Orlando Health’s 7 Steps to Data-Driven Transitional Care Management

Editor’s Note: This article is based on an educational breakout session at the Healthcare Analytics Summit 2024 (HAS 24) entitled, How Data-Driven Transitional Care Management Protocols Saved More Than $4M, presented by Kaylee Adams, MBA, and Allison Schwarting, MHA, who are both Assistant Managers of Value-Based Care & Population Health at Orlando Health (OH).

Healthcare organizations encounter many obstacles in managing their records due to the extensive, varied, and disconnected nature of healthcare datasets. The intricate nature of healthcare data also poses challenges in effectively coordinating and maintaining continuity of patient care during transitions to other healthcare providers or varying levels of care.

However, establishing a data governance plan to ensure healthcare data's quality, security, and usability can improve financial, operational, and quality outcomes, as demonstrated by Orlando Health (OH), a clinically integrated network with over 300,000 patients and 6,600 physicians at the time of writing.

OH sought to improve its transitional care management (TCM) experience and reduce 30-day readmissions. To tackle this issue, the leadership team implemented a data governance initiative to address automation, communication, reporting, and documentation issues — challenges that often result in care gaps, contributing to higher rates of costly readmissions. They also conducted thorough data analysis. The initiative resulted in over $4M in cost savings.

At the Healthcare Analytics Summit 2024 (HAS 24), presenters Allison Schwarting, MHA, and Kaylee Adams, MBA, who are both assistant managers of Value-Based Care & Population Health, shared more about OH’s value-based care arrangements and financial commitments for both cost and quality.

OH’s Technology-Backed Transitional Care Management Project, Subsequent Enhancements

As part of their efforts to improve how OH manages data to enhance transitional care and minimize readmissions, the pair explained how they took the following seven steps:

1. Standardizing assessments and protocols.
2. Tracking performance outcomes.
3. Automating care manager tasks.
4. Refining workflows and reports through continuous review and adjustment.
5. Improving clinical stratification criteria to prioritize high-need patients.
6. Enhancing patient identification methods.
7. Cataloging successful patient outreach initiatives.

Steps 1 through 3 involved efforts to ensure the accuracy and reliability of data in their EMR and generate actionable reports. To do so, OH employed months of data scrubbing, which included spending considerable time aligning data in spreadsheets across payors and vendors.

Steps 4 through 7 led OH to collaborate with a vendor to synchronize data across various systems. The technology seamlessly integrates with their current EMR, allowing all providers, including affiliated ones using different systems, to access the data without the need for additional training. The presenters also shared that they undertook discussions with payors and vendors throughout this initiative to identify new data needs.

Utilizing a ‘Tuck-In’ Strategy to Reduce Readmissions and ER Visits Key to Patient Engagement

The U.S. health system spends about $52 billion on patients who are readmitted to hospitals within 30 days of their initial treatment. Accountable Care Organizations (ACOs) like OH are working diligently to reduce acute care usage, recognizing that effective post-acute care management is crucial in preventing hospital readmissions.

During the HAS 24 session, the presenters also explained how OH took additional steps to identify and monitor high-utilization patients, aiming to involve them in efforts to minimize readmissions.

OH interacts with roughly 30 percent of patients through post-discharge communication, with variations seen across different patient populations. Schwarting and Adams said one of the challenges faced is reaching patients over the phone, especially if they are employed and work on-site.

For instance, OH patients working at Disney are unable to answer calls during their working hours. In such cases, OH will attempt to contact them through a secure portal or traditional mail if necessary. If follow-up contact is unsuccessful, this information is logged in the EMR, making other providers aware of potential gaps in care when the patient seeks care again.

Another method OH has implemented to boost patient engagement and lower readmissions is the “tuck-in” approach. This approach entails contacting high-utilization patients on Fridays to ensure they have all the necessary resources, aiming to curb preventable ER visits over the weekend.

Additionally, OH has established a patient engagement governance committee tasked with cataloging all patient outreach initiatives within the healthcare system. Their primary focus is on assessing the effectiveness of these strategies to avoid excessive communication between patients and providers and ensure that outreach efforts reach patients in a timely manner.

OH Excels in Value-Based Care Thanks to Proactive Data Management

In conclusion, Adams and Schwarting said they observed the following outcomes from their data management and governance project:

• Unified patient records. By having integrated patient records, everyone accesses a single patient file, including affiliated providers who are not employees.
• Automated patient IDs and workflows. This automation enables targeted identification of individuals more likely to utilize healthcare services at higher rates.
• Standard assessments and reporting. They developed streamlined best practices for assessing patient needs through better, more timely data.
• Health system alignment. Patients leaving the hospital can receive a 30-day supply of medication to prevent any interruptions in their care due to missing essential medications.
• Community resource alignment. OH offers various community services to assist with non-medical needs that impact patient health outcomes. One such service is providing and covering the cost of ride-shares for patients facing transportation challenges to ensure they can attend medical appointments. Additionally, OH offers financial aid, operates a food pantry, and runs community paramedicine initiatives.

The health system’s implementation of various strategies—implementing a data governance structure, utilizing data analysis, and employing a patient engagement committee—has decreased readmissions, shortened hospital stays, and addressed the complexities of transitional care. As a result, the health system has enhanced its value-based care model and financial commitments, serving as an exemplar for fellow healthcare leaders with similar goals.

Additional Reading

Want to learn more about this topic? Here are three articles we suggest:

How to Optimize Patient Care Transitions Through Whole Person Care

Improving Transitional Care Management -- A Five-Step Framework

Improved Care Transitions Reduces Readmissions Saving $3.2M Annually