Care coordination is a critical success factor in the broader spectrum of improved outcomes and effective cost management. There are many considerations when evaluating care coordination successes and opportunities.
Potentially avoidable events have been identified as a means of opportunity savings and improved access to care, including, but not limited to:
• Preventable hospitalizations
• Avoidable emergency department (ED) visits
These are critical components to analyze because:
• They may be an indication of access difficulties to the appropriate primary care
• When evaluating these events, it is also important to understand the geographic and socioeconomic factors to help identify opportunities for improved care coordination within a given population
• From a financial perspective, these events can also contribute to higher costs, presenting an opportunity for savings if better care coordination is in place
• The ability to identify and monitor occurrences of these types of events depends on the ability to identify events that are potentially preventable and events that are not preventable
Preventable hospitalization: Prevention quality indicators (PQI) of the Agency for Healthcare Research and Quality (AHRQ) provide a consistent and industry-accepted basis for objective measurement and analysis. Based on the AHRQ literature, hospitalization for an ambulatory care sensitive condition (ACSC) is considered to be a measure of access to appropriate primary healthcare. As a reminder, ACSCs are medical problems that are potentially preventable. While not all admissions for ACSCs are avoidable, it is assumed that appropriate ambulatory care could prevent the onset of this type of illness or condition, control an acute episodic illness or condition, or manage a chronic disease or condition. For example, hypertension (high blood pressure) is a condition that can be treated outside of a hospital. With proper medication and management of care, most people should not need to be hospitalized for hypertension. When interpreting the data, a disproportionately high rate is presumed to reflect problems in obtaining access to appropriate primary care.
The identified conditions include angina, asthma, chronic obstructive pulmonary disease (COPD), diabetes, grand mal status and other epileptic convulsions, heart failure and pulmonary edema, and hypertension.
Avoidable ED visits: The use of algorithms that provide bucketing of ED visits based on diagnosis codes supports the analysis of preventable ED visits. Some examples include the New York University algorithm and the Medi-Cal algorithm. Below is a sample from a large data set for a one-year period showing the percent of visits identified as preventable/avoidable and primary care treatable at a high-level rollup by line of business. Further analysis would include population-specific information to identify factors contributing to these types of visits. Risk adjusting these populations and evaluating by more specific demographics such as age and gender will provide further detail to drive an action plan to reduce these types of visits.
In closing, a better understanding of costs and benefits—how and to whom to target incentives, at which levels of risk—is essential for care coordination and other improvement initiatives to be economically viable and sustainable.
An interesting strategy to address readmissions: Nurse Led Clinics Battle Readmissions.
This article first appeared at Milliman MedInsight.