to successfully transition them back to their home and community.

While these steps may seem intuitive, addressing them can prove challenging for health plans. Using claims data to identify the right member results in significant lag time, which means that follow up attempts may not be able to catch patients in their time of need. Van Reesema asks, “How can we, as a Medicaid Managed Care Organization, identify members experiencing a transition?”

Although most plans are reaching out to the most high-risk cohorts, many do not take advantage of a population health approach that reaches and engages with all members during their transition.

How Automated Outreach Technology Supports Care Transitions with Engagement and Collaboration
In order to engage with more than the highest risk members, health plans must leverage technology to streamline communication efforts. For example, one payer/provider collaboration demonstrated that they were able to reach more people through automation than they did previously with manual outreach. The team resolves 90% of issues within hours, not days – including scheduling follow up appointments. When there is the right infrastructure and collaborative process in place, it is easier to engage the right member, at the right time.

Once members have been engaged post-visit, collaboration between payers and medical providers is critical to success.

Lagone shared, “Every individual desires having a different level of involvement in their care, but there is a strong connection between a member’s preferred involvement in their care and trust in the medical profession as a whole.”

Ultimately, the presenters showed that although the processes around care transitions are often complicated, there are many ways in which collaboration and engagement can lead to better results.

To watch the full webinar and hear some of the case studies shared during the event, please click here.

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