Physician Group Capitalizing on Care Coordination and Patient Outreach

By Christopher Cheney

A Tennessee-based physician group is utilizing care coordination and patient outreach to fill gaps in care and manage transitions of care.

Care coordination and patient outreach is a proactive approach to care management that can drive positive outcomes such as reduced emergency department visits, decreased hospitalizations, and fewer hospital readmissions. For example, Massachusetts General Hospital has deployed community health workers to conduct care coordination and patient outreach for inpatients after discharge, which has reduced readmissions 50%.

Kingsport, Tennessee–based Holston Medical Group has developed a robust care coordination and patient outreach program combined with data analytics to target individual patients. The physician group operates 50 clinics in eastern Tennessee and southwestern Virginia.

“We can identify when there are gaps in care. We utilize the OnePartner Insights analytics tool to close gaps in care. We can identify each individual gap, perform outreach to ensure that we are able to close those gaps, and increase our quality measure scores,” says Samantha Sizemore, chief operations officer at Holston Medical Group.

The analytics tool allows Holston Medical Group to track patients, she says. “If a patient arrives in an emergency room or is admitted at a hospital system, we know in real time and we can outreach with the patient. We can provide education about the reason a patient arrived in an emergency room. We can provide alternatives for high-quality, low-cost options for care such as our group’s urgent care extended hours. More importantly, we can direct access to the patient’s physician office. We also schedule follow-up appointments immediately.”

Care coordination and patient outreach

Holston Medical Group takes a team approach to care coordination and patient outreach, Sizemore says.

“We have a care coordination team that is centralized and focused on the acute setting outreach. Every morning, we get a list from OnePartner Insights of patients who have been discharged from hospitals. The centralized care coordination team performs immediate outreach to patients to ensure that they received their discharge summary, make sure they understand what their discharge summary encompasses, ask whether they have any questions, check whether they received their medications, and try to set up an appointment with their primary care physician within the next 72 business hours,” she says.

Connecting with hospital inpatients quickly after discharge is crucial, Sizemore says. “The reason why our follow-up appointment goal is within three business days is we believe that if we can see a patient sooner rather than later and we can stabilize the patient’s condition in an outpatient setting, then we have a better chance of preventing a readmission. We do that real-time outreach on a daily basis.”

The administrative staff at Holston Medical Group physician practices also conducts care coordination and patient outreach, Sizemore says.

“For example, with L3 patients who have five or more chronic conditions, we want to touch those patients. We want to see those patients on a quarterly basis at the very minimum. If we see these patients often, we feel we can keep their conditions stable and prevent a future hospitalization. Every month, reports on L3 patients go out to our physician offices that list who has not been seen that quarter. Office managers conduct outreach to those patients. For example, the office manager will call and say, ‘You have not seen Dr. Jones and we need to go ahead and schedule an appointment,’ ” she says.

Nursing staff also are engaged in care coordination and patient outreach, Sizemore says. “We have individual quality gaps that we have disseminated through our value-based coordinators, who are part of the nursing team. They focus on the individual quality gaps. For example, we have a gap list for breast cancer screening. The value-based coordinators will receive that list, conduct outreach to the patients, and educate the patients on why they are on the list. Then, they go ahead and get mammograms scheduled.”

Holston Medical Group focuses on transitions of care, she says.

“We are reaching out to patients within 12 hours of their hospital discharge—in some cases on the same date of service. If a patient is discharged early in the morning, we reach out to them by the afternoon. We try to schedule an appointment with the patients’ primary care physicians within three working days. What we find at that transition of care appointment is that the primary care physician often feels that the patient’s condition is not fully stabilized and schedules another appointment for the following week,” Sizemore says.

The care coordination and patient outreach effort is funded through value-based contracts, she says. “With our accountable care organization, we allot for care coordination—we allot a care coordination budget of $1 per attributed life for that population. In partnership with our value-based payers such as Medicare Advantage, we receive a care coordination payment each month that is spent for the centralized care coordination team.”

Generating positive results

Statistics show that care coordination and patient outreach is achieving positive results for Holston Medical Group (HMG) and its patients.

  • 125.7 emergency room visits per 1,000 patients for HMG compared to 192.8 for regional healthcare providers
  • For HMG, the overall average for ER visits were 131.8 per month in 2020 and 116.6 per month so far in 2021
  • In 2020, hospital admissions per 1,000 patients for HMG were 35.3 compared to 54.1 for regional healthcare providers
  • For HMG, the overall average for hospital admissions were 39.4 per month in 2020 and 29.9 per month so far in 2021

Teamwork and patient-centered care are the keys to success in care coordination and patient outreach at a physician group, Sizemore says. “It is very important to use teamwork, and the patient must be the central focus. If you can come at outreach and care coordination from different angles in a coordinated manner you can be successful. The last thing you want to do is have a fragmented approach, with the patient receiving three or four disjointed calls from the same organization. When it all comes together, that is when success will follow.”

Right-sizing care coordination and patient outreach is also essential, she says. “We have achieved an effective balance. A lot of organizations fail because they try to overcompensate with the care coordination department, which is an enormous expense. So, rather than having 50 care coordinators for 170 providers, we have a minimal care coordination staff—six care coordinators for 170 providers.”

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.