NHPCO NewsLine Fall 2021 - 12

continued
Develop your insight into your outcome measures,
including symptom burden, patient and family
satisfaction levels and on-call utilization. Know the
acuity of those you serve, including their acute
utilization levels, their length of stay, their
diagnoses, and other utilization and clinical factors
that segment them from the general patient
population. Understand your referral sources,
including their referral and attending rates, their
specialties, their system affiliations, their utilization
over time and the timeliness of their referrals. Try to
recognize what else your data may be telling you
and see what connections may stand out across
these data classifications.
Be mindful of what matters to your potential
partner, not just what matters to you. For instance,
once a patient is on hospice, you may not be focused
on past hospitalization and rehospitalization rate.
But those metrics do matter to any payer system
that you are going to talk to, especially if you have
impacted that rate. Break down the data by
stakeholder. Know the referral patterns for an entire
practice. Know the rehospitalization rate for a
provider group. Know the number of patients you
served that were beneficiaries of a specific MA plan
or ACO. This will all be impactful when you are
meeting to discuss a partnership.
Once you have a handle on the data you already
have, you need to reach out for any missing data.
There is a wealth of knowledge available publicly,
from quality reports and public reporting to CMS
provider data. You can also access up to 3 years of
CMS claims history for any traditional Medicare
patient you have cared for through Blue Button or
Data at the Point of Care, two CMS programs that
can connect providers with their patients' holistic
medical picture to an effort to improve care. You can
also work with your partners within your healthcare
continuum to set up a data share relationship in
observance of all HIPAA and HITECH requirements.
With strong data, predictive data analytics can be
applied to not only provide a depth of insight into a
patient and/or population's current clinical state, but
also make predictions for their future journey.
Once you have strong insight into your clinical
measurements and a solid understanding of the
patients' and providers' picture, you will need to
examine your healthcare continuum system. The
goal is to identify unmet needs in your patient
population and gaps in care. The best way to do that
is by performing a gap analysis. First, take
advantage of any gap analyses already completed
by community providers and advocacy groups. If
none are readily available, you can do your own
research.
Conversations with stakeholders, including patients
and their families, providers, your staff, community
agency staff, your leadership peers, your referral
sources, and others can provide great insights into
what potential barriers to patient success are out
there. Is there a lack of accessible transportation
support? Are patients with specific diagnoses, such
as heart failure, COPD, or diabetes, consistently
showing poorer quality or utilization metrics? What
public perceptions may be getting in the way of
access? Are patients avoiding getting the care they
need because they do not want to leave pets alone
at home? Do cultural and ethnic barriers exist? Is
loneliness and isolation an issue? Once a barrier is
identified, you can be much more precise in your
strategy to overcome it.
You can do similar analyses for your potential
partners. Examine their public quality metrics to
identify areas of strength and need. For instance,
how do they compare to benchmark in providing
cardiac care? What is their readmission rate? If they
are in a shared savings arrangement, have they met
their metrics and received any savings? Knowing
this, you can better match your value to their need. If
they have high readmission rates, for instance, a
transitions support care model that will help
discharged patients stay home successfully will be of
great value to them.
For potential partners, you want to have a solid
understanding of their background. You will want to
get to know their history, their relationships with
other systems, their ownership and corporate
12
Newsline / Fall 2021
https://bluebutton.cms.gov/ https://dpc.cms.gov/
NHPCO NewsLine Fall 2021

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