For the past year, VHAN operations and clinical staff have participated in the American Medical Group Association’s (AMGA) Medicare Advantage (MA) Learning Collaborative. During the 18-month peer sharing program, Katie Herron, Phillip Denny, Pam Bruce and Dr. Cindy Powell have met with other healthcare organizations across the country to explore ways to maximize the effectiveness of MA and value-based contracts.
In early September, VHAN’s learning collaborative participants had the opportunity to virtually present on the network’s success in managing MA patients, specifically focusing on VHAN’s Transitions of Care program.
“There’s a lot of great work at VHAN that we could share with other Learning Collaborative participants," explained Katie Herron, VHAN Director of Network Operations. "We chose the Transitions of Care work because, in listening to other presentations, it's clear that VHAN truly has a unique, nationally leading approach. We're leveraging the Tennessee Hospital Association (THA) data feeds to reach patients when they need support most.”
With help from Jenn Booker, Director of Transition Care, and Julie Scott, Director of Care Coordination, the VHAN team highlighted several differentiators during its presentation. They began by focusing on how VHAN’s interdisciplinary approach to care management has yielded impressive results, with outreach to more than 7,700 patients. Building on an existing relationship with the THA, VHAN was able to pull real-time Admission, Discharge, and Transfer (ADT) data feeds from all member hospitals to identify patients who need care management assistance after discharge. It’s one of the few population health management organizations to launch such a program.
“We have the ability to reach out to a patient within minutes of being discharged from the ED or inpatient hospital setting,” says Nikki York, Manager of Care Coordination.
The VHAN Transitions of Care team provides outreach beyond what a traditional Transitional Care Management (TCM) service code requires, including following up with patients regularly for 30 days. VHAN also offers a Complex Care Program for patients who have difficulty managing complicated medical conditions and need additional help after 30 days. The program allows patients to work with the same care coordinator for three to six months beyond the 30-day discharge.
“The Complex Care Program is another differentiating factor for VHAN’s Transitions of Care program,” York says. “Our THA portal allows us to identify utilization trends and spot patients who visit the emergency department frequently. We’re able to enroll them into the complex care program and provide an additional layer of support, symptom management and provider communication for a longer period of time.”
“The VHAN Transitions of Care program is a unique design," Herron says. "Our team has done a great job building and executing this complex program. We were excited to showcase it nationally.”
View the slide deck to learn more about the VHAN Transitions of Care presentation.