In an attempt to improve patient outcomes and reduce care costs, ACOs in value-based care models across the country have devoted significant attention to the inpatient setting—focusing care management resources on inpatient discharges in particular. This is understandable, given the risk associated with that transition of care and potential for 30-day readmissions, which impact ACOs from a total medical expense (TME) perspective as well as quality measures performance.

However, ACOs that focus almost exclusively on inpatients risk neglect a much earlier opportunity to support their members’ care—as they enter the Emergency Department (ED). 

The ED is the healthcare gateway for many vulnerable populations, providing a first look into a patient’s background and care histories. The ED is also an inflection point that offers cost savings opportunities. ACOs should ensure they have robust strategies and solutions in place to engage members in the ED and optimize care decisions out of the gate.

The ED and ACO Value-based Care Goals

What happens in the ED can either help or hinder ACOs that are trying to succeed in value-based care models. Three high priority areas influenced by ED utilization and ED decision-making are cost management, quality metrics, and patient experience. 

• Cost management: Seven years after their creation, many ACOs are still struggling to meet even the initial goals to manage rising healthcare costs—regardless of the ACO model they participate in.
  
  One underlying reason may be that ED cost in that period has grown roughly 31 percent, according to a study by the Health Care Cost Institute. Additionally, studies suggest that up to 27 percent of ED visits are preventable or unnecessary—yielding an extra $4.4 billion of unnecessary cost annually.
  
  Even more significant drivers of healthcare costs are avoidable inpatient admissions and readmissions—the majority of which originate in the ED. US hospitals spend $41.3 billion per year on adult 30-day all-cause readmissions. Nearly 27 percent of readmissions are considered potentially preventable.
• Meeting CMS quality metrics: ED visits that convert to inpatient stays and result in a 30-day readmission not only contribute to TME, but also negatively impact ACO performance on care coordination quality measures established by the Center for Medicaid and Medicare Services (CMS). Many ACO models also measure “unplanned” admissions, including both readmissions and admissions that are not readmissions.
• Patient experience: As part of healthcare’s Triple Aim framework, patient experience continues to be a top priority for ACOs. Payer risk contracts, including CMS ACO models, commonly feature patient experience quality metrics. The ED is the entry point to the healthcare system for many patients, so first impressions here are critical.

The key to improvement across all of these areas lies in ED optimization, and the approach is twofold: it involves improving ED access to critical patient care insights and ensuring care teams are aware, in real time, when their patients present to the ED. This will allow collaboration to begin when patient care does, too—supporting better patient care and overall ACO performance.

A Proactive Approach to ED Optimization

As ACOs look to the upcoming Direct Contracting ACO model, proactive ED optimization will continue to play a key role in improving value-based care practices to better help patients—including vulnerable patient populations that may have been previously overlooked.

Care Insights

In order to make the most appropriate care decisions and ensure the best outcomes for patients, EDs need access to patient information that is not typically captured during an ED visit—social determinants of health, behavioral health needs, and care team and/or community partner involvement. This is especially true for high risk patients with unique care needs that require extra attention. While EDs are not always privy to these non-medical patient characteristics, ACOs are gathering these insights on a daily basis through their outpatient care teams and other care management and population health efforts. 

If ACOs expect EDs to assist with identifying avoidable admissions, reducing ED re-visits, and supporting other value-based care goals, ACOs need to make their care insights accessible to ED providers and hospital case managers. It behooves ACOs to help “fill in the story” and connect the dots between patients, providers, and the appropriate care teams—including primary care providers, specialists, MAT providers, and post-acute care.  

Technology exists to help make these connections. When care teams work together and leverage technology to create actionable care insights, patient outcomes improve. In one study, reducing readmissions for two northeastern hospitals by 12.8 percent resulted in a significant $3.7 million in savings.

Real-time notification for ACO Care Teams

Another way that ACOs can take advantage of opportunities in the ED is by enabling ACO case managers, social workers, and other care team members to step in and intervene during the encounter. With their specialized skills and knowledge of community resources, these staff can assist with ED discharge planning—helping to avoid an admission or readmission. Connecting with EDs in real time also gives ACO care teams crucial insight that can make outpatient care management more effective. 

Additionally, real-time notifications can help ACOs manage out-of-network leakage. When case managers are notified of visits to an out-of-network hospital, they have an opportunity to reach out and redirect follow up care to an approved provider, potentially resulting in cost savings and helping ensure quality care standards are met. 

Impact of technology-supported collaboration with EDs

Columbia Medical Associates (CMA), now part of Kaiser Permanente, is a multi-specialty group practice that participates in the Medicare Shared Savings Program as an ACO. Its care teams realized they could improve care for many of their high-risk patients by working with ED teams to direct patients to appropriate care settings. The organization implemented a care coordination platform that was integrated into workflows. The platform facilitated instant notifications when patients presented at the hospital, allowing CMA staff to follow up. 

The enhanced collaboration yielded a 15 percent reduction in ED utilization, a 7 percent reduction in avoidable ED admissions, and a 13 percent increase in provider engagement scores—resulting in an estimated $6.5 million in saved care costs for the ACO. In addition, patient satisfaction rose 16 percent, placing CMA first in patient satisfaction for Washington state.

At Sturdy Memorial Hospital, ED care teams were seeing a large number of patients with behavioral health diagnoses. Many of these conditions could not be adequately treated within the ED and required treatment from outside behavioral health services. Sturdy began using designated case managers to coordinate care for these patients and connect them with behavioral health resources in clinics and the community. The case managers created care insights for individual patients, which were available to the ED via the care coordination platform. 

As a result, Sturdy Memorial saw a 73 percent reduction in unnecessary ED utilization for behavioral health patients engaged in collaborative care plans, lowering care costs and improving overall patient outcomes. Furthermore, patient experience improved as these patients were able to receive the care they really needed, in an acuity setting designed specifically for their needs. 

The ED provides a window of opportunity to positively influence transitions of care from the ED and beyond. Through improved coordination with the ED, ACO care teams can support better patient care, meet existing ACO goals, and successfully navigate the change to Direct Contracting models in 2021. ACO leadership should consider the role of technology in facilitating this collaboration. Solutions that put care insights at the fingertips of ED providers and connect care team members will help ACOs achieve success in the competitive value-based care arena.

Ben Zaniello, MD, MPH, is the Chief Medical Officer at Collective Medical, the nation’s most effective network for care collaboration. Dr. Zaniello has worked in care transformation for over a decade, most recently at Providence St. Joseph Health as Chief Medical Information Officer in Population Health.

Nikki Starrett, MS, is the Director of Accountable Care and Population Health at Collective Medical. Prior to this Nikki spent many years working for accountable care organizations, helping lead initiatives focused on value-based care and system transformation.